Dysphagia and Oesophageal Motility disorders Flashcards
Define odynophagia
Pain when swallowing
Define dysphagia
Difficulty swallowing
What is the most common congenital cause of Dysphagia?
Oesophageal atresia
What is a bolus bezoar?
Partially digested material
What is plummer vinson syndrome?
Plummer Vinson Syndrome causes Upper GI bleeding and dysphagia due to webs
Triad of:
Esophageal webs
Iron deficiency anaemia (due to bleeding)
Dysphagia (post-cricoid)
Give 10 differentials for Dysphagia
Congenital -> Oesophageal atresia
Acquired:
1) Oesophageal:
Luminal - Bolus Bezoar, foreign body
Wall - Oesophageal web, carcinoma, Plummer Vinson Syndrome, stricture, GORD, oesophageal motility disorders
Extramural - Hilar lymphadenopathy, pharyngeal pouch, goitre, lung Ca
2)Neurological:
Stroke, Myasthenia Gravis, Motor neuron disease, MS
What are your top 3 differentials for Odynophagia
Pharyngitis, tonsillitis, oesophagitis, abscess
A patient has presented with odynophagia and later diagnosed with oesophagitis. Give 2 organisms that can cause that
HSV, CMV, Candida
What are your ddx for nocturnal cough?
pharyngeal pouch, achalasia, GORD
Quick! What would you ideally ask about in a hx of dysphagia
1) Degree of dysphagia (solids vs liquid vs both)
2) Timeline (progressive suggests malignancy, sudden onset = luminal)
3) Hx of dyspepsia (strictures from GORD/reflex)
4) Weight loss (malignancy or poor feeding)
5) Nocturnal cough (pharyngeal pouch, achalasia, severe GORD)
6) Nausea, vomiting, and Haematemesis (coffee ground vs frank, amount, timeline)
7) Anaemia (pallor, SOB, chest pain, pre-syncope)
8) Recurrent chest infection (pleuritic chest pain, fever)
9) Neurological symptoms (weakness, sensory loss)
What imaging is used for staging of oesophageal tumours?
Endoscopic US and CTTAP
What investigations will you perform for Dysphagia
Bedside: ABG - Check for hypochloraemic metabolic alkalosis with U&E
Bloods: FBC (anaemia). U&E (Dehydration => hypernatraemia + Hyperchloraemic metabolic acidosis with ABG)
Imaging: CXR - Showing air-fluid level in mediastinum (achalasia & rolling hiatus hernia)
Barium swallow
Endoscopic US & CTTAP for staging of oesophageal tumours
Procedures:
OGD + biopsy
Link with SLT for swallow studies
State the top 6 causes of Oesophageal motility disorder
Primary: Achalasia, Diffuse oesophageal spasm
Secondary: Chagas disease, scleroderma, DM, Amyloid, Myasthenia Gravis
What are your differentials for progressive difficulty to swallow both liquids and solids
Oesophageal Ca
All oesophageal motility disorders
Primary: Achalasia, Diffuse oesophageal spasm
Secondary: Chagas disease, scleroderma, DM, Amyloid, Myasthenia Gravis
What are the characteristic features of achalasia (4)?
Loss of oesophageal paristalsis
Increased LOS tone
SM failure to relax. (increased tone)
Progreessive dysphagia of BOTH solids and liquids
What is the pathophysiology of achalasia
Neurological deficit in Auerbach’s plexux (part of myenteric plexus)
The myenteric plexus is composed of 2 subplexus. What are they and what does each control?
Auebach’s plexus - Controls motility => peristalsis
Meissner’s plexus - controls secretion and blood flow
What are the 3 main diagnostic tests for achalasia?
Barium Swallow
Manometry
OGD/Endoscopy
What is this image showing?
What is it consistent with?
Bird beak sign consistent with Achalasia
What is the main cause of the bird beak sign in this image (not the name of the disease)
Increased tone of the LOS causing poor barium emptying
What does manometry measure?
Muscle movement and intra-oesophageal pressure
What findings on barium swallow and manometry would be consistent with achalasia?
Barium swallow: !!Bird beak apperance, narrow GOJ, aperistalsis, dilation of oesophagus, poor barium emptying
Manometry: High resting intra-oesophageal pressure >30 + aperistalsis
What is the normal amount of intra-oesophageal pressure on manometry. What would be consistent with achalasia
Normal 0-30
Achalasia >30
What are the complications of Achalasia?
Nocturnal aspiration (lying flat) causing bronchiectasis and lung abcess formation
SCC in mid oesophagus
What is the definitive management of achalasia?
1) Balloon dilatation
2) Botulinium Toxin injection into LOS
3) Endoscopic myotomy
4) Heller’s Cardiomyotomy with anterior/Dor’s Fundoplication
What is the main downfall of using Botulinum Toxin injection into LOS as a treatment for achalasia?
Not a long term option. Needs to be repeated
Balloon dilatation is the best first line management for achalasia with a 70% success rate. What is the most important complication?
Perforation
Where would you see a scar after Heller’s cardiomyotomy with anterior/Dor’s fundoplication?
Incision scar 5cm above to 3cm below the cardia
A diffuse oesophageal spasm causes intermittent increases in tone and dysphagia. Is the dysphagia that of solids, liquids or both?
What is the characteristic feature of the disease?
Both solids and liquids just like achalasia.
Atypical angina-like chest pain
What is being shown in this image
Manometer showing Nutcracker or corkscrew oesophagus consistent with Diffuse oesophageal spasm
How is Diffuse oesophageal spasm diagnosed?
How is it managed?
dx: manometer showing nutcracker or corkscrew sign
Tx: Nifidipine + Reassurance
What is Nifidipine
Dihydropyridine CCB
Do not confuse with Nimodipine which is used to prevent vasospasm in patients post-SAH
What is Chagas Disease? (include pathophysiology)
Chronic infection with Trypanosoma Cruzi causing destruction of intramuscular ganglion cells
Where is Chagas disease native to?
Brazil/south america
How does Chagas disease present?
Dysphagia with a hx of south american travel
Chagas disease typically presents with dysphagia. What is this disease also associated with
Mega everything
Cardiomyopathy
Megacolon
Megaduodenum
Megaureter
Oesophageal involvement is present in 80% of patients with Scleorderma. How is it diagnosed?
Treatment of scleroderma requires a multidisciplinary approach. With regards to the oesophageal involvement, how is it specifically treated?
Manometry showing an adynamic oesophagus with hypotensive LOS (unlike the rest)
Tx: Partial fundoplication = Dor/Toupet
Scleroderma manifestations are known by a pneumonic. What is it and expand it?
CREST Syndrome
Calcinosis - deposits on skin
Reynaud’s phenomenon
Esophageal dysfunction - Hypotensive
Sclerodactyly
Telangiectasia
What is Reynaud’s phenomenon?
spasm of peripheral blood vessels in cold
What is sclerodactyly
Thickening and tightening of skin
What is telangiectasia
Describe the finding on exam
Capillary dilatation
Red spots on skin
