Dysphagia Flashcards
Name oesophageal symptoms
- Dysphagia
- Odynophagia
- Heartburn
- Regurgitation
- Waterbrash
- Chest pain
Define dysphagia
difficulty swallowing
- things might be stuck in the throat
define odynophagia
pain on swallowing
- something is painful
What is heartburn
- reflux in the chest
describe how oropharyngeal swallowing works
- when you swallow
- tongue presses up to the roof of your mouth
- soft palate blocks the nasal cavity
- epiglottis blocks the trachea entrance
- opens passageway to the oesophagus
- then the nasal cavity and trachea opens up again
How does oesophageal swallowing works
- Gravity pushes it down
- orientated contraction of muscles that helps push the food down
- propels food down into the stomach
- has to go through the LOS
What does the LOS do
prevents gastric contents from refluxing back into the oesophagus but allows food in
What happens when oesophageal swallowing fails
- feel food that sticks in your chest
- things move down slowly
- drink a lot of water to push it through
- or induce vomiting when things dont go through
What are the two types of causes of dysphagia
- Obstructive
- Non obstructive
What are the types of obstructive dysphagia
Intraluminal
- foreign body
Within walls
- cancer
- strictures
- rings
- webs
Extraluminal
- lymphadenopathy
- compression from heart and aorta - anuerysms
What are non obstructive causes of dysphagia
Oesophageal
- motility problems
- neuromuscular problems
What should you take in a history with dysphagia
- sudden v gradual
- duration
- lipids v solids
- other oesophageal symptoms
- red flags
What are the red flags of dysphagia
- weight loss
- anaemia
- family history
- smoking
What are the causes of oesophageal stricture
- Untreated GORD (10-20% risk)
- Radiotherapy
- Caustic injury - e.g. bleach
Drugs
- Bisphosphanates
- NSIADS
- tetracyclines
What drugs can cause oesophageal strictures
- Bisphosphanates
- NSIADS
- tetracyclines
what are the two types of cancer effect the oesophagus
- adenocarcinoma
- squamous cell carcinoma
what is the more common cancer that effects the oesophagus
adenocarcinoma
where do the two types of cancer that affect the oesophagus arise from and what part of the oesophagus are they in
- adenocarcinoma = from columnar glandular epithelium in the lower 1/3 of the oesophagus
- squamous cell carcinoma = from squamous epithelium in the top 2/3rds
What are the risk factors for squamous cell carcinoma
- Smoking
- alcohol
- chewing betel nut
What can squamous cell oesophageal cancer effect around it
- usually very aggressive
- can invade the trachea, causing fistuale
- effect the laryngeal nerve causing hoarseness and dysphonia
Where does squamous cell oesophageal cancer metastasise to
- bone
- brain
- liver
- lungs
How do you treat squamous cell oesophageal cancer
- radiotherpy
- +/- chemotherapy
What are the risk factors for adenocarcinoma
- GORD
- beretts oesophagus
how aggressive is adenocarcinoma oesophageal cancer
less aggressive than squamous cell carcinoma
Where does adenocarcinoma oesophageal cancer metastasise
Liver
Lymph nodes
What is the treatment for adenocarcinoma oesophageal cancer
- Surgery - resect a lot of the oesophagus
- +/- chemotherapy
What are the complications after adenocarcinoma oesophageal cancer surgery
- vagal damage
- reflux - due to loss of gastro oesophageal junction (LOS).
