Dysphagia
Objectives
Knowledge Cognitive skills
1. State the major classification of dysphagia, and 1. Choose the most appropriate investigation to
correlate them to their anatomical relation and the diagnose different causes of dysphagia based on the
physiological abnormality available clinical data
2. Correlate dysphagia classification to anatomical 2. Interpret the results of barium swallow test used in
relations and to the physiological abnormality dysphagia diagnosis
3. Formulate and prioritize a differential diagnosis for
3. Recognize the risk factors of dysphagia
dysphagia
4. Develop an evidence-based management plan for
4. Identify the red flag symptoms in patients with dysphagia taking into consideration the
dysphagia advantages/disadvantages of each treatment modality
and preference.
5. Recognize the role of surgery related to dysphagia 5. Demonstrate the appropriate skills for
management education.
Definition
Dysphagia: any difficulty in swallowing, which can be divided into the following subtypes:
Oropharyngeal dysphagia: difficulty initiating the swallowing process
ependtol
site Esophageal dysphagia: the impaired passage of solid food and liquid through the esophagus towards the stomach
Motility-related dysphagia: dysphagia due to a neurological or muscular defect
Dependtof
etiology Structural dysphagia: dysphagia due to a mechanical or anatomical obstruction
Aphasia: the inability to swallow
Presbyphagia: the characteristic changes and mild decline in swallowing function seen in older adults; typically,
asymptomatic
Odynophagia: a painful sensation triggered by swallowing
tevelopmentof
esophagus
Heartburn: stomach content are forced back up into the esophagus (GERD) congationofesophag
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Anatomy of the esophagus
f
stomach
forgutaneanum
Site: Posterior to mediastinum
liningepemelamimeocusmem from
endoderm
Length:
Start: At the level of cricoid cartilage opposite from C6
Passes at the level of T10 via aortic opening of the diaphragm to join the stomach.
It starts in midline and as it descends, it inclines to the left side.
Blood supply:
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surrounding
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tissue
Neck region: Inferior thyroid artery www my
upperais lowers
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Thorax region: Aortic proper esophageal artery
Abdomen region: Left gastric artery
In the abdomen region it is not covered by peritoneum. skeletal
striated smooth
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anteriortieftside
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o neckanoraxregionsoia CongenitalAnomalies
snioperitoneum
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There Are 3 physiological constrictions (Narrow areas of the esophageal lumen):
At the beginning, behind the cricoid cartilage of the larynx [6 inches from incisor teeth]
At the arch of the aorta and left main bronchus (Carina) which crosses in front of the esophagus [10 inches]
Where it pierces the diaphragm into the stomach [16 inches] Summary
Why is it important to know this? awwww
awhitainernia
Common site for esophageal cancer. on
Common sites of arrest of foriegn body.
Can offer resistance to passage of an esophagoscopy into the stomach.
A slight delay in the passage of food or fluid occurs at these levels.
Strictures can develop from here after drinking caustic fluids.
Esophageal layers: (Mucosa, submucosa, muscularis,Fosconnective
adventitia) there is nofubiemelm
serosa
sits a of
layer
epimensitistological
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peritoneum
Stages of swallowing: Writhe
1. Oral/transfer phase: Voluntary, under cortical control. ulcerorviralinfection
2. Pharyngeal phase: Involuntary (from oropharynx to esophagus less than 1 second), it is the most critical stage
due to the pharynx it transfers fromlarynx
esophagus
air to food channel.
3. Esophageal phase: Involuntary, controlled by waves.
Important note about swallowing:
The resting high pressure of the upper and lower esophageal sphincter helps to prevent the reflux and
regurgitation of digestive material back up to the esophagus.
Etiology
Oropharyngeal dysphagia:
Motility-related dysphagia:
Neurological disorders: Guillain-Barré syndrome, neurodegenerative diseases [Parkinson disease,
acute paralytic
polyneuropathy
operpnerainerve
Alzheimer disease].
