8.1 (10.1) Dysphagia, dyspepsia, and hiccup Flashcards
A patient presents with a sensation of food getting stuck in her throat and then coming out her nose. What are the two types of dysphagia and what type does she likely have?
oropharyngeal dysphagia - difficulty initiating swallow - as a result of difficulty transferring either food/fluid from either the mouth to the pharynx or from the pharynx to the oesophagus
Esophageal dysphagia - food bolus does not easily traverse upper esophagus - due to narrowing of the lumen of the oesophagus, impaired motor function, or altered oesophageal sensation.
Oropharyngeal dysphagia
List four complications of oropharyngeal dysphagia
aspiration and respiratory complications*
malnourishment*
dehydration*
poorer survival
death*
airway obstruction
chemical pneumonia
What are 2 phases of swallowing? Which is under voluntary control?
What types of muscles are located under the esophagus?
The initial phase (oral phase) is under voluntary control.
The next stage (transfer phase) where the tongue pushes solid/fluid bolus is pushed back into the pharynx. The involuntary swallow response is evoked when the bolus enters the hypopharnyx -> the larynx is elevated and pushed anteriorly, opening the upper esophageal sphincter. The lower esophageal sphincter relaxes and triggers peristaltic wave (2 purposes: clear residual bolus in the pharynx and propel bolus through the esophagus and into stomach).
Cervical esophagus -> striated muscle
Thoracic esophagus -> smooth muscle
List four causes of oropharyngeal dysphagia
◆ Poor dentition
◆ Structural: malignancy, enlarged thyroid, Zencker’s diverticulum
◆ Myopathic: dermatophytosis, muscular dystrophy, polymyositis, myasthenia gravis, thyroid disease
◆ Iatrogenic: medications that must result in a myopathy (botulin toxin, procainamide, amiodarone, statins, vincristine), medications that inhibit saliva (opioids, tricyclic antidepressants, phenothiazines, atropine, hyoscine), radiotherapy, surgical procedures of head and neck
◆ Neurological: CVA, ALS, MS, dementia, Parkinson, brainstem tumours, bulbar poliomyelitis, neuropathy (diabetes, alcohol, cachexia)
◆ Anxiety
VINDICATE NP
List 4 causes of esophageal dysphagia
◆ Structural: stricture secondary to reflux, diverticula, esophageal/gastric malignancy, benign tumours, external vascular compression, mediastinal masses, foreign body
◆ Mucosal injury due to: medications (NSAIDs, alendronate, ascorbic acid, ferrous sulphate, antibiotics, theophylline), infections (candidiasis, cytomegalovirus, HIV), allergic disorders (eosinophilic oesophagitis), skin disorders (pemphigus vulgaris, pemphigoid, epidermolysis bullosa dystrophica)
◆ Vascular: ischaemic oesophagus
◆ Neuromuscular: achalasia, oesophageal spasm, scleroderma, SLE, RA, IBD
FS
GAS (GERD, achlasia, stricture)
+
V - ischemia
I - infection (fungal)
N - cancer
D - strictures
I - meds - nsaids, iron
C
A - EE
T - trauma
E
N - achalasia, esophageal spasm
P
How common is oropharyngeal dysphagia in older populations?
40-50% of aged care resident
List 5 clinical presentations of oropharyngeal dysphagia and 2 of esophageal dysphagia.
What is the relationship between food/fluid thickness and how they cause problems in each type of dysphagia?
Oropharyngeal dysphagia:
(1) difficulty initiating swallow and then having to swallow repeatedly to effect pharyngeal clearance
(2) coughing on swallowing (typically due to aspiration)
(3) nasopharyngeal regurgitation
(4) hoarse voice
(5) sense of food being ‘stuck’ (both types)
More difficult to swallow thin fluids rather than solids
Esophageal dysphagia:
-symptoms localized to chest
-chest pains
-sense of food being ‘stuck’ (both types)
More difficult to swallow solids rather than liquids
What are the three most useful investigations to assess dysphagia in a patient? What are other initial investigations to order?
barium videofluoroscopy (i.e. barium swallow) - visualize all phases of swallowing, risk of aspiration
flexible endoscopic evaluation of swallow - viewing pharynx and larynx, not as comprehensive and cannot see oral phase of swallowing
esophageal manometry - quantify pharyngeal swallowing strength and whether upper esophageal sphincter relaxes appropriately, should be used in combination of above 2 tests
initial investigations: BWK to assess malnutrition/dehydration, CT/MRI if acute onset, CXR to exclude pneumonia
2 investigations specific to esophageal dysphagia
Gastro-esophageal endoscopy - allows visualization of mucosa, allows biopsies to be taken and dilatation/stent placement; main risk of perforation
Esophageal pH monitoring - best tool to diagnose reflux
What cranial nerves should be assessed when examining a patient with dysphagia
V and VII-XII
3 main assessments/clarifications needed to create management plan for dysphagia
- Oropharyngeal or esophagus issue
- Acute or chronic
- Overall patient prognosis
A patient with a long prognosis is found to have non-reversible dysphagia. A discussion is undertaken about a PEG placement. The patient wants to know three complications of malnourishment if PEG is not placed.
