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DYSPHAGIADYSPHAGIA

Drravikumar M.S(ENT)Drravikumar M.S(ENT)



Esophageal AnatomyEsophageal Anatomy

Muscular tube connecting theMuscular tube connecting thepharynx to the stomachpharynx to the stomach

Esophagus begins where theEsophagus begins where theinferior pharyngeal constrictor inferior pharyngeal constrictor merges with the cricopharyngeusmerges with the cricopharyngeus ± ± Upper esophageal sphincter Upper esophageal sphincter

(UES)(UES)

18 to 26 cm in length18 to 26 cm in length

Lower esophageal sphincter (LES)Lower esophageal sphincter (LES) ± ± Thickened circular smooth muscleThickened circular smooth muscle

± ± 40cm from incisors40cm from incisors

Extrinsic indentationsExtrinsic indentations ± ± Anterior body of C7 (worsen by Anterior body of C7 (worsen by

osteophytes)osteophytes)

± ± Arch of the aorta, the left Arch of the aorta, the leftmainstem bronchusmainstem bronchus

± ± Diaphragmatic hiatusDiaphragmatic hiatus



Innervation mainly byInnervation mainly by

Vagus n.Vagus n. Auerbach¶s (myenteric) plexus Auerbach¶s (myenteric) plexus

± ± Between the two muscle layersBetween the two muscle layers

± ± Controls esophageal peristalsisControls esophageal peristalsis

± ± Acetylcholine mediates Acetylcholine mediatescontractioncontraction

± ± Nitric oxide relaxationNitric oxide relaxation

Meissner's plexusMeissner's plexus

± ± Submucosal layer Submucosal layer

± ± Sensory inputSensory input

± ± Pain sensation overlap with thePain sensation overlap with theheart and respiratory systemheart and respiratory system



Esophageal physiologyEsophageal physiology

1.1. swallowswallow (Esophageal Transport by(Esophageal Transport byGravity)Gravity)The oropharyngeal phaseThe oropharyngeal phase : Swallowing begins: Swallowing beginswhen a food bolus is propelled into the pharynxwhen a food bolus is propelled into the pharynxfrom the mouth. It isfrom the mouth. It is voluntaryvoluntary..

The esophageal phaseThe esophageal phase. It is. It is involuntary.involuntary.

It takes approximately 8 to 10 seconds fromIt takes approximately 8 to 10 seconds frominitiation of the swallow to entry into theinitiation of the swallow to entry into the

stomach .stomach . In rapid sequence and with precise coordination,In rapid sequence and with precise coordination,

the larynx is elevated and the epiglottis seals thethe larynx is elevated and the epiglottis seals theairway.airway.



Esophageal physiologyEsophageal physiology

2.Secretion (submucosal mucous2.Secretion (submucosal mucous

glands)glands)

3.Protection : Gastroesophageal3.Protection : Gastroesophageal

reflux (machenic , secretion )reflux (machenic , secretion )



DysphagiaDysphagiaGreekGreek dysdys (difficulty, disordered) and(difficulty, disordered) and phagia phagia (to(toeat)eat)

Sensation that food is hindered in its passageSensation that food is hindered in its passage

from the mouth to the stomachfrom the mouth to the stomach

Most patients complain that foodMost patients complain that food ± ± ³sticks,´ ³hangs up,´ ³stops,´ or ³just won't go down³sticks,´ ³hangs up,´ ³stops,´ or ³just won't go down

right´right´



Anatomically classified into two Anatomically classified into two separate clinical categories:separate clinical categories:

Oropharyngeal and esophageal.Oropharyngeal and esophageal.