Em gesunicenrier weakness
auicionsetsummatricalascending
neuropathy
sensory
Muscular disorders:
Myasthenia gravis, systemic sclerosis, CREST syndrome.
Structural dysphagia:
Mucosal disorders: Zenker diverticulum
Esophageal dysphagia: (Lumen obstruction or motility disorder)
Motility-related dysphagia:
Achalasia
GERD
Esophageal hypermotility disorders [Diffuse Esophageal spasm]
Structural dysphagia:
Intraluminal disorders: impacted foreign objects or food boluses.
Mucosal disorders (intrinsic narrowing):
Esophagitis [Eosinophilic, Candidiasis]
symptom's
awes em
ininmem
Esophageal webs (Plummer-Vinson syndrome), Esophageal rings (Schatzki ring) Hiatal
iestpnegiarwers
hernia
Atsquamocolumnar
Esophageal cancer
agg
Dysphasia
emob Autoimmune conditions (CREST syndrome, Crohn disease,
unction
onlinemeded
whereboseitfeellikeitgetsstuck
Extrinsic compression: Tumor, Hiatal hernia.
aboveslavical Belowclavical
oropharyngeal esophageal
cancer canal
margyoscope endoscope
rooaniania
Boat
motility fooatitemiani
mechanical
ng
r
How to approach AboveorBelowclavicalHistory
site ins
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g
1. Define is it Oropharyngeal or esophageal dysphagia depending on the symptoms the patient is presenting with.
tore2. Distinguish between motility-related dysphagia and structural dysphagia. Food
C
f
liquid
3. If there was no organic cause and they are feeling a lump in their throat think about globus sensation (As a last
answer)
4. Perform a complete physical examination, with particular importance to Neurological evaluation (including
cranial nerve examination)
Observe a swallow
Coughing on swallowing indicates a high aspiration risk
Nasopharyngeal regurgitation is suggestive of oropharyngeal dysphagia
Identify red flags for dysphagia
Absent gag reflex and facial asymmetry indicate cranial nerve palsies (due to stroke)
Ptosis, diplopia, deviation of the tongue should increase the suspicion for Amyotrophic lateral sclerosis
Head and neck examination: for lymphadenopathy, thyromegaly
Type Description of dysphagia Associated findings and conditions
Drooling
Choking
Nasal regurgitation
Oropharyngeal dysphagia Difficulty initiating swallowing. Voice changes (nasal speech, wet voice)
Recurrent pneumonia (aspiration pneumonia)
Malnutrition and/or anorexia
Dificultyspeeking
Neurological symptoms (dysarthria) Dysphagia Dysarthria
Symptoms occur seconds after
Esophageal dysphagia Bolus impaction.
swallowing.
Dysphagia predominantly with Esophageal hypermotility disorders: episodic
Motility-related central chest pain.
liquids (or liquids and solid
dysphagia Esophageal hypomotility disorders
food)
Regurgitation of undigested food (achalasia)
Dysphagia predominantly with Red flags for dysphagia in esophageal cancer
Structural dysphagia solid food (or initially to solids Fever in infectious causes (deep neck infection,
that progressed to liquids) infectious esophagitis)
Red Flags for Dysphagia
Features should raise suspicion for malignancy as the underlying etiology:
> 50 years of age at onset
Clinically significant involuntary weight loss
An unintentional or involuntary weight loss of > 5% of usual body weight over a time period of 6 12
a consecutive months.
xx Symptom progression over a short period of time (< 4 months)
Achalasia can present for months or years.
