Approach to the patient with Approach to the patient with Dysphagia Dysphagia Dr Ehsani Dr Ehsani...

Approach to the patient Approach to the patient with with

DysphagiaDysphagia

Dr EhsaniDr Ehsani

Gastroenterologist/internistGastroenterologist/internist

DysphagiaDysphagia

Definition: sensation of sticking or Definition: sensation of sticking or obstruction of the passage of food obstruction of the passage of food through the mouth ,pharynx,or through the mouth ,pharynx,or esophagus.esophagus.

AphagiaAphagia OdynophagiaOdynophagia PhagophobiaPhagophobia Feeling of fullness in the epigastriumFeeling of fullness in the epigastrium

DysphagiaDysphagia

Dysphagia is a subjective sensation Dysphagia is a subjective sensation that suggests the presence of an that suggests the presence of an organic abnormalityorganic abnormality in the passage of in the passage of liquids or solids from the oral cavity to liquids or solids from the oral cavity to the stomach.the stomach.

Dysphagia is considered to be an Dysphagia is considered to be an alarmalarm symptomsymptom,indicating the need for an ,indicating the need for an immediate evaluation to define the exact immediate evaluation to define the exact cause and initiate appropriate therapy.cause and initiate appropriate therapy.

DysphagiaDysphagia

Dysphagia in elderly subjects should Dysphagia in elderly subjects should not be attributed to normal not be attributed to normal agingaging..

Aging alone causes mild esophageal Aging alone causes mild esophageal motility abnormalities,which are motility abnormalities,which are rarely symptomatic.rarely symptomatic.

DysphagiaDysphagia

The The normal transportnormal transport of an ingested of an ingested bolus through the swallowing passage bolus through the swallowing passage depends on the depends on the size of the ingested size of the ingested bolus,the luminal diameter of the bolus,the luminal diameter of the swallowing passage , the force of swallowing passage , the force of peristaltic contraction,theperistaltic contraction,the deglutitivedeglutitive inhibitioninhibition,including normal relaxation of ,including normal relaxation of UES,LES during swallowing UES,LES during swallowing

DysphagiaDysphagia

ClassificationClassification

MechanicalMechanical (large bolus,luminal (large bolus,luminal narrowing)narrowing)

MotorMotor (weakness of peristaltic (weakness of peristaltic contractions ,impaired deglutitive contractions ,impaired deglutitive inhibition causing nonperistaltic inhibition causing nonperistaltic contractions , impaired sphincter contractions , impaired sphincter relaxation)relaxation)

DysphagiaDysphagia

classificationclassification

Oropharyngeal dysphagiaOropharyngeal dysphagia Esophageal dysphagiaEsophageal dysphagia Functional dysphagiaFunctional dysphagia

DysphagiaDysphagia

Medical historyMedical history the cornestone of evaluationthe cornestone of evaluation Distinguish from odynophagia & Distinguish from odynophagia &

globus sensationglobus sensation Determine the types of food that Determine the types of food that

produce symptomsproduce symptoms Progressive or intermitent symptomsProgressive or intermitent symptoms Others symptoms or findings Others symptoms or findings

Approach to the patient with Approach to the patient with dysphagiadysphagia

Dysphagia,Dysphagia,esophagealesophagealDifferential diagnosisDifferential diagnosis

Peptic stricturePeptic stricture in in 10%10% of patients with GERD ,in of patients with GERD ,in

older age, male gender,longer older age, male gender,longer duration of reflux symptoms.duration of reflux symptoms.

In In scleroderma,Z-E syndrom,NG tube, scleroderma,Z-E syndrom,NG tube, Heller myotomy.Heller myotomy.

Infectious esophagitis,post Infectious esophagitis,post surgical,caustic injury,pill induced surgical,caustic injury,pill induced esophagitis,radiation exposure.esophagitis,radiation exposure.


Esophageal rings and websEsophageal rings and webs

Thin,fragile structures that partially or Thin,fragile structures that partially or completely compromise the esophageal completely compromise the esophageal lumen.lumen.

Web:thin mucosal fold,covered with Web:thin mucosal fold,covered with squamous epithelium,in anterior cervical squamous epithelium,in anterior cervical esophagus, causing focal narrowing in the esophagus, causing focal narrowing in the postcricoid area.postcricoid area.

