6. Dysphagia

Question 1

Dsyphagia definition

Answer 1

Difficulty swallowing

Question 2

High dysphagia

Answer 2

(oropharyngeal + upper oesophageal) describe difficulty initiating a swallow or immediately upon swallowing

Question 3

Low dysphagia

Answer 3

(lower oesophageal) feel the food getting stuck a few seconds after swallowing

Question 4

Odynophagia

Answer 4

painful swallowing

may be due to malignancy, but more commonly a feature of infection eg candidiasis

Question 5

Globus

Answer 5

common sensation of having a lump in the throat without true dysphagia
It is v.common + aetiology poorly understood, benign

Question 6

High dysphagia- FUNCTIONAL mechanism

Answer 6

STROKE
PD
Myasthenia Gravis
MS
Myotonic dystrophy
MN disease
Inadquate saliva production (2ary Sjogrens, anticholinergics etc)

Question 7

High dysphagia - STRUCTURAL mechanism

Answer 7

Luminal–> N/A
Mural –> cancer, pharyngeal pouch, cricopharyngeal bar
Extrinsic–> N/A

Question 8

Low dysphagia- FUNCTIONAL mechanism

Answer 8

ACHALASIA
Chagas disease
Nutcracker oesophagus
Diffuse oesophageal spasm
Limited cutaneous scleroderma (CREST)
Infective oesophagitis 
Eosinophilic oesophagitis

Question 9

Low dysphagia - STRUCTURAL mechanism

Answer 9

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

Question 10

Duration of dysphagia

Answer 10

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

Question 11

Progressive or intermittent dysphagia

Answer 11

Progressive= stricture (benign or malignant)
Intermittent = motility disorders

Question 12

Dysphagia to solids, fluids or both

Answer 12

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)

Question 13

Associated symptoms?

Answer 13

Coughing related to eating?
Halitosis?
Gurgling or dysphonia?
Heartburn or waterbrash?
Weight loss?
Neurological symptoms?
Rheumatological symptoms?

Question 14

Coughing related to eating

Answer 14

1. Coughing immediately after swallowing ie choking = problem with co-ordination of swallowing events (Stroke or PD)
2. 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
3. Nocturnal cough = when most ppl are lying flat and not eating (achalasia)

Question 15

Halitosis

Answer 15

Feature of conditions where food remains lodged in oropharynx eg Zenker’s diverticulum (also known as pharyngeal pouch)

Question 16

Gurgling or dysphonia

Answer 16

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

Question 17

Heartburn or waterbrash

Answer 17

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

Question 18

WL

Answer 18

cardinal red flag for Oesophageal C although any cause of Dysphagia will cause WL if it’s sufficiently severe or prolonged

Question 19

Neurological symptoms

Answer 19

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

Question 20

Rheumatological symptoms

Answer 20

Relevant in context of limited cutaneous scleroderma (prev known as CREST syndrome) = Calcinosis, Raynauds, (O)Esophageal dysmotility, Sclerodactyly, and Telangiectasia

Question 21

2 most common causes of Dysphagia

Answer 21

GORD

Peptic ulcer disease

Question 22

GORD

Answer 22

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

Question 23

Peptic ulcers

Answer 23

Can lead to scarring and strictures around the gastric cardia and lower oesophagus

Question 24

Drugs contributing to Dysphagia

Answer 24

1. Calcium channel blockers and nitrates - relax SM - can cause or exacerbate symptoms by decreasing oesophageal tone
2. NSAIDs, aspiring, steroids + bisphosphonates predispose to peptic ulceration

Question 25

5 features on examination

Answer 25

1. CN pathology- imp if features suggest ftnl dysphagia as pt may have bulbar palsy 2. Signs of GI malignancy 3. Neck mass 4. Features of CREST syndrome 5. Koilonychia : severe IDA, associated with Plummer-Vinson syndrome (oesophageal webs) but v rare

Question 26

GI malignancy signs

Answer 26

1. Cachetic 2. Palpable Virchow's node 3. Lymphadenopathy 4. If oesophageal carcinoma extends into cardia of STOMACH this may be palpable in thin pts 5. If metastasises to liver --> HEPATOMEGALY but uncommon

Question 27

Neck mass signs

Answer 27

1. Large pharyngeal pouch palpable in thin pts, and this may even gurgle on palpation 2. Goitre may also be palpable, causing dysphagia by extrinsic compression

Question 28

Adenocarcinoma

Answer 28

Subtype accounts for about 65% of oesophageal carcinoma in UK

Question 29

4 Ix for Dysphagia

Answer 29

1. Barium swallow 2. Endoscopy 3. Videofluoroscopy 4. Manometry

Question 30

Barium swallow indications

Answer 30

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

Question 31

Endoscopy indications

Answer 31

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

Question 32

Videofluoroscopy indications

Answer 32

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

Question 33

Manometry indications

Answer 33

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

Question 34

Staging oesophageal carcinoma

Answer 34

1. Spiral CT chest/abdo 2. Positron emission tomography (PET) scanning 3. Endoscopic US (EUS) 4. Laporoscopy

Question 35

Spiral CT chest/abdo

Answer 35

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

Question 36

PET scannings

Answer 36

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

Question 37

EUS

Answer 37

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

Question 38

Laparoscopy

Answer 38

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

Question 39

Oesophageal Cancer Tx options

Answer 39

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

Question 40

Prognosis for Oesophageal cancer

Answer 40

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

Question 41

Achalasia tx options

Answer 41

1. Pneumatic balloon dilatation 2. Surgical (Heller's) myotomy 3. Botox injections 4. Drugs

Question 42

Pneumatic balloon dilatation (Achalasia tx)

Answer 42

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%)

Question 43

Surgical (Heller's) Myotomy (Achalasia tx)

Answer 43

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)

Question 44

Botox injections (Achalasia tx)

Answer 44

Produces good results that lasts up to 1 yr, and may be favoured in pts unsuited to interventional therapy

Question 45

Drugs (Achalasia tx)

Answer 45

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

Question 46

RF for SCC

Answer 46

``` 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 ```

Question 47

RF for Adenocarcinoma

Answer 47

BO (hence any factor which predisposes to reflux oesophagitis) Smoking + alcohol intake are not as important as they are for SCC

Question 48

Types of Oesophageal cancer

Answer 48

1. Adenocarcinoma (incr incidence) 2. SCC (decr incidence) 3. Carcinoid 4. Small cell carcinoma 4. Leiomyoma

Question 49

Plummer - Vinson Syndrome

Answer 49

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

Question 50

Pathophysiology of Achalasia

Answer 50

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

Question 51

Ortner's syndrome

Answer 51

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

Question 52

Palliative tx options for oesophageal adenocarcinoma

Answer 52

1. Intubation with rigid silastic endoprosthesis or expandable metal stent 2. Endoscopic resection 3. Ablation with laser or argon beam plasma coagulation 4. Chemo 5. Radiotherapy 6. Psychological and social support

Question 53

Oesophageal cancer symptoms

Answer 53

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

Question 54

Complications of oesophagectomy

Answer 54

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