Dysphagia

DysphagiaDr. Ali M Ahmad

Consultant Pediatric Surgery; MBBCH, MS, MD, MRCS-ED, EBPS

Associate Pediatric Surgery KAAUH_ PNU

Dysphagia

Difficulty in swallowing

Sensation of food being hindered in its normal passage from the mouth to the stomach

Dysphagia

1. May be underlying Serious disease

2. Its complications: Risk of aspiration pneumonia Malnutrition, dehydration, weight loss Others

Can be a serious health Problems

Applied Anatomy

Anatomy of the esophagus

25 cm Soft muscular tube From the lower border of the cricoid (C6) Descends posterior mediastinum {Front of

the spine} Passes through Diaphragm into the

abdomen Terminates at the cardiac orifice of the

stomach, opposite to T11 vertebra

3 Natural constrictions

Site LevelCricopharynx C 6Aortic arch T 4Oesophageal hiatus T 10

Upper Esophageal sphincters {UES}

True sphincter {striated muscle} Level C5-C6 level Fibers of cricopharyngeus, part of the

inferior constrictor, which encircles the oesophageal entrance

Lower Esophageal sphincters

Physiological sphincter

High-pressure zone located where the

esophagus merges with the stomach

Swallowing phases

Oro-Pharyngeal stage Mastication Salivation Tongue/ soft palate movements Closure of oral/ nasopharynx/ larynx Opening of cricopharynx

Esophageal stage Involuntary propulsion of bolus

Causes of Dysphagia

Oral Causes of dysphagia

Congenital Cleft palate

Inflammatory Stomatitis, ulcer, TMJ arthritis ……….etc.

Trauma Maxilla/ mandible, cheek/ tongue bite, corrosive poisoning

Neurological Palsy: palatal/ lingual/ facial Spasm: trismus/ tetanus

Neoplastic Salivary tumors, carcinoma, jaw tumors ……… etc.


Congenital Cleft palate


Inflammatory Stomatitis, ulcer, TMJ arthritis ……….etc.


Trauma Maxilla/ mandible, cheek/ tongue bite, corrosive


Neurological Palsy: palatal/ lingual/ facial Spasm: trismus/ tetanus


Neoplastic Salivary tumors, carcinoma, jaw tumors ……… etc.

Pharyngeal Causes of dysphagia

Congenital Pharyngeal diverticulum (Zenker’s diverticulum)

Inflammatory Pharyngitis, retro-pharyngeal abscess, acute epiglottitis, etc.

Trauma FB, corrosive poisoning, iatrogenic trauma, road traffic accidents

Neurological Cricopharyngeal spasm, VC palsy (aspiration), tetanus, etc.

Neoplastic Benign: salivary tumors, papilloma, etc., Malignant: tongue/ hypopharynx/ larynx, salivary tumors, etc.



Pulsion diverticulum Originates in the midline of the

posterior wall of the hypopharynx at an anatomic weak point known

as Killian's dehiscence Above cricopharyngeus at fiber

divergence with inferior pharyngeal constrictor

During swallowing increased

intraluminal pressure forces

mucosa to herniate through the wall




Inflammatory Pharyngitis, retro-pharyngeal abscess, acute epiglottitis, etc.


Trauma Corrosive poisoning, iatrogenic trauma, road traffic accidents


Neurological Cricopharyngeus spasm, VC palsy (aspiration), tetanus, etc.


Neoplastic Benign: salivary tumors, papilloma, etc., Malignant: tongue/ hypopharynx/ larynx, salivary tumors, etc.

Esophageal Causes of dysphagia

Congenital Congenital esophageal stenosis, Vascular Ring {Double Aortic Arch}

Inflammatory GERD esophagitis, strictures

Trauma FB, Corrosive esophageal stricture

Neurological Achalasia, Scleroderma, Diffuse esophageal spasm

Neoplastic Benign: Leiomyoma Malignant: Esophageal cancer


Congenital Congenital esophageal stenosis, Double Aortic Arch


Congenital Congenital esophageal stenosis, Vascular Ring {Double Aortic Arch}


Inflammatory GERD esophagitis, strictures

Common cause of esophagitis Common in adults over age 40 Common symptoms is

heartburn Esophageal stricture is

common complication



Coins is most common in children Meat bolus is most common in adults Foreign bodies in adults may be due to an

underlying stricture that should be ruled out after foreign body removal

Endoscopic Removal



Esophageal Causes of dysphagiaNeurological

Achalasia Scleroderma Diffuse

esophageal spasm

Failure of relaxation of LES

Degeneration of myenteric plexus

Long standing dysphagia and regurgitation

Barium swallow: dilated esophagus with a smooth tapering stricture at its lower end

Esophageal Causes of dysphagiaNeurological


esophageal spasm

Generalized disorder of connective tissue affecting skin and many other organs.

Dysmotility of gut Normal peristalsis in the proximal

striated esophagusAbsent peristalsis in the distal

smooth muscle portion


Neurological


esophageal spasm

Dysphagia, Intermittent abdominal pain & constipation Fingers swollen , stiff and tips become ulcerated. Trismus, Raynaud phenomenon, Polyarthritis…… etc.

Barium swallow shows dilated esophagus and loss of peristalsis in distal esophagus, patulous LES.

