6. Dysphagia Flashcards
Dsyphagia definition
Difficulty swallowing
High dysphagia
(oropharyngeal + upper oesophageal) describe difficulty initiating a swallow or immediately upon swallowing
Low dysphagia
(lower oesophageal) feel the food getting stuck a few seconds after swallowing
Odynophagia
painful swallowing
may be due to malignancy, but more commonly a feature of infection eg candidiasis
Globus
common sensation of having a lump in the throat without true dysphagia
It is v.common + aetiology poorly understood, benign
High dysphagia- FUNCTIONAL mechanism
STROKE PD Myasthenia Gravis MS Myotonic dystrophy MN disease Inadquate saliva production (2ary Sjogrens, anticholinergics etc)
High dysphagia - STRUCTURAL mechanism
Luminal–> N/A
Mural –> cancer, pharyngeal pouch, cricopharyngeal bar
Extrinsic–> N/A
Low dysphagia- FUNCTIONAL mechanism
ACHALASIA Chagas disease Nutcracker oesophagus Diffuse oesophageal spasm Limited cutaneous scleroderma (CREST) Infective oesophagitis Eosinophilic oesophagitis
Low dysphagia - STRUCTURAL mechanism
Luminal-->foreign body Mural--> CANCER STRICTURE (caustic or inflammatory) Plummer-Vinson syndrome Schatzki ring Congenital atresia Post- fundoplication Extrinsic-->Mediastinal mass Retrosternal goitre Bronchial carcinoma Thoracic aortic aneurysm Pericardial effusion Ortner's syndrome Dysphagia lusoria
Duration of dysphagia
Immediately during meal: food bolus stuck in oesophagus
Days to weeks: Cancer that has reached size where symptoms become rapidly apparent
Mths to years: Chronic motility disorders eg achalasia
Progressive or intermittent dysphagia
Progressive= stricture (benign or malignant) Intermittent = motility disorders
Dysphagia to solids, fluids or both
D to solids = mechanical obstruction ie stricture (B or M)
D to fluids = motility disorder eg achalasia or NM condition
Absolute D to solids , liquids + saliva = food bolus, occasionally due to underlying stricture or malignancy (if so will be repeated problem)
Associated symptoms?
Coughing related to eating? Halitosis? Gurgling or dysphonia? Heartburn or waterbrash? Weight loss? Neurological symptoms? Rheumatological symptoms?
Coughing related to eating
- Coughing immediately after swallowing ie choking = problem with co-ordination of swallowing events (Stroke or PD)
- Coughing occurs some time after a meal = regurgitation of food retained within pharyngeal pouch, aspiration of food remaining in a dilated oesophagus above gastro-oesophageal jtn (achalasia) or GORD
- Nocturnal cough = when most ppl are lying flat and not eating (achalasia)
Halitosis
Feature of conditions where food remains lodged in oropharynx eg Zenker’s diverticulum (also known as pharyngeal pouch)
Gurgling or dysphonia
Pts with Pharyngeal pouch make gurgling noises if they attempt to speak too soon after eating or drinking
May also see a visible bulging of the neck
Hoarseness may be related to vocal cord dysfunction due to involvement of the recurrent laryngeal nerve eg if compressed by a tumour
Heartburn or waterbrash
Dysphagia related to reflux disease, with or without a stricture. Chronic dyspepsia can predispose to oesophageal cancer. apporx 40% pts with achalasia complain of retrosternal burning
WL
cardinal red flag for Oesophageal C although any cause of Dysphagia will cause WL if it’s sufficiently severe or prolonged
Neurological symptoms
Enquired about in any pt who has features suggestive of functional dysphagia eg difficulty coordinating swallowing, slow eating, extra effort required to eat/chew, tried after eating and early dysphagia for liquids
Rheumatological symptoms
Relevant in context of limited cutaneous scleroderma (prev known as CREST syndrome) = Calcinosis, Raynauds, (O)Esophageal dysmotility, Sclerodactyly, and Telangiectasia
2 most common causes of Dysphagia
GORD
Peptic ulcer disease
GORD
Predisposes to oesophageal adenocarcinoma nd non malignant strictures of the oesophagus.
History of GORD due to sliding hiatus hernia is significant if pt has had fundoplication operation to tighten the LOS.
