Transcript Dysphagia - صندوق بیان

Approach to the patient with
Dysphagia
Dr Ehsani
Gastroenterologist/internist
Dysphagia
Definition: sensation of sticking or
obstruction of the passage of food
through the mouth ,pharynx,or esophagus.
 Aphagia
 Odynophagia
 Phagophobia
 Feeling of fullness in the epigastrium

Dysphagia
Dysphagia is a subjective sensation
that suggests the presence of an organic
abnormality in the passage of liquids or solids
from the oral cavity to the stomach.
 Dysphagia is considered to be an alarm
symptom,indicating the need for an immediate
evaluation to define the exact cause and
initiate appropriate therapy.

Dysphagia
Dysphagia in elderly subjects should not
be attributed to normal aging.
 Aging alone causes mild esophageal
motility abnormalities,which are rarely
symptomatic.

Dysphagia
The normal transport of an ingested bolus
through the swallowing passage depends
on the size of the ingested bolus,the luminal
diameter of the swallowing passage , the
force of peristaltic contraction,the deglutitive
inhibition,including normal relaxation of
UES,LES during swallowing
Dysphagia
Classification
Mechanical (large bolus,luminal narrowing)
 Motor (weakness of peristaltic contractions
,impaired deglutitive inhibition causing
nonperistaltic contractions , impaired
sphincter relaxation)

Dysphagia
classification
Oropharyngeal dysphagia
 Esophageal dysphagia
 Functional dysphagia

Dysphagia
Medical history
 the cornestone of evaluation
 Distinguish from odynophagia & globus
sensation
 Determine the types of food that produce
symptoms
 Progressive or intermitent symptoms
 Others symptoms or findings
Approach to the patient with dysphagia
Dysphagia,esophageal
Differential diagnosis
Peptic stricture
 in 10% of patients with GERD ,in older
age, male gender,longer duration of reflux
symptoms.
 In scleroderma,Z-E syndrom,NG tube,
Heller myotomy.
 Infectious esophagitis,post surgical,caustic
injury,pill induced esophagitis,radiation
exposure.
Dysphagia,esophageal
Differential diagnosis
Esophageal rings and webs
Thin,fragile structures that partially or
completely compromise the esophageal lumen.
 Web:thin mucosal fold,covered with squamous
epithelium,in anterior cervical esophagus,
causing focal narrowing in the postcricoid area.
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Dysphagia,esophageal
Differential diagnosis
Esophageal rings and webs
 Rings:Schatzki ,mucosal structures at the GE
junction , smooth,thin,(<4mm).covered with
squamous mucosa above and columnar
epithelium below.
 Pathogenesis,mucosal,muscular,GERD
 Changing the caliber during peristaltism.
Dysphagia,esophageal
Differential diagnosis
Esophageal rings and webs
Diagnosis:Barim swallow,EGD
 Symptoms:acute(steak house syndrome)
,intermittent,with chest discomfort
 Plummer-vinson or paterson-kelly syndrom

Dysphagia,esophageal
Differential diagnosis
Carcinoma
Esophagus,gastric cardia
 History,others symptoms,age
 Histologic type
 Risk factors
 incidence

Dysphagia,esophageal
Differential diagnosis
Cardiovascular abnormalities
 Compressing the esophagus
 Complete vascular ring :double aortic arch,
R. aortic arch with retroesophageal
L. subclavian artery and L. ligamentum
arteriosum,R. aortic arch with mirror-imaging
branching and L. ligamentum arteriosum
 Incomplete:retroesophageal R.aberrent
subclavian artery and L.pul artery
Dysphagia,esophageal
Differential diagnosis
Cardiovascular…
Severe atherosclerosis in elderly
 Large aneurysm of the thorasic aorta
 Enlargement of the left atrium
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Dysphagia,esophageal
Differential diagnosis
Radiation injury
 Acute :esophagitis
 Chronic:>2 months after radiotherapy
(ulceration or strictures)
 Location
 Motility disorder
Dysphagia,esophageal
Differential diagnosis
Achalasia
Etiology
 Symptoms
 Manometric abnormalities
 Secondary achalasia

High-resolution esophageal pressure
topography ,conventional manometry :
normal swallow
Classic achalasia
Achalasia with compression
Spastic achalasia

Secondry achalasia
Dysphagia,esophageal
Differential diagnosis
Spastic motility disorders
 DES,nutcracker esophagus,hypertensive LES
,non specific spastic esophageal motility
disorders
 Pathophysiology
 Symptoms
 diagnosis
Variants of esophageal spasm: spastic
nutcracker (left) and diffuse esophageal
spasm (right)
Dysphagia,esophageal
Differential diagnosis
Connective tissue disorders
 Scleroderma:esophageal involvement in
up to 90% of patients
 sjogren”s syndrom:dysphagia up to 74%

