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Semester 4 > Case 1 - swallowing and dysphagia > Flashcards

Case 1 - swallowing and dysphagia Flashcards

1
Q

what are the three phases of normal swallowing

A

oral phase
pharyngeal phase
oesophageal phase

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2
Q

what is included in the oral phase

A

striated muscle
neural control is by the cortex and the medulla
full voluntary control

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3
Q

what is included in the pharyngeal phase

A

striated muscle
medulla neural control
some voluntary control

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4
Q

what is included in the oesophageal phase

A

striated/smooth muscle
medulla/ENS neural control
no voluntary control

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5
Q

what occurs in the oral phase

A

components for the preparation of bolus and initiation of swallowing

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6
Q

what is chewing

A

prepares solid food for transfer through the pharynx

the effectors are the teeth, jaws, and masseter muscles

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7
Q

what is salivation

A

lubricates bolus and begins digestion

the effectors are mucus, amylase, lipase, water and HCO3-

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8
Q

what is the movement of bolus

A

delivers prepared bolus to oropharynx

the effectors are the tongue

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9
Q

bolus transfer from the mouth to the oesophagus

A
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10
Q

what are the boundaries of the sphincters defined by and what do they prevent

A

defined by sphincters and these sphincters prevent influx of air and reflux of gastric contents into the oesophagus

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11
Q

what is the atmospheric pressure

A

0mmHg

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12
Q

what is the upper oesophageal sphincter pressure

A

100mmHg

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13
Q

what is the intraoesophageal pressure

A

-5mmHg

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14
Q

what is the lower oesophageal sphincter pressure

A

20mm

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15
Q

what is the intragastric pressure

A

5mmHg

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16
Q

what prevents reflux

A

the lower oesophageal sphincter having a higher pressure than the intragastric one

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17
Q

neuroanatomy of swallowing diagram

A
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18
Q

what is the nucleus solitarious

A

primary an afferent relay centre in the medulla

19
Q

what is the nucleus of trigeminal

A

output from this system and have the dorsal motor nucleus and nucleus ambigous

20
Q

what is the the nucleus ambiguous to do with

A

swallowing

21
Q

what is transcranial magnetic stimulation used for

A

to oversee this action and tell us about the integrity of this system

22
Q

what is oropharyngeal dysphagia

A

abnormal bolus transfer to the oesophagus

difficulty initiating a swallow

only one manifestation of the primary disease e.g stroke

23
Q

what is oesophageal dysphagia

A

abnormal bolus transport through the oesophagus
Food stops after initiation of swallow
Oesophagus is the location of the primary disease e.g achalasia

24
Q

what are the methods used to look at swallowing

A

VFS
fiberoptic endoscopic examination of swallowing

25
Q

dysphagia after a stroke

A

common - 50% of all stroke victims
Usually oropharyngeal
30% increased risk of mortality
Aspiration most important complication
Natural swallowing recovery in majority
Decisions about alternative feeding difficult
Optimal timing
Method of delivery
treatment options limited
SALT

26
Q

what side of the brain takes on the swallowing mechanism after a stroke

A

the non-dominant side of the brai

27
Q

what allows pressure to be used to measure the swallow in the oesophagus and the sphincters

A

manometry

28
Q

what is manometry

A

More precise measurement of upper GI motility
Catheters with multiple sensors <2cm apart (24+ arrays)
Spatiotemporal or topographic plot of pressure data (Clouse Plots)
Evolutionary technology

29
Q

what is Clouse plot

A

display method can Improve accuracy and speed of recognition of motility disorders even in manometry-naive individuals
It is a coloured plot
We get location, temporal and pressure information

30
Q

what is achalasia

A

failure of a ring of muscle fibres such as a sphincter of the oesophagus, to relax

31
Q

what gene is achalasia associated with

A

HLA-DQw1

32
Q

what suggests that alchasia may be autoimmune

A

circulating antibodies to enteric neurone s

33
Q

what is the prevalence of achalasia

A

annual incidence of approx 1 case per 100,000
Men = women
Onset before adolescence unusual
Usually diagnosed between the ages of 25 and 60 years

34
Q

what is used to diagnose achalasia

A

clinical history
Endoscopy
Radiology
Manometry
In one series of 87 consecutive patients with newly diagnosed achalasia, the mean duration of symptoms was 4.7 years

35
Q

what would endoscopy reveal

A

may reveal a dilated oesophagus containing residual material
May appear normal
Oesophageal stasis predisposes to candida infection that may be apparent

36
Q

what would be the radiology findings

A

barium swallow diagnostic accuracy around 95%
Dilated oesophagus with beak like narrowing
Dilation may be so profound that the oesophagus assumes a sigmoid shape
Fluoroscopy reveals the absence of peristalsis
Purposeless, spastic contractions can be observed - some radiologist call this vigorous achalasia

37
Q

what would manometry show

A

manometric examination is usually required for confirmation
Three primary findings:
Elevated resting LES pressure - above 45mmHg
Incomplete LES relaxation - this manometric finding distinguishes achalasia from other disorders associated with aperistalsis
aperistalsis - in the smooth muscle portion of the body of the oesophagus. For most patients, low amplitude; in some cases, however, the simultaneous oesophageal contractions have higher amplitudes (>60mmHg) such patients are said to have vigorous achalasia.

38
Q

what is botulinum toxin

A

endoscopic injection of BT (type A) into the lower oesophageal sphincter.

39
Q

mechanism of action of botulinum toxin

A

inhibits the calcium dependent release of acetylcholine from nerve terminals, thereby countering the effect of the selective loss of inhibitory neurotransmitters

40
Q

is botulinum toxin effective

A

it is initially effective in relieving symptoms, in about 85% of patients.

symptoms recur in more than 50% of patients within 6 months, possibly because of regeneration of the affected receptors

41
Q

what is pneumatic dilation

A

most effective non-surgical treatment for achalasia

involves placing a balloon across the lower oesophageal sphincter, which is then inflated to a pressure adequate to tear the muscle fibres of the sphincter

42
Q

what is Hellers Myotomy

A

involves carrying out an anterior myotomy across the lower oesophageal sphincter

however, whether myotomy should be combined with an antireflux procedure is a cause for debate

43
Q

how are myotomies usually carried out

A

laparoscopically through the abdomen with a 1-2c distal myotomy onto the stomach

44
Q

what is the major complication of Hellers myotomy

A

uncontrolled gasto-oesophageal reflux in 10% of patients

Semester 4 (80 decks)

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