Skin biopsy confirms diagnosis

Treatment: Proton pump inhibitors & Metoclopramide


Neurological


esophageal spasm

Primarily involvement of lower 1/3 High pressure nonperistaltic contractions Severe chest pain / dysphagia Treatment:

Calcium channel blockers Balloon dilatation Botox Heller myotomy


Neoplastic Benign: Leiomyoma Malignant: Esophageal cancer

Ten fold rise in the last 20 y

This increase is not squamous cell carcinoma but in the incidence of adenocarcinoma

Related to damaging effects of GERD

Approach to Diagnosis

History Exam

Investigations

Children: Foreign body or congenital malformation

Middle aged: Reflux oesophagitis, achalasia

Elderly: Malignancy, pharyngeal pouch, motility & neurological disorders.

AgeHistory

History

Sudden onset: suggests a foreign body Rapid onset: over a period of weeks as In carcinoma Gradual onset: over years as in achalasia and benign strictures

Onset

Motility disorders: dysphagia for liquids and solids Structural disorders: dysphagia for solids only

once a solid bolus becomes impacted,

the patient will report dysphagia for liquids and solids

Solids or liquidsHistory

At the beginning of swallowing: oro-pharyngeal Retrosternal bolus hold-up: esophageal

SiteHistory

Progressive: Neoplastic causes (benign or malignant) Intermittent: Motility disorders

ProgressionHistory

Coughing or choking with swallowing

Difficulty initiating swallowing Food sticking in the throat

Symptoms Mostly to oral- pharyngealHistory

Sialorrhea Recurrent pneumonia Change in voice or speech Nasal regurgitation

Patient's conscious level & mental status Vital signs Examination of cranial nerves V and VII-XII Assessment of voice Examination of neck and chest including assessment

LN Swelling Gurgling or crepitus in Zenker’s diverticulum.

Examination

Direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility, palatal and laryngeal elevation

Inspection the oral cavity and pharynx Examination of gag reflex by stroking the pharyngeal mucosa with a

tongue depressor Direct observation of the act of swallowing

Watch the patient while drinks a water Assess the patient's eating of various food textures

Examination

Skin should be examined for features of connective tissue disorders, particularly scleroderma

Signs of malnutrition, weight loss and pulmonary complications from aspiration should be looked for

Examination

Investigations

Infectious or inflammatory conditions Nutritional status Fluid-electrolyte imbalance Thyroid function - in detecting dysphagia associated with

hypothyroidism or hyperthyroidism

Laboratory

FB

X-rayRadiological

Aspiration Pneumonia Retrophary widening

Barium SwallowRadiological

http://www.ajronline.org/content/vol183/issue2/images/large/08_03_0330_01.jpeg

Endoscopy

1. Direct laryngoscopy

2. Flexible nasopharyngoscopy

3. Bronchoscopy

4. Oesophago –gastro -dudenoscopy {OGD} is the first-line investigation for almost all upper GI symptoms

Endoscopy Diagnostic:

Give direct Visualizations Permits biopsy Endoscopic Ultrasound {EUS}

Therapeutic: Dilatation of strictures Insertion of stents Thermal ablation of tumors Removal of foreign bodies Control of bleeding

Endoscopy

EUS is mostly used for staging for oesophagogastric cancer.

Used to allow fine needle biopsy of suspicious lymph nodes.

Endoscopy

Special Tests

Definitive study for evaluation of the swallowing mechanism

Uses different barium consistencies and simulated foods

Assess pharyngeal anatomy and motility and may evaluates all phases of swallowing

Modified Barium Swallow (MBS)

Esophageal Manometry

For Motility Disorders

Inadequate relaxation of the LES – Achalasia

Uncoordinated contractions – Diffuse

Esophageal Spasm (DES)

Hypocontraction – Ineffective motility

Esophageal pH Monitoring

Diagnosing GERD A nasogastric probe is inserted into the

patient's esophagus to record ph. levels These levels are compared with the patient's

record of symptoms over 24 hours to determine whether acid reflux contributes to his/her symptoms

Management

Evaluation of the severity of dysphagia Avoid dysphagia related complications

Nutritional intake Maximize airway protection

Diagnosis of underling cause Treatment: Medical, conservative , surgically or palliative

Goals of Management {Dysphagia}

Conservative

Dietary modification Training in swallowing

techniques and maneuvers

Management

Entearal feeding

NGT OGT Gastrostomy Jujonostomy

Up to 40- 60 F Hydrostatic or pneumatic Indications –

Strictures Achalasia Anastomotic stenosis

Esophageal dilatation

Diverticulotomy: diverticulum Myotomy: motility disorders Fundoplication: GERD Esophageal resection &

Reconstruction: Malignancy caustic injuries

Surgery

Self expanding metal stents Sever dysphagia in non resectable

cancer esophagus Complication - stent blockage & stent

erosion

Palliative Stent

DysphagiaDr. Ali M Ahmad

Consultant Pediatric Surgery; MBBCH, MS, MD, MRCS-ED, EBPS

Associate Pediatric Surgery KAAUH_ PNU

Thank You

Date post:	15-Apr-2017
Category:	Health & Medicine
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Dysphagia

Health & Medicine