Dysphagia,Dysphagia,esophagealesophageal

Differential diagnosisDifferential diagnosis

Esophageal rings and websEsophageal rings and webs Rings:Rings:SchatzkiSchatzki ,mucosal structures at the ,mucosal structures at the

GE junction , smooth,thin,(<4mm).covered GE junction , smooth,thin,(<4mm).covered with squamous mucosa above and with squamous mucosa above and columnar epithelium below.columnar epithelium below.

PathogenesisPathogenesis,mucosal,muscular,GERD ,mucosal,muscular,GERD Changing the caliber during peristaltism.Changing the caliber during peristaltism.


Esophageal rings and websEsophageal rings and webs

DiagnosisDiagnosis:Barim swallow,EGD:Barim swallow,EGD SymptomsSymptoms:acute(steak house syndrome) :acute(steak house syndrome)

,intermittent,with chest discomfort,intermittent,with chest discomfort Plummer-vinsonPlummer-vinson or paterson-kelly or paterson-kelly

syndromsyndrom


CarcinomaCarcinoma

Esophagus,gastric cardiaEsophagus,gastric cardia History,others symptoms,ageHistory,others symptoms,age Histologic typeHistologic type Risk factorsRisk factors incidenceincidence


Cardiovascular abnormalitiesCardiovascular abnormalities Compressing the esophagusCompressing the esophagus Complete Complete vascular ring :double aortic vascular ring :double aortic

arch, R. aortic arch with retroesophageal arch, R. aortic arch with retroesophageal L. subclavian artery and L. L. subclavian artery and L. ligamentum arteriosum,R. aortic arch with ligamentum arteriosum,R. aortic arch with mirror-imaging branching and L. mirror-imaging branching and L. ligamentum arteriosumligamentum arteriosum

IncompleteIncomplete:retroesophageal R.aberrent :retroesophageal R.aberrent subclavian artery and L.pul arterysubclavian artery and L.pul artery


Cardiovascular…Cardiovascular…

Severe atherosclerosisSevere atherosclerosis in elderly in elderly Large aneurysmLarge aneurysm of the thorasic aorta of the thorasic aorta Enlargement of the Enlargement of the left atriumleft atrium


Radiation injuryRadiation injury Acute :esophagitisAcute :esophagitis Chronic:>2 months after Chronic:>2 months after

radiotherapy (ulceration or radiotherapy (ulceration or strictures)strictures)

LocationLocation Motility disorderMotility disorder


AchalasiaAchalasia

EtiologyEtiology SymptomsSymptoms Manometric abnormalitiesManometric abnormalities Secondary achalasiaSecondary achalasia

High-resolution esophageal pressure High-resolution esophageal pressure topography ,conventional topography ,conventional

manometry : normal swallowmanometry : normal swallow

Classic achalasiaClassic achalasia

Achalasia with compressionAchalasia with compression

Spastic achalasiaSpastic achalasia

Secondry achalasiaSecondry achalasia


Spastic motility disordersSpastic motility disorders DES,nutcracker esophagus,hypertensive DES,nutcracker esophagus,hypertensive

LES ,non specific spastic esophageal LES ,non specific spastic esophageal motility disordersmotility disorders

PathophysiologyPathophysiology SymptomsSymptoms diagnosisdiagnosis

Variants of esophageal spasm: spastic Variants of esophageal spasm: spastic nutcracker (nutcracker (leftleft) and diffuse ) and diffuse

esophageal spasm (esophageal spasm (right)right)


Connective tissue disordersConnective tissue disorders SclerodermaScleroderma:esophageal :esophageal

involvement in up to 90% of patientsinvolvement in up to 90% of patients sjogren”ssjogren”s syndrom:dysphagia up to syndrom:dysphagia up to

74%74%

sclrodermasclroderma


Functional dysphagiaFunctional dysphagia Is a diagnosis of exclusionIs a diagnosis of exclusion Complete diagnostic evaluation is Complete diagnostic evaluation is

needed.needed. No structural abnormality or motility No structural abnormality or motility

disturbance,no reflux.disturbance,no reflux. At least 12 weeks in the preceding 12 At least 12 weeks in the preceding 12

months of a sense of having solid and/or months of a sense of having solid and/or liquid food sticking,lodging,or passing liquid food sticking,lodging,or passing abnormally through the esophagus.abnormally through the esophagus.

