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A Multidisciplinary Approach to Esophageal Dysphagia

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					 A Multidisciplinary Approach
  to Esophageal Dysphagia:
        Role of the SLP

Darlene Graner, M.A., CCC-SLP, BRS-S
         Sharon Burton, M.D.
   What is the role of the SLP?


• Historically
  – SLPs the preferred providers for
    evaluation and treatment of oral and
    pharyngeal stage dysphagia

  – Assessment of the esophagus was not
    always included in the evaluation
                ASHA Guidelines
• Guidelines for Speech-Language
  Pathologists Performing Videofluoroscopic
  Swallowing Studies (2004)

Issue: Pharyngoesophageal considerations
While it is the responsibility of appropriately trained physicians to
  evaluate and diagnosis esophageal stage dysphagia….
  Clinicians should be aware that oropharyngeal swallowing
  function is often altered in patients with esophageal motility
  disorders and dysphagia. …SLP have knowledge and skills to
  recognize patient signs and symptoms..associated with
  esophageal phase dysphagia.
       ASHA Policy Statement
• Knowledge and Skills Needed by Speech-Language
  Pathologists Performing Videofluoroscopic
  Swallowing Studies (2004)

  B. Skills required
  7. If esophageal screening is completed, describe
  any suspected anatomic and/or physiologic
  abnormalities of the esophagus which might impact
  the pharyngeal swallow, deferring to radiology for
  diagnostic statements
      ASHA Position Statement
Instrumental Diagnostic Procedures for
  Swallowing (1991)

The results of the VFSS may suggest that referral to a
  radiologist/gastroenterologist for an upper GI series
  or air contrast esophagram may be needed to view
  the esophagus. SLPs should have sufficient
  knowledge to make an appropriate referral and plan
  cooperative management.
   ACR Appropriateness Criteria

• Abnormalities of the mid or distal esophagus
  or gastric cardia can cause referred dysphagia
  to the upper chest or pharynx

• Therefore, a combined radiographic
  evaluation of the pharynx, esophagus and
  gastric cardia is recommended in patients
  with unexplained pharyngeal dysphagia
                 Goals

• Review normal esophageal anatomy and
  physiology and how we evaluate them

• Demonstrate anatomic and/or physiologic
  abnormalities of the esophagus which
  might impact the pharyngeal swallow and
  produce dysphagia symptoms

• Present unknown case examples
Normal Esophagram

• Double Contrast
  – High density barium
  – “thick”
  – Fizzies


• Goal: Mucosal detail
  – Esophagitis
  – Neoplasm
Single Contrast Phase

  • Low density barium
    – “thin”
    – Single swallows for
      peristalsis
    – Multiple swallows for
      detection of
       • Rings
       • Strictures
       • Hernia
       Esophageal Dysphagia

Structural Causes   Motility Disorders

  –   Diverticula     –   Achalasia
  –   Web             –   Scleroderma
  –   Ring            –   Diffuse spasm
  –   Stricture       –   Non-specific
  –   Hernia              esophageal
  –   Neoplasm            dysmotility (NEMD)
   Cervical Web

• 1 - 2 mm, anterior wall

• Hemispheric and
  circumferential webs
  (rings) cause solid
  food dysphagia

• Associations:
  – GE reflux, Plummer-
    Vinson syndrome
       GE Reflux

• Fluoroscopic evaluation is
  limited for detection of GER

• 24-hour ambulatory pH
  testing is the most accurate
  way to document reflux

• Evaluate patient for
  complications of GERD
Peptic Esophagitis

 •   Abnormal Motility
 •   Granular mucosa
 •   Thickened folds > 3mm
 •   Nodularity
 •   Ulceration
 •   Better detected with
     endoscopy
   Peptic Strictures

• Distal esophagus
• Hiatal hernia in > 90%
• Fluoroscopy better than EGD for
  ring and stricture detection
  – 95% sensitivity


• EGD for biopsy and dilatation
 Barrett Esophagus

• Columnar metaplasia

• Occurs in 10-15% of patients
  with reflux esophagitis

• Premalignant

• High stricture or ulcer,
  reticular pattern
Eosinophilic Esophagitis

• Esophageal biopsies:
  – Many intraepithelial eosinophils
    (80/high power field)
• Associated with food allergies

• Treatment:
  – Oral steroid (Fluticasone) therapy
  – 220 mcg two puffs a day
    Hiatal Hernias


•   Sliding
•   Paraesophageal
•   Mixed
•   Intrathoracic stomach
     Esophageal Cancer


 Chronic GERD    Risk factors for
                 squamous cell
                   carcinoma:
    Barrett
                    Smoking
  esophagus
                      ETOH
                   Achalasia
Adenocarcinoma
       Achalasia

• Primary
  –   Idiopathic
  –   Progressive dysphagia
  –   Dilated esophagus
  –   Birdbeak


• Secondary
  – Neoplasm of distal
    esophagus or gastric cardia
  – Chagas disease
      Achalasia

– Aperistaltic esophagus
– Failure of relaxation of lower
  esophageal sphincter

Treatment options
– Dilatation
– Heller myotomy and
  fundoplication
– Botox injection
          Scleroderma

• Motility pattern
  – Proximal 1/3 striated muscle
     • normal peristalsis
  – Distal 2/3 smooth muscle
     • impaired motility


• Patulous GE junction
  – GE reflux can cause distal stricture
Diffuse Esophageal Spasm (DES)


   •   Chest pain
   •   Intermittent dysphagia
   •   Segmental nonperistaltic contractions
   •   Corkscrew esophagus
   •   Muscular hypertrophy
                       References
• Adler, D. G., Romero, Y., Primary esophageal motility disorders.
  Mayo Clin Proc. 2001;76:195-200.
• Crescenzo, D. G., Trastek, V. F., Allen, M. S., Deschamps, C.,
  Pairolero, P. C. Ann Thorac Surg. 1998; 66:347-350.
• Martin, R. E., Letsos, P., Taves, D. H., Inculet, R. I., Johnston, H.,
  Preikasaitis, H. G., Oropharygeal dysphagia in esophageal
  cancer before and after transhiatal esophagectomy, Dysphagia.
  2001; 16:23-31.
• Philippsen, L. P., Weisberger, E. C., Whiteman, T. S., Schmidt,
  J. L., Endoscopic stapled diverticulotomy: Treatment of choice
  in Zenker’s diverticulum. The Laryngoscope. 2000; 110:1283-
  1286.
• Sofer, E., Murray, J. A., Schulze-Delrieu, K., Esophagoscopy
  and tests of esophageal function. In Perlman, A. L. and
  Schulze-Delrieu, K. (eds) Deglutition and its Disorders. Singular
  Publishing Group: San Diego. 1998.
              Reference Links

– Levine M.S., Rubesin S.E. Diseases of the
  Esophagus: Diagnosis with Esophagography.
  Radiology 2005; 237:414-427.
– http://radiology.rsnajnls.org/cgi/content/full/237/2/414?maxtoshow=&
  HITS=10&hits=10&RESULTFORMAT=&author1=levine&fulltext=esop
  hagus&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcety
  pe=HWCIT



– ACR Appropriateness Criteria: Dysphagia
  http://www.acr.org/s_acr/bin.asp?CID=1207&DID=11772&DOC=FILE.
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