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MD2 Surgery and Anaesthesia > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

What is dysphagia?

A

Difficulty swallowing

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2
Q

What is odynophagia?

A

Pain on swallowing

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3
Q

What sorts of foods often cause dysphagia?

A

Often solids

Can be both solids and liquids

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4
Q

Is the level of obstruction actually at where it is indicated?

A

Generally lower

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5
Q

What are oropharyngeal causes of dysphagia?

A 
Usually neuromuscular dysfunction
- Stroke
- Head and neck surgery/radiotherapy
Structural disorders
- Stricture
- Web
- Pharyngeal pouch/diverticulum
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6
Q

What are oesophageal causes of dysphagia?

A 
Stricture
- Reflux disease
- Malignant
- Extrinsic compression
Functional
- Achalasia
- Dysmotility - diffuse oesophageal spasm/scleroderma
- Pouches/diverticula
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7
Q

What are the questions on history to ask about the dysphagia?

A

Does patient have dysphagia?
Oropharyngeal vs oesophageal
Structural vs functional
Underlying cause

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8
Q

What is globus pharyngis?

A

Feeling of lump in one’s throat

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9
Q

Is globus pharyngis a true dysphagia?

A

No

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10
Q

Where can the level of swallowing difficulty be? Is this a reliable question to ask the patient?

A

Neck
Retrosternal
Unreliable

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11
Q

What can sudden onset of dysphagia be?

A

Bolus obstruction

CVA

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12
Q

What can dysphagia that progresses over weeks to months be?

A

Malignancy
Stricture
Achalasia

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13
Q

What can dysphagia that is intermittent and non-progressive be?

A

Benign stricture
Web
Hiatus hernia

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14
Q

What can dysphagia that is intermittent and progressive be?

A

Functional; eg:

  • Achalasia
  • Scleroderma
  • Spasm
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15
Q

What can dysphagia for solids be?

A

Likely structural problem

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16
Q

What can dysphagia for liquids be?

A

Likely functional problem

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17
Q

What can associated symptoms suggest about the cause of achalasia?

A 
Weight loss 
- Malignancy
- Achalasia
Long-term reflux
- Peptic stricture
Associated disease
- Scleroderma
- CVA
Aspiration
- Neuromuscular issues; eg:
   - CVA
   - Achalasia
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18
Q

What is relevant past history in the context of dysphagia?

A

Reflux
CVA
Neurological disorders
Caustic ingestion > Hx of self harm

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19
Q

What are the significant signs on examination for dysphagia?

A

Often aren’t any

20
Q

What should you look for in examination for dysphagia?

A 
General appearance
- Wasted > ?malignancy
Periphery
- Scleroderma
Head and neck
- Lymph nodes
- Previous surgery
- Gurgling pouch in neck
Neurological function
21
Q

What are the investigations for oropharyngeal dysphagia?

A

Video swallow

  • Often done by speech pathologist post-stroke
  • Uses contrast
  • Provides functional info
  • Can ID pharyngeal pouch
22
Q

What are the investigations for oesophageal dysphagia?

A 
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)
23
Q

What causes a pharyngeal pouch?

A

Dysfunction/spasm of upper oesophageal sphincter

24
Q

What is a pharyngeal pouch?

A

Part of oesophagus herniates between 2 muscles in pharynx

25
Q

What are the clinical features of a pharyngeal pouch, other than dysphagia?

A

Gurgling in neck

Brings up previously eaten foods

26
Q

How is pharyngeal pouch diagnosed?

A

Barium swallow

Gastroscopy

27
Q

What is the treatment for a pharyngeal pouch?

A

Cricopharyngeal myotomy via

  • Open procedure in neck
  • Endoscopic transoral myotomy
28
Q

What is the surveillance for Barrett’s oesophagus?

A

Gastroscopy every 2 years

29
Q

How many people with Barrett’s oesophagus go on to develop cancer?

A

1%

30
Q

What are the common types of oesophageal cancer that can develop, and in what proportions?

A

Adenocarcinoma = 50%

Squamous cell carcinoma = 50%

31
Q

What are the staging investigations for oesophageal cancer?

A 
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
32
Q

What is the treatment for oesophageal cancer?

A

Surgery - aim to resect, if not locally advanced, and no metastastis
Chemo/radiotherapy

33
Q

What are the clinical features for reflux related stricture, other than dysphagia?

A

Hx of reflux/heartburn

34
Q

What is the investigation for reflux related stricture?

A

Gastroscopy

  • Confirms diagnosis
  • Excludes malignancy
35
Q

What is the treatment for reflux related stricture?

A 
Dilate stricture at time of gastroscopy
- Balloon dilatation
Treat cause
- PPI
- Anti-reflux operation - fundoplication
36
Q

What are the clinical features of a large hiatus hernia, other than dysphagia?

A 
Lengthy Hx
Intermittent symptoms possible
May not have heartburn
May have vomiting/regurgitation
feel hold up sensation
Full and bloated, especially after big meal
37
Q

What are the investigations for a large hiatus hernia?

A

Gastroscopy

CT/barium swallow

38
Q

What is the treatment for a large hiatus hernia?

A

Symptomatic in fit patient > laparoscopic repair

Asymptomatic in elderly/unfit patient > conservative management

39
Q

What is achalasia?

A

Failure of relaxation of oesophageal sphincter

40
Q

What are the clinical features of achalasia, other than dysphagia?

A 
Lengthy Hx
Progressive: solids > liquids
Weight loss
Odynophagia
Regurgitation
Malnutrition
41
Q

What are the investigations for achalasia?

A

Gastroscopy - exclude cancer
Oesophageal manometry - gold standard
Barium swallow can be helpful

42
Q

What is the treatment for achalasia?

A

Laparoscopic cardiomyotomy = divide lower oesophageal sphincter
- Dissect muscle without dissecting mucosa
Oesophageal dilatation can occasionally be used - not permanent solution

43
Q

When should you consider anti-reflux surgery?

A

Failed medical therapy
Complications despite adequate treatment
Preference to avoid drugs
Intolerance of therapy

44
Q

What is a Nissen fundoplication?

A

Pull oesophagus into abdomen

Suture fundus of stomach around bottom of oesophagus

45
Q

What are the side-effects of anti-reflux surgery?

A

Inability to burp/vomit
Increased flatus
Bloating

46
Q

What is the algorithm if you see a benign stricture on gastroscopy?

A

Dilate >

  • PPI
  • Consider fundoplication
47
Q

What is the algorithm if you see a malignant stricture on gastroscopy?

A

Staging investigations >

  • Advanced disease > chemo/radiotherapy
  • Early disease >
    • Surgery
    • Neo-adjuvant chemotherapy > surgery

MD2 Surgery and Anaesthesia (31 decks)

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