Transcript Dysphagia

Dysphagia
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
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:
1. Oropharyngeal
2. Esophageal
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
Oropharyngeal Dysphagia
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)
Esophageal Dysphagia
Diagnosis
 Etiology of dysphagia can be determined
with an accuracy of approx. 80% by
careful history alone
History: questions
1.
2.
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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 both solids and liquids
History: questions
3.
Where does the patient perceive that ingested
material sticks?
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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
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History: questions
4. Is the dysphagia intermittent or
progressive?
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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
History: questions
5. Is there a history of chronic heartburn?
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A history of chronic heartburn and/or GERDsymptoms supports the possibility possible
peptic stricture
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Study of 154 patients with benign strictures
showed that 75% related a history of significant
heartburn
History: questions
6. Has the patient taken medications likely to
cause pill esophagitis?
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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
History: questions
7. Is there a history of collagen vascular
disease?
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Scleroderma, RA and SLE can all cause
disordered motility
The esophageal dysmotility is often associated
with Raynaud’s phenomenon
History: questions
8. Is the patient immunocompromised?
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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
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

Diagnostic Modalities
1.
Barium swallow (Esophagram)
2.
Endoscopy
3.
Esophageal Manometry
4.
Videofluoroscopy
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)
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)
Endoscopic Therapy
Endoscopic Therapy
Endoscopic Therapy
Diagnostic Modalities
Manometry
 Gold standard for
motility disorders
(achalasia, DES)
Videofluoroscopy
 Used by speech
therapy to assess
oropharyngeal
function
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
???
Esophageal Rings
Two types of distal esophageal rings:
1. A Rings
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A broad (4-5mm) symmetrical band of hypertrophied
muscle
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Rare
2. B Rings
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Shatzki’s ring
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Very common (6-24% of UGIS, 4% of EGD)
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Usually seen in association with a hiatal hernia
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Thin 2mm membrane
Esophageal Rings
Symptoms:
 Intermittent solid food dysphagia
 No weight loss
Treatment:
 No treatment if asymptomatic
 Dilation if symptomatic
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
???
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
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
 ???
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
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
Achalasia - Treatment
Case
 85 y/o male presents with progressive solid
food dysphagia. Now notes difficulty with
every meal. Denies significant weight loss
 PMH: GERD, DM2, HTN, HLP, CHD
 Meds: zantac, glyburide, lisinopril, zocor,
asa
???
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
Peptic Stricture
 Symptoms:
 Progressive
solid food dysphagia, usually
older males with history of GERD, no
weight loss
 Treatment:
 Biopsies to exclude malignancy
 Dilation
 PPI
GERD Associated Dysphagia
 11,945 patients with endoscopically proven
erosive esophagitis and no evidence of
obstruction.
 4,449 (37%) had dysphagia at baseline
 43% of patients with severe esophagitis (Grade
C or D)
 35% of patients with mild esophagitis (Grade A
or B)
GERD Associated Dysphagia
 Resolution of dysphagia in 83% of patients after 4
weeks of various PPIs
 Esomeprazole
20 or 40 mg daily
 Omeprazole 20 mg daily
 Lansoprazole 30 mg daily
 Repeat endoscopy showed healed esophagitis in
90% of those with resolution of dysphagia
 In 17% without dysphagia resolution, esophagitis
healing only 72% (p<0.0001)
 Dysphagia common in uncomplicated GERD
Case
 65 y/o male with a h/o H&N cancer s/p
radical neck dissection and XRT in 2002
 Reports progressive solid food dysphagia
over last year and 20# wt. loss over that
time period
 ???
Radiation Stricture
 More than 60% of patients who receive full
dose XRT to the esophagus may develop
stenosis/stricture
 Develops 3-8 months after completion of
radiotherapy
 Symptoms: progressive solid, +/- liquid
dysphagia
 Treatment: sequential dilation then
maintenance dilation
Case
 67 y/o AA male has c/o solid food
dysphagia that has been progressive over
the last 6 months. Daily symptoms.