HistoryHistory

Three questions are crucialThree questions are crucial::

(1) What type of food or liquid causes symptoms?(1) What type of food or liquid causes symptoms? ± ± Mechanical vs neuromuscular defectMechanical vs neuromuscular defect

± ± Primarily solidsPrimarily solidsStructural lesionStructural lesion-- peptic stricture, ring, or malignancypeptic stricture, ring, or malignancy

± ± Both solid and liquidBoth solid and liquida motility disorder like achalasia or sclerodermaa motility disorder like achalasia or scleroderma

(2) Is the dysphagia intermittent or progressive?(2) Is the dysphagia intermittent or progressive? ± ± Esophageal rings tend to cause intermittent solid food dysphagiaEsophageal rings tend to cause intermittent solid food dysphagia

± ± Strictures and cancer cause progressive dysphagiaStrictures and cancer cause progressive dysphagia

(3) Does the patient have heartburn?(3) Does the patient have heartburn? ± ± Complication of GERDComplication of GERD-- Esophagitis, stricture & Barrett¶sEsophagitis, stricture & Barrett¶s



HistoryHistory

Location of dysphagiaLocation of dysphagia

± ± Limited value (Referred from any site)Limited value (Referred from any site)

Weight lossWeight loss

± ± Significance and duration of the diseaseSignificance and duration of the disease

Dietary changesDietary changes

± ± Nature and severity of disease.Nature and severity of disease.

Dysphagia must be distinguished fromDysphagia must be distinguished fromodynophagiaodynophagia

± ± Associated with an inflammatory condition Associated with an inflammatory condition

(esophagitis)(esophagitis)



Physical ExaminationPhysical ExaminationComplete head and neck examComplete head and neck exam

Look for signs of chronic illness or recent weightLook for signs of chronic illness or recent weightlossloss

³wet´ voice³wet´ voice ± ± failure to clear the HP of retained secretionsfailure to clear the HP of retained secretions

Palpable crepitus or gurgling noises in the neckPalpable crepitus or gurgling noises in the neck ± ± Possible Zenker's diverticulum or other pouchPossible Zenker's diverticulum or other pouch

DroolingDrooling



OropharynxOropharynx

Ulcerative cancer of Ulcerative cancer of

the right tonsilthe right tonsil

The source might beThe source might be

VERY OBVIOUSVERY OBVIOUS

during the H&N examduring the H&N exam



ExamExam

Absence of an upward movement of larynx with Absence of an upward movement of larynx withdeglutitiondeglutition ± ± indicates fixation due to inflammation, tumor, or indicates fixation due to inflammation, tumor, or

paralysisparalysis

Neurologic examNeurologic exam ± ± Evaluate for other deficits or CN palsiesEvaluate for other deficits or CN palsies

Flexible fiberoptic laryngoscopyFlexible fiberoptic laryngoscopy ± ± identify defects in the larynx/pharynx, pooling of identify defects in the larynx/pharynx, pooling of

secretions in the hypopharynx, or mass lesions thatsecretions in the hypopharynx, or mass lesions thatmay produce obstructionmay produce obstruction



TestsTestsflexible telescope



RadiographyRadiography

CXRCXR ± ± foreign bodyforeign body

± ± perforationperforation

± ± mediastinal anatomymediastinal anatomy

CTCT ± ± Only to evaluate mass lesions in the neckOnly to evaluate mass lesions in the neck

MRIMRI ± ± useful when neurologic disorders are suspecteduseful when neurologic disorders are suspected

± ± Delineate mass lesions in the brainDelineate mass lesions in the brain

± ± Evaluate degenerative processes in the brain and spinal cordEvaluate degenerative processes in the brain and spinal cord



FluoroscopyFluoroscopy

Standard barium swallowStandard barium swallow uses thin barium, is auses thin barium, is aquick view, and is not satisfactory for mostquick view, and is not satisfactory for mostswallowing disordersswallowing disorders

MBSMBS is the definitive study for evaluation of theis the definitive study for evaluation of theswallowing mechanismswallowing mechanism

Uses both thick and thin barium consistenciesUses both thick and thin barium consistenciesand simulated foodsand simulated foods

Assess pharyngeal anatomy and motility Assess pharyngeal anatomy and motility



FEESFEES(Fiberoptic endoscopic evaluation)(Fiberoptic endoscopic evaluation)