Dysphagia,Dysphagia,esophagealesophageal

Specific testingSpecific testing Should be based upon the medical Should be based upon the medical

historyhistory Early referral for EGDEarly referral for EGD Barium swallow in proximal Barium swallow in proximal

esophageal lesionesophageal lesion Esophageal motility studyEsophageal motility study

Acute dysphagiaAcute dysphagia

Require immediate evaluation and Require immediate evaluation and interventionintervention

Annual incidence:13/100,000Annual incidence:13/100,000 M/F:1.7/1-increase with age.M/F:1.7/1-increase with age. Commonly have an underlying Commonly have an underlying

component of mechanical obstractioncomponent of mechanical obstraction Food impaction is the most common Food impaction is the most common

cause in adults.cause in adults.

Dysphagia,Dysphagia,oropharyngealoropharyngealphysiology of swallowingphysiology of swallowing

Normal swallowingNormal swallowing consist of 3 phases consist of 3 phases ((oral preparatory , pharyngeal , oral preparatory , pharyngeal , esophageal)esophageal)

Up to 600 times/dayUp to 600 times/day Once begin , it takes less than Once begin , it takes less than 1 second1 second

for a bolus to reach the esophagus,and an for a bolus to reach the esophagus,and an additional additional 10-15 seconds10-15 seconds to complete the to complete the swallowswallow

Involve more than Involve more than 30 muscles30 muscles

Sagittal and diagrammatic views of the Sagittal and diagrammatic views of the musculaturemusculature (involved in enacting (involved in enacting

oropharyngeal swallowing)oropharyngeal swallowing)


Oral preparatory phaseOral preparatory phase The bolus is processed by mastication to The bolus is processed by mastication to

an appropriate size,shape and consistencyan appropriate size,shape and consistency The tongue is a critical part for controlling The tongue is a critical part for controlling

the food so that proper chewing can occur the food so that proper chewing can occur and for directing the bolus to its proper and for directing the bolus to its proper position for swallowing.position for swallowing.

Voluntary control/cranial nerve V,VII,XII.Voluntary control/cranial nerve V,VII,XII.


Pharyngeal phasePharyngeal phase The bolus is advanced through the The bolus is advanced through the

pharynx and into the esophagus by pharynx and into the esophagus by pharyngeal peristalsispharyngeal peristalsis

Is controlled reflexivelyIs controlled reflexively Cranial nerve V,X,XI,XIICranial nerve V,X,XI,XII Respiration is inhibited centrally.Respiration is inhibited centrally.


Esophageal phaseEsophageal phase

In this phase , peristaltic In this phase , peristaltic contractions in the body of the contractions in the body of the esophagus combined with esophagus combined with simultaneous relaxation of the LES simultaneous relaxation of the LES propel the bolus into the stomachpropel the bolus into the stomach

Dysphagia,Dysphagia,oropharyngealoropharyngealpathogenesispathogenesis

Disturbance in oral preparatory or Disturbance in oral preparatory or pharyngeal phase pharyngeal phase

Arise from diseases of the upper Arise from diseases of the upper esophagus , pharynx ,UES esophagus , pharynx ,UES dysfunctiondysfunction


Disorders of the oral preparatory phaseDisorders of the oral preparatory phase

Poor dentitionPoor dentition Decrease in salivary flowDecrease in salivary flow Neurologic disorders such as stroke, Neurologic disorders such as stroke,

parkinson”s dis(weakness of muscles, parkinson”s dis(weakness of muscles, decrease in coordination)decrease in coordination)

Disruption of the oropharyngeal mucosaDisruption of the oropharyngeal mucosa


Disorders of the pharyngeal phaseDisorders of the pharyngeal phase a normal phase requires neuromuscular a normal phase requires neuromuscular

coordination for propulsion of the bolus, coordination for propulsion of the bolus, an unobstructed lumen , and normal an unobstructed lumen , and normal relaxation of the UES.relaxation of the UES.