Subjectively has lost weight.
 PMH: GERD, HTN
 SocHx: daily alcohol (2-4 beers), >50 pack
years smoking
Barium Swallow
Esophageal Cancer
 Characterized by progressive solid food
dysphagia
 Most patients are:
 > 60 years old
 have symptoms for < 1yr
 have significant weight loss (>10kg)
 May have anemia
Esophageal Cancer
Two main histologic types:
1) Adenocarcinoma
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Associated with longstanding GERD, Barrett’s
esophagus
2) Squamous Cell Carcinoma “STAPLES”
Smoking
Tylosis
Achalasia
Plummer-Vinson
Lye
Ethanol
Sprue
Case
 33 y/o male referred to GI for hematochezia
 On ROS endorses intermittent solid food
dysphagia
 Hx of food impaction at age 14
 PMH: Seasonal Allergies (claritin prn)
???
Eosinophilic Esophagitis
 Increasingly recognized condition
 M>F Childhood to 30’s
 Characterized by eosinophilic infiltration of the
esophagus
 Clinical Presentation:
- Solid food dysphagia
- Refractory GERD
- Many have hx of food impaction
- Many have personal and/or Famhx of atopy
Eosinophilic Esophagitis
 Diagnosis:
No consensus
 Clinical presentation
 Characteristic endoscopic findings
 Biopsy with > 15-20 Eos/hpf
 Treatment:
 Fluticasone (220mcg 2 puffs swallowed bid)
 Consider Allergy consult
 Elimination diet
 Dialation
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Case
 58 y/o female with hx of refractory
dyspepsia/GERD
 Now with progressive dysphagia to solids
and liquids
 PMH: Raynaud’s, arthritis, HTN
 Exam: puffy/indurated hands
???
Scleroderma/CREST
 Esophageal dysfunction (as detected by motility
testing) present in approximately 90% of patients
 Most are asymptomatic
 Dysphagia is multifactorial
 Severe GERD leading to solid food dysphagia
 Altered motility leading to solid and liquid
dysphagia
Dysphagia Lusoria
 Lusorian artery - Right subclavian artery that arises from
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aortic arch distal to the left subclavian and crosses midline
behind esophagus and anterior to vertebral bodies.
Despite prevalence of lusorian artery in 0.7% of general
population, 60-70% are asymptomatic
Commonly presents in 40’s
Endoscopy - Pulsating mass
Better seen on barium study (characteristic diagonal
impression at level of 4th thoracic vertebra)
Treatment: Vascular Sx
Zenker’s diverticulum
 Herniation of mucosa through Killian’s triangle
(proximal to cricopharyngeal muscle)
 Rare: prevalence 0.01-0.11% of general
population
 Typically older patients
 Thought to be due to motor abnormalities of the
esophagus with a high intrabolus pressure during
swallowing and resistance through UES
 Symtoms: usually c/w oropharyngeal dysphagia
 Treatment: surgical (cricopharyngeal myotomy
with diverticulecotomy)
?
References
 Spechler, J. AGA Technical Review on Treatment of Patients with Dysphagia
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caused by benign disorders of the distal esophagus. Gastroenterology
1999;117:233-254.
Lind CD. Dysphagia: evaluation and treatment. Gastroenterology clinics of
North America 2003;32:553-75
Vakil NB, et al. Dysphagia in patients with erosive esophagitis: Prevalence,
severity, and response to proton pump inhibitor treatment. Clinical
Gastroenterology and Hepatology 2004;2:665-668
Devault KR. Symptoms of Esophageal Disease in Sleisenger and Fordtran’s
Gastrointestinal and Liver Disease, Pathopysiology, Diagnosis, Management
8th ed. Vol. 1. Saunders 2006.
Wilcox C. Localization of an obstructing esophageal lesion. Is the patient
accurate? Dig Dis Sci 1995;40:2192-2196
Ott D. Radiographic and endoscopic sensitivity in detecting lower esophageal
mucosal rings. AJR 1986;147:261-265