DYSPHAGIA by yurtgc548

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									DYSPHAGIA
                  Question 1
 A 51 yr.old female presented with a hx of
  dysphagia that has been progressively worsening
  for months. Initially dysphagia was for solids only
  but more recently it is for both solids and liquids.
 Which of the following studies will most likely
  establish the diagnosis
 EGD
 Barium swallow
 CT
 manometry
                     Question-2
   A 52 year-old male executive c/o intermittent dysphagia
    which began 2 years ago. When he is eating, he has
    episodes of the sudden sensation of food sticking in his
    throat after he swallows, lower chest discomfortand
    hypersalivation. On two occassions the discomfort has
    caused him to regurgitate undigested food. There is now wt
    loss.Physical exam is normal
   The most likely diagnosis is
   Achalasia
   Diffuse esophageal spasm
   Esophageal ring
   Peptic stricture
   Adenocarcinoma
          INTRODUCTION
 Dysphagia—difficulty   with swallowing—is a
 common condition, reported by 5–8% of the
 general population aged over 50 years, and by
 16% of the elderly.
 Dysphagia, particularly oropharyngeal
 dysphagia, is even more common in the
 chronic-care setting; up to 60% of nursing-
 home occupants have feeding difficulties that
 include dysphagia.
ESOPHAGEAL ANATOMY
ESOPHAGEAL ANATOMY
                 SWALLOWING
   Mechanism is complex
   Involves the actions of 26 muscles and 5 cranial nerves
     – CN V -- both sensory and motor fibers; important in
       chewing
     – CN VII -- both sensory and motor fibers; important for
       sensation of oropharynx & taste to anterior 2/3 of tongue
     – CN IX -- both sensory and motor fibers; important for
       taste to posterior tongue, sensory and motor functions of
       the pharynx
     – CN X -- both sensory and motor fibers; important for
       taste to oropharynx, and sensation and motor function to
       larynx and laryngopharynx; important for airway
       protection
     – CN XII -- motor fibers that primarily innervate the
       tongue
   A normal adult swallows unconsciously 600 times in a 24-
    hour period
         Esophageal Anatomy
 Upper one-third is composed of skeletal muscle
 Distal two-thirds is smooth muscle
 NO SEROSA
 Outer longitudinal, inner circular muscle layer
 Myenteric plexus of Auerbach, parasympathetic
  ganglion cells, interspersed among the muscle
  layers
 Submucosa – blood vessels/lymphatics, myenteric
  plexus of Meissner (parasympathetic ganglion
  cells)
 Mucosa – stratified squamous epithelium
                                 REVIEW
   The outermost collection, lying between
    the    inner     circular    and     outer
    longitudinal smooth-muscle layers of
    the gut, is called the myenteric (or
    Auerbach's) plexus.
   Neurons of this plexus regulate the
    peristaltic   waves,      consisting    of
    polarized muscular activity, that move
    digestive products from oral to anal
    openings.
   In addition, myenteric neurons control
    local muscular contractions that are
    responsible for stationary mixing and
    churning.
   The innermost group of neurons is
    called the submucosal (or Meissner's)
    plexus. This group regulates the
    configuration of the luminal surface,
    controls glandular secretions, alters
    electrolyte and water transport, and
    regulates local blood flow
                Swallowing Stage 1
   Oral
     – Food ingested, prepared
       (mastication) and modified
       (lubrication)
     – Voluntary control
     – Frequently results from
       weakness – lips, tongue,
       cheeks
     – Unable to organize food into
       well formed bolus and move
       posteriorly
     – Xerostomia – difficulty
       breaking down solids
                   Swallowing Stage 2
   Pharyngeal
     – Prevented from entering nasopharynx,
       larynx rises, retroflexion of epiglottis
       and vocal fold closure, synchronized
       contraction of middle and inferior
       constrictors, and synchronized
       relaxation of the cricopharyngeal
       muscle Involuntary
     – Timing – neurologic – epiglottis
       doesn’t protect larynx - leads to
       cough/aspiration
     – Weakness – neurologic injury/cancer –
       residual food after swallow – can lead
       to aspiration
                          Stage 3
   Esophageal
     – Begins with crico-
       pharyngeal relaxation
     – Involuntary
     – Most common
     – Sensation of food
       sticking at base of
       throat/chest
     – Peristalsis, tumor,
       stricture
                  HISTORY
 Taking  a careful history is vital for the
  evaluation of dysphagia.
 The history will yield the likely underlying
     -pathophysiologic process
     -anatomic site of the problem in most
       patients-80
      -crucial for determining whether
       subsequently detected radiographic or
       endoscopic 'anomalies' are relevant or
       incidental..
                               HISTORY
   Three fundamental aims should be met when taking a dysphagia history.

