Dysphagia Flashcards
When a patient describes “swallowing difficulty” what could this mean
Dysphagia - difficulty, initiating (high) or food getting stuck (low)
Odynophagia - pain on swallowing
Globus - sensation of having a lump in the throat
What is high and low dysphagia and what are their general cause
high - oropharyngeal and upper oesophagus
low - lower oesophageal
High dysphagia is more likely to be due to a generalised neuromuscular disease
Low dysphagia is more likely to be due to a local obstructing lesions
What are the functional causes of high dysphagia
Stroke Parkinson's Myasthenia gravis MS Myotonic dystrophy MND Inadequate saliva production (Sjrogens, anticholinergics)
What are the structural causes of high dysphagia and are they luminal, mural or extrinsic
Cancer - mural
Pharyngeal pouch - mural
Cricopharyngeal bar - mural
What are the functional causes of low dysphagia
Achalasia Chagas disease Nutrcracker oesophagus Diffuse oesophageal spasm Limited cutaneous scleroderma (CREST) Infective oesophagitis Eosinophilic oesophagitis
What are the structural causes of low dysphagia and are they luminal, mural or extrinsic
Foreign body - luminal Cancer - mural Stricture (caustic or inflammatory) - mural Plummer-vinson syndrome - mural Schatzki ring - mural Congenital atresia - mural Mediastinal mass - extrinsic Retrosternal goitre - extrinsic Bronchial carcinoma - extrinsic Thoracic aortic aneurysm - extrinsic Ortner's syndrome - extrinsic
What is the red flag for carcinoma in terms of dysphagia
New-onset dysphagia in middle-aged to elderly patients
What questions should be asked about the swallowing
Duration of symptoms - short history (day-week) suggests cancer, months- years suggests chronic motility
Dysphagia progressive or intermittent - progressive suggests stricture, intermittent suggests motility disorder
To solids, fluids or both
What can information about what kind of foods they have difficulty swallowing tell you
solids that they feel are sticking: mechanical osbtruction e.g. stricture
Fluids more than solids: motility disorder e.g. achalasia
Absolute dysphagia: large piece of food that is stuck
What associated symptoms should be asked about in the history
Any coughing related to eating
Do they suffer with halitosis (pharyngeal pouch)
Any gurgling (pharyngeal pouch)
Dysphonia/hoarsensess (vocal cord dysfunction due to recurrent laryngeal nerve involvement
Heartburn or waterbrash: reflux disease
Weight loss: red flag for oesophageal cancer
Neuro symptoms: for anyone with functional D
Rheumatological symptoms: CREST
What is the association between dysphagia and coughing
Coughing immediately after: stroke and parkinsons
Sometimes after: pharyngeal pouch regurgitation, aspiration of food in a dilated oesophagus (achalasia) or FORD
Nocturnal cough - achalasia
What symptoms are associated with CREST
Calcinosis Raynaud's Esophageal dysmotility (dysphagi) Sclerodactyly Tengiectasia
What past medical history is relevant in dysphagia
GORD and peptic ulcers are important to enquire about.
GORD - predisposes adenocarcinoma and non-malignant strictures. Any surgery to tighten the lower sphincter (fundoplication) may cause dysphagia
Peptic ulcers - leads to scarring and strictures
MS or parkinson’s also useful
What in the drug history should be enquired about for dysphagia
CCBs and nitrates (relaxes smooth muscle) can cause or exacerbate reflux symptoms
NSAIDs, aspirin, steroids and bisphosphonates predispose to peptic ulceration
What should be emphasised/prioritised on physical examination for dysphagia
Cranial nerve pathology: bulbar palsy may be present in functional dysphagia
GI malignancy signs: cachetic, Virchow’s node, palpable carcinoma, hepatomegaly in metastasis
Neck mass: pharyngeal pouch which may gurgle, goitre, cervical lymphadenopathy (due to head and neck cancers)
Features of CREST: calcinosis, Raynaud’s, Sclerodactyly and tenlengiectasia
What investigations can be done for dysphagia
Barium swallow
Endoscopy
Videofluroscopy
Manometry
Describe the barium swallow
Monitors the passage of a bolus of barium contrast through a supine patient to the lower sphincter and not further
Lesions often have a characteristic appearance
They may also swallow an effervescent agent to produce a double-contrast study for mucosal lesions
What do the following appearances on barium swallow suggest:
See notes in Presentations
Describe endoscopy for dysphagia
Visualisation of luminal and mural lesions
Opportunity to biopsy and treat lesions
Stricture dilatation, stent insertion, laser coagulation and botox can all be done this way
More sensitive and specific than the double-contrast barium swallow
Often first line for low dysphagia
Describe videofluoroscopy for dysphagia
Modified barium swallow where patients are given barium in liquids, solid or semi-solid form.
