Dysphagia

seminar presented on dysphagia by our unit on 4/2/2016 @ pmch

1. DYSPHAGIA Dr (PROF.) A B SINGH UNIT Department of general surgery Patna medical college & Hospital

2. CONTENTs Definition Swallowing mechanism Clinical presentation Grading of dysphagia Etiology Investigations Management

3. DYSPHAGIA The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). Eating becomes unenjoyful . It refers to the sensation of food being obstructed in the food passage anywhere from the mouth to the stomach. The basic impairment behind dysphagia are 1)neurological 2)mechanical / obstructive

4. SWALLOW MECHANISM The act of swallowing requires the passage for food and drink from the mouth into the stomach. From mouth to hypopharynx covers 1/3 rd of passage (distance) while 2/3 rd is covered by the esophagus . The swallowing center in brain stem is located in the floor of fourth ventricle and adjacent regions of medulla . From here it is connected to cerebral cortex, vomiting and respiratory centre. All these areas works in coordinated manner to provides voluntary as well the involuantary control of swallowing. An adult swallow approximately 580 times daily and the act goes on unconsciously . Swallowing phase Oro-Pharyngeal phase( voluntary phase) Esophageal phase( involuntary phase )

5. OROPHYRANGEAL PHASE

6. ELEVATION OF TOUNGE POSTERIOR MOVEMENT OF TOUNGE ELEVATION OF SOFT PALATE ELEVATION OF HYOID ELEVATION OF LARYNX TILTING OF EPIGLOTTIS

7. Esophageal Phase Food bolus is propelled through the esophagus by an involuntary wave of contraction mediated by the enteric nervous system. Pressure gradient speeds the movement of food from the hypopharynx into the esophagus when the cricopharyngeus muscle relaxes. The primary peristaltic contraction which is initiated by a swallowing , moves down the esophagus at the rate of 2 to 4 cm/s and reaches the distal esophagus about 9 seconds . This duration varies from 8 to 20 seconds

8. Clinical presentation Pain and difficulty in swallowing. Sensation of food being stuck into throat or chest. Coughing or gagging while swallowing. Nasal regurgitation Dysarthria Nasal speech because of associated muscle weaknesses Frequent burning sensation in chest. Having food or stomach acid back up into the throat. Unexpectedly losing weight.

9. FUNCTIONAL GRADES OF DYSPHAGIA There are 6 grades of dysphagia GRADE 1 : Complains of dysphagia but still eating normally GRADE 2 : Requires liquid with Meals GRADE 3 : able to take semisolid ,but unable to take any solids GRADE 4 : able to swallow liquids only GRADE 5 : unable to swallow liquid, but able to swallow saliva GRADE 6 : unable to swallow saliva also

10. Etiology Dyspahgia has been classified broadly into two types on the basis of site. Oropharyngeal Esophageal

11. Abnormalities Causing Oropharyngeal Dysphagia Inability to initiate the act of swallowing. Etiology (1) Neuromuscular Diseases Central nervous system (CNS) Cerebral vascular accident involving the brain stem. Parkinson disease Wilson disease Multiple sclerosis Brain stem tumor Peripheral nervous system poliomyelitis Peripheral neuropathies ( e.g. diphtheria, tetanus rabies, diabetes mellitus) Motor end plate Myasthenia gravis

12. CONTINUED ........................ Muscle Oculopharyngeal muscular dystrophy Primary myositis Metabolic myopathy (e.g., glycogen storage disease, lipid storage disease) (2) mechanical or obstructive Lesions 1) Inflammatory Pharyngitis Abscess ( peri-tonsillar , paraphryngeal / retrophryngeal ) Tuberculosis Syphilis 2) Neoplastic 3 ) Plummer-Vinson syndrome 4 )Extrinsic compression Thyromegaly ( hashimoto’s thyroiditis ) cervical osteophytes Lymphadenopathy