   -The first is to establish whether or not dysphagia is actually present; that is, to
    distinguish true dysphagia from
          globus sensation (in b/w meals),
          xerostomia-loose the lubrication properties and stimulus
          odynophagia-transient than dysphagia, and persists only during the
          15–30 s that a bolus takes to traverse the esophagus.

   -The second is to determine whether the site of the problem is esophageal or
    pharyngeal

   -The third is to distinguish a structural abnormality from a motor disorder These
    avenues of enquiry are outlined below in an order that corresponds to that of a
    highly effective diagnostic algorithm.

   The history will also dictate whether the next diagnostic procedure should be
    endoscopy, a barium swallow or esophageal manometry. In some difficult
    cases, all three diagnostic techniques may need to be performed to establish an
    accurate diagnosis.
    Where is the site of bolus hold-up?

 Retrosternal bolus hold-up indicates that the disorder
  lies within the esophagus.
 However, the patient's perception of an apparent
  bolus hold-up in the neck has low diagnostic
  specificity, and cervical localization per se does not
  help the clinician to distinguish pharyngeal from
  esophageal causes of dysphagia.
 Owing to viscerosomatic referral, in 30% of cases the
  perceived site of hold-up is above the suprasternal
  notch when the actual hold-up is within the
  esophageal
Does the patient report symptoms that are predictive
               of oropharyngeal dysfunction
   there are four symptoms that have high specificity for
    oropharyngeal dysfunction:
         -delayed or absent oropharyngeal swallow initiation;
         -deglutitive postnasal regurgitation or egress of fluid
            through the nose during swallowing
         -deglutitive cough indicative of aspiration and
          -the need to swallow repetitively to achieve
    satisfactory clearance of swallowed material from the
    hypopharynx.

   If one or more of these four symptoms are present then the cause
    of dysphagia is probably oropharyngeal, either structural or
    neuromyogenic
OROPHARYNGEAL VS
   ESOPHAGEAL
         Etiology of oropharyngeal dysphagia.
   Structural
    Tumor
    Stenosis
   Postsurgical
   Radiation
   Idiopathic
    Zenker's diverticulum
    Cricopharyngeal bar
    Web
    Extrinsic compression

   Neuromyogenic
    Stroke
    Head trauma
    Parkinson's disease and parkinsonism
    Amyotrophic lateral sclerosis
    Multiple sclerosis
    Myasthenia gravis
    Myopathies (inflammatory, metabolic)
                 ESOPHAGEAL
   Structural disorders
   Inflammatory and/or fibrotic strictures
         Peptic
         Caustic
         Pill-induced
         Radiation-induced
   Mucosal rings and webs
         Schatzki's ring
         Multiringed esophagus (eosinophilic esophagitis)
         Carcinoma
   Primary (squamous, adenocarcinoma)
   Secondary (e.g. breast, melanoma)
   Disorders related to systemic diseases
         Pemphigus and pemphigoid conditions
         Lichen planus
         Scleroderma (multifactorial)
         Intramural lesions
         Leiomyoma
         Granular cell tumor