Directly viewing liquid or food bolus viaDirectly viewing liquid or food bolus viascopescope

Positioned high in oropharynxPositioned high in oropharynx

Observation of Observation of

± ± vocal and arytenoid movementsvocal and arytenoid movements

± ± Elevation of larynx and tongue baseElevation of larynx and tongue base

Pooling and aspiration can be notedPooling and aspiration can be noted



EsophagoscopyEsophagoscopy

FlexibleFlexible (in office)(in office) vs. rigidvs. rigid ± ± Foreign body, biopsy of lesions, evaluation of Foreign body, biopsy of lesions, evaluation of

stenosisstenosis

Esophagus should be biopsied in all patientsEsophagus should be biopsied in all patientssuspected of having esophagitis, asuspected of having esophagitis, aneuromuscular disorder, or a collagen vascular neuromuscular disorder, or a collagen vascular

diseasedisease



TestsTests

EndoscopyEndoscopy (Rigid & flexible telescope(Rigid & flexible telescope--under sedation)under sedation)

Rigid Endoscopy



Special TestsSpecial Tests

pH probepH probe -- monitors over a 24 hour periodmonitors over a 24 hour period

Acid infusion tests Acid infusion tests ± ± infuses a dilute HCL solution into the esophagusinfuses a dilute HCL solution into the esophagus

± ± checks reproducibility of symptomschecks reproducibility of symptoms

ManometryManometry ± ± essential if dysfunction of theessential if dysfunction of thecricopharyngeus, esophagus or LES identifiedcricopharyngeus, esophagus or LES identified

on swallow studyon swallow study ± ± Quality laboratoryQuality laboratory

± ± Interpreted by an experienced gastroenterologistInterpreted by an experienced gastroenterologist



Causes of dysphagiaCauses of dysphagia

OesophagealOesophagealIn the lumenIn the lumen

Foreign bodyForeign bodyLarge bolusLarge bolus

In the wallIn the wall

congentialcongential

TraumaticTraumatic

InflammationInflammation

NeoplasmsNeoplasms

NeurologicalNeurological

MiscellaneousMiscellaneous




Pressure on the oesophagusPressure on the oesophagus

CervicalCervical

ThroracicThroracicabdominalabdominal




ExtraExtra--oesophageal causesoesophageal causes--

Oral cavityOral cavity

PharynxPharynxLarynxLarynx

FunctionalFunctional--Globus hystericusGlobus hystericus



Definition

Primary esophageal motility disorder characterized by:

1) Absence of peristalsis,

2) Elevated pressure of the LES,

3) Failure of the LES to relax during swallowing,

Causing functional obstruction at the gastroesophageal junction.

Achalasia of the cardia Achalasia of the cardia





Achalasia Achalasia

Primary esophageal motilityPrimary esophageal motilitydisorder disorder ± ± Insufficient LES relaxationInsufficient LES relaxation

± ± Loss of esophageal peristalsisLoss of esophageal peristalsis

PrimaryPrimary ± ± idiopathic degeneration of the ganglion cells of idiopathic degeneration of the ganglion cells of

Auerbach¶s plexus Auerbach¶s plexus

SecondarySecondary -- caused by other conditionscaused by other conditions ± ± i.e. Distal esophageal carcinoma, Chagas¶i.e. Distal esophageal carcinoma, Chagas¶

disease, postvagotomy syndrome, CVA, DMdisease, postvagotomy syndrome, CVA, DM



Clinical picture of AchalasiaClinical picture of AchalasiaHistoryHistory

Dysphagia (most common)Dysphagia (most common)RegurgitationRegurgitation

Chest painChest painHeartburnHeartburnWeight lossWeight loss

Physical:Physical:

Physical examination is noncontributory.Physical examination is noncontributory.





