Dysphagia

1. Dysphagia Dr.Krisana Thaitong

2. Dysphagia • must be distinguished from globus sensation • Globus is a sensation of a lump in the throat in which food transport is not limited • globus is not related to swallowing and, in fact, may improve with swallowing

3. Dysphagia • Oropharyngeal dysphagia • Esophageal dysphagia

4. Dysphagia

5. Dysphagia ↙ ↘ Oropharyngeal dysphagia Esophageal dysphagia ▼ ▼ Neuromuscular dysfunction • Achalasia • Nonachalasia Motility • Disorders • Strictures • Rings/Webs • GERD • Extraesophageal GERD ▼ • Cerebrovascular accidents • Amyotrophic Lateral • Sclerosis (AML) • Parkinson's disease • Myasthenia gravis • Tardive dyskinesia. • Neoplasia • Esophageal Diverticula • Foreign Bodies • Pill-Induced Injury • Infectious Esophagitis • Caustic Injury

6. Esophageal dysphagia ↙ ↘ Solids only Solids & liquids ▼ ▼ Mechanical obstruction Motility disorder ↙ ↘ ↙ ↘ Intermittent progressive Intermittent progressive ▼ ▼ ▼ ▼ • Rings/Webs • Strictures • Achalasia • Esophageal • spasm • Malignancy • Scleroderma

7. Oropharyngeal dysphagia • abnormality related to the movement of a food bolus from the hypopharynx to the esophagus • arises from disease of the upper esophagus, pharynx, or UES.

8. typically present with difficulty initiating a swallow and immediately experience coughing, choking, gagging, or nasal regurgitation when attempting to swallow

9. most common caused by disruptions in swallowing secondary to neuromuscular dysfunction • this setting, the symptoms may be more severe when swallowing liquids • The history and physical examination should focus on neurologic signs and symptoms

10. Neuromuscular dysfunction • Cerebrovascular accidents • Amyotrophic Lateral Sclerosis (AML) • Parkinson's dis­ease • Myasthenia gravis • Tardive dyskinesia.

11. Rarely, structural abnormalities caused such as ♥ cervical osteophytes ♥ hypopharyngeal diverticulum (Zenker's diverticulum) ♥ tumors ♥ postcricoid webs • typically note difficulty with a solid food bolus leaving the mouth

12. Oropharyngeal swallow is best assessed by videofluoroscopy, also known as the modified barium swallow • Videofluoroscopy not only serves to confirm the presence of oropharyngeal dysfunction • It can also assess the degree of aspiration

13. Esophageal dysphagia • the difficulty in propagating food down the esophagus • arises within the body of the esophagus either due to a mechanical or a motility disturbance.

14. Esophageal Disease States • Achalasia • Nonachalasia Motility Disorders • Strictures • Rings/Webs • Gastroesophageal Reflux Disease • Extraesophageal GERD

15. Neoplasia • Esophageal Diverticula • Foreign Bodies • Pill-Induced Injury • Infectious Esophagitis • Caustic Injury

16. 1. Achalasia

17. Achalasia • a primary esophageal motility of unknown cause • characterized by insufficient LES relaxation and loss of esophageal peristalsis • hereditary, degenerative, autoimmune, and infectious factors as possible causes

18. Pathologic changes occur in the myenteric plexus • consist of a patchy inflammatory infiltrate of T lymphocytes, eosinophils, and mast cells • loss of ganglion cells and myenteric neural fibrosis

19. selective loss of post-ganglionic inhibitory neurons, nitric oxide and vasoactive intestinal polypeptide • The postganglionic cholinergic neurons are spared, leading to unopposed cholinergic stimulation.

20. This produces high basal LES pressures, and the loss of inhibitory input • results in insufficient LES relaxation • Aperistalsis along the esophageal body—a process mediated by nitric oxide.

21. m/c symptoms of achalasia include ♥ dysphagia for solid & liquid ♥ regurgitation ♥ chest pain • Patients with achalasia localize their dysphagia to the cervical or xiphoid areas.

