Dysphagia Flashcards
Differential diagnosis for dysphagia?
Functional: "ACE - nut des les sem"
Achalasia
Chaga's
Esophageal spasm syndromes
Nutcracker esophagus
Diffuse esophageal spasm (DES)
Hypertensive lower esophageal sphincter
Non-specific elongated motor disorders
Mechanical disorders "HaNDS"
Hiatal hernia
Neoplasm
Diverticuli - Zenker, epiphrenic, traction
Stricture
Dysphagia
Disordered or difficulty swallowing
Achalasia
failure of relaxation of the LES
Mechanism of achalasia?
loss of vagal innervation of the esophageal body, LES resulting in incomplete relaxation
Triad of physiological findings in achalasia
- Atony and aperistalsis
- Dilatation
- Failure of LES to relax
Age of onset for achalasia and what increased risk happens?
30s-40s
Slightly increased risk of esophageal cancer
HPI for achalasia?
Dysphagia, difficulty swallowing liquids and solids, regurgitation, chest pain
Diagnostic test for achalasia?
Barium swallow - birds beak with proximal dilatation
Esophagoscopy - dilatation with retained food, mucosal evidence of retention esophagitis
Esophageal manometry - incomplete or absent LES
Treatment for Achalasia?
Medical: CCBs, Long acting nitrates for short period of time
Mechanical: Esophageal dilation 65-81% good response, Botulinum toxin - direct injection into LES via endoscopy
Surgical: Longitudinal esophagomyotomy from 1 cm below EG junction to 6 cm above EG junction with partial fundoplication. 80-95% relief
Chaga’s disease
- caused by Trypansoma cruzi which destroys myenteric plexus
- South America
- Indistinguishable from achalasia
What causes esophageal spasm disorders?
disruption of normal motility
HPI for esophageal spasm disorders?
Chest pain + dysphagia
- dysphagia to solids and liquids (functional) exacerbated by stress or liquids that are hot or cold.
- Neck pain radiates to neck or down arm
Diagnostic testing for Esophageal spasm disorders
Video esophogram - first step, r/o anatomic causes
Endoscopy - evaluate for anatomic or mucosal abnormalities, not helpful for spastic disorders
Manometry - gold standard to ID esophageal motor disorders, measure pressures for 24 hours.
24 hour pH Monitoring - differentiate spasm from GERD (both cause chest pain). Differentiate if dysphagia present with adequate acid suppression.
Tx for esophageal spasm disorders?
Medical: Diltiazem lowers distal contraction of esophagus and reduces chest pain in nutcracker esophagus
Nifedipine, hydralazine isosorbide for DES
Mechanical - dilitation only works for DES
Surgical - long esophageal myotomy - only for recurrent, <30% mealtime effectiveness
Name esophageal tumors:
Leiomyomas
Esophageal polyps
Squamous cell cancer
Adenocarcinoma
What age doe most leiomyomas occur? How many?
20-50 y/o, multiple in 3-10% of patients
HPI for benign tumor?
symptomatic when > 5 cm in diameter, dysphagia, vague retrosternal pain
Diagnosis for benign tumor?
Barium swallow
Esophagoscopy to r/o cancer
Endoscopic U/S - hypoechoic homogenous masses beneath intact mucosa
Tx for benign tumors
followed with periodic barium or endoscopic U/S
Symptomatic - enucleated with primary closure
HPI for esophageal polyps
80% in cervical esophagus
Respiratory obstruction, dysphagia, periodic regurgitation of polyp in mouth
Diagnosis for esophageal polyp?
Barium - huge filling defects simulating malignancy
Esophagoscopy - soft, mobile, covered by normal mucosa, easily missed.
Tx esophageal polyp?
Endoscopic - small polyps
Surgical - cervical esophagotomy to remove complete
PMH for esophageal cancer?
Achalasia GERD Barrets Esophageal burns Plummer vincent, Leukoplakia
PE for esophageal cancer?
Cervical or supraclavicular lymphadenopathy, abdominal masses, hepatomegaly.
Diagnosis for esophageal cancer?
“BBCEEus”
Barium swallow - irregular rigid narrowing of esophageal wall
Esophagoscopy - ID lesion wiht biopsy and brushings (obtains diagnosis in 95%)
Chest and abdominal CT: staging - assess local invasion, pulmonary, LN, liver, adrenal mets
Bronchoscopy - if upper or middle third of esophagus to deteromine invasion of tracheobronchial invasion contradiction to esophagectomy
Endoscopic ultrasound - assess depth of esophageal wall invasion, regional nodal status
Tx for esophageal cancer
75-80% present stage IV - palliation with mean survival 6-12 months
Surgical: Esophagectomy with gastric or intestinal reconstruction
Adjuvant chemo and radiation - controversial
Causes of stricture?