Chest xChest x--rayray



Achalasia Diagnosis Achalasia Diagnosis

Best initial diagnosticBest initial diagnosticstudystudy

± ± Barium esophagramBarium esophagram

with fluoroscopywith fluoroscopy

Esophageal dilationEsophageal dilation

Closed LESClosed LES

Loss peristalsisLoss peristalsisBird's beakBird's beak



Normal Barium

Swallow

Birds beak xrayBird¶s Beak



Esophageal manometryEsophageal manometry ± ± Establish the diagnosisEstablish the diagnosis

Absent or incomplete LES Absent or incomplete LESrelaxationrelaxation

Loss peristalsisLoss peristalsis



The goal of therapy for achalasia is to relieveThe goal of therapy for achalasia is to relievesymptoms by eliminating the outflow resistancesymptoms by eliminating the outflow resistancecaused by the hypertensive and nonrelaxing LEScaused by the hypertensive and nonrelaxing LES..

1)1) Medical Management Medical Management 2)2) Surgical Management Surgical Management

How would you manage thisHow would you manage thispatient?patient?



Medical Management Medical Management a)a) Botulinum toxinBotulinum toxin:: intrasphincteric injectionintrasphincteric injection

Only 30% of patient's treated endoscopically stillOnly 30% of patient's treated endoscopically stillhave relief of dysphagia 1 year after treatment.have relief of dysphagia 1 year after treatment.

bb)) Pharmacologic therapyPharmacologic therapy:: relax the smoothrelax the smooth

muscle of the LES.muscle of the LES.Calcium channel blockersCalcium channel blockers -- Nifedipine andNifedipine andverapamilverapamil

Anticholinergic agents Anticholinergic agents -- Cimetropium bromideCimetropium bromide

NitratesNitrates -- Isosorbide dinitrateIsosorbide dinitrate





TreatmentTreatment

Pneumatic dilationPneumatic dilation

± ± Should be a surgical candidatesShould be a surgical candidates

2% to 5% risk of perforation2% to 5% risk of perforation

± ± After dilation need a gastrograffin study After dilation need a gastrograffin study

followed by barium swallow to excludefollowed by barium swallow to exclude

esophageal perforationesophageal perforation

± ± Good to excellent relief of symptoms in 50%Good to excellent relief of symptoms in 50%

to 93% of patientsto 93% of patients







Surgical myotomySurgical myotomy

± ± Myotomy across the LESMyotomy across the LES

± ± Laparoscopy with a response rate of 80% toLaparoscopy with a response rate of 80% to

94%94%

± ± ComplicationComplication-- GERD in 10% to 20%GERD in 10% to 20%





NonNon--achalasia Motility Disordersachalasia Motility Disorders

Diffuse esophageal spasm (DES)Diffuse esophageal spasm (DES) ± ± Simultaneous and repetitive contractions inSimultaneous and repetitive contractions in

the esophageal bodythe esophageal body

± ± Normal LES relaxationNormal LES relaxation ± ± Dysphagia if the contraction amplitudes areDysphagia if the contraction amplitudes are

lowlow

± ± Chest pain if the contraction amplitudes areChest pain if the contraction amplitudes arehighhigh





Diffuse esophageal spasmDiffuse esophageal spasm

DiagnosisDiagnosis ± ± EsophagogramEsophagogram

"corkscrew" esophagus"corkscrew" esophagus

± ± ManometryManometrySimultaneous andSimultaneous andrepetitive contractionsrepetitive contractionsin the esophageal bodyin the esophageal body

TreatmentTreatment ± ± Medications that relaxMedications that relax

the esophagusthe esophagusNitrates and calciumNitrates and calcium--channel blockerschannel blockers



SclerodermaScleroderma

Connective tissue diseaseConnective tissue disease

Peristalsis is absent in thePeristalsis is absent in thedistal twodistal two--thirdsthirds

Mild dilation of the distalMild dilation of the distalesophagusesophagus

LES becomes incompetentLES becomes incompetent

Associated Associated ± ± Aspiration pneumonia Aspiration pneumonia

± ± Reflux esophagitis with Barrett'sReflux esophagitis with Barrett'sesophagusesophagus



Esophageal StricturesEsophageal Strictures

Loss of lumen areaLoss of lumen area ± ± Normal 20 mm inNormal 20 mm in

diameter diameter

Dysphagia mainDysphagia main

symptomsymptom ± ± Less than 15 mmLess than 15 mm

Worse with largeWorse with largefood pieces such asfood pieces such as

meat and breadmeat and bread Acid/peptic stricture Acid/peptic strictureaccounting for theaccounting for themajority of casesmajority of cases(60%(60%± ±70%).70%).



