Dysphagia Approach to the patient with Dr Ehsani Gastroenterologist/internist

Dysphagia Definition: sensation of sticking or obstruction of the passage of food through the mouth ,pharynx,or esophagus. Aphagia Odynophagia Phagophobia Feeling of fullness in the epigastrium

Dysphagia Dysphagia is a subjective sensation that suggests the presence of an organic abnormality in the passage of liquids or solids from the oral cavity to the stomach. Dysphagia is considered to be an alarm symptom,indicating the need for an immediate evaluation to define the exact cause and initiate appropriate therapy.

Dysphagia Dysphagia in elderly subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities,which are rarely symptomatic.

Dysphagia The normal transport of an ingested bolus through the swallowing passage depends on the size of the ingested bolus,the luminal diameter of the swallowing passage , the force of peristaltic contraction,the deglutitive inhibition,including normal relaxation of UES,LES during swallowing

Dysphagia Classification Mechanical (large bolus,luminal narrowing) Motor (weakness of peristaltic contractions ,impaired deglutitive inhibition causing nonperistaltic contractions , impaired sphincter relaxation)

Dysphagia classification Oropharyngeal dysphagia Esophageal dysphagia Functional dysphagia

Dysphagia Medical history the cornestone of evaluation Distinguish from odynophagia & globus sensation Determine the types of food that produce symptoms Progressive or intermitent symptoms Others symptoms or findings

Approach to the patient with dysphagia

Dysphagia,esophageal Differential diagnosis Peptic stricture in 10% of patients with GERD ,in older age, male gender,longer duration of reflux symptoms. In scleroderma,Z-E syndrom,NG tube, Heller myotomy. Infectious esophagitis,post surgical,caustic injury,pill induced esophagitis,radiation exposure.

Dysphagia,esophageal Differential diagnosis Esophageal rings and webs Thin,fragile structures that partially or completely compromise the esophageal lumen. Web:thin mucosal fold,covered with squamous epithelium,in anterior cervical esophagus, causing focal narrowing in the postcricoid area.

Dysphagia,esophageal Differential diagnosis Esophageal rings and webs Rings:Schatzki ,mucosal structures at the GE junction , smooth,thin,(<4mm).covered with squamous mucosa above and columnar epithelium below. Pathogenesis,mucosal,muscular,GERD Changing the caliber during peristaltism.

Dysphagia,esophageal Differential diagnosis Esophageal rings and webs Diagnosis:Barim swallow,EGD Symptoms:acute(steak house syndrome) ,intermittent,with chest discomfort Plummer-vinson or paterson-kelly syndrom

Dysphagia,esophageal Differential diagnosis Carcinoma Esophagus,gastric cardia History,others symptoms,age Histologic type Risk factors incidence

Dysphagia,esophageal Differential diagnosis Cardiovascular abnormalities Compressing the esophagus Complete vascular ring :double aortic arch, R. aortic arch with retroesophageal L. subclavian artery and L. ligamentum arteriosum,R. aortic arch with mirror-imaging branching and L. ligamentum arteriosum Incomplete:retroesophageal R.aberrent subclavian artery and L.pul artery

Dysphagia,esophageal Differential diagnosis Cardiovascular… Severe atherosclerosis in elderly Large aneurysm of the thorasic aorta Enlargement of the left atrium

Dysphagia,esophageal Differential diagnosis Radiation injury Acute :esophagitis Chronic:>2 months after radiotherapy (ulceration or strictures) Location Motility disorder

Dysphagia,esophageal Differential diagnosis Achalasia Etiology Symptoms Manometric abnormalities Secondary achalasia

High-resolution esophageal pressure topography ,conventional manometry : normal swallow

Classic achalasia

Achalasia with compression

Spastic achalasia

Secondry achalasia

Dysphagia,esophageal Differential diagnosis Spastic motility disorders DES,nutcracker esophagus,hypertensive LES ,non specific spastic esophageal motility disorders Pathophysiology Symptoms diagnosis

Variants of esophageal spasm: spastic nutcracker (left) and diffuse esophageal spasm (right)

Dysphagia,esophageal Differential diagnosis Connective tissue disorders Scleroderma:esophageal involvement in up to 90% of patients sjogren”s syndrom:dysphagia up to 74%

sclroderma

Dysphagia,esophageal Differential diagnosis Functional dysphagia Is a diagnosis of exclusion Complete diagnostic evaluation is needed. No structural abnormality or motility disturbance,no reflux. At least 12 weeks in the preceding 12 months of a sense of having solid and/or liquid food sticking,lodging,or passing abnormally through the esophagus.

