TBL 3 - Dysphagia

8/9/2019 TBL 3 - Dysphagia

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TBL 3: DYSPHAGIA

By: Anis, Aishah, Nubla, Hanafi, Hidayah

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Dysphagia: is a difficulty in swallowing and always

need investigation to exclude malignancy.

Odynophagia: is painfull while swallowing in themouth or oesophagus

Globus hystericus :The sensation of having a lump in

the throat when there is nothing there

If symptoms are progressive or prolonged thenurgent investigation is required.


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HOW TO TAKE HISTORY?

Dysphagia

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History

Duration

Progression

Aggravating factorRelieving factor

Level

Vomiting history

Saliva accumulation

Heartburn

Belching

LOWLOA

SOB

Cough

hemoptysis

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Physical Examination

Inspection

Mouth

Ulcer Swelling -tonsil

Hydration status

Neck

Swelling or mass

Lymph node

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Abdominal examination

Respiratory examination

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Causes of Dysphagia - Mural

Ca esophagus Progressive cause, LOW, anorexia, low-

grade anemia, small hematemesis

Reflux esophagitis

& stricture

Preceded by heartburn, progressive course,

nocturnal regurgitationAchalasia Frequent regurgitation, recurrent chest

infection

Tracheo-esophageal

fistula

Recurrent chest infection, coughing after

drinkingCaustic stricture Examination shows corrosive ingestion,

chronic dysphagia

Scleroderma Slow onset, a/w skin and hair changes

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Causes of Dysphagia - Intraluminal

Foreign body Acute onset, marked retrosternal dicomfort,

dysphagia even to saliva

Causes of Dysphagia - Extramural

Pulsion

diverticulum

Intermittent symptoms, unexpected regurgitation

External

compression

Mediastinal lymph nodes, left arterial

hyperthrophy, bronchial malignancy


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Risk Factors for Oesophageal Ca

Squamous cell carcinoma Adenocarcinoma

1. Heavy alcohol intake

2. Smoker

3. Poor diet- low intake offruit and vegetables

1. Poor diet- low intake of

fruit and vegetables

2. Acid suppressingmedications

3. Peptic oesophagitis and

stricture

4. Achalasia

5. Oesophageal web/

pharyngeal pouch

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INVESTIGATIONS

By: Aishah Azman

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Investigations

Full blood count (FBC)

Liver function test (LFT)

Renal profile Chest Xray& CT scan

Oesophageal-gastric-duodenal scopy (OGDS)

Barium swallow

Esophageal monometry

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Full Blood Count

Anaemia Tumours much more commonly cause this

rather than reflux

Test Result interpretation

Hemoglobin 10.4 Low

Hematocrit 31.1 Low

Mean Corpuscular

Hemoglobin (MC

H)

26. 2 Low

Platelets 595 High

RBC Dist Width 15.2 High

Total RBC 3.95 Low

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Liver Function Test

Looking out for any hepatic disease or involvement

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Renal profile

To look for signs of dehydration

BUN 4.3 mmol/L N

Sodium 135.2 mmol/L N

Potassium 4.83 mmol/L NCreatinine 89 Umol/L N

Chloride 103.7 mmol/L N

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Chest X-ray and CT scan

To rule out external compression

Allow tumour staging

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OGDS

The study of choice for evaluating persistent

heartburn, dysphagia, odynophagia, and structural

abnormalities detected on barium esophagography.

In addition to direct visualization, it allows biopsy of

mucosal abnormalities and of normal mucosa (to

evaluate for eosinophilic esophagitis) as well as

dilation of strictures.

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Barium Swallow

Patients with esophageal dysphagia often are evaluated first with aradiographic barium study to differentiate between mechanicallesions and motility disorders, providing important information aboutthe latter in particular.

In patients with esophageal dysphagia and a suspected motilitydisorder, barium esophagoscopy should be obtained first.

In patients whom there is a high suspicion of a mechanical lesion,many clinicians will proceed first to endoscopic evaluation because itbetter identifies mucosa lesions and permits mucosal biopsy anddilation.

However, barium study is more sensitive for detecting subtleesophageal narrowing due to rings, achalasia, and proximalesophageal lesions.

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Esophageal Monometry

Used to assess oesophageal motility

Indication:

determining LES location to allow precise placement of

conventional electrode pH probe establishing the aetiology of dysphagia in patients in whom

a mechanical obstruction cannot be found, especially if adiagnosis of achalasia is suspected by endoscopy or bariumstudy

for the preoperative assessment of patients beingconsidered for antireflux surgery to exclude an alternativediagnosis (eg, achalasia) or possibly to assess peristalticfunction in the esophageal body.

