Approach to dysphagia

dysphagia:
difficulty in swallowing

1. Approach to dysphagia
Dr MOHAMMAD RUHUL AMIN
REGISTRAR
GASTROENTEROLOGY
JRRMCH

2. definition
dysphagia:
difficulty in swallowing
odynophagia:
painful swallowing
Globus:
constant sensation of a lump in the throat -
no organic defect.

3. epidemiology
a number of disorders can cause dysphagia-
both benign and malignant,
involve either the oropharynx or the esophagus,
can be associated with multiple systemic
disorders

4. Epidemiology
a very common condition encountered in clinical
practice; affects-
1.6 –15% of the middle-aged and
13 –35% of the elderly populations.
1.Lindgren S, Janzon L. Dysphagia. 1991;6:187-192.
2.Chen CL, Orr WC. Dysphagia. 2005;20:261-265.
3.Achem SR, Devault KR. J Clin Gastroenterol. 2005;39:357-371.

5. Anatomy and physiology
of deglutition
deglutition:
swallowing-food / fluid :mouth -stomach
voluntary & involuntary neuromuscular
contractions
oropharyngeal & oesophageal stages

6. oropharyngeal stage:
tongue/muscles of mastication/saliva-from
anterior oral cavity to oropharynx,
involuntary reflexes-V, VII, XII, cerebellum
soft palate closes nasopharynx, suprahyoid pulls
larynx up-forward, epiglottis closes airway,
striated pharyngeal muscles-pushes to pass
cricopharyngeous-IX, X
Anatomy and physiology
of deglutition

7. oesophageal stage:
proximal oesophagus -skeletal muscles,
involuntary forces down to stomach-
medulla
Anatomy and physiology
of deglutition

8. Pathophysiology of
oro-pharyngeal dysphagia
striated muscles of mouth, pharynx , upper
oesophageal sphincter affected -mostly in the
elderly
-inability to initiate a swallow,
-failure of bolus transfer from the mouth
to the esophagus.
this condition may result from a variety of
neurologic and muscular abnormalities.

9. pathophysiology of oesophageal
dysphagia
difficulty in transporting ingested material down
the esophagus -
-mechanical problem
-disordered peristalsis /motility
this condition can result from either
-intrinsic causes -obstruct luminal flow
-extrinsic causes -wall compression
-motor disorders

10. what should be the approach when
a patient comes with dysphagia ?

11. Q. do solid/liquid/both elicites dysphagia ?
-solids –mechanical : intrinsic/extrinsic
-both liq/solid -very onset : motility disorders
Q. what is the course of dyaphagia -
-acute : food impaction, ulcers
-sudden : CVA
-progressive/long duration : strictures / malignancy
-non -progressive/intermittent : rings
history taking:

12. History taking
Q. what is the duration of the dysphagia?
short progressive history -malignancy
Q. whether can localize the site?
accurately locate -oropharyngeal cause,
oeso -can’t localize,
some can point it at xiphoid.

13. History -evaluation
Q. whether has any additional symptoms ?
heart burn, regurgitation, aspiration, weight loss,
chest / abdominal pain
-chronic heart burn : erosive oesophagitis
/stricture
-cough/wheeze/sleep disruption -
GERD, or achalasia-if also chest pain

14. History taking
Q. whether has any additional symptoms ?
food sticking at throat / inability to chew /
choking -neurologic disease
-pain during swallowing : malignancy/infection/
inflammation from corrosive agents
-weight loss -malignancy/ achalasia

15. History -evaluation
Q. does the patient have any comorbidities?
-scleroderma / SLE –dysphagia
Q. What medication does the patient take?
-chronic immunosuppressives -
infectious oesophagitis (fungal/viral),
dysphagia, as well as odynophagia
-

16. Q. What medication does the patient take?
-centrally acting drugs-tardive dyskinesia
-NSAID’s/ tetracycline/iron/K/vit-c-
oesophagitis/ulcers -
mid or distal oesophagus -strictures even.
History -evaluation

17. Physical examination
general exam-
-eye, buccal cavity /v.cord/soft palate/nasopharynx,
-head -neck region -fo lymp nodes, masses, signs of
prior surgery, radiotherapy, thyroid -mass or
thyrotoxicosis, any tremor
HPF
cranial nerves –
motor & sensory of V,VII,IX,X, & motor of XII,
deep tendon reflexes; cerebellar exam

18. focusd organ specific /symptoms specific exam.
-chest -signs of pneumonia -aspiration -OPD
-abdomen -organomegaly, masses
-joints -collagen vascular disease
Physical examination

19. Laboratory evaluation
good history & detailed exam -correct diagnosis: 80
-85% cases, atypical symptoms/signs -detailed
evaluation
tests will depend on -
OPD or ED; structural or motility disorder
OPD -
-modified Ba -swallow (MBS) -pharyngeal swallow
-endoscopic swallow exam (FEES) -vocal cord or
airway closure
ED -EGD, then motiloity, manometry etc.

20. Lab evaluation
Ba -swallow :
roadmap to endoscopy
if proximal stricture suspected -
caustic ingestion/radiation/ larynx surgery
Endoscopy -initial test, except achalasia/OPD,
gold -standard-anatomic lesion/tissue collection

21. oesophageal manometry
-mechanical problem excluded
-achalasia/motility disorders suspected
high -resolution intra-luminal USG -to identify
oesophageal muscle abnormality
CT
Lab evaluation-others

22. differential diagnosis of dysphagia

23. etiology of OPD
neurologic structural others
CVA
Parkinson’s
MS, polio,
neoplasm,
Alzheimer’s,
pharyngitis,
TB,abscess,
P-V syndrome,
diverticulum,
compression,
corrosives,
radiation
hyperthyroidism,
sarcoidosis,
SLE,
diphtheria,
herpes,
myasthenia,
myositis

24. etiology of esophageal dyspagia
structural
(intrinsic)
structural
(extrinsic)
neuromuscular
disorders
peptic stricture,
neoplasm,
FB impaction,
pill injury,
ring/web/diverti
cula,
mediastinal
mass,
vascular
compression,
achalasia,
diffuse
oesophageal
spasm,
GERD,
scleroderma,

25. Treatment
upon underlying abnormalities
stroke -
-re -training/ physiotherapy
-permanently impaired -feeding gastrostomy,
thyrotoxicosis -specific Rx -3 weeks to improve,
achalasia -pneumatic dilatation /surgery/
botulinium
scleroderma/GERD-aggressive PPI / dilatation

26. web /ring/ benign stricture –dilatation & PPI
diverticulum -surgery
pemphigous -steroids
caustics/ radiation-intralesional steroid &
dilatation
refractory stricture/ malignancy -stent
placement
Treatment

27. treatment
squamous cell ca -surgery
inoperable -radio/chemo/PDT
dysphagia due to external compression -stent
placement

28. Summary
dysphagia –a common symptom, &
now considered as alarm symptom.
needs early evaluation
to differentiate between OPD & ED
ED -most cases EGD to be done for evaluation
treatment depends on underlying
pathophysiology