Post- op dysphagia is a potential complication of op if wraps are made too tight
Peptic ulcers
Can lead to scarring and strictures around the gastric cardia and lower oesophagus
Drugs contributing to Dysphagia
- Calcium channel blockers and nitrates - relax SM - can cause or exacerbate symptoms by decreasing oesophageal tone
- NSAIDs, aspiring, steroids + bisphosphonates predispose to peptic ulceration
5 features on examination
- CN pathology- imp if features suggest ftnl dysphagia as pt may have bulbar palsy
- Signs of GI malignancy
- Neck mass
- Features of CREST syndrome
- Koilonychia : severe IDA, associated with Plummer-Vinson syndrome (oesophageal webs) but v rare
GI malignancy signs
- Cachetic
- Palpable Virchow’s node
- Lymphadenopathy
- If oesophageal carcinoma extends into cardia of STOMACH this may be palpable in thin pts
- If metastasises to liver –> HEPATOMEGALY but uncommon
Neck mass signs
- Large pharyngeal pouch palpable in thin pts, and this may even gurgle on palpation
- Goitre may also be palpable, causing dysphagia by extrinsic compression
Adenocarcinoma
Subtype accounts for about 65% of oesophageal carcinoma in UK
4 Ix for Dysphagia
- Barium swallow
- Endoscopy
- Videofluoroscopy
- Manometry
Barium swallow indications
Ix for pts who have a HIGH lesion
It’s indicated in pts with features suggesting achalasia (BIRDS BEAK appearance) eg intermittent symptoms, difficulties with fluids + solids
During endoscopy this region is intubated blindly + in the presence of a pharyngeal pouch or high oesophageal cancer there’s risk of injury or perforation
Endoscopy indications
Endosocopy = more sensitive + specific test than double contract barium swallow + is often the 1st LINE investigation for LOW dysphagia
Allows visualisation of mural and luminal lesions, and you can biopsy and treat lesions.
Various procedures, eg stricture dilation, stent insertion, laser coagulation and botox injections can all be carried out endoscopically
Videofluoroscopy indications
Modified form of barium swallow in which upright pts are given barium in liquid, solid or semi-solid form. A speech therapist modifies the swallowing technique throughout the study
Most suited to pts with a FTNL HIGH dysphagia
Manometry indications
Assesses the pressures in the LOS + the peristaltic wave in the rest of the oesophagus
Manometry= key ix for diagnosing a MOTILITY disorder + distinguishing between diff types of motility disorders eg achalasia and nutcracker oesophagus
It’s indicated when barium swallow +/or endoscopy are unremarkable, suggesting a cause OTHER than mechanical obstruction
Staging oesophageal carcinoma
- Spiral CT chest/abdo
- Positron emission tomography (PET) scanning
- Endoscopic US (EUS)
- Laporoscopy
Spiral CT chest/abdo
Principal modality for initially staging the tumour
If the scan reveals inoperable or metastatic disease then there may be no advantage in further assessment of the primary tumour
PET scannings
Used to further assess whether an equivocal lesion or LN seen on CT is ‘hot’ (avidly uptakes fluorodeoxyglucose FDG, a marker of metabolic activity) or ‘cold’.
Increasingly, CT and PET are combined into single PET-CT Ix
EUS
If no evidence of metastatic dis on CT/PET and the pt is candidate for surgery, EUS is performed as it’s the most accurate modality for locoregional staging (consistently better than CT, PET or MRI)
It provides particularly useful info about intramural vs transmural disease and local LN involvement
Laparoscopy
If there’s NO evidence of metastatic disease on CT/PET ie radical tx is still an option and pt has distal oesophageal tumour, laparoscopy may be used to EXCLUDE peritoneal deposits.