ETIOLOGY OF ESOPHAGEALETIOLOGY OF ESOPHAGEAL

STRICTURESSTRICTURESIntrinsic strictures

Acid peptic

Pill-induced

Chemical/lye

Post-nasogastric tube

Infectious esophagitis

Sclerotherapy

Radiation-induced

Esophageal/gastric malignanciesSurgical anastomotic

Congenital

Systemic inflammatory disease

Epidermolysis bullosa

Extrinsic strictures

Pulmonary/mediastinal malignancies

Anomalous vessels and aneurysms

Metastatic submucosal infiltration (breast

cancer, mesothelioma, adenocarcinoma of gastric cardia)



DiagnosisDiagnosis

EsophagogramEsophagogram

± ± Initial diagnostic studyInitial diagnostic study

± ± Delineate the strictureDelineate the stricture

EndoscopyEndoscopy ± ± Evaluate the mucosaEvaluate the mucosa

Distal stricture Caustic ingestion

normal mucosa Barrett's metaplasia





Esophageal Rings & WebsEsophageal Rings & WebsSymptomsSymptoms ± ± Intermittent solid foodIntermittent solid food dysphagiadysphagia,,

aspiration, and regurgitationaspiration, and regurgitation

RingsRings ± ± CircumferentialCircumferential

± ± Mucosa or muscleMucosa or muscle

± ± Most commonly occur in the distalMost commonly occur in the distalesophagusesophagus

± ± Schatzki's ring occurs at the GEJSchatzki's ring occurs at the GEJ

WebsWebs ± ± Only part of the esophageal lumenOnly part of the esophageal lumen

± ± Always mucosal Always mucosal ± ± Located in the proximal esophagusLocated in the proximal esophagus

± ± Association with iron deficiency Association with iron deficiency(Plummer and Vinson)(Plummer and Vinson)



DiagnosisDiagnosis

Barium EsophagogramBarium Esophagogram ± ± Most sensitive testMost sensitive test

Endoscopic visualizationEndoscopic visualization ± ± NormalNormal--appearing mucosalappearing mucosal

± ± Cervical webs are associatedCervical webs are associatedwith carcinomawith carcinoma

TreatmentTreatment ± ± Endoscopic dilationEndoscopic dilation

± ± Large bougie or balloon (15 toLarge bougie or balloon (15 to20 mm) so as to fracture the20 mm) so as to fracture the

ringring ± ± Refractory ringsRefractory rings

Pneumatic dilation (largePneumatic dilation (largeballoon)balloon)

Electrosurgical incisionElectrosurgical incision

Surgical resectionSurgical resection

Treat GERDTreat GERD



Dysphagia lusoriaDysphagia lusoria

Aberrant right subclavian artery Aberrant right subclavian artery ± ± Arises from the left side of the aortic arch Arises from the left side of the aortic arch

± ± Compress the posterior esophagusCompress the posterior esophagus

± ± 20% of cases anterior 20% of cases anterior Barium esophagogramBarium esophagogram

± ± Indentation at the level of the third and fourthIndentation at the level of the third and fourth

thoracic vertebraethoracic vertebrae

ConfirmationConfirmation

± ± CT, MRI, arteriography, or EUSCT, MRI, arteriography, or EUS



Dysphagia lusoriaDysphagia lusoria

EndoscopyEndoscopy ± ± Right radial pulse may diminish with compression of Right radial pulse may diminish with compression of

the right subclavian arterythe right subclavian artery

Esophageal manometryEsophageal manometry ± ± HighHigh--pressure zone at the location of the aberrantpressure zone at the location of the aberrantarteryartery

