Dysphagia and Achalasia Flashcards
What is the esophagus?
- a posterior mediastinal structure
- Esophagus 25 cm long(cricoid cartilage to cardiac orifice), 2 cm in diameter
- 43 cm from incisor teeth
Layers of the esophagus?
- mucosa
—surface epithelium, lamina propria, and glands. - submucosa
—connective tissue, blood vessels, and glands. - muscularis (middle layer)
- upper third, striated muscle
- middle third, striated + smooth
- lower third, smooth - adventitia
—connective tissue that merges with connective tissue of surrounding structures.
Note: no serosal layer - only on distal part
3 types of esophagus?
cervical, thoracic and abdominal
Vasculature of the esophasgus?
- cervical oesophagus
- is supplied by the inferior thyroid artery - The thoracic oesophagus
- is supplied by the brachial and oesophageal branches of the thoracic aorta - abdominal esophagus
- left gastric artery
The 3 natural constriction points of the esophagus?
- cricopharyngeal junction
- where left bronchus cross it
- gastroesophageal junction
What is dysphagia?
difficulty swallowing
2 categories of dysphagia?
- oropharyngeal dysphagia
- esophageal dysphagia
Oropharyngeal dysphagia?
results from a functional impairment in the initiation of swallowing: the oral and pharyngeal phases
- This form is most commonly a sequela of systemic neurologic or myopathic syndromes
Esophageal dysphagia?
dysphagia involves intrinsic functional (motor) and anatomic abnormalities of the esophagus resulting in difficulty swallowing
Things to ask on history taking of a dysphagia patient?
- timing of dysphagia
- painful swallowing
- location (cervical vs thoracic)
- intolerance of solid or liquid food
- onset/progression
- associated symptoms
Hx of timing of dysphagia?
Described with respect to swallow: immediate vs. delayed
1. Oropharyngeal dysphagia
- Immediate coughing, choking regurgitation
2. Esophageal dysphagia
- Sensation of food “sticking”, getting “caught”, or delayed regurgitation of undigested food
3. “Globus sensation”
- Benign, constant, nonpainful sensation of fullness in neck / throat
- Should not be associated with swallowing difficulties
Hx of painful swallowing?
Odynophagia is not typically associated with dysphagia
- Prompts consideration of infectious / inflammatory etiologies
e.g. Pharyngitis, mucositis following radiation therapy, caustic ingestion
HX of location of dysphagia?
Patients will self localize: cervical, retrosternal, epigastric regions
- Accurate to within 4 cm of lesion via patient history in up to 74% of cases
History of solid vs liquid intolerance?
- both solids and liquids - functional/ neuromuscular cause
- Solid food only - mechanical/anatomic cause
- Progression from purely solid to both - narrowing attributable to evolving mechanical obstruction (eg., esophageal cancer)
Hx of onset/progression of dysphagia?
- Intermittient, nonprogressive - suggestive of intrinsic motor dysfunction
- Short duration, or rapidly progressive - must rule out malignancy
Hx of associated symptoms of dysphagia?
- Anorexia or weight loss
• Suggests underlying malignancy (associated peptic stricture may cause dysphagia without GERD in up to 25-35% of cases)
• Achalasia can also be cause - Passive regurgitation of undigested food
• Achalasia, cricopharyngeal or esophageal diverticulae - Retrosternal chest pain (once cardiac etiologies eliminated)
• Esophageal spasm, GERD, eosinophilic esophagitis - Medication lists must be reviewed to rule out drug-induced injury
• Alendronate, doxy cy dine, NSAIDs, MMF
Examining a dysphagia patient?
- The head and neck
- size of the thyroid gland, any lymphadenopathy or masses. - The cranial nerves
- may demonstrate deficits contributing to oropharyngeal dysphagia
- corresponding neurologic assessment may reveal signs of a cerebrovascular accident (CVA), myasthenia gravis, or Parkinson disease. - The chest and abdomen
- presence of subcutaneous nodules or masses that may indicate underlying malignancy. - Dermatologic rashes
- may indicate a paraneoplastic syndrome or a primary autoimmune disorder. - Murmurs or thrills on cardiac auscultation
- may represent atrial enlargement (secondary to mitral valvular stenosis), causing extrinsic esophageal compression
Etiologies of oropharyngeal dysphagia?