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Investigations Gastro-esophageal

reflux disease (GERD)

Oesophagus ca Achalasia

Barium swallow reverse flow of bariuminto the lower end of

oesophagus (from the

stomach)

irregular, persistent,intrinsic feeling defect

-uniformly dilatedoesophagus above,

with a smooth tapering

segment below-

cucumber oesophagus

-chronic case, may be

sigmoid shape

Endoscopy red, angry looking

mucosa in the lower

end of the oesophagus

-Early stage: superficial

plaque or ulceration

-Advance: ulcerated

mass with stricture or

circumferential mass

or a large ulceration

dilated sac containing

stagnant food & fluid

due to stasis which

splashes out with each

heart beat & with each

respiratory movement

Oesophageal

manometry

- - -Hypertensive lower

oesophageal sphincter

(LOS)

-increase resting

pressure in oesophagus

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ACHALASIA

By: Aishah Azman

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Achalasia

The rhythmic contractions of the esophagusare greatly decreased, LES does not relaxnormally, and the resting pressure of the

lower esophageal sphincter is increased. Persons with achalasia lack non-adrenergic,

non-cholinergic, inhibitory ganglion cells,causing an imbalance in excitatory and

inhibitory neurotransmission. The result is ahypertensive non-relaxed esophagealsphincter.

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Etiology/Pathophysiology

Most common 1 esophageal motility disorder

Due to

absence of esophageal smooth muscle peristalsis

Increased lower esophageal sphincter (LES) restingpressure

Failure of LES to relax in response to a bolus of food.

Results in functional obstruction with esophageal

dilatation (Esophagus: widened, lengthened) Manifestation: 20-40 year old (May be seen in

infancy and early childhood)

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Achalasia vs other esophageal motility

disorders

Diffuse esophageal spasm: uncoordinated, high

amplitude esophageal contractions

Nutcracker esophageal: exceedingly high amplitude

esophageal contractions

Strictures: secondary to ingestion of caustic agents

or longstanding gastroesophageal reflux or

esophagitis

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Signs and symptoms

Progressive dysphagia (Solids and liquids)

Substernal chest pain

Regurgitation of undigested food

Weight loss Aspiration and respiratory symptoms secondary to

esophageal retention, regurgitation, and overflow intotrachea

Recurrent aspiration pneumonia Bloating

Inability to burp

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Diagnostic evaluation

CXR Mediastinal widening with possible air-fluid level

Barium esophagram Marked dilatation of esophagus

Narrowed, tapered bird beak distal esophagus

Longstanding: lengthened, tortuous esophagus (sigmoid esophagus)

Manometry (Gold standard) High LES resting pressure

Incomplete relaxation upon swallowing

Failure of peristalsis

*elevated resting pressure in the body of the esophagus may also be present Upper GI endoscopy with biopsy to rule out esophageal cancer,

esophagitis and strictures

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Treatment and Management

Medical therapy Eg. Ca channel blocker, nitrates, sildenafil

Short term improvement

Pneumatic dilatation of LES

>60% effective Botulinum toxin injections

Efficacy questionable

Must repeat every few months

Surgical treatment Esophagomyotomy (Heller myotomy) with

sectioning of the LES Prefer laparoscopy than open thoracotomy or laparotomy

Include anti-reflux procedure

Best: abdominal laparoscopic myotomy with an anti-reflux procedure

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Prognosis and Complication

Prognosis increased risk of esophageal ca

Pneumatic dilatation One: 60% effective

Two: 80% effective

Perforation: 2-15% (*increased with repeated dilatations andprior botox)

Botulinum injection 40% : not effective

Multiple injections

Scar: increase risk of complication following pneumatid dilatationor surgery

Surgery 3-4% : pneumothorax and esophageal mucosalperforation

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2. GORD

Gastro-oesophageal reflux is a condition caused by

the retrograde passage of gastric contents into the

oesophagus resulting in inflammation (oesophagitis),which manifests as dyspepsia. It manifests from the

lower pressure of the LOS.

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Causes of GORD

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Reflux OesophagitisSymptomatic esophagitis occur with:

Prolonged exposure of mucosa to excessive reflux,

both in number of episodes & volume.

Impaired normal mechanisms from clearing the loweresophagus.

High levels of acid & pepsin.

Presence of bile & pancreatic enzymes (alkalinereflux).

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Clinical Features

Retrosternal burning pain, radiating to epigastrium,jaw and arms. (Oesophageal pain is often confused

with cardiac pain.)

Triad (Heartburn, epigastric pain, regurgitation)

Regurgitation of acid contents into the mouth &execessive salive proir to reflux(waterbrash).

