Apporach to Dysphagia And benign esophgeal diseases
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Apporach to Dysphagia
And benign esophgeal diseases
Presented by;
Lina bani hamad
dysphagia - The physiology of swallowing
- Definition
- Epidemology
There are two forms of dysphagia
Oropharyngeal dysphagia (transfer dysphagia):
There's problem in initiating the swallowing occurs in
patients with neurologic conditions or muscular
disorders that affect skeletal muscles.
It will be associated with cough-ing, chocking, nasal
regurgitation
Esophageal dysphagia relates to intrinsic functional (motor) and anatomic abnormalities of the esophagus that result in swallowing difficulties.
May associated with history of food impaction and food sticking of the chest
Oropharyngeal dysphagia
Neurologic
• Stroke
• Parkinson's disease
• Multiple sclerosis
• motor neuron disorders (
progressive bulbar palsy,
pseudobulbar palsy) • Bulbar
poliomyelitis
Muscular
• Myasthenia gravis •
Dermatomyositis
• Muscular dystrophy •
Cricopharyngeal incoordination
Esophageal dysphasia
Motility disorder
• Achalasia
• Diffuse esophageal spasm
• Systemic sclerosis(scleroderma)
• Eosinophilic esophagitis
Mechanical obstruction
Peptic stricture
• Esophageal cancer
• Lower esophageal
rings(Schatzki's ring)
• Caustic ingestion
SIGNIFICANCE AND
COMPLICATIONS points to a serious underlying pathology
Aspiration can cause acute pneumonia
recurrent aspiration may eventually lead to chronic lung
disease.
inadequate nutrition and weight loss.
death
Apporach to the patient
-History age
Onset
Duration
Intermittent or progressive
Solids or liquids
Level of stuck
Odynophagia
Hx pf caustic ingestion ,GERD,PUD
Fever, weight loss,anorexia,fatigue
Immunocomprised pt (DM,steriods) why?
Chest pain ,cough (pneumoina)
Hx of neck mass
Hx of cardiac problems
Drugs (anticholingeric,doxycyclin)
Family hx
PHYSICAL EXAMINATION
General examination(nutritional status ,skin, lymph
nodes, signs of sleroderma
Neck examination
The abdomen is checked for masses, tenderness, and
organomegaly
complete neurologic examination
Muscles are inspected for wasting and fascicula- tions
and are palpated for tenderness (dermatomy-sitis,
myopathy).
Diagnostic Tests
the barium swallow is the ideal first test as it is readily available, cost effective, and rapidly performed.
anatomic relations, esophageal transit patterns, and the presence or absence of mass lesions and diverticula.
. Upper endoscopy allows for a visual assessment of mucosa after caustic ingestion or due to an infectious
etiology
Other tests for specific causes are done as sug-gested
by findings.
When reflux disease is suspected, extended pH monitoring is invaluable in assessing the presence and severity of GERD.
Motility disorders are best diagnosed using manometric techniques.
In cases where extrinsic compression is
suspected or demonstrated, cross-sectional imaging using computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in identification of malignant masses or vascular anomalies (aberrant subclavian vessels, aortic aneurysms
Treatment
Treatment is directed at the specific cause.
emergent upper endoscopy If com-plete obstruction
occurs
careful endoscopic dilation is performed. If a stricture,
ring, or web is found
Patients with severe dysphagia and re-current aspiration
may require a gastrostomy tube.
Esophagus
eso
Anatomy 25 cm long. It has cervical
(5 cm), tho-racic (18 cm)
and abdominal (2 cm)
Blood supply
lymphatic drainge
PHYSIOLOGY
The main function of the esophegus is to transfer food
from the mouth to the stomach in a coordi-nated
fashion and prevents stomach acid and con-tent reflux
upward
USE: antaomical sphincter
LES: fuctional sphincter
Assessment of esophageal function:
Structural
-Radiology
-Endoscopy(rigid, flexible)
Functional
Stationary manometry
24 Hours pH monitoring
GERD:
it is chronic problem that occur when acid from the stomach washes up into the esophagus. it is a common dis-ease that accounts for approximately two thirds of esophageal pathology.
