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Isfahan university of medical sciences Dysphagia Dr. Hamid Kalantari Isfahan university of medical sciences

Esophagus یک لوله عضلانی دارای سه منطقه: The upper esophageal sphincter (UES) The esophageal body The lower esophageal sphincter (LES)

Physiology of swallowing Voluntary: Oral phase Involuntary: pharyngeal and esophageal phase (deglutition Reflex) Primary peristaltism Secondary peristaltism Tertiary contractions

Dysphagia Sensation of sticking or obstruction of the passage of food through the mouth , pharynx or esophagus.

Dysphagia should be distinguished from: Aphagia Odynophagia Globus pharyngeous Phagophobia hysteria rabies tetanus pharyngeal paralysis

Pathophysiology of Dysphagia Size of the ingested bolus The luminal diameter The force of peristaltic contraction Deglutive inhibition: normal relaxation of upper and lower esophageal phincters during swallowing

Classification of Dysphagia Mechanical Motor

Mechanical Dysphagia Luminal Intrinsic narrowing A-large bolus B- Foreign body Intrinsic narrowing Esophagitis Web, rings Benign stricture Malignant tumor Benign tumor

Extrinsic Compression Cervical Spondylitis Vertebral Osteophytes Retropharyngeal abscess and Masses Thyromegaly Zenker`s diverticulum Vascular Compression Posterior mediastinal masses Pancreatic tumor, Pancreatitis Postvagotomy hematoma and Fibrosis

Motor Dysphagia Pharyngeal paralysis Cricopharyngeal Achalasia Scleroderma of the esophagus Diffuse esophageal spasm

Approach to the patient with dysphagia History : 80% Barium swallow Endoscopy Manometry PH metry

Oropharyngeal dysphagia Esophageal dysphagia Algorithm for the differential diagnosis of dysphagia Dysphagia Difficulty initiating swallows (includes coughing. choking. and nasal regurgitation) Food stops or “sticks” after swallowed Oropharyngeal dysphagia Esophageal dysphagia

Algorithm for the differential diagnosis of dysphagia Esophageal dysphagia Solid food only Solid and liquid food Mechanical obstruction Neuromuscular disorder (Motor) Intermittent Progressive Intermittent Progressive Bread/steak Chronic heartburn No weight loss Age > 50 Weight loss Chest pain Chronic heartburn Blandregurgitation Weight loss Achalasia Carcinoma Scleroderma Lower esophageal ring Peptic Stricture Diffuse esophageal spasm

Esophageal motor Disorders Achalasia Scleroderma Diffuse Esophageal Spasm symptoms Dysphagia Gastroesophageal reglux disease Substernal chest pain (anginalike) Regurgitation of nonacidic material Dysphagia with pain Aperistaltic esophagus Simultaneous noncoordi- nated contractions X- ray appearance Dilated, fluid- filled esophagus Distal “bird beak”stricture Free reflux Peptic stricture Manometric findings lower esophageal sphincter High resting pressure Incomplete or abnormal re- laxation with swallow Low resting pressure Normal pressure body Low- amplitude, simultaneous contractions after swallow Low- amplitude peristaltic contractions or no peristasis Some peristalsis Diffuse and simultaneous nonperistaltic contractions, occasionally high amplitude