Caustic injury, reflux, esophagitis
HPI stricture
progressive dysphagia for solids, long history of hearburn with regurgitation if GERD
PMH stricture
Caustic injury or GERD
Diagnosis for stricture?
Barium
Endoscopy - biopsy to r/o cancer
Manometry and 24 hour pH study
Tx stricture
Mechanical: Dilatation
Surgery: Esophagectomy indicated when stricture lasts > 1year or perferation
Causes of GERD
-occurs due to loss of lower esophageal sphincter resistance permitting reflux of
gastric contents into the esophagus
-can be transient (gastric distension, increased intragastric or intraabdominal
pressure, delayed gastric emptying) or persistant.
HPI of GERD
HPI: Heartburn, dysphagia, regurgitation, chest pain, cough, hoarseness, asthma, pregnancy
How is gastroesophageal reflux disease diagnosed?
-Patients presenting for the first time with symptoms suggesting GERD may be tried on H2 blockers to see if symptoms abate.
-Failure of control of symptoms or immediate return of symptoms with cessation of therapy should prompt further workup to determine the diagnosis and severity of disease.
How is GERD diagnosed?
Barium swallow: may suggest reflux
Endoscopy: early identification of complications including Barrett’s esophagus
24-hour pH study: confirm abnormal presence of acid in the esophagus
Esophageal manometry: identify features predictive of severe disease such as LES deficiency and duodenogastroesophageal reflux.
Treatment for GERD?
Medical therapy: H2-blockers, Proton pump inhibitor
Surgical: manometry test to determine if enough power and esophagus to propel food. Barium swallow to exclude scarring
Nissen Fundoplication
Name the different types of hiatal hernias
Type I (sliding): leading edge of hernia at EG junction, which is displaced into the thorax, often no true hernia sac
Types II and III: paraesophageal hernias
Type II (rolling): EG junction is in normal intraabdomingal location and a hernia sac with portions of the stomach develops alongside the esophagus.
Type III: EG junction in thorax, and hernia sac present containing parts of Stomach
What is a hiatal hernia?
protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.
Compare and contrast a type one hiatal hernia to a type II hiatal hernia.
Type I: Sliding Hiatal Hernia (accounts for 95% of cases)
STOMACH herniation located at or near the diaphragmatic opening for the ESOPHAGUS, esophageal hiatus. When the ESOPHAGOGASTRIC JUNCTION is above the DIAPHRAGM, it is called a SLIDING HIATAL HERNIA. When the ESOPHAGOGASTRIC JUNCTION is below the DIAPHRAGM, it is called a PARAESOPHAGEAL HIATAL HERNIA.
Type II: Paraesophageal Herniation
–Complication of Anti-Reflux Surgery
–Risk of gastric Volvulus (surgical emergency)
–Surgical repair is indicated if symptoms occur
How do you diagnose a hiatal hernia?
CXR: large hernia evident posterior to heart +/- air fluid level, NG tube placement prior to study can show it coiled in the intrathoracic portion of the stomach.
Barium swallow: demonstrates the hernia, and may show poor emptying of intrathoracic portion of stomach
Endoscopy: identify location of the EG junction, assess presence of esophagitis and evaluate degree of gastritis, assess esophageal length.
Esophageal manometry and 24-hr pH study: not indicated unless patient has symptoms of reflux or evidence of a motility disorder on other studies.
Treatment for hiatal hernias?
Paraesophageal hernias should be repaired due to risk of strangulation or incarceration
reduction of hernia sac and contents back into the abdomen with repair of the diaphragmatic defect (primary or using a patch) and gastropexy to prevent recurrent herniation
What are the two categories of esophageal diverticuli?
-two categories: Pulsion or pseudodiverticuli and traction or true diverticuli.
What is the most common diverticulum?
Where is it located?
When does it usually present
Pharyngoesophageal (Zenker’s) diverticulum
-located posteriorly, just proximal to the cricopharyngeal muscle.
-usually presents in the 5th to 8th decades
What is the common history for a Zenker’s diverticulum?
HPI: Oropharyngeal dysphagia, spontaneous
regurgitation of undigested food and saliva, noisy swallowing, halitosis, interruption of eating and drinking by episodes of regurgitation and aspiration with or without coughing or choking, respiratory complications including hoarseness, bronchospasm, and pneumonia.
Treatment for a Zenker’s diverticulum?
Surgical: Cricopharyngial myotomy with
diverticulectomy if the diverticulum is greater than 2cm in diameter.
Describe a traction diverticulum?
-usually sits in the midesophageal area
-usually secondary to a granulomatous inflammatory reaction (often histoplasmosis or tuberculosis)
-usually are small and asymptomatic, not requiring
treatment.
-rare complications such as fistulization to the
tracheobronchial tree or great vessels require thoracotomy, excision of the inflammatory mass, and primary closure of the esophagus and the airway or vessel.