Common symptoms – esophageal crises
heartburn: substernal burning-type discomfort beginning in the epigastrium
and radiating upwards. Aggrevated post prandial, spicy,smoking
Regurgitation: The effortless return of acid or bitter gastric contents into the chest , pharynx or mouth.
Atypical symptoms – respiratory crises
Chest pain and dysphagia
Human antireflux mechanisms:
High pressure zone at GE junction
Specialized thickening
Collar sling and clasp fibres
Receptive relaxation
Association with HH:
Repeated gastric distension
GEJ ( upside down funnel-shaped )
Progressive opening of the angel of His )
Stretching of phrenico esophageal ligament
Enlargement of hiatal opening
Axial herniation
DIAGNOSIS
History
Barium study
a hiatus hernia, the presence of severe ulceration, benign
strictures
Endoscopy
confirm reflux if esophagitis is seen and allow taking
biopsies to detect complications (Barrett’s esophagus
24 Ph monitoring
the gold standard in establishing the diagno-sis of acid
reflux
GERD treatment:
High doses of PPIs
If symptoms return …….Endoscopy
Surgery:anti-reflux surgery - Nis-sen’s
fundoplication
Advice on:
Change of life style(advice against weight loss,
smoking, excessive consump-tion of alcohol, tea or
coffee.)
Dietary measures
25-50% persistent or progressive disease
Anti reflux Surgery:
create a new anti reflux valve at GEJ,while preserving
the patient ability to swallow normally and to belch to
relieve the gaseous distension.
( Nissen fundoplication)
COMPLICATIONS
BARRETT'S ESOPHAGUS Barretts esophagus (BE ):
10-20% of GERD
Defined as the presence of columnar mucosa extending at least 3 cms into the esophagus
Complicated by:
Ulceration
Stricture
Dysplasia-cancer sequence
Respiratory complications
Hiatus Hernias (HH ):
Types:
Sliding: type 1m.c
Para esophageal (PEH) Rolling type 11
Combined type111
Sliding is 7 times more than PEH
PEH are more in elderly women
Manifestations
Usually GERD in type 1
But in PEH ( pressure symptoms )
Significant incidence of catastrophic life-threatening
Complications risk of strangulations )
Diagnosis:
lateral Erect CXR; fluids above diaphragm in PEH
Barium study: determine which the type
Fiberoptic esophagoscopy
Treatment:
Life style changes
Surgery
Scleroderma:
80% of patients have esophageal motility
abnormalities
Result from vascular compromise due to
collagen deposition -Smooth muscle atrophy
In general Motility Disorders:
Manifested by dysphagia
Pain, chokes or vomits with eating,Require liquids
with eating,The last to finish
Diagnosis is by manometry
Zenkers Diverticulum:
Occur in proxmial part of esophagus
Elderly
Dysphagia with spontaneous regurge ( bland )
Repeated Respiratory tract infections Diagnosed by Barium swallow and endoscopy
Treated surgically by diverticulopexy or
diverticulectomy
acc to the size
Motility disorders of the esophagus:
Abnormalities in
Propulsive pump action
Relaxation of LES
Primary, or
Generalised:
Neural, Muscular, Collagen deposit
Four categories:
1. Achalasia
2. diffuse esophgeal spasms
3. Nutcracker esophagus
4. HH , lower esophgeal spasm
Achalasia:
Failure of lES to relax during propulsive foods –stick
foods in esophgus –dilation of proximal esophagus
Esophageal dilatation ( bird peak and air fluid level )
it is common 1 : 100 000
Treatment
involves either balloon dilatation of the
lower oesophageal sphincter
surgical myotomy (Hellers myotomy;
division of the muscles over the lower
esophagus and proximal stomach).
Diverticula of the esophagus
Location : in the body of the esophagus
May present with dysphagia or pressure symptoms
Pathophysiology ;
-Pulsion; increase in pressure in esophagus wall due to any
motilty disorders – push esophagus wall outside-true
divericula (zenker diverticulum)
- traction: normal esohagus wall
- The wall pulled outside by inflamed l.n in hilum of the
lung -TB
Thank you
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