Dysphagia Flashcards
Definition of dysphagia
Difficulty/inability in swallowing foods or liquids
-Oropharyngeal/ oesophageal
What is oropharyngeal dysphagia due to?
-Impaired food bolus formation or propagation into hypopharynx
Causes of oropharyngeal dysphagia
-Neuromuscular disorders
-Cerebrovascular events
-Mechanical obstruction in oral cavity or hypopharynx
-Decreased salivation
-Parkinson’s and Alzheimer’s disease
-Depression
What is oesophageal dysphagia caused by?
-Mechanical obstruction (benign or malignant stricture)
-Dysmotility disorders or secondary to gastro-oesophageal reflux
-Aspiration pneumonia
History clues in dysphagia in younger patients
-Chest pain during swallowing: oesophageal spasm
-Dysphagia for both liquids and solids= achalasia
-Consider food impaction eosinophilic oesophagitis
History clues in dysphagia in elderly patients
-Short duration progressive dysphagia for solids with regurgitation and weight loss= oesophageal cancer
-New onset hoarse voice and dysphagia= malignant infiltration of recurrent laryngeal nerve
-High dysphagia associated with regurgitation of undigested food from previous days= pharyngeal pouch
Scoring system parameters for predicting malignancy
-Advanced age
-Male gender
-Weight loss >3kg
-New onset dysphagia
-Localisation to chest
-Absence of acid reflux at presentation
Overview of achalasia
-Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
-P: dysphagia of both liquids and solids, heartburn, regurgitation of food
-I: oesophageal manometry (excessive LOS tone which doesn’t relax on swallowing), barium swallow (expanded oesophagus, birds beak), CXR (wide mediastinum, fluid level)
-M: pneumatic balloon dilation, Heller cardio myotomy (recurrent or persistent symptoms), intra-sphincteric injection of botulinum toxin, nitrates and calcium channel blockers?
Oesophageal cancer
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
Oesophagitis
There may be a history of heartburn
Odynophagia but no weight loss and systemically well
Oesophageal candidiasis
There may be a history of HIV or other risk factors such as steroid inhaler use
Pharyngeal pouch
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
Barium swallow with dynamic video fluoroscopy
Systemic sclerosis
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased
Myasthenia gravis
Other symptoms may include extraocular muscle weakness or ptosis
Dysphagia with liquids as well as solids
Causes of dysphagia by classification
-Extrinsic
=Mediastinal mass
=Cervical spondylosis
-Oesophageal wall
=Achalasia
=Diffuse oesophageal spasm
=Hypertensive lower oesophageal sphincter
-Intrinsic
=Tumour
=Stricture
=Oesophageal web
=Schatzki rings
-Neurological
=CVA
=Parkinson’s disease
=MS
=Brainstem pathology
=Myasthenia gravis