- feel full quickly
- nausea
What happens in surgery of adenocarcinoma oesophageal cancer
- oesophagus is shortened
- stomach sits in the chest
- loss of LOS
What can you use to help symptoms in non curative oesophageal cancer
- place stents in the oesophagus - pushes the walls open to keep it open
How does a hiatus hernia cause reflux
- Hernia can occur due to weakness in the muscles
- sliding hiatus hernia - when it slide up you loose LOS
- things are more likely to reflux up into the chest
How do you know it is a sliding hiatus hernia
= see two restrictions
- LOS and diaphragm
how do you manage a stricture
- dilatation - balloon dilatation
- balloon is completely deflated
- with X ray guidance you inflate the balloon - and stretch open the stricture
- end up with the lumen that is bigger than before
What does a rolling hiatus hernia cause
rolling hernia can cause pain but doesnt tend to cause reflux
What is the most common hiatus hernia
Sliding hernia
What does achalasia look like in a barium swallowing
- birds beak
What is achalasia
Oesophageal motility disorder
- happens when the LOS fails to relax - tight and gone into spasm
- problem with the neurones
What is achalasia associated with
- Regurgitation
- food stasis
- oesophageal dilatation
What is achalasia associated with
aperistalsis - absence of peristalsis
What is aperistalsis
absence of peristalsis
what do you have an increased risk of when you have achalasia
- increased risk of squamous cell carcinoma
why can you digest solids more easily in achalasia
- solids have more weight so they push open the LOS
- liquids will just sit on top
What is the management of achalasia
- Surgical - cut open the muscle
- Endoscopic - can use botox into the LOS which will paralyse the muscle and cause it to relax also can use a balloon to widen the LOS
What is it called when you get rings in the oesophagus
- oesophageal trachealisation
What can cause oesophageal trachealisation
eosinophilic oesophagitis
How does eosinophilic oesophagitis present
- dysphagia and food impaction
- leads to dysmotility
- associated with atopy
What is the treatment of eosinophilic oesophagitis
- Dietary elimination
- Medication (steroids) - topical steroids
- Endoscopic for strictures
does eosinophilic oesophagitis present in men or women more
men
What questions in dysphagia history do you ask
History:
- Onset: Sudden vs gradual
- Duration
- Liquids vs solids
- Red flags: Weight loss, anaemia, family history, smoking
Systems enquiry:
- Heartburn, odynophagia, regurgitation , cough
Past Medical History
- GORD, atopy, cancer
Medications:
- Bisphosphanates, radiation
Social history:
- Smoking, alcohol
How do you classify dysphagia
- is it pharyngeal or oesophageal
- is it obstructive or non-obstructive
Obstructive
- problems with lumen
- problems in walls of lumen
- problems outside lumen
What questions help you narrow what the cause of dysphagia is
- onset
- duration
- difficulty swallowing solids or liquids
- associated symptoms and signs and pathology
What is the
- onset
- duration
- difficulty swallowing solids or liquids
- associated symptoms and signs and pathology
of cancer
- onset = gradual
- duration = short
- difficulty swallowing solids or liquids = solids
- associated symptoms and signs and pathology = weight loss, cachexia, anaemia
What is the
- onset
- duration
- difficulty swallowing solids or liquids
- associated symptoms and signs and pathology
of strictures
- onset = gradual
- duration = short
- difficulty swallowing solids or liquids = solids
- associated symptoms and signs and pathology = reflux
What is the
- onset
- duration
- difficulty swallowing solids or liquids
- associated symptoms and signs and pathology
of achalasia
- onset = gradual
- duration = long
- difficulty swallowing solids or liquids = liquids
- associated symptoms and signs and pathology = cough, regurgitation, weight loss
What is the
- onset
- duration
- difficulty swallowing solids or liquids
- associated symptoms and signs and pathology
of eosinophillic oesphagitis and food bolus
- onset = gradual
- duration = long
- difficulty swallowing solids or liquids = solids
- associated symptoms and signs and pathology = rashes, allergy, atopy
What are the key questions to ask for dysphagia
Key questions to ask
- Was there difficulty swallowing solids and liquids from the start
- If yes then motility disorder such as CNS, achalasia
- If no and only solids then stricture benign or malignant - Is it difficult to initiate a swallowing movement?
- If yes bulbar palsy - Is it painful to swallow?
- If yes – viral infection, candida, malignancy, oesophagitis, suspected ulceration - Is the dysphagia intermittent or is it constant and getting worse?
- Intermittent – suspected oesophageal spasm
- Constant and getting worse – oesophageal malignancy - Does the neck bulge on drinking?
- Yes pharyngeal pouch
What is the difference between a sliding and paraoespheageal hiatal hernias
Sliding
- Gastrooephageal junction slides up into the chest
Paraesophageal
- Gastrooesophageal junction remains in the abdomen but a bulge in the stomach goes up into the chest
How do you treat a hiatus hernia
Imaging
- Upper GI requires endoscopy
Treatment
- Loose weight
- Treat GORD
