[9] Dysphagia

Question 1

How long is the oesophagus?

Answer 1

25cm

Question 2

How long is the distance from the oesophageal junction to the lips?

Answer 2

40cm

Question 3

Where does the oesophagus start?

Answer 3

At the level of the cricoid cartilage (C6)

Question 4

Where does the oesophagus lie in the neck?

Answer 4

In the visceral column

Question 5

Where does the oesophagus run after the neck?

Answer 5

In the posterior mediastinum

Question 6

Where does the oesophagus pass through the diaphragm?

Answer 6

At the right crus of the diaphragm, at T10

Question 7

How long does the oesophagus continue in the abdomen before entering the cardia?

Answer 7

2-3 cm

Question 8

Where are the locations of narrowing of the oesophagus?

Answer 8

Level of cricoid
Posterior to left main bronchus and aortic arch
Lower oesophageal sphincter

Question 9

What is the oesophagus divided into?

Answer 9

3rd

Question 10

What do the divisions of the oesophagus represent?

Answer 10

Change in musculature, from striated, to mixed, to smooth

Question 11

What is the oesophagus lined by?

Answer 11

Non-keratinising squamous epithelium

Question 12

What is the Z-line?

Answer 12

Transition from squamous epithelium to gastric columnar

Question 13

What are the categories of causes of dysphagia?

Answer 13

Inflammatory
Neurological/motility disorders
Mechanical obstruction

Question 14

What are the inflammatory causes of dysphagia?

Answer 14

Tonsillitis or pharyngitis
Oesophagitis
Oral candidiasis
Apthous ulcers

Question 15

Give two examples of causes of oesophagitis

Answer 15

GORD

Candida

Question 16

What are the local neurological/motility causes of dysphagia?

Answer 16

Achalasia
Diffuse oesophageal spasm
Nutcracker oesopahgus
Bulbar/pseudobulbar palsy

Question 17

What can cause a bulbar/pseudobulbar palsy?

Answer 17

CVA

Motor neurone disease

Question 18

What are the systemic neurological causes of dysphagia?

Answer 18

Systemic sclerosis

Myasthenia gravis

Question 19

What are the categories of mechanical oesophagus obstruction?

Answer 19

Luminal
Mural
Extra-mural

Question 20

What can cause luminal obstruction of the oesophagus?

Answer 20

Foreign body

Large food bolus

Question 21

What can cause mural obstruction of the oesophagus?

Answer 21

Benign strictures
Malignant strictures
Pharyngeal pouch

Question 22

What can cause benign oesophageal strictures?

Answer 22

Web, e.g. Plummer Vinson
Oesophagitis
Trauma, e.g. OGD

Question 23

Where can malignant strictures occur causing dysphagia?

Answer 23

Pharynx
Oesophagus
Stomach

Question 24

What are the extra-mural causes of oesophageal obstruction?

Answer 24

Retrosternal goitre
Rolling hiatus hernia
Lung cancer
Enlarged mediastinal lymph nodes
Thoracic aortic aneurysm

Question 25

Give an example of something that can cause enlarged mediastinal lymph nodes

Answer 25

Lymphoma

Question 26

How is dysphagia investigated?

Answer 26

Upper GI endoscopy Ba swallow Manometry

Question 27

What is a pharyngeal pouch also known as?

Answer 27

Zenker's Diverticulum

Question 28

What is a pharyngeal pouch?

Answer 28

An outpouching between crico- and thyro-pharyngeal components of the inferior pharyngeal constrictor

Question 29

What is the area of weakness where a pharyngeal pouch can form called?

Answer 29

Killian's dehiscence

Question 30

In what direction does a pharyngeal pouch occur?

Answer 30

The defect usually occurs posteriorly, but the swelling usually bulges to the left side of the neck

Question 31

How does a pharyngeal pouch lead to dysphagia?

Answer 31

Food debris leads to pouch expansion, which leads to oesophageal compression and therefore dysphagia

Question 32

How does pharyngeal pouch present?

Answer 32

Regurgitation Hallitosis Gurgling sounds

Question 33

How is a pharyngeal pouch managed?

Answer 33

Excision | Endoscopic stapling

Question 34

How does diffuse oesophageal spasm present?

Answer 34

Intermittent severe chest pain, with or without dysphagia

Question 35

What does barium swallow show in diffuse oesophageal spasm?

Answer 35

Corkscrew oesophagus

Question 36

How does nutcracker oesophagus present?

Answer 36

Intermittent dysphagia, with or without chest pain

Question 37

What happens in nutcracker oesophagus?

Answer 37

There is an increase in contraction pressure of the oesophagus, with normal peristalsis

Question 38

What is Plummer-Vinson syndrome?

Answer 38

When severe iron deficiency anaemia leads to hyperkeratinisation of the upper 3rd of the oesophagus, leading to web formation

Question 39

Why is Plummer-Vision syndrome significant?

Answer 39

It is a pre-malignant condition q

Question 40

What is the risk that Plummer-Vision syndrome will develop into SCC?

Answer 40

20%

Question 41

What are the causes of oesophageal rupture?

Answer 41

``` Iatrogenic Violent emesis Carcinoma Caustic ingestion Trauma ```

Question 42

What % of cases of oesophageal rupture are iatrogenic?

Answer 42

85-90%

Question 43

What are the iatrogenic causes of oesophageal rupture?

Answer 43

Endoscopy Biopsy Dilatation

Question 44

What is it called when the oesophagus ruptures due to emesis?

Answer 44

Boerhaave's syndrome

Question 45

What are the clinical features of oesophageal rupture?

Answer 45

Odonophagia Mediastinitis Surgical emphysema

Question 46

What are the symptoms of mediastinitis?

Answer 46

Tachypnoea Dyspnoea Fever Shock

Question 47

How is iatrogenic oesophageal rupture managed?

Answer 47

PPI NGT Abx

Question 48

How is oesophageal rupture managed when it the cause is not iatrogenic?

Answer 48

``` Resus PPI ABx Antifungals Debridement and formation of an oesophago-cutaneous fistula ```