B5.062 Dysphagia

Question 1

is dysphagia a disease?

Answer 1

no

its an alarm symptom that warrants a prompt evaluation to investigate the cause and initiate therpay

Question 2

reasons for dysphagia

Answer 2

may be due to a structural or motility abnormality in the passage of solid and/or liquids from the oral cavity to the stomach

Question 3

range of patient complaints regarding dysphagia

Answer 3

inability to initiate swallow

sensation of items stuck in esophagus

Question 4

definition of dysphagia

Answer 4

subjective sensation of difficulty or abnormality of swallowing

Question 5

classification systems related to dysphagia

Answer 5

acute vs nonacute
oropharyngeal vs esophageal
solids, liquids, or both
progressive vs intermittent
structural/mechanical vs motor/motility vs others
associated symptoms

Question 6

acute dysphagia

Answer 6

inability to swallow solids and/or liquids, including secretions, suggests impaction of a foreign body in the esophagus
requires immediate attention

Question 7

epidemiology of acute dysphagia

Answer 7

males > females
increased with age (esp after 70)
meat most common offending agent

Question 8

odynophagia

Answer 8

painful swallowing

Question 9

possible causes of odynophagia not related to impaction

Answer 9

pharyngitis
infectious cold/candida/HSV
pill induced ulcer/abrasion

Question 10

globus sensation

Answer 10

lump in throat feeling
no actual lump
non painful
no dysphagia
typically worse swallowing saliva than food/liquid
not due to structural or motility disorder

Question 11

questions to ask pts with dysphagia?

Answer 11

initiation or getting stuck?
coughing/choking?
solids, liquids, both?
how long?
location?
other symptoms?
medical problems? surgery? radiation? medications?

Question 12

symptoms of oropharyngeal dysphagia

Answer 12

difficulty initiating a swallow
coughing
choking
aspiration
regurgitation
drooling, food spillage. sialorrhea, dysarthria

Question 13

common causes of oropharyngeal dysphagia

Answer 13

often neuromuscular dysfunction

• vagus nerve
• MS
• cerebrovascular accident
• transverse myelitis

Question 14

oral dysfunctions resulting in dysphagia

Answer 14

mastication (cranial nerve involvement)

decreased saliva production

Question 15

pharyngeal dysfunctions resulting in dysphagia

Answer 15

neuromuscular
UES, decreased relaxation
Zenkers

Question 16

common complaints with esophageal dysphagia

Answer 16

difficulty swallowing several seconds after initiation of the swallow
sensation that foods and/or liquids are obstructed/stuck in the passage from upper esophagus to the stomach

Question 17

classes of mechanical lesions causing esophageal dysphagia

Answer 17

intrinsic: occurring within esophagus
extrinsic: outside esophagus but affecting function

Question 18

solids + liquids dysphagia

Answer 18

motor disorder

Question 19

just solid dysphagia

Answer 19

mechanical obstruction

Question 20

intermittent motor disorder etiologies

Answer 20

primary and secondary esophageal motility disorders

Question 21

progressive motor disorder etiologies

Answer 21

scleroderma (chronic heartburn)

achalasia

Question 22

nonprogressive mechanical obstruction etiologies

Answer 22

esophageal ring/ eosinophilic esophagitis

foreign body

Question 23

progressive mechanical obstruction etiologies

Answer 23

peptic stricture (chronic heartburn)
esophageal/ cardia cancer

Question 24

why would you do a barium swallow instead of an EGD

Answer 24

if youre worried about damaging the esophagus

history of prior radiation, caustic injury, surgery for cancer, complex stricture

Question 25

what additional testing is used for dysphagia if motility disorder is suspected

Answer 25

esophageal manometry

Question 26

purpose of EGD

Answer 26

diagnostic and therapeutic | can view, biopsy, and manipulate/grab

Question 27

when do you do a pre-endoscopy barium esophagram

Answer 27

suspect proximal esophageal lesion | known complex stricture

Question 28

when do you do a post-endoscopy barium esophagram

Answer 28

after negative EGD if mechanical obstruction is still suspected lower esophageal rings or extrinsic esophageal compression can be missed on upper endoscopy

Question 29

what is achalasia

Answer 29

loss of peristalsis in distal esophagus | incomplete relaxation of LES with swallowing

Question 30

epidemiology of achalasia

Answer 30

any age (usually 25-60) women and men equal frequency progressively worsening dysphagia of solids and liquids