Deteriorating performance status
anaemia
increased risk of pressure sores
impaired wound healing
accelerated osteoporosis
Inadequate hydration also places people at risk of metabolic complications and aspiration, increasing the risk of pneumonia (salivary flow may be reduced therefore altering the normal flora of the oropharynx)
What are 4 general management techniques for OROPHARYNGEAL dysphagia when life is measured in months to years
◆ Oral hygiene - regular mouth wash and artificial salvia
◆ Diet changes: pureed diet (avoid hard or chewy foods), thickened
fluids, nutritional support, adequate fluid intake to maintain hydration
◆ Modification of swallowing behaviours: sitting upright, increasing number of chews/swallows, taking fluids from a spoon, turning the head to one (stronger) side to swallow, ensuring residual food is removed from the oral cavity
◆ Avoid medications likely to contribute to a dry mouth
◆ SLP to provide targeted exercise routine to improve swallowing safety - lip, tongue, jaw, vocal cord adduction exercises
◆ Electrical stimulation - along with exercise
◆ Compensatory techniques
◆ Surgery - laryngeal closure, laryngotracheal separation-diversion
◆ Parenteral or enteral feeding
FS:l
(1) Tx underlying condition (eg meds, surgery)
(2) Tx symptoms
- diet changes
- good oral hygiene
- position/ swallowing / SLP
(3) Tx complications
- enteral / parenteral feeds
What are 4 general management techniques for OROPHARYNGEAL dysphagia when life is measured in weeks
Tx source:
◆ Avoidance of medications likely to contribute to sedation
Tx symptoms:
◆ Positioning
◆ Diet modification
◆ Oral care (cleaning after meals, improve dry mouth)
What are 3 general management techniques for OROPHARYNGEAL dysphagia in the final stages of life
◆ Diet as tolerated.
◆ Oral hygiene
◆ Family education and reassurance
FS:
Tx underlying (meds)
Tx symptoms
- diet modification
- education
- Mouth care
- Position
What are 4 general management techniques for ESOPHAGEAL dysphagia when life is measured in months to years
General
◆Diet modification
◆Enteral feeds
Treating underlying cause
◆GERD: PPI, H2 blockers, antacids, sulcrate, maxeran/domperidone
◆Stricture: Stenting, dilation
◆Achalasia: Botox
FS
Tx underlying condition (GAS above)
Tx symptoms
- diet
- position*
Tx complication
- feeds
What are 4 general management techniques for ESOPHAGEAL dysphagia when life is measured in weeks
Tx source
◆Medication
◆Dilatation
◆Stenting
Tx symptoms
- Diet modification
What are 2 general management techniques for ESOPHAGEAL dysphagia in the final stages of life
◆Diet
◆Medication
For esophageal strictures - when to dilate versus to stent
Dilate if:
- simple stricture (< 2 cm long, straight and endoscope can pass easily)
(Common for pts to need 3 min dilatations, if more than 7 attempts - considered resistant)
Stent if:
- complex stricture
What are 3 general approaches to the management of BENIGN esophageal strictures?
dilatation
stent placement
treat underlying cause
What are 4 general approaches to the management of MALIGNANT esophageal strictures?
dilatation - if life expectancy is VERY short
stent placement - offered alone if prognosis <3months
treat underlying cause
+ adjuvant radiotherapy or brachytherapy <3 month prognosis
Stenting MALIGNANT esophageal stricture - what % of patients are likely to develop problems within first 2 months? What % of these patients will have successful re-stenting?
40%
90% of the 40%
How is percutaneous gastrostomy tube inserted through the abdo wall?
- Surgical gastrostomy (requires general anesthetic)
- Endoscopic gastrostomy (requires sedation)
- Image-guided gastrostomy insertion by IR (will need NG tube to inflate stomach so that it is visible on Xray)
What are 3 acute complications from feeding tube insertion?
What are 4 longer term complications from having a feeding tube insitu?
