Approach to dysphagia

1. Approach to dysphagia

2. Definition of Dysphagia The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). It specifically refers to the sensation of food being hindered in its normal passage from the mouth to the stomach.

3. CLASSIFICATION Two distinct syndromes Oropharyngeal dysphagia Esophageal dysphagia Produced by abnormalities affecting the finely tuned neuromuscular mechanism of the striated muscle of the mouth, pharynx, and UES Caused by the variety of disorders affecting the smooth muscle esophagus

4. Oropharyngeal dysphagia • Inability to initiate the act of swallowing. • It is a transfer problem caused by • impaired ability to transfer food from mouth to upper esophagus • impaired oral preparatory phase • Clinical presentation: • food sticking in the throat • difficulty initiating a swallow • nasal regurgitation • coughing during swallowing • They may also complain of • dysarthria • nasal speech because of associated muscle weaknesses • Other Neurological clinical findings

5. Abnormalities Causing Oropharyngeal Dysphagia • Neuromuscular Diseases • Central nervous system (CNS) • Cerebral vascular accident (e.g., brain stem or pseudobulbar palsy) • Parkinson disease • Wilson disease • Multiple sclerosis • Amyotrophic lateral sclerosis • Brain stem tumors • Tabes dorsalis • Miscellaneous congenital and degenerative disorders of CNS

6. Abnormalities Causing Oropharyngeal Dysphagia • Neuromuscular Diseases • Peripheral nervous system • Bulbar poliomyelitis • Peripheral neuropathies (e.g., diphtheria, botulism, rabies, diabetes mellitus) • Motor end plate • Myasthenia gravis • Muscle • Muscular dystrophies • Primary myositis • Metabolic myopathy (e.g., thyrotoxicosis, myxedema, steroid myopathy) • Amyloidosis • SLE

7. Abnormalities Causing Oropharyngeal Dysphagia • Local Structural Lesions • Inflammatory • Pharyngitis • Abscess • Tuberculosis • Syphilis • Neoplastic • Congenital webs • Plummer-Vinson syndrome • Extrinsic compression • Thyromegaly • cervical spine hyperostosis • Lymphadenopathy • Surgical resection of the oropharynx

8. Abnormalities Causing Oropharyngeal Dysphagia • Disorders of the Upper Esophageal Sphincter (UES) • Hypertensive UES (i.e., spasm, possibly in globus, or gastroesophageal reflux • Hypotensive UES (e.g., esophagopharyngeal regurgitation or aspiration) • Abnormal UES relaxation or opening • Incomplete relaxation (e.g., cricopharyngeal achalasia CNS lymphoma, oculopharyngeal muscular dystrophy) • Inadequate opening (e.g., cricopharyngeal bar, Zenker diverticulum) • Delayed relaxation (e.g., familial dysautonomia)

9. Etiology Of Esophageal Dysphagia Neuromuscular (Motility) Disorders • Most common • Achalasia • Scleroderma • Diffuse esophageal spasm • Other associated motility abnormalities • Nutcracker esophagus • Hypertensive lower esophageal sphincter • Vigorous achalasia • Nonspecific esophageal dysmotility • Other secondary motility disorders • Other collagen disorders • Chagas disease

10. Etiology Of Esophageal Dysphagia Mechanical Lesions, Intrinsic • Most common • Peptic stricture • Lower esophageal (Schatzki) ring • Carcinoma • Other • Esophageal webs • Esophageal diverticula • Benign tumors • Foreign bodies

11. Etiology Of Esophageal Dysphagia Mechanical Lesions, Extrinsic • Vascular compression • Mediastinal abnormalities • Cervical osteoarthritis

12. Esophageal Dysphagia • Three important questions are particularly crucial. • What kind of food (i.e., liquid or solid) produces the symptom? • Is the dysphagia intermittent or progressive? • Is there associated heartburn? • Physical examination is usually not revealing in patients with esophageal dysphagia, with the exception of scleroderma.

13. Diagnosis • History • Examination • CBC • CxR • Barium studies • Endoscopy • Computed tomography scanning • Endoscopic ultrasound • Endoscopy • Esophageal Manometry • Esophageal pH studies