DYSPHAGIA.pptx

Dyspahgia by Harrison Mbohe

1. dysphagia

2. introduction Difficulty with swallowing. Classification: Pharyngeal dysphagia – patient develops cough or splutter while swallowing as food enters the airway or stays in the mouth. Esophageal dysphagia - specified by “food getting stuck” in the pathway. Can be progressive or intermittent. Can affect swallowing of solids and/or fluids. Can also be acute—due to foreign body impaction or acute infection or chronic due to causes like stricture or carcinoma.

3. Common causes GERD Ca esophagus – dysphagia is of short duration and progressive. 2/3 of the lumen should be blocked by tumour to develop dysphagia. Foreign body impaction – causes acute dysphagia. Common in children and may be life threatening. Carcinoma of pharynx or posterior 1/3rd of the tongue. Corrosive strictures – usually alkali stricture as the squamous mucosa is resistant to acid effect to certain extent. Oesophageal candidial infection – common due to immunosuppressed patients. Presents with dysphagia and odynophagia. Plummer-Vinson syndrome - Dysphagia occurs due to the presence of a postcricoid web that is associated with IDA. Mediastinal swellings—primary tumours/nodal mass either lymphoma or secondaries or tuberculosis.

4. RARE CAUSES Diffuse oesophageal spasm – incoordinated contractions of oesophagus causing chest pain or dysphagia. It is common in distal 2/3rd of the oesophagus. Congenital anomalies – esophageal atresia (most common). Hiatal hernias – sliding hiatal hernias (most common). Achalasia – caused by loss of ganglion cells within the esophageal myenteric plexus. Esophageal diverticula – the most common being epiphrenic, hypopharyngeal (Zenker’s), and mid-esophageal. A lower esophageal mucosal ring, also called a B ring , is a thin membranous narrowing at the squamocolumnar mucosal junction. Web-like constrictions higher in the esophagus can be of congenital or inflammatory origin.

5. Boerhaave’s syndrome: It is vertical full thickness tear of lower oesophagus due to vomiting with closed glottis. It is often life threatening and emergency. Neurological causes like stroke, bulbar palsy, motor neuron disease, Parkinson’s disease, etc. Drug-induced dysphagia: Drugs like KCl, quinine, NSAID can cause dysphagia. Thyroid swelling – There will be always dyspnea when dysphagia develops.

6. Clinical co-relates Esophageal strictures typically cause progressive dysphagia, first for solids, then for liquids. Motility disorders often cause intermittent dysphagia for both solids and liquids. Schatzki’s/B ring causes episodic dysphagia for solids, typically at the beginning of a meal. Oropharyngeal motor disorders typically present with difficulty initiating deglutition ( transfer dysphagia ) and nasal reflux or coughing with swallowing; and achalasia may cause nocturnal regurgitation of undigested food.

7. investigations Dysphagia should always be investigated urgently. Endoscopy (Esophagoscopy) is the investigation of choice because it allows biopsy and dilatation of strictures. Even if the appearances are normal, biopsies should be taken to look for eosinophilic esophagitis. Barium swallow with videofluoroscopic swallowing assessment is indicated to detect major motility disorders. They may show irregular filling defect or extrinsic compression. Esophageal manometry It is the gold standard for the assessment of oesophageal motor activity. It is not a primary investigation and should be performed only when the diagnosis has not been achieved by history, barium radiology or endoscopy.

8. pH monitoring – 24-hour ambulatory monitoring uses a pH-sensitive probe positioned in the lower oesophagus and is used to identify acid reflux episodes (pH < 4) in situations of GERD. Endosonography can assess site, layers of the oesophagus, nodes, spread, etc. properly. Different layers are seen as alternating hyperechoic and hypoechoic bands. Chest X-ray often shows mediastinal mass lesion/foreign body. CT scan chest is very useful method to identify the anatomical location of the cause (nodes/tumour/aorta/cardiac cause/congenital). Extent, spread, nodal status, size and operability of an extra-luminal tumour also well-assessed.

9. TREATMENT Dependent on the cause. In GERD surgery is indicated in failure of drug treatment, sliding hernia, Barrett’s ulcer, severe pain and presence of complications like bleeding/stricture/shortening, respiratory problems. Fundoplication is the only effective long-term beneficial therapy ideally available and considered now. Hernias are surgically repaired by excision of sac and repair of the defect. DES is treated nitrates, calcium channel blockers, bougie dilatation, long oesophageal myotomy either video assisted or thoracotomy approach. Achalasia cardia is surgically treated with Modified Heller’s cardiomyotomy with Toupet’s / Dor’s fundoplication. Symptomatic rings and webs are easily treated by dilatation.

10. Treatment of diverticular is by surgical diverticulectomy and cricopharyngeal myotomy or a marsupialization procedure in which an endoscopic stapling device is used to divide the cricopharyngeus. If it does not spontaneously resolve, impacted food is dislodged endoscopically. Healing of more severe grades of caustic injury is commonly associated with severe stricture formation and often requires repeated dilatation.

11. THANK YOU