Dysphagia Flashcards
Describe normal motility of oesophagus.
Peristalsis moves food down to stomach
Two waves of peristalsis
When peristalsis reaches the lower oesophageal sphincter it opens and allows food into stomach
What is peristalsis?
Sequential, coordinated contraction waves that travels the entire length of the oesophagus, propelling intraluminal contents to the stomach.
Describe the two waves of peristalsis that occur?
Primary wave: triggered by swallowing centre
Secondary wave: triggered by food bolus distending the oesophagus
What are oesophageal motility disorders?
Problems with the oesophagus that restrict its movement, so causing difficulty swallowing and moving food down to the stomach
What two categories of oesophageal motility disorders are there?
Primary: problem with oesophagus directly
Systemic: systemic disease that causes problems with the oesophagus
Name an important primary oesophageal motility disorder?
Achalasia
What is achalasia?
Where the muscles in the lower part of the oesophagus fail to relax and open
Lack of peristalsis
Preventing food getting into the stomach
Diagnosed when you’ve ruled out other causes like cancer
Clinical features of achalasia?
Dysphagia Regurgitation Chest pain Weight loss + malnutrition Aspiration of oesophagus contents into lungs
What causes achalasia?
Unknown!
Maybe autoimmune, hereditary
What do you need to rule out when you see a patient with suspected oesophageal motility disorder?
Essential to rule out:
- GORD
- Hiatus hernia
- Psychosomatic disorders
- Cancer
Investigations for achalasia?
Barium swallow: barium shows up clearly on fluoroscopy, you will see the blockage
Endoscopy: to rule out cancer
What might you see on an endoscopy in a patient with achalasia?
Normal looking oesophagus
Difficulty passing endoscope through LOS, food debris trapped above it
Treatment of achalasia?
Sublingual nifedipine: a Ca channel blocker
Lifestyle changes: eat slowly, chew well, drink plenty of water with food, raise head of bed while sleeping
Botox injection into LOS: to paralyse the muscles holding it shut
Pneumatic dilatation: use a balloon to stretch the muscles
Which systemic disease causes oesophageal motility disorders?
Systemic sclerosis: CREST syndrome
What is CREST syndrome?
A type of systemic sclerosis (AKA scleroderma)
A connective tissue disorder which has many features, one of which is oesophageal dysmotility
Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia.
How does CREST cause oesophageal dysmotility?
CREST causes atrophy of the GI tract wall smooth muscle
So less peristalsis occurs, food can’t move down properly
How does oesophageal dysmotility caused by CREST present?
Dysphagia
Sensation of food getting stuck
Atypical chest pain
Cough
The need to drink liquids in order to swallow food
You may see other features of CREST
Investigations of oesophageal dysmotility caused by CREST?
Endoscopy
Barium swallow
Tests for CREST: serum antibodies
Treatment of oesophageal dysmotility caused by CREST?
Treat CREST
Lifestyle: eat slowly, chew well, drink plenty of water with food, raise head of bed while sleeping
Oesophageal dilation
What should you consider with a patient who has solid dysphagia?
Obstruction
Oesophageal cancer
Stricture
What should you consider with a patient who has solid + liquid dysphagia?
Oesophageal motility disorder
- Stroke
- Myasthenia Gravis
- CREST
- Achalasia
What are some causes of dysphagia?
Stroke Myasthenia Gravis CREST Achalasia Tonsilitis
How can you tell from the patient’s history whether their dysphagia is likely to be caused by an oesophageal motility disorder or an obstruction?
If they have had problems with liquid + solid swallowing from the beginning = Oesophageal motility disorder
If they started with solid dysphagia and have progressed to liquid dysphagia = obstruction
What are the red flag symptoms of dysphagia?
Solid dysphagia progressing to liquid
Painful swallowing
Problem is constant and getting worse
Weight loss
What tests should you perform on patients with dysphagia?
Bloods:
- FBC to look for anaemia
- U&E to check for dehydration / malnutrition
- Serum antibodies to check for CREST
CXR: to look for aspiration
Endoscopy + biopsy: malignancy
Barium swallow
