Dysphagia

Question 1

Define dysphagia?

Answer 1

Difficulty swallowing

Question 2

Which questions should be asked to help differentiate different causes of dysphagia?

Answer 2

Progressive (solids then fluids)
Site (high or low)
Any regurgitation* (and timing)

Associated symptoms:

• Weight loss
• odynophagia
• heartburn

*Effortless return of food from behind a mechanical or functional oesophageal obstruction. Different to vomiting as vomiting is forceful

Question 3

What are the causes of dysphagia?

Answer 3

Oesophageal:
Malignancy (oesophageal or gastric)
Oesophageal strictures
Motility disorders (Oesophageal spasm/achalasia aka lack of peristalsis)
Pharyngeal pouch (diverticulum of the mucosa of the pharynx)

Neurological: Cannot swallow liquid or solids

Extramural:
Hiatus Hernia
Malignancy

Question 4

What history of dysphagia would be most consistent with a diagnosis of oesophageal Ca?

Answer 4

Short history of dysphagia with weight loss

Question 5

Describe how any dysphagia should be investigated?

Answer 5

Dysphagia is a red flag symptom therefore you must do an endoscopy.

Question 6

What are the different types of oesophageal carcinoma and the main risk factors for each?

Answer 6

Squamous cell (upper 1/3)
Risk factors:
-Smoking 
-Alcohol
-Pickled/smoked foods

Adenocarcinoma (lower 2/3)
Risk factors: 
-Barrett's oesophagus
-Reflux
-Obesity

Question 7

Describe the symptoms associated with oesophageal malignancy?

Answer 7

Main sx:
Dysphagia +/- regurgitation
Weight loss

Other sx:

• Reflux
• Haematemesis/melaena
• Iron deficiency anaemia

Presentation is unfortunately late usually as 75% of the lumen is excluded before a patient experiences dysphagia

Question 8

Describe the endoscopic appearance of an oesophageal Ca?

Answer 8

Ulcer with a raised irregular edge
Mass
Stricture

Question 9

Describe how confirmed oesophageal Ca is staged if surgical intervention is an option?

Answer 9

TNM classification

Stage:
Staging CT looking for metastases and nodes

Further staging if considering surgery:

• PET CT
• Endoscopic US
• Staging laparoscopy (to look for metastatic deposits on the omentum/intrabdominally)

Question 10

Describe the potential treatment options for oesophageal Ca?

Answer 10

Staging is looking for any metastasis if this is found then palliative care is the only option.

If there are no mets secondary investigations to look for spread if non found then:

• Surgery.
• Chemo + surgery.
• Chemo + radio + surgery
• Treatment dose radiotherapy.

Surgery is called an Ivor lewis oesophagectomy (removal of Ca + anastamosis) usually performed open but some centres offer laparoscopy.

Question 11

Describe the different palliative options available in oesophageal Ca?

Answer 11

Palliative stenting procedure to allow swallowing

Chemotherapy to extend life

Normal palliative management: aka control secretions, pain and nausea.

Question 12

What is the prognosis of oesophageal Ca?

Answer 12

Very poor prognosis even in operable malignancies.

25-30% 5 year survival for operable local disease.

Question 13

What is achalasia?

Answer 13

It is a motility disorder of the lower oesophagus or lower oesophageal sphincter. Characterised by:

-impaired peristalsis

And/Or

-failure of the sphincter to relax causes a functional stenosis

Note: it is most commonly idiopathic but may be secondary to: oesophageal Ca

Question 14

Describe how achalasia typically presents?

Answer 14

Dysphagia +/- regurgitation.
Retrosternal pain (relieved by regurgitation)
Heartburn.

Weight loss is not a typical symptom and is more suggestive of malignancy.

Mean age of diagnosis is in 50’s.

Question 15

Describe how achalasia is investigated?

Answer 15

Dysphagia = red flag therefore endoscopy

May do a barium swallow before this

Question 16

Describe how achalasia is managed?

Answer 16

Surgical:
Heller myotomy: the muscles of the lower oesophageal sphincter are cut allowing food to pass.

Endoscopic:

• Pneumatic dilation: essentially balloon dilation to rupture the muscles of the lower oesophagus to allow food to pass. Used in elderly patients unfit for surgery. Carries a 10% perforation risk.
• Botox injection into the lower oesophagus (high success rate short term)

Medical:
Calcium-channel blockers* and nitrates** may reduce pressure in the lower oesophageal sphincter only effective in 10%

• amlodopine
• *isosorbide mononitrate