22. Initially, the dysphagia may be for solids only • most patients have dysphagia for solids and liquids at time of presentation • Regurgitation occurs in 75% of achalasia and becomes a greater problem as the esophagus dilates with progression of disease

23. Choking and Coughing may awaken the patient from sleep • Chest pain 40% • Weight loss 60% (minimal loss) • barium esophagram with fluoroscopy is the best initial diagnostic study

24. This test will reveal a loss of primary peristalsis in the distal two thirds of the esophagus • In the upright position, there will be poor emptying • with retained food and saliva producing a heterogeneous air-fluid level at the top of the barium column.

25. Achalasia

26. The esophagus may be dilated (Figure 80-18). esophagus is dilated with a "bird's beak" tapering of the distal esophagus Retained secretions form the heteroge-nous air-fluid level seen at the top of the barium column.

28. chronic disease be massive with sigmoid-like tortuosity sigmoid-like tortuosity with large amount of retained debris. late-stage achalasia

29. smooth tapering of the lower esophagus leading to closed LES, resembling a bird's beak • presence of epiphrenie diverticulum may suggest achalasia

30. Bird’s beak deformity at LES

31. Esophageal manometry can be used to diagnosis • In the body of the esophagus, aperistalsis is always present • all swallows are typically with low contraction amplitudes.

32. Elevated resting LES pressure (>35 mmHg ) Incomplete LES relaxation Absence of peristalsis Manometry

33. Manometry

34. Manometric findings in achalasia The aperistalsis is manifested by isobaric contractions without propagation The LES pressure, which is elevated, shows minimal relaxation with swallowing.

35. Abnormal LES relaxation in all achalasia • 70% - 80% of patients absent/ incomplete LES relaxation with swallows • baseline LES pressure is usually elevated but may be normal in up to 45% of patients

36. Esophagus is dilated with retained fiuid and debris.

37. Nonrelaxation of LES • Asynchronous contraction and Nonperistaltic • Fibrotic and atrophic • Retention and stagnation of chronic food • Retention esophagitis

38. All should upper endoseopy to exclude Pseudoaehalasia arising from a tumor at the GEJ • Pseudoaehalasia may mimic with classic achalasia both clinically and manometrically • suspected in older age with short duration of symptoms and more significant weight loss

39. Therapy • 1.Medical therapy • 2.Pneumatic dilation of the LES • 3.Surgical myotomy • 4.Botulinum toxin injection

40. The two most effective treatments • graded pneumatic dilation and surgical myotomy

41. 1.Medical therapy • Nitrates, calcium channel blockers (nifedipine) • Cause smooth muscle relaxation but with limited success

42. 2.Pneumatic dilation of the LES -good short-term results -2% to 5% risk of perforation - performed endoscopy uses air pressure to dilate and disrupt the circular muscle fibers of the LES

43. Balloon dilators,: three diameters • (3, 3.5, and 4 cm) are positioned over a guidewire • After pneumatic dilation  gastrograffin study by barium swallow to exclude esophageal perforation • relief of symptoms in 50% to 93%

44. Pneumatic dilation of the LES

45. 3.Surgical myotomy -fail repeated pneumatic dilations -an anterior myotomy across the LES (Heller's myotomy) usually associated with an antire-flux procedure -laparoscopy

46. good-to-excellent response rate of 80% to 94% • A potential complication of myotomy is GERD, which occurs in 10% to 20%

47. 4.Botulinum toxin injection -Inhibits release of excitatory acetylcholine from nerve endings (thus causing lower LES pressures) -Good short-term results, but long term efficacy unknow -Effective in about; 85% of patients

48. However, symptoms recur in more than 50% of patients after 6 months • do not improve LES relaxation or improve peristalsis • do not provide complete symptom relief • The clinical response is short acting • efficacy decreases with time.

49. 2.Nonachalasia Motility Disorders

50. Nonachalasia Motility Disorders • Other described primary motility disorders of the esophagus • Defined based on the presence of specific manomctrie criteria