What percentage of patients won’t survive 12 months following PEG tube placement?
What is an absolute contraindication to PEG tube placement?
Feeding tube insertion complications
- bleeding
- infections
- peritonitis
- perforation of other abdominal organs.
PEG tube complications
- aspiration/asp PNA/chemical PNA (10%)*
- tube leakage
- tube removal, displacement or migration*
- bleeding*
- gastric mucosal overgrowth or ulceration
- metabolic and biochemical complications such as re-feeding syndrome*
- GI side effects
- microbial contamination of the feeds*
Approximately 50–60% of people are unlikely to survive 12 months after enteral feeding is commenced.
Short life expectancy is absolute contraindication (FS: BO?)
A patient has a stent placed for an esophageal stricture. What are 3 possible complications you will warn them about?
pain*
stent migration*
stent obstruction (benign overgrowth, malignant overgrowth, food)
reflux (complicated by asp pna)
fistula formation (esp if proximal stricture)*
difficulty removing the stent*
A patient has brachytherapy (passing applicator to the esophagus) for a malignant stricture. What are 3 possible complications you would warn them about?
esophagitis
fistula formation
stricture formation
List 3 management strategies of eosinophilic esophagitis
identifying allergen
trial of inhaled steroids
oral steroids
List 4 treatments for management of esophageal spasm
botulism toxin injection
Smooth muscle relaxants (buscopan)
TCA
calcium channel blockers (nitrate)
sildenafil (phosphodiesterase 5 inhibitor aka viagra) - complicated by headache and vertigo
Other than the use of PPI and H2 blockers, what are 3 adjuvant treatments for GERD and 1 non-pharm management
antacids - during intermittent exacerbations (e.g. almagel, tums, pepto bismol)
sucralfate - barrier therapy
prokinetic agents (maxeran, domperidone)
baclofen - inhibiting reflux
avoid foods that impair gastric emptying
What are up to four cardinal features of dyspepsia?
What is dyspepsia a disease of?
epigastric pain
epigastric burning
postprandial fullness
early satiety
It is a disease of gastric motility
What are two major categories of etiology for dyspepsia
- functional - patients present with complex symptoms of pain, burning, early saties, fullness but no clearly identifiable cause
- secondary to underlying condition
List four secondary causes of dyspepsia
Secondary:
◆ Esophagitis secondary to medications: Iron, NSAIDs, steroids, opioid, theophylline, digoxin, antibiotics, calcium channel blockers, nitrates, bisphosphonates
◆ GERD
◆ Peptic ulcer disease: H. pylori, NSAIDS
◆ Malignancy: oesophageal cancer, gastric cancer
◆ Coeliac disease
Dyspepsia like symptoms
◆ Infection/inflammatory
◆Infiltrative
◆gastroparesis (drugs, diabetes, metabolic, cancer)
◆other (idiopathic, post-surgical, paraneoplastic)
FS:
V
I
N - esophageal, gastric cancer
D -
I - meds that cause esophagitis - NSAIDs, steroids or decrease motility - anticholinergic
C
A - esophagitis
T
E - diabetes
N - stroke, Parkinson
A - GERD, achalasia, stricture, GOO, PUD, adhesions, ascites
P - psych
What 3 minimum investigations to order to exclude secondary causes of dyspepsia (suggesting functional dyspepsia)?
◆ Upper GI endoscopy
◆ H pylori assessment
◆ 24h Esophageal pH monitoring
A patient is found to have functional dyspepsia. What are 3 diet recommendations?
- smaller more frequent meals
- avoid foods with high fat
- avoid foods that aggravate symptoms
A patient is diagnosed with functional dyspepsia. What are three meds you would consider trying?
PPI*
prokinetic - metoclopramide, domperidone*
Mirtazapine*
TCA
buspirone - anti anxiety, to relax gastric fundus
acotiamide - muscarinic receptor antagonist, cholinesterase inhibitor
What are 3 medications and 3 non-pharm recommendations for functional dyspepsia when life is measured in months-years?
◆ Oral PPIs or H2 antagonists for pain or burning
◆ Prokinetics when early satiety is a feature
◆ Antidepressants
◆ Dietary advice
◆ Positioning
◆ Supportive counselling
What are four recommendations for dyspepsia when life is measured in weeks?
◆ Dietary advice
◆ Positioning
◆ Oral PPI or H2 antagonists for pain or burning
◆ Prokinetics.
