Dysphagia

1. Dysphagia

2. Definitions Dysphagia: difficulty swallowing Odynophagia: pain with swallowing Globus: feeling of “lump” or tightness in the throat Pyrosis: mid-epigastric burning or pain that radiates from the retrosternum up to the throat

3. Dysphagia: Background • Dysphagia is a common symptoms • Present in 12% of patients admitted to acute care hospital and 50% of those in chronic care facilities • Subdivided into: • Oropharyngeal • Esophageal

4. Oropharyngeal Dysphagia • aka Transfer dysphagia • Patient is unable to initiate swallow • Frequently describe coughing or choking when attempting to eat • Dysphagia that occurs immediately or w/in 1s of swallowing • Recurrent pulmonary infections, hoarseness, pharyngonasal regurgitation, or dysarthria • Neuromuscular >> Mechanical

5. Oropharyngeal Dysphagia

6. Esophageal Dysphagia • Sensation that food is hindered in its passage from mouth to the stomach • Patients complain that food “sticks,” “hangs up,” or “stops” • Occasionally associated with pain • Can be relieved by certain maneuvers including repeated swallowing, raising arms over the head, and Valsalva • Mechanical >> Neuromuscular (Motility)

7. Esophageal Dysphagia

8. Diagnosis • Etiology of dysphagia can be determined with an accuracy of approx. 80% by careful history alone

9. History: questions • Do you have trouble initiating swallowing, cough or choke with swallowing? • Is the dysphagia for solids, liquids, or both? • Diseases that affect the mucosa or cause luminal narrowing usually pose little barrier to the passage of liquids and thus these patients have dysphagia of solids • Diseases that disrupt peristalsis by affecting smooth muscle and its innervation may cause dysphagia to bothsolids and liquids

10. History: questions • Where does the patient perceive that ingested material sticks? • Pts. often perceive that material sticks either at or above the level of the lesion causing obstruction • Study of 139 patients with dysphagia due to stricture showed that the patients perception of the level of obstruction agree with endoscopist localization 74% of the time • Localization above the sternal notch is of little value • If localized below sternal notch than chances are excellent that the disorder involves the distal esophagus

11. History: questions • Is the dysphagia intermittent or progressive? • Benign rings/webs typically produce symptoms in intermittent episodes which can be separated by weeks, months, or years • Strictures/tumors will typically produce progressive symptoms

12. History: questions • Is there a history of chronic heartburn? • A history of chronic heartburn and/or GERD-symptoms supports the possibility possible peptic stricture • Study of 154 patients with benign strictures showed that 75% related a history of significant heartburn

13. History: questions • Has the patient taken medications likely to cause pill esophagitis? • A number of medications have the potential to have caustic effects on the esophagus with subsequent stricture formation • These include: doxycycline, potassium chloride, NSAIDs, quinidine, alendronate

14. History: questions • Is there a history of collagen vascular disease? • Scleroderma, RA and SLE can all cause disordered motility • The esophageal dysmotility is often associated with Raynaud’s phenomenon

15. History: questions • Is the patient immunocompromised? • 30-40% of patients with AIDS develop symptoms of esophageal disease • Primarily infectious with candida, CMV and HSV • Odynophagia is usually the predominant symptom but most will experience dysphagia as well

16. Physical Examination • Infrequently provides specific clues as to the etiology but… • Joint abnls, calcinosis, telangiectasias, rash  CVD • Supraclavicular node  malignancy • Dental erosions  GERD • Conjunctival pallor  web, malignancy

18. Diagnostic Modalities • Barium swallow (Esophagram) • Endoscopy • Esophageal Manometry • Videofluoroscopy

19. Barium Swallow • Safe, cheap initial study • More sensitive in detecting subtle narrowing by rings, strictures • Study of 60 pts with LE rings: BS demonstrated ring in 95% of cases whereas endoscopy only 58% • Fluoroscopy can identify abnormalities in motility (useful in achalasia, DES)

20. Endoscopy • Unless contraindicated, recommended in most cases of dysphagia • More sensitive than any study in identifying mucosal disease • Diagnostic: biopsy, direct visualization • Therapeutic: dilation (Maloney, Savory, balloon) and palliation (stenting, PEG)

21. Endoscopic Therapy

22. Endoscopic Therapy

23. Endoscopic Therapy

24. Manometry Gold standard for motility disorders (achalasia, DES) Videofluoroscopy Used by speech therapy to assess oropharyngeal function Diagnostic Modalities

25. Case • 36 y/o male CPO. Complains of several year h/o food sticking in his chest which resolves after 5-10s and drinking water. Not getting worse. Has h/o mild heartburn treated with OTCs. • PMH: unremarkable • Meds: none • ???

29. Esophageal Rings Two types of distal esophageal rings: • A Rings • A broad (4-5mm) symmetrical band of hypertrophied muscle • Rare • B Rings • Shatzki’s ring • Very common (6-24% of UGIS, 4% of EGD) • Usually seen in association with a hiatal hernia • Thin 2mm membrane

30. Esophageal Rings Symptoms: • Intermittent solid food dysphagia • No weight loss Treatment: • No treatment if asymptomatic • Dilation if symptomatic

31. Case • 71 y/o female has longstanding h/o intermittent solid food dysphagia. • On exam: • Thin, pale • Angular cheilitis, spooning of fingernails • Labs: • Hb 8, MCV 72 ???

35. Esophageal Webs • Developmental anomalies characterized by one or more thin horizontal membranes of stratified squamous epithelium within the upper esophagus • Rarely encircle the lumen (unlike rings) • Plummer-Vinson syndrome: esophageal web, dysphagia, and IDA • Symptoms: solid food dysphagia or asymptomatic • Treatment: fragile membranes therefore respond well to dilation

36. Case • 32 y/o male presents to ER with c/o severe burning chest pain. • Further questioning reveals 6 months of dysphagia for both solids and liquids • Hx of weight loss • Occasionally vomits undigested material • ???

41. Achalasia • Most recognized motor disorder of the esophagus • Term achalasia means “failure to relax” which describes the cardinal feature of the disorder – failure of LES to relax • M=F • Usually seen in 20s-40s • Symptoms: solid and liquid dysphagia, regurgitation, chest pain, weight loss

42. Achalasia Diagnosis: • 1) CXR: air-fluid level, widened mediastinum • 2) Barium Swallow: “bird’s beak”, dilated esophagus • 3) Endoscopy: dilated esophagus, retained food, difficulty passing through the LES • 4) Manometry: • confirms/establishes the diagnosis • Cardinal features: a) aperistalsis, b) failure of LES relaxation, c) hypertensive LES

44. Achalasia - Treatment

45. Case • 85 y/o male presents with progressivesolid food dysphagia. Now notes difficulty with every meal. Denies significant weight loss • PMH: GERD, DM2, HTN, HLP, CHD • Meds: zantac, glyburide, lisinopril, zocor, asa • ???

49. Peptic Stricture • 7-23% of pts w/ untreated GERD • Smooth walled, tapered, circumfrential narrowing of the lower esophagus • Reversible inflammationedema, cellular infiltrate, vascular congestioncollagen depositionirreversible fibrosis

50. Peptic Stricture • Symptoms: • Progressive solid food dysphagia, usually older males with history of GERD, no weight loss • Treatment: • Biopsies to exclude malignancy • Dilation • PPI