Dysphagia Flashcards
What imaging/tests should you consider with oropharyngeal dysphagia?
Esophagram
What imaging/test should you consider with esophageal dysphagia?
Endoscopy
If someone is having difficulty swallowing solids and/or liquids, what does that indicate?
Motor disorder
If someone is having difficulty swallowing just solids, what does that indicate?
Mechanical obstruction
Medications that cause dysphagia
Potassium chloride, vitamin C, tetracycline, NSAIDs, bisphosphonates, ferrous sulfate, aspirin
Risk factors for dysphagia
- Children (hereditary/congenital)
- Adults (esophageal cancer > neurologic disorders)
- Smoking
- Long hx of GERD
- Meds
- Neurologic events or diseases (CVA, NM disease, Parkinson)
History taking for oropharyngeal dysphagia
- Do you have problems with initiating a swallow?
- Do you cough or choke or is food coming through your nose after swallowing?
- Could you point to where the food gets stuck? (localizing source of dysphagia is unreliable, but better with oropharyngeal)
- Do you have chronic medical problems?
- Any surgeries on your larynx, esophagus, stomach, or spine?
- Any radiation therapy?
- Are you taking any medications/herbs/OTCs?
History taking for esophageal dysphagia
- Do you feel food getting stuck after swallowing?
- Do you have a problem swallowing solids, liquids, or both?
- How long have you had problems swallowing? (if rapidly progressive, there is a concern for malignancy)
- Do you have chronic medical problems?
- Any surgeries on your larynx, esophagus, stomach, or spine?
- Any radiation therapy?
- Are you taking any medications/herbs/OTCs?
Targeted physical exam for oropharyngeal dysphagia
- Choking with swallowing
- Coughing, drooling, food spillage with swallowing
- Nasal speech
- Aspiration pneumonia
- Weight loss
- Dysarthria (unclear articulation of speech)
Targeted physical exam for esophageal dysphagia
- Pressure sensation in mid-chest, below suprasternal notch—solids? Liquids? Both?
- Aspiration pneumonia
- Weight loss
- GERD symptoms
- Neck and oral cavity for lesions, masses, goiter
- Signs of collagen vascular disease
- Cranial nerve testing (gag test)
Zenker Diverticulum
Outpouching of the mucosa and submucosa (false diverticulum) through Killian triangle, an area of muscular weakness between the cricopharyngeus and the lower inferior constrictor
Possible causes of Zenker
- Abnormal esophageal motility
- Tightness of cricopharyngeus muscle, which is supposed to relax during swallowing
- Esophageal shortening
- Abnormalities in function of the Upper Esophageal Sphincter (UES)
Complications of Zenker
- Aspiration pneumonia
- Squamous cell carcinoma in diverticulum
Zenker presentation
- Mass in neck
- Gurgling
- foul breath
- geriatric patients
Amytrophic lateral sclerosis
ALS is a progressive, incurable neurodegenerative disorder that causes muscle weakness, disability, and death
- muscle wasting > mostly tongue compared to other oropharyngeal mm.
- 25% present with dysphagia as initial complaint
Xerostomia symptoms
- Difficulty with swallowing or speech
- Dry, uncomfortable mucosal tissues
- Thick, ropy saliva
- Frequent oral candidiasis
- Atrophic glossitis (lack of papilla) on the tongue
- Atypical dental caries at the gingival margin
Work up and tx for Xerostomia
- Sialogram
- Pilocarpine tx
Globus pharyngeus symptoms
- Persistent or intermittent non-painful sensation of a lump or foreign body in the throat
- Occurrence of the sensation between meals
- Absence of dysphagia and odynophagia *
- Absence of evidence that GERD is the cause of symptoms
- Occurs over the past 3 months with symptom onset at least 6 months prior to diagnosis
Esophageal spasm
Intermittent mechanical obstruction sometimes causing intermittent dysphagia and chest pain
-Corkscrew appearance
Limited Scleroderma
- Progressive motor disorder
- Excessive collagen deposits throughout the body
- Rigidity of facial skin and tongue causing impaired chewing and swallowing
- Vascular (Raynaud’s) and immunological disorders
- Coughing, aspiration, nasal regurgitation, oral Leakage
- GERD, heartburn, dysphagia to solids and liquids
- Hypomotility in LES
Achalasia
- Progressive motor disorder
- Difficulty swallowing, sensation of swallowed material getting stuck in chest
- Chest pain, regurg (rarely causes aspiration pneumonia), heartburn, hiccups, weight loss
- Tx: balloon dilation or myotomy
- Bird’s beak on barium swallow
Achalasia etiology
Nerve cells of myenteric plexus in the esophagus degenerate for unknown reasons causing 2 problems:
- Esophageal muscles do not contract normally—food is does not move through esophagus and stomach properly
- LES (lower esophageal sphincter) does not function correctly
Diabetic gastroparesis work up
Scintigraphy/radio isotope emptying scan is gold standard
What does fiber do in diabetic gastroparesis?
Slows the rate of gastric emptying FURTHER and can lead to bezoars
Bezoars
Solid masses of partially digested food that can cause blockage
Imaging for progressive dysphagia in diabetes
- Barium XR: 12 hour fast, then drink liquid barium, which is then viewed under XR. If food is remaining in the stomach, gastroparesis is likely
- Barium Beefsteak meal: eat a meal that contains barium, which allows the doctor to observe the patient’s stomach digesting the meal
- Scintigraphy/Radio-isotope gastric emptying scan: nuclear medicine study that shows how quickly food leaves the stomach. Gastroparesis is diagnosed if more than half the food remains after 2 hours
- Gastric manometry: measures muscular and electrical activity of the stomach as it digests liquid and solid food
Peptic stricture
Progressive mechanical obstruction
Esophageal carcinoma
- Geriatric patients
- Dysphagia (first solids > liquids) is progressive and most common presenting symptom followed by weight loss
- Barium esophagography is sensitive for mucosal irregularities
- Suspicion high > endoscopy essential
Drug-Induced esophagitis causes
- Tetracyclines
- Bisphosphonates, iron, vitamin C, NSAIDs, aspirin, potassium chloride
Drug-induced esophagitis presentation
- Odynophagia w/ or w/o dysphagia
- can be mistaken for GERD or cardiac etiology
- patients may describe a foreign-body sensation in esophagus
Drug-induced esophagitis dx
Upper endoscopy with mucosal biopsies gold standard
Drug-induced esophagitis tx
- STOP MED
- symptomatic relief from: H2 blockers, PPIs, or coating agents