Symptoms usually respond to changes in diet toSymptoms usually respond to changes in diet tosoft consistency and small sizesoft consistency and small size

When necessary, surgery relieves theWhen necessary, surgery relieves theobstruction by reanastomosing the aberrantobstruction by reanastomosing the aberrantartery to the ascending aortaartery to the ascending aorta





Globus hystericusGlobus hystericus

Pressure, fullness, or a lump in the throat,Pressure, fullness, or a lump in the throat,

not related to mealsnot related to meals

overweight, depressed, obsessive,overweight, depressed, obsessive,menopausal femalesmenopausal females

Pt may have fear of cancer in the throatPt may have fear of cancer in the throat

Actually often associated with GERD Actually often associated with GERDClinical examClinical exam--normalnormal

TreatmentTreatment--reassurancereassurance



Gastroesophageal RefluxGastroesophageal Reflux

DiseaseDisease

GERD is recognized in about 10GERD is recognized in about 10--15% of the15% of thepopulationpopulation

Ref lux esophagitisRef lux esophagitis ± ± Changes in the esophageal mucosaChanges in the esophageal mucosa

± ± Present in 30% to 40%Present in 30% to 40%

Barrett's esophagusBarrett's esophagus ± ± 10% to 20%10% to 20%

Defects in the esophagogastric barrier such asDefects in the esophagogastric barrier such as ± ± LES incompetenceLES incompetence

± ± Transient relaxation of LESTransient relaxation of LES

± ± Hiatal herniaHiatal hernia



55







BravoBravo pH probepH probe

Size of a capsuleSize of a capsule

Placed endoscopicallyPlaced endoscopically ± ± 6 cm above the GEJ6 cm above the GEJ

Transmits to a recordingTransmits to a recordingdevicedevice

48 hours of pH data48 hours of pH data

Falls off after 4 to 10 daysFalls off after 4 to 10 days

Patients prefer this devicePatients prefer this deviceover the catheter over the catheter--basedbasedsystem due to reducedsystem due to reduceddiscomfortdiscomfort



EndoscopyEndoscopy

± ± Reflux esophagitisReflux esophagitis

Erosions or ulcerationsErosions or ulcerations

± ± pH probe results arepH probe results arenormal in 25% of normal in 25% of

patients with erosivepatients with erosive

esophagitisesophagitis







62



Barrett's esophagusBarrett's esophagus

Potentially serious complication of longPotentially serious complication of long--standing GERDstanding GERD

Stratified squamous epithelium of theStratified squamous epithelium of the

distal esophagus is replaced by intestinaldistal esophagus is replaced by intestinalcolumnar metaplasiacolumnar metaplasia

It is the most significant outcome of It is the most significant outcome of

chronic GERD and predisposes patients tochronic GERD and predisposes patients tothe development of esophagealthe development of esophagealadenocarcinoma.adenocarcinoma.







Zenker¶s DiverticulumZenker¶s Diverticulum

Esophageal diverticula areEsophageal diverticula areclassified based on:classified based on: ± ± Anatomic location Anatomic location

± ± Mechanism of origin (pulsion or Mechanism of origin (pulsion or traction).traction).

Zenker's diverticulum (ZD)Zenker's diverticulum (ZD) ± ± Pulsion type diverticulumPulsion type diverticulum

Herniation of esophageal mucosa andHerniation of esophageal mucosa and

submucosa through an area of weakenedsubmucosa through an area of weakenedesophageal musculatureesophageal musculature

± ± Males predominance (2 to 3 times)Males predominance (2 to 3 times)



Risk factorsRisk factors

Older ageOlder age

Male gender Male gender

Hiatal herniaHiatal herniaGastroesophageal refluxGastroesophageal reflux

NOTES:

Up to 94% of patients with pharyngeal pouches are found to have GERD

and/or hiatal hernias.