Y
Evidence of GI bleeding
Recurrent vomiting
History of cancer
Odynophagia
Hoarseness of voice due to recurrent laryngeal nerve invasion or compression
Globus
Halitosis
Diagnostics of esophageal dysphagia dysphagia moditidbariumswanow
Esophagogastrod orogphyaryngeal
uodenoscopy Allows for direct visualization of mucosal lesions and structural abnormalities
(EGD): preferred Biopsies can be taken during the procedure.
initial test for Simultaneous therapeutic intervention (e.g., dilation) or endoscopic ultrasound is
most patients possible accurate
zuitpitmonitoremore
GERD patents
Bravo
p
Esophageal Consider as an initial test in the following cases:
barium swallow o High likelihood of esophageal stricture (e.g., history of esophageal caustic injury,
Gastrograph
surgery, or radiation)
o If EGD is not immediately available
o Suspected achalasia if manometry is not immediately available
Second-line test (adjunct) if initial EGD is normal
High-resolution
esophageal
manometry
g
Gold standard for diagnosing esophageal motility disorders (e.g., achalasia)
swallow I
Suspected esophageal motility disorder in individuals with a normal EGD and barium
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Thoracic imaging if extrinsic esophageal compression is suspected (e.g., due to goiter, thoracic aortic
aneurysm, mediastinal mass)
Achalasia Protasoa
Esophageal motility disorder characterized by inadequate relaxation of the lower esophageal sphincter (LES) and
non-peristaltic contractions in the distal two-thirds of the esophagus due to the degeneration of inhibitory neurons
Norman
Clinical Features nonunion
g
na
Dysphagia
Difficulty in swallowing solids and liquids weight one
con an
loss
Regurgitation which may lead to aspiration
Diagnosis
esophagus and a large, dilated esophagus proximal to the narrowing, delayed barium emptying or barium
retention.
1stUpper GI endoscopy: to rule out secondary causes of achalasia (pseudoachalasia) such as gastric carcinoma,
esophageal cancer or retention esophagitis.
Manometry: best test for achalasia; reveals failure of LES relaxation and aperistalsis of the esophagus
Chest x-ray
Widened mediastinum
AEyia
Air-fluid level on lateral view
Treatment
Medical: Smooth muscle relaxants or botulinum toxin.
Surgical: HM iPOEM
Pneumatic dilation: Balloon to dilate LES endoscopically.
arson
Myotomy orPer
Best Heller OralEndoscopicMyotomy POEM
Extra-Note: )
causes degeneration of myenteric plexus leading to a motor disorder of the esophagus that is indistinguishable from
achalasia (Leads to Secondary Achalasia), taking antiparasitic can hopefully fix the problem.
a
Tiaret
Zenker's diverticulum
An esophageal diverticulum is an abnormal pouch that arises from the wall of the esophagus. The most common
false diverticulum, meaning only the mucosa and submucosa bulge through weak points, unlike true diverticula
where all layers of the esophageal wall protrude
Clinical presentation
Dysphagia and regurgitation of undigested foor
Halitosis (unpleasant odor to the breath, due to retention of food into the diverticulum)
Aspiration or coughing after food intake
Large diverticula present as a palpable lump
Diagnosis
Barium swallow (best confirmatory test): contrast-filled pouch protruding from the hypopharynx at level of
C5/C6
Endoscopy: to rule out malignancy in the pouch and exclude other causes. Risk of divertriculum perforation
Esophageal manometry: usually not required, useful for identifying motor abnormalities
Transcutaneous ultrasound
Treatment: cricopharyngeal myotomy with/without diverticulectomy
Diffuse Esophageal spasm
in
tactics
oaf
Non-Peristaltic spontaneous contraction of the esophageal body, several segments of the esophagus contract
rmal
LES pressure; unlike achalasia).
Clinical Features
meals
During
Non-cardiac chest pain that mimics the angina, it can radiate to the jaw, arms and back.
Dysphagia.
Diagnosis
Esophageal manometry is diagnostic; simultaneous, multiphasic and repetitive contractions that occur after
a swallow but sphincter response is normal.
Upper GI barium swallow; (Corkscrew esophagus).
Esophageal Hiatal Hernia
There are 2 types:
Sliding Hiatal hernia (type 1): Gastroesophageal junction and a portion of the stomach herniate to the thorax.
It is associated with GERD, reflux esophagitis (with a risk of barrett esophagus/cancer) and aspiration.
Paraesophageal hiatal hernia (types 2-4):
Complications are potentially life-threatening including obstruction, hemorrhage, incarceration and
strangulation.