Speech therapist modifies the swallowing technique throughout the study
Most suited for those with functional high dysphagia
Describe manometry for dysphagia
Assesses the pressures in the lower oesophageal sphincter and peristaltic wave in the rest of the oesophagus
Key investigation for diagnosing a motility disorder and distinguishing between the different types of motility disorder e.g. achalasia and nutcracker
How may an oesophageal adenocarcinoma be staged
Spiral CT chest/abdomen - for initial staging, checks for metastases PET scan - assess whether lesion of lymph node on CT is hot or cold Endoscopic ultrasound (EUS) - done if no evidence of disease on CT/PET and patient is a candidate for surgery (most accurate modality for locoregional staging) Laparoscopy - Done if no evidence of metastatic disease and there is a distal oesophageal tumour, used to exclude peritoneal deposits
What assessment must be done in those who are suitable for treatment for oesophageal adenocarcinoma
Fitness assessment for surgery with combination of lung function tests, ECG, exercise tolerance test +/- echo
What is the prognosis for oesophageal cancer
Usually poor
Stage-dependent
5 year survival for cancer caught at stage 1 is 50%
Lymph node involvement (70%) - 5 year survival 15%4
27F with 2 year history mild dysphagia to both solids and liquids. No problems coordinating a swallow but feels food is sticking. No choking or gurgling and no weight loss.
Complains to GP about heartburn and nocturnal cough and the treatment given did not work.
Exams are unremarkable
Barium swallow shoes beak-like terminal narrowing.
Manometry shows elevated lower oesophageal sphincter pressure + incomplete relaxation of the sphincter + aperistalsis
What is the diagnosis and treatment options?
Achalasia
Options: Pneumatic balloon dilatation Surgical (Heller's) myotomy Botox injections Drugs: CCBs/nitrates to relax the sphincter
64M with 5 week progressive dysphasia to solids. Feels food getting stuck. No choking, gurgling, heartburn, or waterbrash
Coughs day and night has recently been associated with episodes of haemoptysis. Lost 4 kg and has felt increasingly lethargic.
No significant PMH, no drinking, 40 pack years
Cachetic, hepatomegaly, palpable lymph nodes in left supraclavical fossa, neuro and resp exam unremarkable
CXR shows widened mediastinum and hilar lymphadenopathy
CT shows mediastinal mass + biopsies come back as small cell lung cancer
What is the mechanism of dysphasia
Caused by extrinsic compression of the oesophagus by the lung cancer + mediastinal lymph nodes.
Describe Barrett’s oesophagus
Metaplasia of squamous epithelium of the lower oesophagus into columnar epithelium
Associated with inflammation and ulceration of the distal oesophagus
Endoscopically visible as “velvety” epithelium
Caused by persistent irritation by GORD
Precursor lesion to adenocarcinoma (risk increases 30-40x)
What are the risk factors for squamous cell oesophageal cancer
Alcohol Smoking Dietary nitrosamines Aflatoxins Achalasia Plummer-Vinsons syndrome hereditary tylosis Coeliac disease
What are the risk factors for oesophageal adenocarcinoma
Barrett’s
Smoking and alcohol intake (not as important as for squamous cell)
What is Plummer-Vinsons syndrome
Collection of features that include atrophic glossitis, cheilosis, koilonychia, dysphagia associated with iron deficiency anaemia
What is the pathophysiology of achalasia
Absence of ganglion cells in the myenteric plexus (Auerbach’s) of the oesophagus.
Failure of relaxation of the lower sphincter and aperistalsis in the oesophageal body
Chagas will result in identical pathophysiology and infiltrating carcinoma may produce a pseudo-achalasia.
What is Hirschprung’s disease
Complete absence of myenteric plexus ganglion cells
A dysphagic patient presents with hoarse voice and bovine cough. What pathology may account for both of these.
Characteristic of recurrent laryngeal nerve pathology.
Nerve + dysphagia - either infiltration by primary malignancy of the oesophagus or mediastinal malignancy
OR
Ortner’s syndrome - compression by the cardiovascular system (left atrial dilatation secondary to mitral stenosis)
How can oesophageal cancer present
Dysphagia Weight loss GI reflux Odynophagia Dyspnoea Less common: GI bleeding, fatigue due to anaemia, hoarseness, cough, facial flushing due to SVC obstruction
What are the complications after oesophagectomy
Breakdown of anastomosis Pneumonia Cardiac arrhythmia Recurrent laryngeal nerve injury Chylothorax/chyle leak.