Such deposits are notoriously diff to diagnose on imaging, but their presence would be a relative contraindication to aggressive tx. BUT most laps are -VE
Oesophageal Cancer Tx options
1.Radical tx + neo-adjuvant chemotherapy -req fitness assessment, lung ftn tests, ECG, exercise tolerance test + echo
60-70% pts are unsuitable for surgery at dx (due to stage or comorbidities) SO offered
2.Endoscopic mucosal resection/ablation (if localised disease)
3.Multidisciplinary palliative care
Prognosis for Oesophageal cancer
POOR
Stage dependant
Stage 1 (no invasion of muscularis propria and no nodal involvement) - 5 yr survival = 80%
70% pts present with LN involvement + in these pts, 5 yr survival is about 15% even with modern tx
Achalasia tx options
- Pneumatic balloon dilatation
- Surgical (Heller’s) myotomy
- Botox injections
- Drugs
Pneumatic balloon dilatation (Achalasia tx)
Achieves good results in majority of pts, and about 60% of pts are free of dysphagia at 5 yrs
Most pts require repeat tx
Main risk is oesophageal perforation (5%)
Surgical (Heller’s) Myotomy (Achalasia tx)
Longitudinal incision of the muscle fibres of the distal oesophagus tends to produce better short and long term relief of dysphagia, but risks the development of GORD in about 10% of pts
Debate as to whether to perform Nissen fundoplication simultaneously (wrapping stomach around lower oesophagus to prev reflux)
Botox injections (Achalasia tx)
Produces good results that lasts up to 1 yr, and may be favoured in pts unsuited to interventional therapy
Drugs (Achalasia tx)
Eg calcium channel blockers +/or nitrates may relax the LOS sufficiently to produce relief of symptoms, but are often ineffective and therefore not first line therapies. They are primarily reserved for pts unsuitable for surgery or dilatation who fail Botox tx
RF for SCC
Alcohol Smoking Dietary nitrosamine (in pickled/mouldy foods) and nitrates (found in chinese, iranian + south african diets) Aflatoxins Achalasia Plummer-Vinson syndrome Hereditary tylosis Coeliac disease
RF for Adenocarcinoma
BO (hence any factor which predisposes to reflux oesophagitis)
Smoking + alcohol intake are not as important as they are for SCC
Types of Oesophageal cancer
- Adenocarcinoma (incr incidence)
- SCC (decr incidence)
- Carcinoid
- Small cell carcinoma
- Leiomyoma
Plummer - Vinson Syndrome
Rare collection of features including atrophic glossitis (smooth tongue), cheilosis (cracks at the corner of mouth), koilonychia, and dysphagia assoc. with IDA
Dysphagia is due to development of a postcricoid web of hyperkeratinisation
Correction of D requires balloon dilatation
Syndrome most common in middle aged to elderly women and is premalignant for cricopharyngeal carcinoma
Condition also known as Paterosn - Brown - Kelly S
Pathophysiology of Achalasia
Absence of ganglion cells in Myenteric plexus (Auerbach’s) of the oesophagus
Failure of relaxation of LOS an aperistalsis in the oesophageal body, cause is unknown
ALSO 1.Chagas disease results in identical pathophysiology
2.Infiltrating carcinoma can also produce a ‘pseudo achalasia’ by invasion of the myenteric plexus
3.Hischprung’s disease (megacolon) of the intestine = congenital absence of the myenteric plexus ganglion cells
Ortner’s syndrome
Recurrent laryngeal nerve is compressed by the CV system -most commonly left atrial dilatation secondary to mitral stenosis
Sufficiently severe left atrial enlargement can also cause dysphagia by extrinsic compression
Palliative tx options for oesophageal adenocarcinoma
- Intubation with rigid silastic endoprosthesis or expandable metal stent
- Endoscopic resection
- Ablation with laser or argon beam plasma coagulation
- Chemo
- Radiotherapy
- Psychological and social support
Oesophageal cancer symptoms
1.Dysphagia 75%
2.WL 60%
3.GI reflux 20%
4.Odynophagia 20%
5.Dyspnoea 10%
Less common symptoms include GI bl, fatigue due to anaemia, hoarseness (due to involvement of the recurrent laryngeal nerve), cough, facial flushing due to SVC obstruction, and breathlessness due to malignant pleural effusion
Complications of oesophagectomy
Removal of oesophagus and refashioning of the gullet using the stomach is a major op
Major complications=
1.Breakdown of the anastamosis, due to poor bl supply, infection + pt factors
2.Pneumonia
3.Cardiac arrythmia
4. Reccurrent laryngeal nerve injury
5. Chylothorax/Chyle leak, resulting from injury to the thoracic duct