13. CONTINUED......................... 5 ) Disorders of the Upper Esophageal Sphincter (UES) It is related to the abnormal UES relaxation or opening Incomplete relaxation cricopharyngeal achalasia oculopharyngeal muscular dystrophy Inadequate opening cricopharyngeal bar Zenker diverticulum Delayed relaxation familial dysautonomia

14. Esophageal Dysphagia Patients usually complains of feeling of food getting stuck several seconds after swalloing and will point towards the suprasternal notch or behind the sternum . ETIOLOGY 1) Neuromuscular (Motility) Disorders Most common Achalasia Diffuse esophageal spasm Other motility abnormalities Nutcracker esophagus Hypertensive lower esophageal sphincter motility disorders secondary to Scleroderma collagen disorders Chagas disease

15. CONTINUED ........ (2) Mechanical or obstructive Esophagitis: dysphagia is due to mucuosal edema or benign stricture Gastroesophageal reflux disease (GERD) Infectious esophagitis HIV , H. pylori, Herpes, Candidiasis Medication-induced esophagitis NSAIDs , quinidine , potassium, vitamins (B. complex), Iron sulphate Radiation treatment Caustic injury ii ) Disorders of wall Esophageal stricture Zenker diverticulum Epiphrenic diverticula

16. CONTINUED............ (iii) Disease causing external compression Hiatus hernia ( mainly paraesophageal hernia ) Cervical osteophytes Mediastinal growth Vascular ring ( dysphagis lusoria ) (iv)Luminal obstruction: Foreign bodies Esophageal webs Schatzki rings Carcinoma esophagus

17. Associated symptoms and possible etiologies Condition Diagnosis to consider Difficulty in initiating swallow Oropharyngeal dysphagia Food sticks after swallow in chest Esophageal dysphagia Progressive dysphagia Neuro muscular dysphagia, carcinoma Sudden dysphagia Foreign body , esophagitis Intermittent dysphagia Rings and webs, Diffuse esophageal spasm, Nutcracker esophagus Cough: Early in swallow Late in swallow Neuromuscular dysphagia Obstructive dysphagia Weight loss: In elder patient With regurgitation Carcinoma Achalasia Pain after swallowing Esophagitis Dysphagia related to: solid foods only Solid and liquid both Obstructive dysphagia Neuromuscular dysphagia Regurgitation of old food and halitosis Zenkers diverticulum Dysphagia relieved with repeated swallow Achalasia

18. Evaluation of dysphagia History Clinical examination Blood investigations Hb % , TC ,DC ,serum iron Radiology – plain x-ray , barium meal , CECT thorax / Neck Upper GI endoscopy laryngoscopy Manometery 24 hr pH monitoring Endoscopic ultrasound Histopathology

19. Radiology Plain x-ray neck & chest – for foreign bodies DENTURES PIN

20. Barium swallow Mid esophageal diverticulam Epiphrenic diverticulam Zenkers diverticulam

21. Barium Swallow Bird beak sign – Achalasia Sigmoid esophagus Achalasis Nut Cracker Esophagus

22. Barium Swallow Stricture – caustic injury Sliding Hernia Irregular filling defect – carcinoma Esophagus

23. Cine-radiography Dynamic assessment Radiographic visualisation of food bolus movement from oral cavity to hypophyrnx

24. Endoscopy Rigid Flexible Diagnostic visual biopsy Therapeutic foreign bodies removal Stentings Dilations

25. Barret’s Esophagitis Schzkati ring Esophagitis Esophagial diverticulam

26. Corrosive stricture Carcinoma Esophagus Foreign body – bone Paraesophageal hernia retro flexion view

27. Manometery Indications - Achalasia cardia - diffuse esophageal spasm - Nutcracker esophagus - hypertensive esophageal sphincter Types Stationary Manometery High Resolution manometery

28. Manometery Normal peristalsis Achalasia Nutcracker esophagus Diffuse esophageal spasm

29. 24-Hour Ambulatory pH Monitoring The most direct method of measuring increased REFLUX (esophageal exposure to gastric juice ) is by an indwelling pH electrode , or more recently via a radio-telemetric pH monitoring capsule that can be clipped to the esophageal mucosa.