Diagnosis: Barium upper GI and upper endoscopy.
Treatment:
pplmedically, if it was unresponsive or there was evidence of esophagitis it may require surgery
Type 1: Treated
(Nissen Fundoplication).
Type 2-4: Treated with elective surgery.
Esophagitis
inflammation of the esophageal mucosa that is secondary to direct mucosal injury or to inflammatory infiltrates due
to a systemic inflammatory disorder. It has multiple types, the importance of which is:
Substance-induced esophagitis (Lye stricture, also called corrosive esophagitis)
Acid or Alkaline ingestion (e.g., drinking Clorox often as a suicide attempt) causes ulceration and fibrosis of
the esophagus GEndoscopyPunchoutulcer
Eosinophilic esophagitis
Allergicdisease
Patients present with dysphagia associated with atopy, and gets worse by ingestion of food containing
allergens
Diagnosis is done with endoscopy, the esophagus mostly looks normal, diagnosis is confirmed with a biopsy
(high eosinophilia)
Medication (Bisphosphonate, Tetracycline, NSIAD)
Infections (CMV,HIV, Herpes, Candida) longitudinal
Ifwithstricturesurgicalailation
CREST Syndrome
also known as limited cutaneous systemic sclerosis, is an autoimmune rheumatological condition that affects
esophageal motility. The name is an acronym for:
a. Calcinosis cuits: small white calcium deposits at pressure points
b. Raynaud phenomenon: recurrent vasospasm of fingers and toes
c. Esophageal hypomotility: dysphagia, gastroesophageal reflux
d. Sclerodactyly: tightening of the skin over the fingers
e. Telangiectasia: visible dilation of small, superficial, cutaneous blood vessels
Esophageal cancer
It has two pathologic types:
1. Squamous cell carcinoma
2. Adenocarcinoma
Clinical features
Dysphagia - most common symptoms (Initially solids only then it progresses to liquids).
Weight loss - second most common symptoms
Anorexia
Odynophagia (Due to mediastinal invasion).
Hematemesis, hoarseness of voice (recurrent laryngeal nerve involvement)
Aspiration pneumonia and respiratory symptoms (due to involvement of tracheobronchial tree).
Tracheoesophageal or bronchoesophageal fistula
Chest pain.
Diagnosis
Barium swallow to evaluate dysphagia
Upper endoscopy with biopsy for definitive diagnosis (confirmatory)
Transesophageal ultrasound helps to determine the depth of penetration of the tumor (most reliable test for
staging local cancer)
Full metastatic workup (CT scan of the chest/abdomen, CXR, bone scan)
Other Esophageal conditions
Mallory-Weiss syndrome: Mucosal tear at or below the gastroesophageal junction as a result of forceful
vomiting or retching.
o Hematemesis is always present.
o Upper endoscopy is diagnostic.
o Treatment is surgery or angiographic embolization if bleeding continues.
Plummer-Vinson syndrome (upper esophageal webs): a premalignant lesion, causes dysphagia.
o Treatment: Esophageal dilatation.
NOendoscopy toriskofperforation
Due
pSchatzki Ring (Distal esophageal webs): Circumferential ring in the lower part of the esophagus which is always
accompanied by sliding hiatal hernia.
o Can be due to alkali, acids, bleach or detergents (suicide attempts)
o Ingestion of Alkali is more dangerous; it can lead to liquefactive necrosis with full thickness perforation of
the esophagus (Acid ingestion does not cause full-thickness damage).
Esophageal perforation (Boerhaave syndrome):
o Caused by a blunt trauma, medical tubes and instruments or forceful vomiting (if the tear is transmural)
o Clinical features: Pain (severe retrosternal/chest/shoulder pain), tachycardia, hypotension, tachypnea,
dyspnea,ammonia's
fever, Hamman [Link]
sign, pneumothorax or pleural effusion
o Contrast esophagram is definitive diagnostics study (Soluble gastrografin swallow is preferred due to
perforation)
o CXR shows air in mediastinum
