DYSPHAGIA Aswad H. Al.Obeidy FICMS, FICMS GE&Hep Kirkuk General Hospital

DYSPHAGIA Dysphagia, from Greek phagia (to eat) and dys (difficulty, disordered). Most patients complain that food “sticks,” “hangs up,” or “stops. Occasionally they complain of associated pain. Dysphagia indicates malfunction of some type in the esophagus. associated psychiatric disorders can amplify this symptom. Dysphagia is a common symptom that is present in 12% of patients admitted to an acute care hospital. more than 50% of those in a chronic care facility.

PATHOPHYSIOLOGY Caused either by a problem with the strength or coordination of the muscles. By a fixed obstruction somewhere between the mouth and the stomach. Occasional patients may have a combination of the two processes. The oropharyngeal swallowing mechanism and the primary and secondary peristaltic contractions of the esophageal body that follow usually transport solid and liquid boluses from the mouth to the stomach within 10 seconds. Minimally obstructing lesions cause dysphagia only with large, poorly chewed boluses of such foods as meat and dry bread, lesions that obstruct the esophageal lumen completely lead to symptoms with both solids and liquids. GERD may produce dysphagia related to an esophageal stricture. Abnormal sensory perception within the esophagus may lead to dysphagia. Amplification of symptoms in patients with spastic motility disorders

Oropharyngeal Dysphagia Processes that affect the mouth, hypopharynx, and upper esophagus. Unable to initiate a swallow and repeatedly has to attempt to swallow. Frequently describe coughing or “choking. The inability to propel a food bolus successfully from hypopharyngeal area through the upper esophageal sphincter (UES) into the esophageal body is called oropharyngeal, or transfer, dysphagia. Dysphagia that occurs immediately or within 1 second of swallowing. Some patients describe recurrent bolus impactions. Saliva cannot be swallowed, and the patient drools. Abnormalities of speech such as dysarthria or nasal speech. Recurrent bouts of pulmonary infection. Hoarseness may result from recurrent laryngeal nerve dysfunction or intrinsic muscular disease. Swallowing associated with a gurgling noise may be described by patients with Zenker's diverticulum. Unexplained weight loss may be the only clue to a swallowing disorder

Common Causes of Oropharyngeal Dysphagia Neuromuscular Causes Stroke Parkinson's disease Multiple sclerosis Myasthenia gravis Amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) Idiopathic UES dysfunction CNS tumors (benign or malignant) Post-polio syndrome Muscular dystrophy Poly- or dermatomyositis Thyroid dysfunction Manometric dysfunction of the UES or pharynx

Common Causes of Oropharyngeal Dysphagia Structural Causes Carcinomas Osteophytes and other spinal disorders Zenker's diverticulum Proximal esophageal webs Prior surgery or radiation therapy Infection of pharynx or neck Thyromegaly

Oropharyngeal Dysphagia:Approach After an adequate history is obtained the initial test is a carefully prepared barium examination performed with the assistance of a swallowing therapist (and is also known as a modified barium swallow). If the examination is normal with liquid barium the examination is repeated after the patient is fed a solid bolus in an attempt to bring out the patient's symptoms and thereby aid in localizing any pathology If the oropharyngeal portion of the study is normal, the remainder of the esophagus should be examined

Esophageal Dysphagia Most patients localize their symptoms to the lower sternum/ can be relieved by various maneuvers, including repeated swallowing, raising the arms over the head, throwing the shoulders back, and using the Valsalva maneuver. To clarify the origin of symptoms of esophageal dysphagia, the answers to three questions are crucial: (1) What type of food or liquid causes symptoms? (2) Is the dysphagia intermittent or progressive? (3) Does the patient have heartburn?

Common Causes of Esophageal Dysphagia Motility (Neuromuscular) Disorders Primary Disorders Achalasia Diffuse esophageal spasm Nutcracker (high-pressure) esophagus Hypertensive LES Ineffective esophageal motility Secondary Disorders Scleroderma and other rheumatologic disorders Reflux-related dysmotility Chagas' disease

Common Causes of Esophageal Dysphagia Structural (Mechanical) Disorders Intrinsic Peptic stricture Lower esophageal (Schatzki) ring Other esophageal rings and webs Diverticula Carcinoma and benign tumors Medication-induced strictures Foreign bodies Extrinsic Vascular compression Mediastinal masses Spinal osteophytes

Esophageal Dysphagia Dysphagia with both solids and liquids are more likely to have an esophageal motility. Achalasia is the prototypical, in addition to dysphagia, many patients complain of bland regurgitation of undigested food, especially at night, and of weight loss Spastic motility disorders such as diffuse esophageal spasm may complain of chest pain and sensitivity to either hot or cold liquids. Scleroderma of the esophagus usually have Raynaud's phenomenon and severe heartburn. In patients who report dysphagia only after swallowing solid foods and never with liquids alone, a mechanical obstruction is suspected Episodic and nonprogressive dysphagia without weight loss is characteristic of an esophageal web or a distal esophageal (Schatzki) ring. The first episode typically occurs during a hurried meal, The offending food frequently is a piece of bread or steak, hence the description “steakhouse syndrome. Progressive, the differential diagnosis includes peptic esophageal stricture and carcinoma True dysphagia may be seen in patients with pill, caustic, or viral esophagitis

Esophageal Dysphagia: Approach After a focused history of the patient's symptoms is obtained A barium radiograph, including a solid bolus challenge Many experts have advocated endoscopy as the first test Especially in patients with intermittent dysphagia for solid food suggestive of a lower esophageal ring or with pronounced reflux symptoms. If the barium examination demonstrates an obstructive lesion, endoscopy is usually done for confirmation and biopsy. Endoscopy also permits dilation of strictures, rings, and neoplasms If the barium examination is normal, an esophageal manometry test is often performed Some patients with reflux and dysphagia and a normal barium study or endoscopy, or both, will respond to a trial of gastric acid– suppressive therapy.