Dysphagia,esophageal Specific testing Should be based upon the medical history Early referral for EGD Barium swallow in proximal esophageal lesion Esophageal motility study

Acute dysphagia Require immediate evaluation and intervention Annual incidence:13/100,000 M/F:1.7/1-increase with age. Commonly have an underlying component of mechanical obstraction Food impaction is the most common cause in adults.

Dysphagia,oropharyngeal physiology of swallowing Normal swallowing consist of 3 phases (oral preparatory , pharyngeal , esophageal) Up to 600 times/day Once begin , it takes less than 1 second for a bolus to reach the esophagus,and an additional 10-15 seconds to complete the swallow Involve more than 30 muscles

Sagittal and diagrammatic views of the musculature (involved in enacting oropharyngeal swallowing)

Dysphagia,oropharyngeal physiology of swallowing Oral preparatory phase The bolus is processed by mastication to an appropriate size,shape and consistency The tongue is a critical part for controlling the food so that proper chewing can occur and for directing the bolus to its proper position for swallowing. Voluntary control/cranial nerve V,VII,XII.

Dysphagia,oropharyngeal physiology of swallowing Pharyngeal phase The bolus is advanced through the pharynx and into the esophagus by pharyngeal peristalsis Is controlled reflexively Cranial nerve V,X,XI,XII Respiration is inhibited centrally.

Dysphagia,oropharyngeal physiology of swallowing Esophageal phase In this phase , peristaltic contractions in the body of the esophagus combined with simultaneous relaxation of the LES propel the bolus into the stomach

Dysphagia,oropharyngeal pathogenesis Disturbance in oral preparatory or pharyngeal phase Arise from diseases of the upper esophagus , pharynx ,UES dysfunction

Dysphagia,oropharyngeal pathogenesis Disorders of the oral preparatory phase Poor dentition Decrease in salivary flow Neurologic disorders such as stroke, parkinson”s dis(weakness of muscles, decrease in coordination) Disruption of the oropharyngeal mucosa

Dysphagia,oropharyngeal pathogenesis Disorders of the pharyngeal phase a normal phase requires neuromuscular coordination for propulsion of the bolus, an unobstructed lumen , and normal relaxation of the UES. Neuromuscular discoordination(CNS disorders eg:stroke,motor neuron dis eg: ALS,peripheral neuron dis eg:myastenia

Dysphagia,oropharyngeal pathogenesis Continue.. Obstructions within the oropharynx: malignancies (the most common), cervical rings or webs, cervical osteophytes Poor compliance of the UES (parkinson”s dis)

Dysphagia,oropharyngeal history Specific clues in the history can help establish the cause of the dysphagia Older patients,particularly those with a history of alcohol abuse,smoking or weight loss: malignant cause must be R/O Repositioning during the swallowing:difficulte in transfer of bolus History of dry mouth or eye

Dysphagia,oropharyngeal history and physical exam Continue… Changes in speech(neuromuscular dysfunction,vocal cord paralysis,…) Food regurgitation,halitosis,a sensation of fullness in the neck,or a history of pneumonia :Zenker”s diverticulum Pain upon swallowing: inflammation,infection,malignancy

Dysphagia,oropharyngeal clinical manifestations Pointing toward the cervical region Symptoms occur almost immediately after swallowing Feelig of an obstruction in the neck, coughing,chocking,drooling and regurgitation Differentiation with globus sensation,dysphagia related to distal esophageal dis,such as peptic stricture.

Dysphagia,oropharyngeal physical examination Oral cavity,head and neck,supraclavicular region must be examed carefully Neurologic examination should include testing of all cranial nerves,especially those involved in swallowing (sensory components of V, IX, X, and motor components of V, VII, X, XI, XII).

Dysphagia,oropharyngeal diagnostic testing Barium radiography Videofluroscopy Upper endoscopy Fiberoptic nasopharyngeal laryngoscopy Esophageal manometry The choice of specific testing depends upon the clinical presentation and available expertise.

Dysphagia,oropharyngeal therapy The goals of treatment are to improve food transfer and to prevent aspiration. The approach chosen depends in part upon the cause of dysphagia Neoplasms : resection , chemotherapy or radiation therapy

Dysphagia,oropharyngeal therapy Following stroke , head or neck trauma, surgery , or in degenerative neurologic diseases: rehabilitation is recommended Therapeutic endoscopy for esophageal webs or strictures Surgical myotomy Botulinium toxin injection (alternative to cricopharyngeal myotomy)