30. Endoscopic ultrasound tumor confined to the esophageal wall an advanced esophageal carcinoma penetrating through all layers Used for dysphagia due to carcinoma esophagus for T , N staging Biopsy can also be taken

31. HISTOLOGY Barret’s esophagitis Squamous cell carcinoma Adenocarcinoma

32. TREATMENT Life style modification Drug therapy Therapeutic endoscopy Dilation Stentings Chemo-radiation Surgery

33. LIFE STYLE MODIFICATION These include avoidance of precipitating foods(fatty foods, alcohol, caffeine) Oral hygine avoidance of re c umbency postprandially elevation of the head of the bed smoking cessation weight reduction.

34. Inflammatory lesion Antibiotics Antifungal Incision & Drainage – for abscess Neuromuscular dysphagia Maintenance of oral hygine Chew well Semisolid /liquid diet Eat small meals more frequently Thermal tactile stimulation For grade 4-6 dysphagia – cricomyotomy

35. Drug therapy for esophageal dysphagia H2 Blocker Antacids PPI Metaclopromide/ Domperidon Nitrates Calcium channel Blockers sildenafil Botox injection Steroids Vinegar, lemon, orange juice - Alkali ingestion Milk, egg white, Antacid - Acid ingestion Reflux esophagitis Motility disorders Caustic injuries

36. Therapeutic Endoscopy Foreign body / food bolus extraction Graspers Food bolus extracted endoscopically

37. Dilation Upto 40- 60 F ( Hydrostatic / pneumatic ) Indications - Strictures, Schatki rings Achalasia Anastomotic stenosis , Pneumatic Dilator

38. Stents Self expanding metal stents Indication – grade 4 -6 dysphagia in ca esophagus ( not resectable ) Types - covered , uncovered stents Complication - stent blockage , stent migration , erosion Blockage can be removed by coring using laser or cryo ablation Non-covered stents Stent in situ Stent delivery system

39. Chemo-radiation Indications Grade 1-3 dysphagia in case of ca esophagus ( neo adjuvent ) Grade 4-6 dysphagia in case of ca esophagus ( palliative ) Cisplatin+5FU + 60Gy radiation over 8 weeks

40. Surgery Diverticulotomy / diverticulopexy + myotomy - esophagial diverticulum Myotomy – motility disorders neuronal dysphagia Fundoplication – reflux esophagitis Hernia repair ( crural repair) - Hiatus hernia Esophageal resection and reconstruction Malignancy long standing Achalasia caustic injuries

41. Zenker’s diverticulum repair Open Cricomyotomy + diverticulopexy / diverticulectomy Dohlam’s procedure trans oral approach Dohlam’s procedure

42. Motility disorder Long esophageal myotomy Indications Diffuse esophageal spasm Nutcracker esophagus Scleroderma Epiphrenic diverticulum Heller’s myotomy ( modified ) indications Achalasia chagas disease These myotomy are done in conjunction with partial fundoplication – Dor , Toupet , Nissen

43. Reflux esophagitis Fundoplication indications failure of medical treatment structurally defective LES ( lower esophageal spintcher ) stricture Barrets esophagitis in conjunction with myotomy or hiatus hernia repair Types : Nissen’s fundoplication Dor fundoplication Toupet fundoplication Besely fundoplication

44. Esophageal resection Indications Carcinoma esophagus ( with two /three field lymphadenectomy ) long standing achalasia Extensive corosive injury Surgical Approach Open – Trans- hiatal ( Orringer ) Laprotomy + Trans thoracic ( Ivor-lewis ) Three phase (Mc Keown ) Laproscopic Laproscopic Ivor lewis procedure Laproscopic Tran- hiatal VATS (video assited transthoracic surgery) Robotic

45. Ivor - lewis operation Trans- Hiatal approach Mc Keown three phase – post op patient

46. Reconstruction stomach colon jejenuum ( pedicle / free ) Gastroesophageal Anastomosis at Orthotropic site

47. THANK YOU