Dysphagia–diagnosing and evaluating Flashcards
What are the 2 phases of dysphagia
Oral pharyngeal phase and the esophageal phase
Describe the transit of the bolus in the oropharyngeal phase?
The bolus is transferred to the upper esophagus with the soft palate protecting the nasal passageway and the epiglottis protects the airway.
Described the transit of the bolus in the esophageal phase?
The bolus is transferred through the esophagus to the stomach via esophageal peristalsis.
What does dysphagia mean? What does odynophagia mean?
- Difficulty swallowing
- Pain with swallowing
What are the 2 main components of the presentation signs and symptoms of dysphagia that can help narrow down the differential?
- Nature of onset: sudden CVA or foreign body ingestion vs. subacute infectious or autoinflammatory diseases onset
- Speed of progression: Non-progressive developmental abnormality vs. a progressive compressive mass affect
How can other components of the history including review of systems, past medical history of diagnoses and medications help in diagnosing dysphagia?
With review of systems or may be fever, pain, changes in mental status, muscular weakness numbness outside of the GI tract, rashes. With medical diagnosis there may be Crohn’s disease etc. and with medications there may be yeast and immunosuppression or medication induced esophagitis
What underlying etiology of dysphagia to both liquids and solids may be occurring
Dysmotility, which typically occurs in the esophageal phase
What underlying etiology of dysphagia occurs with solids alone?
Suggestive of a structural abnormality or mucosal disease and can occur in both the oropharyngeal or esophageal phase issue.
What symptoms are more common or consistent with disorders of the oropharynx when evaluating for dysphagia?
- Delayed swallow initiation
- Postnasal regurgitation or cough with swallowing
- Drooling
- Throat clearing
What symptoms are more common with the esophageal dysphagia?
Retrosternal chest pain and a sticking sensation during and after swallowing.
What are the differential considerations for oropharyngeal etiologies of dysphagia?
- Structural causes
- Infectious/inflammatory mucosal disease and
- Motility impairment
Structural causes are ruled out first prior to looking to the other 2
What are common structural causes for oropharyngeal etiologies?
- Cleft lip or palate
- Goiter
- Lymphadenopathy i.e. infectious, inflammatory or malignancy.
What are the causes for infectious/inflammatory conditions causing dysphagia?
Retropharyngeal/peritonsillar abscess and
Coxsackie, CMV/HSV, epiglottitis
What are common neuromuscular disorders as the etiology for oropharyngeal dysphagia?
- Guillain-Barré, multiple sclerosis, myasthenia gravis, juvenile dermatomyositis
- CNS tumor or cerebrovascular accident
- Botulism or tetanus
- Globus sensation
What are the 3 major categories for differential diagnosis and the etiologies for esophageal dysphagia?
- Structural causes
- infectious/inflammatory conditions
- Motility disorders
What are some structural causes for esophageal etiologies of dysphagia?
- Esophageal web, stricture, diverticulum, fistula, swallowed foreign body
- Mediastinal mass, vascular ring
What are some of the infectious/inflammatory conditions as etiologies of esophageal dysphagia?
- Pill esophagitis, caustic ingestion
- Candida, eosinophilic esophagitis, HIV
- GERD
What are some of the common motility disorders as etiologies for esophageal dysphagia?
- Achalasia
- Scleroderma
- Diffuse esophageal spasm
How is dysphagia best diagnosed?
Most commonly it is diagnosed by clinical suspicion via the history and physical exam.
When warranted what further investigation into the differential of dysphagia may be needed?
Serum studies, radiographs, CT, MRI and or PET scans
Described fiberoptic endoscopic evaluation.
Fiberoptic scope is used to examine the structure of the oropharynx and the appearance of the tissue, looking for coordination of the rise of the soft palate, protection of the larynx by the epiglottis and movement of the vocal cords
How can videofluoroscopic barium swallow studies help with dysphagia diagnosis?
The bolus is followed through oropharyngeal and esophageal phases which may reveal discoordinated aspiration in the oropharyngeal phase or structural impediments such as a foreign body esophageal web, abnormal dilation or fistulizing track
How does an upper endoscopy help with the diagnosis of dysphagia and who performs it?
A gastroenterologist uses an endoscope and is able to inspect and biopsied the mucosa of the esophagus, stomach and duodenum. This helps to uncover infectious or inflammatory etiologies in the esophageal dysphagia
Describe how manometry of the esophagus or esophageal phase may help.
The manometry catheter is placed in esophagus when the patient is awake and performed a series of swallowing looking for neuro muscular integrity of the esophagus?