Back pain (a penetrating ulcer in Barretts

oesophagus). Dysphagia from a benign stricture.

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Pathophysiology

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The action of the lower esophageal sphincter (LES) isperhaps the most important factor (mechanism) forpreventing reflux.

The esophagus is a muscular tube that extends from thelower throat to the stomach. The LES is a specialized ringof muscle that surrounds the lower-most end of theesophagus where it joins the stomach. The muscle thatmakes up the LES is active most of the time.

This means that it is contracting and closing off thepassage from the esophagus into the stomach. This closingof the passage prevents reflux. When food or saliva isswallowed, the LES relaxes for a few seconds to allowthe food or saliva to pass from the esophagus into thestomach, and then it closes again.

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Several different abnormalities of the LES have been found inpatients with GERD. Two of them involve the function of theLES.

The first is abnormally weak contraction of the LES, which

reduces its ability to prevent reflux. The second is abnormal relaxations of the LES, called

transient LES relaxations.

They are abnormal in that they do not accompany swallowsand they last for a long time, up to several minutes. Theseprolonged relaxations allow reflux to occur more easily.

The transient LES relaxations occur in patients with GERD mostcommonly after meals when the stomach is distended withfood. Transient LES relaxations also occur in individuals withoutGERD, but they are infrequent.

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1. Metaplasia of distal esophagus to columnar

epithelium in persistent gastroesophageal reflux(mixture of gastric & intestinal type)

BARRETS ESOPHAGUS is defined as the presence of

glandular mucosa showing intestinal metaplasia.

Risk of adenocarcinoma (30 x)2. Peptic ulceration & fibrous stricture

3. Motility abnormality (abnormal peristalsis in loweresophagus decrease clearing & aggravate reflux

disease4. Oesophageal shortening

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Diagnostics measurement

24-hour pH recording is the gold standard

TLOSRs are the most important manometric findings

in GORD The length and pressure of the LOS are also

important

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3. Barret Oesophagitis

Metaplastic change in the lining mucosa of theoesophagus in response to chronic GORD

Junction between squamousoesophageal mucosa and

gastric mucosa moves proximally

Risk of adenocarcinoma (30 x)

Divided into:

Classic Barretts (3cm or more columnar epithelium)

Short-segment Barrets (less than 3cm) Cardiametaplasia (intestinal metaplasia at the

oesophagogastric junction without any macroscopic change at

endoscopy)41


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Causes & symptoms

Barrett's esophagus is caused by GERD whichallows the stomach's contents to damage the cellslining the lower esophagus

Warning signs Frequent and longstanding heartburn, dysphagia,

vomitting blood

Change of voices (laryngitis)

**it is a grade 4 esophagitis + displastic change

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The squamocolumnar junction, where the Barrett's

esophagus joins the normal squamous esophagus, is a

great distance from the bottom of the esophagus due

to the long segment of Barrett's esophagus

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The short segment of Barrett's esophagus is seen here as a strip or

"tongue" of red lining surrounded by normal pinkish-white squamous

lining. There is a small island of Barrett's esophagus, surrounded by

normal squamous lining, next to the tongue of Barrett's esophagus.

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Figure 17-6 Barrett esophagus.A, B, Gross view of distal esophagus (top) and proximastomach (bottom), showingA, the normal gastroesophageal junction (arrow) and C,Endoscopic view of Barrett esophagus showing red velvety gastrointestinal mucosaextending from the gastroesophageal orifice. Note the paler squamous esophageal mu

B, the granular zone of

Barrett esophagus

(arrow).

C, Endoscopic view

showing red velvety

gastrointestinal mucosa

extending from the

gastroesophageal orifice.

Barrett esophagus.

A, the normal gastro-

esophageal

junction (arrow)

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HIATUS HERNIA

By: Hidayah

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Hiatal Hernia48


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Hiatus Hernia

A protrusion of a portion of the stomach across the

opening in the diaphragm that the esophagus

normally passes through.

