Dysphagia - SAWA.ppt by shenreng9qgrg132


									Dr. Ghaze Qasaimeh

   Ro’aa Rawagah
    Definition
    Anatomy of oesophagus
   Physiology of oesophagus
   Causes of Dysphagia
   Clinical presentation
   Investigation
   Modality of treatment
          Anatomy of oesophagus
- The oesophagus is a musucular tube, approximately 25 cm long
  occupying the posterior mediastinum and extending from
  cricopharyngeal sphincter to the cardia of stomach ; 2 cm of this
  tube lies below the diaphragm.

- The musculature of upper 5% including the upper oesophageal
  sphinecter is striated the middle 40% has mixed striated and
  smooth muscle with proportion of smooth muscle increasing
  distally and the distal 55% is smooth muscle .
There are upper and lower oesophageal
sphinecters the upper sphinecter consist
of powerful striated muscle wheres
lower sphinecter is much more subtle .
 The main function of oesophagus is to transfer food from
  mouth to the stomach in coordinated fashion .
 the initial movement of food from mouth is voluntary.
 the pharayngeal swallow response is triggered by
  stimulation of pharynx and involve sequential contraction
  of oropharyngeal musclature togother with closure of
  nasal and respiratoy passage and opening of upper
  oesophageal sphinecter.
 the body of the oesophagus propels the food bolus by
  primary peristalisis through relaxed lower oesophageal
  sphinecter in to the stomach taking air with it
 upper oesophageal sphinecter is normally
  closed at rest and it serves as a protective
  mechanism against regurgitation of
  oesophageal contents in to respiratory
  passage and stop air entering the oesophagus
  other than small amount that enters during
 Los prevents gastric and duodenal contents
  from reflexing in to lower oesophagus
 Dysphagia means difficulty in swallowing.
 may or may not be associated with pain on
 may be associated with ingestion of solids or
  liquids, or both.
 should be distinguished from pain alone on
  swallowing (odynophagia), which doesn’t
  interfere with the act of swallowing.
-esophageal atresia.

-Painful mouth ulcer.
                                          4-Outside the wall
-mouth or throat infection.               -paraesophageal (rolling) hiatus hernia.
2-In the lumen                            -pharyngeal pouch.
-food bolus.                              -mediastinal tumors:
-foreign body.                               bronchial carcinoma.
3-In the wall                             -enlarged left atrium (mitral stenosis).
-inflammatory stricture:                  -thoracic aortic aneurysm.
  GERD, caustic stricture, candidiasis.   -dysphagia lusoria (rare).
-carcinoma.                               5-Neuromuscular disorders
-Plummer-vinson syndrome.                 -bulbar palsy.
-irradiation.                             -Guillian-Barre’ syndrome.
-scleroderma.                             -CVA.
-Chagas’ disease (rare).                  -motor neuron disease.
                                          -myasthenia gravis.
 blind-ending esophagus from atresia with fistula to trachea.
    (1500 to 3000 births)
    90% associated with tracheoesophageal fistula.
    May be associated with maternal polyhydramnios.
   associated anomalies VACTERL.
   Types (A-E), type C /common( blind proximal pouch with
    distal tracheoesophageal fistula).

 Sign: the newborn baby will show dribbling of saliva,
    inability to swallow feeds, production of frothy mucus,
    choking attacks, cyanotic attacks and chest infections,
    obvious respiratory compromise (aspiration pneumonia),
    gastric distention as air enters the stomach directly from the
- Initially; suction blind pouch (NPO), upright
position of child, prophylactic antibiotic
(ampicilin, gentamicin).
 - surgical correction via a extrapleural
thoracotomy, usually through the right chest
with division of fistula and end-to-end
esophageal anastomosis. Within 1-2 day of birth
 Following recovery form immediate post
  operative period the long term prognosis is
 The two most feared complications are
  pneumonia and leakage from anastomosis
All manner of foreign bodies have become arrested in the esophagus.

1-The most common impacted material is food (meat bolus) may be the first
presentation of a benign stricture or a malignant tumor (signifies underlying disease).
2-button batteries and coins may be a troublesome problem in children (be aware).
3-false teeth.

-plain radiography are often useful. (modern denture material are not always

-Treatment: flexible endoscopy.
If food bolus then we break it up by given fluid or by endoscopy.

- We should know the cause of impaction after treatment (stricture , tumor..etc)
Gasrtoesophageal reflux: Reflux of gastric contents to the esophagus
Gastroesophageal reflux disease (GERD): Any significant symptomatic clinical
condition or histopathological changes resulting from reflux.
Reflux esophagitis: GERD patients with histopathologically demonstrable
changes in the esophageal mucosa.
-due to loss of competence of the LES.
-may associated with hiatus hernia (sliding or rolling-paraesophagus)

-Heartburn is a very common condition:
3% of population experience heartburn daily
7% frequently
15% weekly
25% monthly
-Most common in pregnant women: 80%
-Common in obese and smokers.
Mechanism of GERD
1-Transient LES relaxation
2-Hypotensive LES
3-Decreased esophageal acid clearance
4-Hiatus hernia
5-Impaired salivation.

Chest pain
Water brash
Nausea and vomiting
Exraesophageal symtoms.
Clinical picture.
UGI endoscopy.
24 hour pH monitoring* the gold standard
Radioisotope scanning
Barium swallow.

1-Stricture formation*
2-Chronic blood loss
3-Barrett’s epithelium
 May be acute condition in a small percentage
 Mostly chronic condition with recurrent
 Majority can be controlled on drugs
 Majority may require a sort of acid
  suppressive therapy at 5 years
 No clear relation exists between symptoms of
  reflux, amount of reflux or degree of
1-lifestyle modification.
- avoid smoking and alcohol .
- Weight loss .
- Tilting the bed .
2-pharmacology (antacid, H2 blocker, PPI).
-Nissen:360 degree fundoplication; wrap fundus of stomach all
the way around the esophagus.
 * Belsey : thoracis procedure in which the oesophagus is
sutured to the diaphram and to the fundus of stomach
to reduce any hiatus hernia and produce 240 anterior
fuonduplication .
* Hill: cardia is tightened and fixed to the preaortic fascia.
 Reflux-induced stricture occur mainly in the
  late middle-aged and elderly, but they may
  present in children.
 immediately above the esophagus junction.
 peptic stricture respond well to dilatation and
  long-term treatment with a PPI.

 OTHER CAUSES: malignancy, radiation.
-fungal and viral infections are common.
-in immunocompromised.
-esophagitis due to Candida albicans is relatively
common in patient taking steroid &
-it may present with dysphagia or odynophagia.
-endoscopy shows numerous white plaque that
can’t be removed.
-Biopsy is diagnostic.
-Treatment: topical antifungal agent.

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