Question 31

symptoms of achalasia

Answer 31

regurgitation and aspiration | chest pain, heartburn, and difficulty belching

Question 32

barium findings in achalasia

Answer 32

dilated esophagus terminating in a 'bird-beak" narrowing aperistalsis poor emptying of barium from esophagus

Question 33

what is systemic sclerosis (scleroderma)

Answer 33

group of conditions linked by presence of thickened, sclerotic lesions esophageal involvement in up to 90% of patients

Question 34

esophageal manifestation of scleroderma

Answer 34

involves smooth muscle layer, resulting in atrophy and sclerosis of distal 2/3 of esophagus (proximal, striated muscle is normal)

Question 35

symptoms of scleroderma

Answer 35

heartburn and progressive dysphagia | secondary to motility abnormality and/or peptic stricture

Question 36

manometry findings in scleroderma

Answer 36

absent peristalsis and low/absent LES pressure

Question 37

EGD findings in scleroderma

Answer 37

may show erosive esophagitis or peptic stricture from chronic acid reflux

Question 38

causes of esophageal strictures

Answer 38

acid reflux, radiation, eosinophilic esophagitis, caustic ingestions, surgical adhesions

Question 39

goal for stricture treatment

Answer 39

relief of dysphagia and prevention recurrence | dilation + acid suppression

Question 40

treatment for stricture secondary to acid reflux

Answer 40

EGD and dilation performed together

Question 41

treatment of complex stricture

Answer 41

barium studies first | if these raise suspicion, diagnostic endoscopy may be required prior to dilation

Question 42

what are esophageal webs/rings

Answer 42

thin structures that partially occlude the esophageal lumen most are asymptomatic but can present with intermittent dysphagia to solids usually mucosal, rarely musclar

Question 43

how are esophageal webs/rings diagnosed

Answer 43

barium or EGD (less sensitive) webs often rupture during EGD and can be dilated rings should be biopsied before dilation

Question 44

plummer vinson syndrome

Answer 44

triad: iron deficiency anemia, dysphagia, esophageal web

Question 45

Schatzki ring

Answer 45

most common esophageal ring | narrow mucosal ring often associated with hiatal hernia

Question 46

esophageal carcinoma

Answer 46

presents with rapidly progressive dysphagia (solids only initially) an achalasia like syndrome (pseudoachalasia) has been described in patients with adenocarcinoma of the cardia due to microscopic infiltration of the myenteric plexus or vagus nerve

Question 47

symptoms of esophageal carcinoma

Answer 47

``` chest pain odynophagia anemia anorexia significant weight loss ```

Question 48

risk factors for esophageal carcinoma

Answer 48

alcohol, achalasia, Barrett's esophagus, cigarettes, diverticula, esophageal web, esophagitis, familial

Question 49

what is eosinophilic esophagitis

Answer 49

allergic reaction to food or allergens | all ages

Question 50

symptoms of eosinophilic esophagitis

Answer 50

``` dysphagia food impaction regurg/vomiting chest/upper abdominal pain refractory heartburn ```

Question 51

endoscopic findings in eosinophilic esophagitis

Answer 51

stacked circular rings proximal strictures whitish papules increased eosinophils on biopsy

Question 52

treatment for eosinophilic esophagitis

Answer 52

elimination diet steroid acid suppression

Question 53

functional dysphagia

Answer 53

sensation of a solid and/or liquid food sticking or passing abnormally through esophagus no evidence of mucosal or structural abnormality no evidence of GERD or eosinophilic esophagitis no evidence of esophageal motor disorder

Question 54

sjogrens syndrome

Answer 54

chronic autoimmune inflammatory disorder characterized by: decreased lacrimal and salivary gland function results in dry eyes and mouth

Question 55

how is Sjogrens related to dysphagia

Answer 55

3/4 of patients have associated dysphagia defective peristalsis has been demonstrated in 1/3 of patients with primary Sjogrens dry mouth exacerbates swallowing discomfort but does not appear to correlate with dysphagia

Question 56

Zenker's diverticulum

Answer 56

false diverticulum | herniation of mucosal tissue at the junction of the pharynx esophagus because of a defect in the muscular wall

Question 57

symptoms of Zenkers

Answer 57

``` oropharyngeal dysphagia halitosis obstruction regurgitation aspiration ```