Dysphagia Flashcards
What is dysphagia?
Difficulty swallowing
What is odynophagia?
Pain on swallowing
What sorts of foods often cause dysphagia?
Often solids
Can be both solids and liquids
Is the level of obstruction actually at where it is indicated?
Generally lower
What are oropharyngeal causes of dysphagia?
Usually neuromuscular dysfunction - Stroke - Head and neck surgery/radiotherapy Structural disorders - Stricture - Web - Pharyngeal pouch/diverticulum
What are oesophageal causes of dysphagia?
Stricture - Reflux disease - Malignant - Extrinsic compression Functional - Achalasia - Dysmotility - diffuse oesophageal spasm/scleroderma - Pouches/diverticula
What are the questions on history to ask about the dysphagia?
Does patient have dysphagia?
Oropharyngeal vs oesophageal
Structural vs functional
Underlying cause
What is globus pharyngis?
Feeling of lump in one’s throat
Is globus pharyngis a true dysphagia?
No
Where can the level of swallowing difficulty be? Is this a reliable question to ask the patient?
Neck
Retrosternal
Unreliable
What can sudden onset of dysphagia be?
Bolus obstruction
CVA
What can dysphagia that progresses over weeks to months be?
Malignancy
Stricture
Achalasia
What can dysphagia that is intermittent and non-progressive be?
Benign stricture
Web
Hiatus hernia
What can dysphagia that is intermittent and progressive be?
Functional; eg:
- Achalasia
- Scleroderma
- Spasm
What can dysphagia for solids be?
Likely structural problem
What can dysphagia for liquids be?
Likely functional problem
What can associated symptoms suggest about the cause of achalasia?
Weight loss - Malignancy - Achalasia Long-term reflux - Peptic stricture Associated disease - Scleroderma - CVA Aspiration - Neuromuscular issues; eg: - CVA - Achalasia
What is relevant past history in the context of dysphagia?
Reflux
CVA
Neurological disorders
Caustic ingestion > Hx of self harm
What are the significant signs on examination for dysphagia?
Often aren’t any
What should you look for in examination for dysphagia?
General appearance - Wasted > ?malignancy Periphery - Scleroderma Head and neck - Lymph nodes - Previous surgery - Gurgling pouch in neck Neurological function
What are the investigations for oropharyngeal dysphagia?
Video swallow
- Often done by speech pathologist post-stroke
- Uses contrast
- Provides functional info
- Can ID pharyngeal pouch
What are the investigations for oesophageal dysphagia?
Gastroscopy - Can ID structural abnormality - May be therapeutic; eg: - Dilate stricture - Remove foreign body Barium swallow - Quick - Easy access - Not easy to see gastro-oesophageal junction - Often doesn't give structural diagnosis - Can give info on functional problem CT - Assessment of - Large hiatus hernia - Extrinsic compression Oesophageal manometry - Assessment of - Achalasia - Diffuse oesophageal spasm Endoscopic US - Characterises lesions in wall; eg: gastrointestinal stromal tumours (GIST)
What causes a pharyngeal pouch?
Dysfunction/spasm of upper oesophageal sphincter
What is a pharyngeal pouch?
Part of oesophagus herniates between 2 muscles in pharynx
What are the clinical features of a pharyngeal pouch, other than dysphagia?
Gurgling in neck
Brings up previously eaten foods
How is pharyngeal pouch diagnosed?
Barium swallow
Gastroscopy
What is the treatment for a pharyngeal pouch?
Cricopharyngeal myotomy via
- Open procedure in neck
- Endoscopic transoral myotomy
What is the surveillance for Barrett’s oesophagus?
Gastroscopy every 2 years
How many people with Barrett’s oesophagus go on to develop cancer?
1%
What are the common types of oesophageal cancer that can develop, and in what proportions?
Adenocarcinoma = 50%
Squamous cell carcinoma = 50%
What are the staging investigations for oesophageal cancer?
Endoscopy and biopsy CT scan chest/abdomen - good for T stage PET scan - assess metastatic disease Staging laparoscopy - Especially for lower third cancers - Lavage with 1L saline > suction > spin fluid down > analyse cells centrifuged for malignancy Bronchoscopy for mid-oesophageal tumours
What is the treatment for oesophageal cancer?
Surgery - aim to resect, if not locally advanced, and no metastastis
Chemo/radiotherapy
What are the clinical features for reflux related stricture, other than dysphagia?
Hx of reflux/heartburn
What is the investigation for reflux related stricture?
Gastroscopy
- Confirms diagnosis
- Excludes malignancy
What is the treatment for reflux related stricture?
Dilate stricture at time of gastroscopy - Balloon dilatation Treat cause - PPI - Anti-reflux operation - fundoplication
What are the clinical features of a large hiatus hernia, other than dysphagia?
Lengthy Hx Intermittent symptoms possible May not have heartburn May have vomiting/regurgitation feel hold up sensation Full and bloated, especially after big meal
What are the investigations for a large hiatus hernia?
Gastroscopy
CT/barium swallow
What is the treatment for a large hiatus hernia?
Symptomatic in fit patient > laparoscopic repair
Asymptomatic in elderly/unfit patient > conservative management
What is achalasia?
Failure of relaxation of oesophageal sphincter
What are the clinical features of achalasia, other than dysphagia?
Lengthy Hx Progressive: solids > liquids Weight loss Odynophagia Regurgitation Malnutrition
What are the investigations for achalasia?
Gastroscopy - exclude cancer
Oesophageal manometry - gold standard
Barium swallow can be helpful
What is the treatment for achalasia?
Laparoscopic cardiomyotomy = divide lower oesophageal sphincter
- Dissect muscle without dissecting mucosa
Oesophageal dilatation can occasionally be used - not permanent solution
When should you consider anti-reflux surgery?
Failed medical therapy
Complications despite adequate treatment
Preference to avoid drugs
Intolerance of therapy
What is a Nissen fundoplication?
Pull oesophagus into abdomen
Suture fundus of stomach around bottom of oesophagus
What are the side-effects of anti-reflux surgery?
Inability to burp/vomit
Increased flatus
Bloating
What is the algorithm if you see a benign stricture on gastroscopy?
Dilate >
- PPI
- Consider fundoplication
What is the algorithm if you see a malignant stricture on gastroscopy?
Staging investigations >
- Advanced disease > chemo/radiotherapy
- Early disease >
- Surgery
- Neo-adjuvant chemotherapy > surgery