   Extramural lesions
         Aberrant right subclavian artery (dysphagia lusoria)
         Mediastinal masses
         Bronchial carcinoma

Anatomical abnormalities
       Hiatal hernia
       Esophageal diverticulum
 Motilitydisorders
     Achalasia and achalasia-like     disorders
     Idiopathic (classic) achalasia
     Atypical disorders of lower esophageal
     sphincter relaxation
     Chagas disease
     Pseudoachalasia
            ESOPHAGEAL
 Differntiation
  mechanical vs motility disorder?
Is the dysphagia for solids or liquids
 Patients who have a motor disorder will
  describe dysphagia for liquids and solids,
 Whereas patients who have structural
  disorders will describe dysphagia for solids
  only.
 Once a solid bolus becomes impacted, the
  patient will report dysphagia for liquids and
  solids,
                      Motility- features
   Three cardinal features of dysmotility
         dysphagia (for solids and liquids),
         chest pain and
         regurgitation.
   Regurgitation during meals, as well as spontaneous regurgitation
    between meals or at night, is highly suggestive of dysmotility.
    Unlike regurgitation that is related to GERD, the regurgitated fluid
    in patients with esophageal dysmotility is generally not noxious to
    taste.
   In addition, spasm or achalasia typically cause chest pain.
    Although this chest pain is frequently described as 'heavy' or
    'crushing', it can be indistinguishable from the typical 'heartburn' of
    reflux.
    The pain frequently occurs during meals, but it can be quite
    unpredictable and sporadic or nocturnal.
   Sipping antacids or even water can relieve the pain related to
    dysmotility, which further confuses its distinction from reflux-
    related pain.
       How long has dysphagia been present? Is it
                intermittent? Is it progressive?
   Slowly progressive, long-standing dysphagia, particularly against a
    background of reflux, is suggestive of a peptic stricture.
         Caveat -severity of heartburn correlates poorly with esophageal
    mucosal damage. For example, patients who have severe mucosal changes,
    including strictures and Barrett's mucosa, could have had minimal or no
    heartburn in the immediate past.

   A short history of dysphagia—particularly with rapid progression (weeks
    or months) and associated weight loss—is highly suggestive of esophageal
    cancer.

   Long-standing, intermittent, nonprogressive dysphagia purely for solids is
    indicative of a fixed structural lesion such as a distal esophageal ring or
    proximal esophageal mucosal web.
     Examination of the patient with
              dysphagia
   The physical examination is generally unremarkable.
   Skin should be examined for features of connective tissue
    disorders, particularly scleroderma and CREST (calcinosis,
    Raynaud's phenomenon, esophageal dysmotility, sclerodactyly
    and telangiectasia) syndrome.
   Muscle weakness or wasting might be evident if myositis is
    present, and myositis can overlap with other connective tissue
    disorders that affect the esophagus.
    Signs of malnutrition, weight loss and pulmonary
    complications from aspiration should be looked for.
   If pharyngeal dysphagia is suspected, evaluation for
    neuromuscular disorders is important
     Investigation of esophageal
             dysphagia
 Barium swallow study,
 Endoscopy and

 Esophageal manometry.
NO DYSPHAGIA
INTERMITTENT DYSPHAGIA
      FOR SOLIDS
DYSPHAGIA WITH LONG HX
       OF GERD
Bulge in the left side of the neck
          while eating
DYSPHAGIA FOR SOLIDS AND
  LIQUIDS WITH WT LOSS
DYSPHAGIA FOR SOLIDS AND
        LIQUIDS
young male patients who present with intermittent
          dysphagia or bolus impaction
  INTERMITTENT DYSPHAGIA
   FOR SOLIDS AND LIQUIDS
 Numerous  nonpropulsive contractions
 “corkscrew/ rosary bead” esophagus
INTERMITTENT DYSPHAGIA
      FOR SOLIDS
IRON DEFIIENCY ANEMIA
Due to an aberrant right subclavian artery
     coursing posterior to esophagus

								
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