Dysphagia

CONTENTS

• Anatomy and Physiology of deglutition

• Evaluation of dysphagia

• Esophageal motility disorders

• Diverticular disorders
ANATOMY & PHYSIOLOGY
• Deglutition

A : Oral preparatory phase

B : Oral propulsive phase C-
D : Pharyngeal phase E :
Relaxation phase
 Esophageal peristalsis : two types

• primary peristaltic wave

• When the bolus enters the esophagus during swallowing
• Forces the bolus down the esophagus and into the
stomach in a wave lasting about 8-9 seconds.

• secondary peristaltic wave

• Local reflex response around the bolus
• When bolus gets stuck or moves slower than the primary
peristaltic wave stretch receptors in the esophageal
lining are stimulated
• Lower Esophageal Sphincter (physiological Sphincter)
• It is normally closed with a resting pressure of 15-25 mm Hg
above gastric pressure (termed the barrier pressure)
Evaluation of Dysphagia
• Does the patient actually have dysphagia?
• Dysphagia vs globus sensation/xerostomia/odynophagia
• Severity of dysphagia

• Anatomical location
• Oropharynx vs esophagus

• Etiology
• Structural vs dysmotility
Functional Grading of Dysphagia

1 Grade Description [

Complaints of dysphagia, but eating normally

1
2 Requires liquids with meals
3 No solids, semisolid diet only

4 Liquid diet only

5 Unable to swallow liquid, able to swallow saliva

6 Unable to swallow saliva

CTCAE grading of dysphagia

Grade | Description

0 Asymptomatic
1 Symptomatic, able to eat regular diet
2 Symptomatic .altered eating /swallowing
3 Severely altered swallowing, req. NG feed/TPN
4 Life threatening consequences ( aspiration, perforation)
 2 Etiology of oropharyngeal dysphagia.

Tumor
Stenosis
• Postsurgical

• Radiation
• Idiopathic Zenker’s
diverticulum
Cricopharyngeal bar
Web Extrinsic
compression

Stroke
Head trauma Parkinson's disease and
parkinsonism
Amyotrophic lateral sclerosis Multiple
sclerosis Myasthenia gravis
Myopathies (inflammatory, metabolic)
Box 1 Etiology of esophageal dysphagia. Structural Extramural lesions

■ Aberrant right subclavian artery (dysphagia lusoria)

disorders
Inflammatory and/or fibrotic strictures Peptic • Mediastinal masses . Bronchial carcinoma Anatomical

Caustic abnormalities
Pill-induced Radiation-induced
• Hiatal hernia
Mucosal nngs and webs Schatzki's nng
• Esophageal diverticulum Motility disorders®
Multiringod esophagus (eosinophilic esophagitis)
Achalasia and achalasia-like disorders
Carcinoma
■ Idiopathic (classic) achalasia
Primary (squamous, adenocarcinoma)
• Atypical disorders of lower esophageal sphincter relaxation
Secondary (o.g. breast, melanoma) Disorders
■ Chagas disease
related to systemic disoasos Pomphigus and
• Pseudoachalasia
pemphigoid conditions Lichen planus Scleroderma

(multifactorial) Hypomotility secondary to systemic disease (e.g. scleroderma, other

ntramural lesions Leiomyoma collagen vascular disorders, amyloid, diabetes) •Adaptod from data

Granular cell tumor presented in reference 31.

Diagnostic Investigations

• Endoscopy
• Indicated in every patient with dysphagia
• Identify structural disorders
• Biopsies to be taken

• Manometry
• Measures intraluminal pressures along the esophageal body and LES during swallowing
• Best modality to evaluate motility disorders
• Chicago classification

• Barium Swallow
• When endoscopy fails
• Esophageal manometry is unequivocal
Esophageal motility disorders

• Can be classified in three ways

• Based on Manometry : Chicago classification

• Based on Etiology : Primary vs Secondary

• Based on anatomical location : Esophageal Body vs LES

Primary Secondary

Achalasia Scleroderma
Diffuse Esophageal Spasm Nutcracker Polymyositis
esophagus Hypertensive Lower esophageal Chagas Myasthenia
sphincter Ineffective esophageal motility Gravis SLE

• Surgical Therapy is based on anatomical classification

 Disorders of esophageal body

Diffuse esophageal Spasm

• Aka distal esophageal spasm in Chicago classification

• Motor abnormality of distal esophagus

• More common in women

• Degenration of motor branches of vagus nerve and muscle

hypertrophy

Contractions are repetitive, simultaneous, and high amplitude

 • Clinical presentation :
• Dysphagia and chest pain (?angina)

• Diagnosis :

• Barium swallow : corkscrew appearance/

pseudodiverticulosis

• Manometry : simultaneous multipeaked

contractions of high amplitude (>120mmHg) or
long duration (>2.5s) in >10% of swallows
• Management

• Medical therapy is mainstay

• Avoid trigger foods
• Antacids/PPIs for acid reflux
• Nitrates/Calcium channel blockers/
anticholinergics

• Endoscopic therapy
• Bougie dilatation (50-60Fr) is effective in upto
80%
• Botulinum toxin inj
A
• Surgical

• Indications:
• If incapacitating pain or dysphagia

• Failure of medical and endoscopic therapy

• Presence of pulsion diverticula

• Long esophagomyotomy extending upto the LES +

antireflux procedure
Nutcracker /jackhammer esophagus

• Aka hypercontractile esophagus in Chicago classificationfchest pain with at

least one swallow DCI >8000)
• Characterized by hypertensive peristalsis or high amplitude contractions
• Most common and most painful of all esophageal motility disorders
• LES tone is normal and relaxes with each swallow
• Barium swallow may/may not reveal any abnormality
• Ambulatory monitoring can help distinguish it from DES
• Management: medical followed by endoscopic dilatation
Disorders of LES