HH is common especially in women and with

advancing years

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Sliding HH PEH

(90% of cases): upwardmigration of the GEJ

through the esophageal

hiatus and into the thorax

Most often caused by

strecthing the esophageal

hiatus

is a rolling of the gastricfundus upward through the

esophageal hiatus into the

esophageal hiatus and ino

the thorax, with normalposition of the GEJ

It have a significantly

increased risk ofVOLVULUS &

STRANGULATION

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Classification

Type Hiatal Hernia

I Sliding H

II PEH

III I + II

IV Herniation of stomach &

additional intra-abdominalorgan: colon, spleen @ omentum

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Clinical features

Sliding HH Paraesophageal HH

1) Often asymptomatic

2) Incompetence of the

GEJ may result: REFLUX

causing symptoms of

GERD (e.g., heartburn,cough, regurgitation,

dysphagia)

1) Often asymtomatic

2) But may present with severe

ischemic symptoms if volvulus @

incarceration of the stomach occurs

3) Since the GEJ is intact, REFLUXRARELY occurs

4) OBSTRUCTIVE symptoms (e.g.,

dysphagia, postprandial fullness,

heartburn, dyspnea) may signalimpending volvulus

5) HEMATEMESIS may occur

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Diagnostic Evaluation

1) Upright chest X-ray may reveal a retrocardiac

shadow or widening

Paraesophageal HH:

1) Air fluid level behind the heart

2) Nasogastric tube that appears o enter the abdomen

but then curves back to the chest

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A plain chest radiograph showing a well-defined, rounded,

soft-tissue mass in the retrocardiac region consistent with a

sliding hiatal hernia55

A frontal chest radiograph in a patient with a large hiatal


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A frontal chest radiograph in a patient with a large hiatal

hernia demonstrating a retrocardiac opacity with radiolucent

gas, which shifts the mediastinum to the right

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A lateral chest radiograph showing a hiatal hernia.

Note the absence of fundal gas below the left

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2) Barium Swallow/upper GI series: usually diagnostic

to differentiate the type of HH & may rule out other

pathology

A barium-meal

examination in a

patient with a

sliding hiatal

hernia that

demonstratessupradiaphragma

tic location of the

gastroesophagea

l junction

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3) Upper GI endoscopy: allow direct visualization of

the hernia and evaluation of the esophageal and

gastric mucosa

4) Chest and abdominal CT Scan are often diagnostic

& provide excellent anatomic information.

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Treatment/ManagementSliding Hernias Paraesophageal Hernia

1) Rarely require treatment

2) If reflux (+), the treatment is

directed at correcting the

reflux disease (lifestyle

modifications: weight loss,dietary changes, avoidance

alcohol & tabacco,

avoidance of food within 4

hours of bedtime & sleeping

with head elevated & anti-

ulcer/antacid)

1) Always operative, regardless

of severity of symptoms, due

to the risk of gastric

VOLVULUS &

INCARCERATION.2) Surgical treatment: reducing

of the stomach into the

abdominal cavity, repairing

the esophageal hiatus, and

possibly an anti-reflux

procedure

3) Gastropexy

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Prognosis/Complication

Infarction, bleeding & perforation may occur in up

to 25% of patients with PEH

Elective surgical repair of PEH carries low operative

mortality

Emergency repair for infarction/perforation of the

stomach carries nearly 20% operative mortality

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Which one is true about Hiatus Hernia?

a) Is an uncommon finding

b) Is caused by stomach herniating through the

membranes part of the diaphragm

c) The rolling type is more commonly associated with

reflux

d) The rolling or paraesophageal type is best

managed conservativelye) Often co-exists with diverticular disease and gall

stones

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OESOPHAGEALCARCINOMA

By: Hidayah

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Malignancy of the esophagus. There are various subtypes,primarily adenocarcinoma (approx. 50-80% of allesophageal cancer) and squamous cell cancer

Most esophageal cancers fall into one of 2 classes:

a) SCC

similar to head & neck cancer in their appearance &association with tobacco/alcohol consumption

b)adenocarcinomas

often associated with a history of GERD and Barrett'sesophagus.

A general rule of thumb is that a cancer in the upper two-thirds is a squamous cell carcinoma and one in the lowerone-third is a adenocarcinoma.

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Clinical features

Dysphagia : first symptom in most patients. Fluids andsoft foods are usually tolerated, while hard or bulkysubstances (such as bread or meat) cause much moredifficulty

Odynophagia Weight loss: as a result of poor nutrition and the

active cancer

Pain : often of a burning nature, may be severe and

worsened by swallowing, and can be spasmodic incharacter. An early sign may be an unusually husky orraspy voice.

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Aspiration pneumonia: Disrupt normal peristalsis (the

organised swallowing reflex), leading to nausea and

vomiting, regurgitation of food, coughing and an

increased the risk.

Hematemesis : the tumor surface may be fragile and

bleed.

Compression of local structures occurs in advanceddisease, leading to such problems as upper airway

obstruction and superior vena cava syndrome.

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Fistulas may develop between the esophagus and

the trachea, increasing the pneumonia risk; this

condition is usually heralded by cough, fever or

aspiration.