DiagnosisDiagnosis

HistoryHistory

± ± Progressive dysphagiaProgressive dysphagia

90% of patients90% of patients

presenting with ZDpresenting with ZD

± ± Regurgitation of foodRegurgitation of food

± ± Unprovoked aspirationUnprovoked aspiration

± ± Noisy deglutitionNoisy deglutition

BariumBariumEsophagogramEsophagogram



TreatmentTreatment

ExternalExternal ± ± cricopharyngealcricopharyngeal

myotomymyotomy

± ± Diverticulum isDiverticulum isexcised and theexcised and thedefect closeddefect closed

Endoscopic techniquesEndoscopic techniques::endoscopic stapleendoscopic staplediverticulostomy, CO2diverticulostomy, CO2laser, electrocauterylaser, electrocautery







InvestigationsInvestigations

Full blood count:Full blood count: hypochromic microcytichypochromic microcytic

anemia, low serum ferritin levelsanemia, low serum ferritin levels

Barium swallow:Barium swallow: narrowing of the upper narrowing of the upper

esophagus with a web in the anterior wallesophagus with a web in the anterior wall

Endoscopy:Endoscopy: friable web can be seenfriable web can be seen

across the lumen of the esophagusacross the lumen of the esophagus

72





Plummer Plummer--Vinson SyndromeVinson Syndrome

Rx: iron replacement alone may reverse someRx: iron replacement alone may reverse some

of the pathologic changesof the pathologic changes

dilation of webdilation of web

Increased incidence of postcricoid CAIncreased incidence of postcricoid CA





Esophageal CarcinomaEsophageal Carcinoma

Oesophageal carcinoma is becoming more common,Oesophageal carcinoma is becoming more common,unlike the trend observed in gastric carcinoma.unlike the trend observed in gastric carcinoma.

Squamous carcinomaSquamous carcinoma typically arises in the upper typically arises in the upper 2/3 of the oesophagus2/3 of the oesophagus

AdenocarcinomaAdenocarcinoma usually arises in a region of usually arises in a region of

specialised columnar epithelium (SCE) metaplasia inspecialised columnar epithelium (SCE) metaplasia inthe lower 1/3 of the oesophagusthe lower 1/3 of the oesophagus -- Barrett'sBarrett'soesophagus.oesophagus.

Risk Factors for Oesophageal CaRisk Factors for Oesophageal Ca



Risk Factors for Oesophageal CaRisk Factors for Oesophageal Ca

Squamous cellcell

carcinomacarcinoma

AdenocarcinomaAdenocarcinoma

1.1.Heavy alcoholHeavy alcohol

intakeintake

2.2.Smoker Smoker 3.3.Poor dietPoor diet-- low intakelow intake

of fruit andof fruit and

vegetablesvegetables

1.1.Poor dietPoor diet-- low intakelow intake

of fruit andof fruit and

vegetablesvegetables2.2.Acid suppressing Acid suppressing

medicationsmedications

3.3.Peptic oesophagitisPeptic oesophagitis

and strictureand stricture

4.4.Achalasia Achalasia

5.5.Oesophageal web/Oesophageal web/

pharyngeal pouchpharyngeal pouch

77



Clinical FeaturesClinical Features

Dysphagia is the most frequently presentedDysphagia is the most frequently presented

feature of oesophageal carcinoma :feature of oesophageal carcinoma :

± ± patient may recount a short history of progressivepatient may recount a short history of progressive

dysphagia, initially affecting solids only, butdysphagia, initially affecting solids only, but

gradually affecting the swallowing of fluids.gradually affecting the swallowing of fluids.

± ± interruption of the passage of food may causeinterruption of the passage of food may cause

the individual to slowly alter the diet from solid tothe individual to slowly alter the diet from solid to

liquid nutrition.liquid nutrition.




± ± the level at which difficulty in swallowing isthe level at which difficulty in swallowing is

encountered may be identifiable by theencountered may be identifiable by thepatient.patient.