Hypertensive LES

• Aka esophagogastric junction outflow obstruction in Chicago

classification

• Characterized by hypertensive poorly relaxing sphincter

• Thought to be achalasia in evolution

• Conventional manometry demonstrates LES tone > 26mmHg

• Normal peristalsis over esophageal body

Management

• Endoscopic : Botox inj/balloon

dilatation
• Surgical: hellers myotomy with
partial antireflux procedure
Disorders affecting both Body and LES

Achalasia
• Failure to relax
• More common in women
• Etiology : neurogenic degeneration due to severe emotional stress,
trauma, drastic weight reduction or Chagas disease
• Hypertensive LES with pressurization of esophagus leading to
esophageal dilatation and loss of progressive peristalsis
• Premalignant condition ( squamous cell carcinoma)
• Classic triad : Dysphagia, Regurgitation and
Weight Loss
• a/w heartburn, postprandial choking, nocturnal coughing
• Dysphagia begins with liquids and progresses to
solids
• Regurgitation can lead to aspiration of fermented
food
• Diagnosis:
• Barium Swallow : Dilated esophagus with bird beak and
delayed emptying through LES
• Sigmoid esophagus/Mega esophagus
Manometry

• LES- hypertensive (>35mmHg, IRP >

15mmHg)
X
• Failure to relax with deglutition
• Pressure in esophageal body above
baseline
• Simultaneous contractions with no
progressive peristalsis
• Low amplitude waveforms
The Chicago classification categorizes Achalasia into three manometric
subtypes based upon the HRM findings.

• Type I (classic achalasia):

• Absent esophageal body smooth muscle contractility -> lack of compartmental

pressurization of the esophagus.
• May represent late stage achalasia
• Loss of muscle tone and subsequent dilation of the esophageal body
• Type II (most common):
• Periods of compartmentalized esophageal pressurization or esophageal
compression
• The smooth muscle of the esophagus retains its tone
• There are pan-esophageal isobaric pressure increases seen on swallow
• Seen in 20% or more of the patient's swallows.

• Type III achalasia

• Spastic contraction of the distal esophagus,
• Seen in at least 20% of swallows
Management

• Goals : To relax LES

• Palliative : No effect on decreased esophageal motility
• Non surgical vs Surgical
• Non surgical :
• Nitrates, CCBs,
• Endoscopic dilatation: excellent relief, multiple interventions, risk of perforation
(<4%)
• Botox inj: effective symptomatic relief, recurrence >50% within 6 months
Surgical

• Laparoscopic Modified Hellers myotomy +

partial antireflux procedure

• Per Oral Endoscopic Myotomy (POEM)

• Esophagaectomy :
• Megaesophagus
• Multiple myotomies
• stricture not amenable to dilatation
Ineffective esophageal motility

• Contraction abnormality of distal esophagus

• GERD -^Inflammation -> dampened motility -> poor acid clearance

• Irreversible condition
• Pt present with acid reflux progressing to dysphagia
• Diagnosis:
• Barium swallow : non specific
• Manometry : >50% swallows have DCI <450
• Management: medical/surgical treatment of GERD
Diverticular Disorders

• Can be classified in three ways:

• Based on Etiology : Pulsion vs Traction

• Based on character: True vs False

• Based on Location : Pharyngoesophageal vs Midesophageal vs Epiphrenic

Pharyngoesophageal (Zenkers)

• Most common

• Seventh Decade

• Pulsion diverticulum(false)

• Loss of tissue elasticity mucosal herniation from the killians triangle

(between thyropharyngeus and cricopharyngeus)

• As the diverticulum enlarges it descends down posteriorly along the

prevertebral fascia
• Patients present with sticking in the throat,
nagging cough, excessive salivation

• Progressively dysphagia and regurgitation of

foul smelling food particles

• Complications : Aspiration pneumonia -> lung

abscess

• Diagnosis : Barium swallow (cricopharyngea

bar)

• Management:
• Diverticula < 3cm : Surgical
• Diverticula >3cm : Endoscopic/surgical
• Surgical
• Diverticulectomy or Diverticulopexy
• Incision over left side of neck
• Involves Myotomy of proximal and distal
thyropharyngeus and cricopharyngeus
• Diverticulum sutured to posterior wall of esophagus

• Endoscopic
• Dohlman procedure
• Division of common wall between esophagus and
diverticulum
• Forms a common channel
Midesophageal

• Traction diverticula (true)

• Infection (TB/Histoplasmosis) ->

inflamed mediastinal LN -> fibrosi
mediastinitis -> traction

• Wide neck

• Mostly asymptomatic, incidental finding

• Diagnosis :
• Barium swallow:
• CT scan : mediastinal lymphadenopathy
• Endoscopy : Mucosal evaluation
• Manometry : To evaluate motility disorder

• Management
• Asymptomatic or <2cm: Observe and treat
primary disease
• Symptomatic or > 2cm : Diverticulopexy to
thoracic vertebral fascia
Epiphrenic

• Adjacent to the diaphragm within 10cm of GE junction

• Pulsion diverticula ( False)

• HLES/DES -» Increased intraluminal pressure -> mucosal herniation

• Associated with congenital abnormalities ( Ehlers Danlos Syn)

• Wide mouth

Mostly asymptomatic, incidental finding

 • Diagnosis :
• Barium Swallow
• Manometry

• Management: similar to midesophageal

diverticula
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