If the disease has spread elsewhere, this may lead

to symptoms related to this: liver metastasis could

cause jaundice and ascites, lung metastasis couldcause shortness of breath, pleural effusions etc.

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Causes (Increased Risk)

Age. Most patients are >60, and the median in USpatients is 67.

Sex. (>men)

Heredity.

Tobacco smoking and heavy alcohol use & togetherappear to increase the risk >either individually.

GERD and its resultant Barrett's esophagus increaseesophageal cancer risk due to the chronic irritation of themucosal lining (adenocarcinoma is >common in thiscondition, while all other risk factors predispose more forSCC).

Human papillomavirus (HPV)

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Corrosive injury to esophagus by swallowing strongalkalines (lye) or acids.

Particular dietary substances, such as nitrosamine.

A medical history of other head and neck cancersincreases the chance of developing a second cancerin the head and neck area, including esophagealcancer.

Plummer-Vinson syndrome (anemia and esophagealwebbing)

Tylosis and Howel-Evans syndrome (hereditarythickening of the skin of the palms and soles).

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Radiation therapy for other conditions in themediastinum

Coeliac diseasepredisposes towards squamous cell

carcinoma. Obesity increases the risk of adenocarcinoma fourfold.It

is suspected that increased risk of reflux may be behindthis association.

Drinking hot brewed tea Alcohol consumption in individuals predisposed to

alcohol flush reaction

Achalasia

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Diagnostic Evaluation

Hx & PE:

evaluate degree of dysphagia (e.g.,solids vs liquids)

subjective location of swallowing dificulty (cervical

esophagus/thoracic esophagus/distal esophagus), presence of lymphadenopathy/abdominal

mass/hepatomegaly

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Upper GI endoscopy with biopsy is diagnostic

Barium esophagogram

CT, broncoscopy & endoscopic ultrasound (mostaccurate) are used for staging and to evaluate formetastases and local invasion.

Additional exaluation may include a FNA ofmetastatic lesions.

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Treatment/Management

Tx: primarily palliative

Surgical resection is rarely curative but may restore

patency of the esophagus

Total esophagectomy for SCC (with reconstruction usingeither the stomach or colon)

Esophagogastrectomy for Adenocarcinoma

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Esophageal dilation/stenting is indicated for

patients with esophageal obstruction or

tracheoesophageal fistula

Radiation @ chemotherapy may marginally improve

survival and/or temporarily relieve dysphagia

Laser & photodynamic therapy

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Prognosis/Complications

Poor Prognosis:

o SCC: 5-year survival


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Which of the following statements relating

to esophageal cancer is incorrect?

a) Is usually diagnosed at an early stage

b) Risk factors include smoking and alcohol

c) Treatment may include radiotherapy &

chemotherapy

d) Is predominantly adenocarcinoma in the UK

e) Dysphagia and weight loss are poor prognostic

signs

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Oesophageal Diverticula

Abnormal protrusions from the oesophagus that in

rare cases cause dysphagia and regurgitation

associated with motility disorders of the esophagus,

such as esophageal spasm and achalasia

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Zenker's Diverticula

A.k.a pharyngeal pouch

caused by an incoordination between movement of

food out of the mouth and relaxation of thecricopharyngeal muscle

This diverticulum can filled with food regurgitatedwhen the person bends over or lies down.

Regurgitate during sleep resulting in aspiration

pneumonia. Rarely, the pouch enlarges and causes swallowing

difficulty and sometimes a swelling in the neck.

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Midesophageal Diverticula

A midesophageal pouch or traction diverticulum is

caused by:

traction from inflamed lesions located in the chest outside theesophagus (mediastinum) or,

secondarily, by esophageal movement (motility) disorders.

A traction diverticulum rarely causes symptoms, but the

underlying disorder may.

Oesophageal Diverticula79


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Epiphrenic Diverticula:

An epiphrenic pouch or diverticulum occurs just above

the diaphragm and usually accompanies a motility

disorder (such as achalasia or esophageal spasm). An epiphrenic diverticulum rarely causes symptoms, but

the underlying disorder may.

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PLUMMER VINSONSYNDROME

By: Nubla

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Plummer Vinson Syndrome

Usually occur in middle aged women

Clinical features: dysphagia, signs of anemia

(kiolonychia, smooth tongue, angular stomatitis)

Triad: oesophageal web, mucosal lesions of mouth

and parynx, iron deficiency anemia

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Investigations

Full blood count: hypochromic microcytic anemia,

low serum ferritin levels

Barium swallow: narrowing of the upper

esophagus with a web in the anterior wall Endoscopy: friable web can be seen across the

lumen of the esophagus

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TBL 3 - Dysphagia