Neuromuscular discoordination(CNS Neuromuscular discoordination(CNS disorders eg:stroke,motor neuron dis eg: disorders eg:stroke,motor neuron dis eg: ALS,peripheral neuron dis eg:myasteniaALS,peripheral neuron dis eg:myastenia


Continue..Continue.. Obstructions within the oropharynxObstructions within the oropharynx: :

malignancies (the most common), malignancies (the most common), cervical rings or webs, cervical cervical rings or webs, cervical osteophytesosteophytes

Poor compliance of the UESPoor compliance of the UES (parkinson”s dis)(parkinson”s dis)

Dysphagia,Dysphagia,oropharyngealoropharyngealhistoryhistory

Specific clues in the history can help Specific clues in the history can help establish the cause of the dysphagiaestablish the cause of the dysphagia

Older patients,particularly those with a Older patients,particularly those with a history of alcohol abuse,smoking or history of alcohol abuse,smoking or weight loss: malignant cause must be R/Oweight loss: malignant cause must be R/O

Repositioning during the Repositioning during the swallowing:difficulte in transfer of bolusswallowing:difficulte in transfer of bolus

History of dry mouth or eyeHistory of dry mouth or eye

Dysphagia,Dysphagia,oropharyngealoropharyngealhistory and physical examhistory and physical exam

Continue…Continue… Changes in speech(neuromuscular Changes in speech(neuromuscular

dysfunction,vocal cord paralysis,…)dysfunction,vocal cord paralysis,…) Food regurgitation,halitosis,a sensation Food regurgitation,halitosis,a sensation

of fullness in the neck,or a history of of fullness in the neck,or a history of pneumonia :Zenker”s diverticulumpneumonia :Zenker”s diverticulum

Pain upon swallowing: Pain upon swallowing: inflammation,infection,malignancyinflammation,infection,malignancy

Dysphagia,Dysphagia,oropharyngealoropharyngealclinical manifestationsclinical manifestations

Pointing toward the cervical regionPointing toward the cervical region Symptoms occur almost immediately after Symptoms occur almost immediately after

swallowingswallowing Feelig of an obstruction in the neck, Feelig of an obstruction in the neck,

coughing,chocking,drooling and coughing,chocking,drooling and regurgitationregurgitation

Differentiation with globus Differentiation with globus sensation,dysphagia related to distal sensation,dysphagia related to distal esophageal dis,such as peptic stricture.esophageal dis,such as peptic stricture.

Dysphagia,Dysphagia,oropharyngealoropharyngeal

physical examinationphysical examination

Oral cavity,head and Oral cavity,head and neck,supraclavicular region must be neck,supraclavicular region must be examed carefullyexamed carefully

Neurologic examination should include Neurologic examination should include testing of all cranial nerves,especially testing of all cranial nerves,especially those involved in swallowing (sensory those involved in swallowing (sensory components of V, IX, X, and motor components of V, IX, X, and motor components of V, VII, X, XI, XII).components of V, VII, X, XI, XII).


diagnostic testingdiagnostic testing

Barium radiographyBarium radiography VideofluroscopyVideofluroscopy Upper endoscopyUpper endoscopy Fiberoptic nasopharyngeal laryngoscopyFiberoptic nasopharyngeal laryngoscopy Esophageal manometryEsophageal manometry

The choice of specific testing depends upon The choice of specific testing depends upon the clinical presentation and available the clinical presentation and available expertise.expertise.


therapytherapy

The goals of treatment are to improve The goals of treatment are to improve food transfer and to prevent aspiration.food transfer and to prevent aspiration.

The approach chosen depends in part The approach chosen depends in part upon the cause of dysphagiaupon the cause of dysphagia

Neoplasms : resection , chemotherapy Neoplasms : resection , chemotherapy or radiation therapyor radiation therapy


therapytherapy

Following stroke , head or neck trauma, Following stroke , head or neck trauma, surgery , or in degenerative neurologic surgery , or in degenerative neurologic diseases: rehabilitation is recommendeddiseases: rehabilitation is recommended

Therapeutic endoscopy for esophageal Therapeutic endoscopy for esophageal webs or strictures webs or strictures

Surgical myotomySurgical myotomy Botulinium toxin injection (alternative to Botulinium toxin injection (alternative to

cricopharyngeal myotomy)cricopharyngeal myotomy)

Approach to the patient with Approach to the patient with Dysphagia Dysphagia Dr Ehsani Dr Ehsani...

Documents

Transcript of Approach to the patient with Approach to the patient with Dysphagia Dysphagia Dr Ehsani Dr Ehsani...