What are two treatments for dyspepsia when life is measured in hours
◆ Parenteral PPI, H2 antagonists
◆ Parenteral metoclopramide
What is a hiccup? What is the hiccup reflex arc?*
Hiccup = sharp involuntary contractions of inspiratory muscles -> sudden sharp inspiration + closure of the glottis (sound is caused from column of air evoked by diaphragmatic contraction hitting closed glottis)
Hiccup reflex arc = afferent limb, efferent limb and central component
◆Afferent limb - phrenic nerve, vagus nerve, sympathetic chain
◆Central component - connections to 4th cerebral ventricle, resp centre in brainstem, medial reticular formation, hypothalamus, phrenic nerve nuclei
◆Efferent limb - phrenic nerve to diaphragm,
made up of 3 parts : afferent limb, central component ( Midbrain connections) and the efferent limb= carrying motor fibers to the diaphragm and IC muscles .
What are two neurotransmitters most likely implicated in neuromodulation of hiccups
dopamine + gamma-aminobutyric acid (GABA)
List four central (CNS) causes of hiccups
◆ Vascular: cerebral aneurysm, ischaemic stroke, haemorrhagic
stoke
◆ Space-occupying lesion: cerebral tumours, cerebral abscess
◆ Head trauma
◆ Encephalitis
◆ Neurodegenerative: multiple sclerosis, Parkinson’s disease.
VINDICATE NP
List three terms that categorize hiccups by duration
less than a few minutes - bout
>48h - protracted
> 1 month - intractable
Investigations of protracted hiccups
What could be abnormal on bwk?
BWK: renal failure, uremia, low Na, low K, low Ca
Imaging per differential
List five peripheral causes of hiccups
◆◆◆ Oesophageal: oesophageal dilatation, achalasia, food impaction, tumours
◆◆◆ GI: gastric distension, gastritis, reflux, peritoneal traction, SBO, ascites
◆◆◆ Respiratory: diaphragmatic irritation (pneumonia, pleural effusion, malignancy), subphrenic abscess
◆◆◆ Hepatic: liver metastases, primary liver cancers, hepatic abscess, cholecystitis
◆◆◆ Cardiovascular: myocardial ischaemia
◆ Toxic/metabolic: renal failure, alcohol intoxication, electrolyte disturbances, hypoadrenalism
◆ Infectious: herpes zoster, gastrointestinal candidiasis
◆ Iatrogenic: benzodiazepines, opioids, corticosteroids, chemotherapy (e.g. cisplatinum)
◆ Perioperative: intubation, general anaesthesia, mechanical
ventilation
◆ Psychological: anxiety, distress
FS:
Dyspepsia causes + lung + liver + heart
What is the relationship between arterial CO2 and hiccup frequency? What is the implication for this in terms of treatment
Hiccup frequency slows when arterial CO2 is high
Hold your breath/breath into a paper bag and stop hiccups (increase PaCO2)
After how many hours of hiccups would you consider initiation of pharmacotherapy
Protracted - >48h
What are four complications from intractable hiccups
sleep disturbances*
daytime drowsiness
cognitive dysfunction
worsen fatigue*
skeletal muscle fatigue
interfere with capacity to eat and drink*
vomiting
aspiration and pneumonia
in a patient with a tracheostomy may lead to respiratory alkalosis secondary to hyperventilation
mood disturbance - anxiety/depression*
significant distress and anxiety to pt and family/informal caregivers*
List five pharm tx for hiccups (see table 8.1.2 for rationale)
Dopamine antagonists: Chlorpromazine, Haloperidol, Metoclopramide
Ca-channel blockers: Gabapentin (Ca-channel blocker)
Anti-convulsants: Phenytoin, Sodium valproate, Carbamazepine
Antispasmodics: Baclofen
Corticosteroid: Dexamethasone
Anti-arrhythmia: Nifedipine (Ca-channel blocker), IV lidocaine (Na-channel blocker)
Benzodiazepines: Midazolam
Nebulized lidocaine
Neurostimulant: Methylphenidate
How is gabapentin proposed to treat hiccups
Inhibiting calcium channel -> increasing GABA release -> modulates diaphragmatic excitability
inhibiting the inspiratory muscles mediated by endogenous GABA or [17] by reducing the calcium influx to the muscles.
List four non pharm strategies for hiccups
Traction on the tongue *
Stimulation of the palate or pharynx with a cotton applicator *
Lifting the uvula with a spoon
Gargling or drinking ice water *
——-
Performing a Valsalva manoeuvre *
Breath holding *
Breathing into a paper bag *
—-
Digital rectal massage*
—-
Sudden fright
Vagal nerve stimulation using nerve stimulator
Acupuncture