sclroderma
Dysphagia,esophageal
Differential diagnosis
Functional dysphagia
 Is a diagnosis of exclusion
 Complete diagnostic evaluation is needed.
 No structural abnormality or motility
disturbance,no reflux.
 At least 12 weeks in the preceding 12
months of a sense of having solid and/or
liquid food sticking,lodging,or passing
abnormally through the esophagus.
Dysphagia,esophageal
Specific testing
 Should be based upon the medical history
 Early referral for EGD
 Barium swallow in proximal esophageal
lesion
 Esophageal motility study
Acute dysphagia
Require immediate evaluation and
intervention
 Annual incidence:13/100,000
 M/F:1.7/1-increase with age.
 Commonly have an underlying component
of mechanical obstraction
 Food impaction is the most common cause
in adults.
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Dysphagia,oropharyngeal
physiology of swallowing
Normal swallowing consist of 3 phases (oral
preparatory , pharyngeal , esophageal)
 Up to 600 times/day
 Once begin , it takes less than 1 second for a
bolus to reach the esophagus,and an additional
10-15 seconds to complete the swallow
 Involve more than 30 muscles

Sagittal and diagrammatic views of the
musculature (involved in enacting oropharyngeal
swallowing)
Dysphagia,oropharyngeal
physiology of swallowing
Oral preparatory phase
 The bolus is processed by mastication to
an appropriate size,shape and consistency
 The tongue is a critical part for controlling
the food so that proper chewing can occur
and for directing the bolus to its proper
position for swallowing.
 Voluntary control/cranial nerve V,VII,XII.
Dysphagia,oropharyngeal
physiology of swallowing
Pharyngeal phase
 The bolus is advanced through the
pharynx and into the esophagus by
pharyngeal peristalsis
 Is controlled reflexively
 Cranial nerve V,X,XI,XII
 Respiration is inhibited centrally.
Dysphagia,oropharyngeal
physiology of swallowing
Esophageal phase
In this phase , peristaltic contractions in
the body of the esophagus combined with
simultaneous relaxation of the LES propel
the bolus into the stomach
Dysphagia,oropharyngeal
pathogenesis
Disturbance in oral preparatory or
pharyngeal phase
 Arise from diseases of the upper
esophagus , pharynx ,UES dysfunction

Dysphagia,oropharyngeal
pathogenesis
Disorders of the oral preparatory phase
Poor dentition
 Decrease in salivary flow
 Neurologic disorders such as stroke,
parkinson”s dis(weakness of muscles,
decrease in coordination)
 Disruption of the oropharyngeal mucosa

Dysphagia,oropharyngeal
pathogenesis
Disorders of the pharyngeal phase
 a normal phase requires neuromuscular
coordination for propulsion of the bolus,
an unobstructed lumen , and normal
relaxation of the UES.
 Neuromuscular discoordination(CNS
disorders eg:stroke,motor neuron dis eg:
ALS,peripheral neuron dis eg:myastenia
Dysphagia,oropharyngeal
pathogenesis
Continue..
 Obstructions within the oropharynx:
malignancies (the most common),
cervical rings or webs, cervical osteophytes
 Poor compliance of the UES (parkinson”s dis)
Dysphagia,oropharyngeal
history
Specific clues in the history can help establish
the cause of the dysphagia
 Older patients,particularly those with a history
of alcohol abuse,smoking or weight loss:
malignant cause must be R/O
 Repositioning during the swallowing:difficulte
in transfer of bolus
 History of dry mouth or eye

Dysphagia,oropharyngeal
history and physical exam
Continue…
 Changes in speech(neuromuscular
dysfunction,vocal cord paralysis,…)
 Food regurgitation,halitosis,a sensation of
fullness in the neck,or a history of pneumonia
:Zenker”s diverticulum
 Pain upon swallowing:
inflammation,infection,malignancy
Dysphagia,oropharyngeal
clinical manifestations
Pointing toward the cervical region
 Symptoms occur almost immediately after
swallowing
 Feelig of an obstruction in the neck,
coughing,chocking,drooling and regurgitation
 Differentiation with globus sensation,dysphagia
related to distal esophageal dis,such as peptic
stricture.

Dysphagia,oropharyngeal
physical examination
Oral cavity,head and neck,supraclavicular
region must be examed carefully
 Neurologic examination should include
testing of all cranial nerves,especially those
involved in swallowing (sensory components
of V, IX, X, and motor components of V, VII,
X, XI, XII).
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Dysphagia,oropharyngeal
diagnostic testing

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Barium radiography
Videofluroscopy
Upper endoscopy
Fiberoptic nasopharyngeal laryngoscopy
Esophageal manometry
The choice of specific testing depends upon the
clinical presentation and available expertise.
Dysphagia,oropharyngeal
therapy
The goals of treatment are to improve food
transfer and to prevent aspiration.
 The approach chosen depends in part upon
the cause of dysphagia
 Neoplasms : resection , chemotherapy or
radiation therapy

Dysphagia,oropharyngeal
therapy
Following stroke , head or neck trauma,
surgery , or in degenerative neurologic
diseases: rehabilitation is recommended
 Therapeutic endoscopy for esophageal
webs or strictures
 Surgical myotomy
 Botulinium toxin injection (alternative to
cricopharyngeal myotomy)
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