± ± Short history of Short history of dysphagiadysphagia in anin an elderlyelderly

male is almostmale is almost certainlycertainly carcinomacarcinoma of theof the

oesophagus or the cardia of the stomach.oesophagus or the cardia of the stomach.




Other local features may include :Other local features may include :

± ± regurgitation of food or bloodregurgitation of food or blood--stained vomitstained vomit

± ± aspiration pneumoniaaspiration pneumonia

± ± pain :pain :

classically, retrosternally and in the interscapular classically, retrosternally and in the interscapular

regionregion

it may radiate to the jaws and armsit may radiate to the jaws and arms





DiagnosisDiagnosis

The diagnosis of oesophageal carcinoma isThe diagnosis of oesophageal carcinoma is

made on :made on :

± ± History and examinationHistory and examination

± ± Barium swallowBarium swallow

± ± Endoscopy and biopsyEndoscopy and biopsy

± ± CytologyCytology

± ± CT scanCT scan ± ± BronchoscopyBronchoscopy

± ± UltrasoundUltrasound




Barium swallowBarium swallow ::

± ± the firstthe first--line investigation after the history of line investigation after the history of

dysphagiadysphagia

± ± characteristic image of an irregular stricturecharacteristic image of an irregular stricturewith shouldered margins, 4with shouldered margins, 4--10 cm long and10 cm long and

often tortuousoften tortuous

± ± a tracheoa tracheo--oesophageal fistula may also beoesophageal fistula may also be

demonstrateddemonstrated

E h l CE h l C



Esophageal Cancer Esophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy



Cancer of the midCancer of the mid--esophagusesophagus

³apple³apple--core´ fillingcore´ filling

defectdefect




Endoscopy and BiopsyEndoscopy and Biopsy ::

± ± establishes histology and limits of lesionestablishes histology and limits of lesion

± ± can be used therapeutically to dilate, socan be used therapeutically to dilate, so

improving nutrition before a definitiveimproving nutrition before a definitiveoperative interventionoperative intervention

I ti tiI ti ti



InvestigationsInvestigationscytologycytology by washing / abrasion techniqueby washing / abrasion technique

CT scanningCT scanning helps to determine mediastinalhelps to determine mediastinal

involvement and whether metastasis hasinvolvement and whether metastasis has

occurred to the liver occurred to the liver

bronchoscopybronchoscopy may be needed to excludemay be needed to exclude

bronchial involvement in upper and middlebronchial involvement in upper and middle--thirdthird

lesionslesions

ultrasoundultrasound may be used to identify secondarymay be used to identify secondary

liver depositsliver deposits



ManagementManagement

Management of oesophageal carcinomaManagement of oesophageal carcinoma

is dependent on the level of the lesion andis dependent on the level of the lesion and

the stage of the disease.the stage of the disease.

± ± Upper third lesionUpper third lesion

± ± Middle third lesionMiddle third lesion

± ± Lower third lesionLower third lesion

M tM t




Upper third lesionUpper third lesion::high dose radiotherapy is indicatedhigh dose radiotherapy is indicated

Middle third lesionMiddle third lesion ::

Early tumours are resectable. Again,Early tumours are resectable. Again,radical radiotherapy may be indicated if theradical radiotherapy may be indicated if the

lesion is up to 5 cm long .lesion is up to 5 cm long .

Lower third lesionLower third lesion ::

most accessible surgically;most accessible surgically;adenocarcinomas areadenocarcinomas are radioresistantradioresistant




Extensive disease requiresExtensive disease requires palliation of palliation of

dysphagiadysphagia::

± ± endoscopic laser surgery for lesions less than 8endoscopic laser surgery for lesions less than 8

cm longcm long

± ± oesophageal stentingoesophageal stenting

e.g. with a Celestin tubee.g. with a Celestin tube -- if longer than 8 cmif longer than 8 cm

± ± alternatives include:alternatives include:oesophagooesophago--gastrostomy or oesophagogastrostomy or oesophago--jejunostomy jejunostomy

short course radiotherapyshort course radiotherapy





Thank

you

dysphagia new1

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