- Fixed mechanical obstruction
- Oropharyngeal cancer
- Webs
- Previous neck surgery or radiation treatment
- Extrinsic compression - Intrinsic motor disorders
- Cricopharyngeal (Zenker) diverticulum - Systemic conditions
- Cerebrovascular accident
- Myasthenia gravis - Inflammatory
- Eosinophilic esophagitis
- HSV /CMV /Candida
- Caustic ingestion
Etiologies of esophageal dysphagia?
- Fixed mechanical obstruction
Neoplasms
Peptic stricture
Webs
Rings
Extrinsic compression - Intrinsic motor disorders
Achalasia
Esophageal spasms - Systemic conditions
Scleroderma
Diabetes mellitus - Inflammatory
Eosinophilic esophagitis
HSV /CMV /Candida
Caustic ingestion
Diagnostic testing for dysphagia?
- primary test
- upper endoscopy
- endoscopic ultrasonography
- 24 hr pH monitoring
- impedance monitoring
- esophageal manometry
- CT and MRI
- F-FDG-PET scan
Management of dysphagia?
Depend on the cause
1. Resuscitation
2. Supportive/palliative care
What is primary motility disorder?
- diffuse esophageal spasm (DES)
- nutcracker esophagus
- hypertensive LES
What is the treatment for primary motility disorders?
- Is based on smooth muscle relaxation using nitrates such as isosorbide dinitrate or calcium channel blockers such as diltiazem.
- Balloon dilatation may be effective for isolated hypertensive LES
What is secondary motility disorder?
the esophageal symptoms are a manifestation of a generalized systemic process
What is the etiology of secondary motility disorder?
is thought to be progressive neuropathy and subsequent fibrosis.
Most common diseases associated with secondary motility disorder?
scleroderma and diabetes mellitus
Management of secondary motility disorder?
Management is directed toward treating the underlying disease process
Zenkers diverticulum and it’s management?
esophageal pouch that develops in the upper esophagus that causes debilitating dysphagia (difficulty swallowing) and regurgitation of food.
- excision/myotomy
Webs and their management?
Esophageal webs are thin membranes that grow across the inside of the upper part of the esophagus and may cause difficulty swallowing
- mechanical dilatation using Savary bougies or endoscopic balloons
Rings and their management?
Rings are bands of normal esophageal tissue that form constrictions around the inside of the esophagus. They occur in the lower esophagus
- mechanical dilatation using Savary bougies or endoscopic balloons
Strictures and their management?
An esophageal stricture refers to the abnormal narrowing of the esophageal lumen
- careful repeated dilatations combined with effective acid suppression therapy/ surgery/antibiotics/ antifungal
Management of CA esophagus?
surgery/palliation
What is achalasia?
This progressive disease
Result from a loss of inhibitory neurons in the Auerbach plexus, altering neural input to the LES and preventing normal relaxation.
Etiology of achalasia?
The majority are idiopathic
Epidemiology of achalasia?
females and males equally affected at a rate of one per 100,000 individuals per year.
The usual age at presentation is between 20 and 50 years, but it has been described in all age groups
Presentation of achalasia?
The disease is slowly progressive and presents typically at an advanced stage
Symptoms of achalasia?
progressive dysphagia to both solids and liquids, accompanied by regurgitation of food particles, chest pain, and weight loss
Diagnostic testing for achalasia?
- Plain X-rays
- Manometry
- Endoscopic assessment
Management of achalasia?
The aim of achalasia management is palliation of dysphagia by enhancing LES compliance and lowering the resting LES pressure
1. Endoscopic injection
2. Balloon dilation
3. Endoscopic myotomy( POEM/Heller)
