Dysphagia Flashcards
Define Oropharyngeal dysphagia
Difficultly emptying material from the oropharynx into the oesophagus
What are the 3 causes of oropharyngeal dysphagia?
- Anatomical e.g. Zenkers Diverticulum (decreases compliance of cricopharyngeus)
- Neurological e.g. stroke (weakens pharyngeal constriction, incoordination etc)
- Muscular e.g. Myasthesia gravis
Lesions to which area are at a high risk of aspiration?
Anterior or Subcortical white matter
Define Oesophageal dysphagia
Difficulty passing food down the oesophagus, resulting from a motility disorder or mechanical obstruction
Name 3 compensation management options in oropharnygeal dysphagia
- Behavioural techniques - timing, positional
- Feeding route alterations - nasogastric tube, percutaneous endoscopic gastrostomy tube (PEG)
- Bolus modification e.g. soft diet, thicken fluids
Name 3 rehabilitation options for oropharyngeal dysphagia
- Pharmacological agents
- Surgical treatment e.g. oesophageal dilation
- Stimulation techniques e.g. pharyngeal electrical stimulation
Name 5 things that take place in dysphagia assessment after stroke
- History, Clinical observations, cognitive screening
- Cranial nerve assessment
- Oral cavity inspection
- Test swallows
- Mealtime observations, posture diet level, self-feeding, respiratory changes
Name two investigative tests which can be used to assess swallowing
Videofluoroscopy (barium meal)
Fiberoptic Endoscopic Examination Swallowing (FEES) - visualises residue in the laryngeal inlet
Define parenteral
Infusion into the bloodsteam via a peripheral vein
Define enteral
Feeding via a tube placed into the gut
Preferred route to maintain digestive, absorptive and immunological barrier functions of the gut
What is the indicated use for percutaneous endoscopic gastrostomy (PEG)?
Enteral nutrition for a prolonged period e.g. >30 days
Name 4 problems associated with dysphagia
- Aspiration
- Incoordination of muscle movements in swallowing (oral)
- Upper oesophageal sphincter dysfunction
- Impaired lower oesophageal sphincter relaxation
Define achalasia
Failure of a ring of muscle fibres to relax
e.g. the lower oesophageal sphinctor
What does loss of inhibitory innervation of the lower oesophageal sphinctor result in?
- Basal sphincter pressure rises
- Sphincter muscle incapable of normal relaxation
- Oesophageal body smooth muscle aperistalsis
What is the pathophysiology of achalasia?
- Degeneration of ganglion cells in the oesophageal wall in the myenteric plexus
- Lymphocytes and eosinophils cause inflammatory degeneration of the inhibitory neurons (usually release nitric oxide to allow the sphincter to relax)
- Cholinergic neurons that contribute to the lower oesophageal sphincter cause smooth muscle contraction are spared
What 4 things may achalasia result from
- HLA-DQw1
- Autoimmune disorder due to Ab targeting the enteric neurons
- Chronic herpes zoster or measles virus infection
- Malignancy, Chagas Disease, Infiltrative disorders e.g. Sarcoid Amyloid
What is the annual incidence of achelasia?
1 case per 100,000
When is achelasia usually diagnosed?
25-60 years
Name six clinical presentations of achalasia
- Long history of intermittent dysphagia, for both liquids and solids from the onset
- Regurgitation of food, particularly at night and aspiration pneumonia is a complication
- Weight loss
- Difficulty breathing
- Chest pain
- Heartburn
Achalasia: Diagnosis
- What can endoscopy reveal?
- What can be present if oesophageal stasis has occured?
- What two techniques are used?
Reveal dilated oesophagus containing residual material or may be normal
If oesphageal stasis is present then this predisposes to candida infection so may be present
Oesophagogastroduodenoscopy (OGD) or colonscopy
Achalasia: Diagnosis
- What radiological test can be used for diagnosis?
- What is seen with this test if achalasia is present?
Barium swallow (95% accuracy)
Dilated oesophagus with beak-like narrowing
Purposeless, spastic contractions “vigorous achalasia”
Achalasia: Diagnosis
- What is used for confirmation of this condition?
- How is this conducted?
Manometry
Method:
- Passing a catheter through the nose into oesophagus
- Patient swallows saline/gel
- The pressures generated by the muscles in the upper oesophageal sphinctor, oesophageal constrictors and lower oesophageal sphincter are monitored as the object passes down
Name the three primary findings in achalasia manometry
- Elevated resting LES pressure (>45mmHg)
- Incomplete LES relaxation - distinguishes achalasia from other peristaltic disoders
- Aperistalsis in the smooth muscle portion of the oesophagus: low amplitude (most) higher amplitude than normal (>60mmHg in vigorous achalasia)
What is an important point regarding the treatment of achalasia?
None can restore muscular activity to the denervated oesophagus
What are the 4 main summary points of achalasia?
- Low but important prevelence
- Symptoms may be initially vague
- Barium swallow and manometry most useful for diagnosis
- Data suggest pneumatic dilatation is most cost effective treatment, with myotomy reserved for failed procedures
Define aspiration
Passing of any foreign substance e.g. saliva or gastric content through the vocal cords and entering the respiratory tract
Define penetration in regards to aspiration
Presence of foreign substances above the vocal cords i.e. without passage through the vocal cords into the airway
How does aspiration pneumonia result?
Inhalation of stomach contents or secretions of the oropharynx leading to lower respiratory tract infection
Name three outcomes of aspirational pneumonia
- Chemical pneumonitis: chemical irritation of the lungs
- Obstruction: large volumes of aspirated material may lead to obstruction of the respiratory tract
- Bacterial infection (pneumonia): infection of the lower airways causing empyema, lung abscess, acute respiratory failure and acute lung injury
What is persistent apspiration pneumonia normally the result of?
Anaerobe infection which progress to lung abscess or even bronchoiectsasis
Due to bronchial anatomy where are the most common spillage sites?
Apical and posterior segments of the right lower lobe
Aspiration pneumonia follows what course?
Necrotising, pursuing a fulminant clinical course and is a frequent cause of death
In those who survive, a lung abscess is a common complication
Name six clinical signs of aspiration pneumona
- Fever
- Tachycardia
- Tachypnoea
- Hypoxia
- Coarse crackles base of right lung
- Decreased percussion to base of right lung
