Dysphagia, Dyspepsia, Hiccup

Question 1

What is dysphagia

Answer 1

• difficult swallowing
• oropharyngeal : difficulty initiating swallowing
• Esophageal swallowing : difficulty of food bolus traversing esophagus

Question 2

Physiology normal swallowing

Answer 2

1. Oral phase (voluntary)
   
   1. mastication
2. Transfer Phase
   
   1. bolus pushed back by tongue to hypopharynx
3. Involuntary phase
   
   1. larynx elevated
   2. UES opens
   3. tongue pushes food into esophagus
4. Esophageal phase
   
   1. LES relaxes
   2. primary peristalsis
   3. secondary peristalsis from esophageal distention

Question 3

Causes of OROPHARYNGEAL dysphagia

Answer 3

difficult transfer of food bolus from mouth to pharynx or pharynx to esophagus

Causes:

• Structural
  
  • malignancy
  • thyroid large
  • Zencker’s diverticulum
• Neurological
  
  • CVS
  • ALS
  • Brain stem tumour
  • MS
  • Parksinons
  • Neuropathy
  • Dementia
• Myopathic
  
  • muscular dystrophy
  • polymyositis
  • thyroid dz
  • myasthenia
• Iatrogenic
  
  • meds (botox, amio, statins, vincristine)
  • anticholingergics (TCA, atropine, opioids)
  • radiation rx
  • surgery head and neck
• Poor dentition
• Anxiety

Question 4

Causes of ESOPHAGEAL Dysphagia

Answer 4

Narrowing of lumen of esopahgeal. Impaired motor function, altered esophageal sensation

Causes:

1. Neuromuscular
   
   1. achalasia, esophageal spasm, SLE, RA, IBD, scleroderma
2. Vascular
   
   1. ischemic esophagus
3. Structural
   
   1. stricture, diverticula, malignancy, external compression
   2. foreign body, medistinal masses
4. Infectious
   
   1. candidiasis, HIV, CMV
5. Medications
   
   1. alendronate, NSAIDS, ascorbic acid, antibiotics, steroids
6. Eosinophilic esophagitis

Question 5

Clinical presentation of dysphagia

Answer 5

• Oropharyngeal :
  
  • repeated swallowing
  • regurgitation
  • choking
  • aspiration
  • hoarse voice
  • coughing on swallowing
  • weight loss
  • malnurtrition
  • pneumonia
  • liquids > solids more difficult
• Esophageal:
  
  • chest pain
  • solids > liquids more difficult

Question 6

What is aspiration?

Answer 6

• passage of food/fluid through vocal cords
• causes pneumonitis, pneumonia
• solids - fatal airway obstruction
• bacterial pna - normal flora of mouth
• chemical pna - acidic aspiration

Question 7

Physical exam for dysphagia

Answer 7

• nutritional status
• hydration
• mental status
• dysphonia/dysarthria
• oral cavity : dentition/ candidiasis
• Neuro exam (CN V< VII-XII)
  
  • symmtery, strength, sensation of lips
  • midline uvula
  • gag reflex
  • tongue for wasting, deviation towards side of lesion
  • cough
• swallowing test
  
  • open/closes mouth
  • clear mouth after swallowing
  • changes with fatigue
  • drooling, cough, wet hoarse voice
• respiratory exam

Question 8

Investigations for dysphagia

Answer 8

• CBC, albumin
• CT/MRI if ? stroke
• Cxray (pna?)
• Barium swallow
  
  • all phases of swallow
  • patient has to be able to sit up
  • risk of aspiration
• Endoscopy
  
  • direct visualization of larynx and pharynx
  • esophagus (biopsy, dilation, stent)
  • esophageal pH monitoring
  • not as comprehensive as barium swallow
  • no risk of aspiration
  • oral phase of swallowing cannot be assessed

Question 9

Management of oropharyngeal dysphagia

Answer 9

• lifestyle
  
  • pureed diet
  • increased numbers of chews/swallows
  • thickened fluids
  • SLP for swallowing exercises
  • SLP for safe swallowing
  • surgery rare - long life expectancy

Question 10

Principles / goals of palliative management of dysphagia

Answer 10

• maximize swallowing function
• maintain adequate nutrition as appropriate
• allow people to participate socially in meals

Question 11

Prevention of aspiration pneumonia in dysphagia

Answer 11

• maintain nutrition
• hydration
• good oral hygiene (altered colonization risk)
  
  • mouthwash, artificial saliva
    *

Question 12

Parenteral / enteral feeds : considerations

Answer 12

• progressive debilitating conditions
• reversibility of underlying problem
• can it be improved with less invasive interventions
• individual wishes of patient
• risks

Question 13

NG Tubes

Answer 13

• least invasive
• simple
• temporary
• short feeds
• risks: bleeding, trauma, esophageal perforation
• nasal ulceration, discomfort, sinusitis, reflux, pna

Question 14

Oroesophageal tube for feeds

Answer 14

• temp tube only during feed
• no gag reflex
• requires compliance and time

Question 15

PEG tube for feeding

Answer 15

• Percutaneous gastrostomy tube
• placed under sedation
• risks: bleeding, infection, perforation, perforation of other organs
• aspiration still a risk (10%)
• infections, tube leakage, blockage,metabolic derangements
• low survival
• NOT for short life expectancy

Question 16

Esophageal strictures

Answer 16

• most common cause Reflux
• Simple strictures (straight, < 2 cm)
  
  • dilatation alone
• Complex strictures (> 2cm, tortuous)
  
  • dilatation (multiple)
  • stent

Risks of dilations: perforation, bleeding, infection

Question 17

Esophageal stents

Answer 17

• Risks:
• Mid distal stents
  
  • stent migration
  • obstruction
  • reflux
• Proximal stents
  
  • food obstruction
  • fistula
  • aspiration

40% need re-stent. it works 90% of the time

CANNOT stent a stricture above or crosses UES

Question 18

Malignant esophageal strictures

Answer 18

• dilatation
  
  • < 3 months prognosis
• stent
  
  • >3 months prognosis
• adjuvant RT
• brachytherapy
  
  • usually longer prognosis

Question 19

Eosiniphilic esophagitis

Answer 19

• inhaled allergens
• ID allergen
• inhaled or systemic corticosteroids

Question 20

Esophageal spasm

Answer 20

• diltiazem
• TCA
• botox
• sildafenil

Question 21

Management of oropharyngeal dysphagia when life is measured in months - years

Answer 21

• diet changes
• thin fluids
• puree
• thickened fluids
• nutritional support
• hydration
• modification of swallowing (sitting, fluids from spoon, turning head to one side)
• oral hygiene
• avoid meds dry mouth
• targeted exercises
• electrical stimulation
• surgery
• parenteral/oral feeding

Question 22

Management oropharyngeal dysphagia in life measured in weeks

Answer 22

• diet
• positioning
• avoidance of dry mouth meds
• oral care

Question 23

Managing oropharyngeal dysphagia with days prognosis/EOL

Answer 23

• oral hygiene
• diet as stolerated

Question 24

Managing esophageal dyspahgia : based on prognosis

Answer 24

Months- years

• diet
• surgery
• stenting
• bracy/radiotherapy
• PPI /H2 blocker
• baclofen
• metoclopramide
• sucralfate
• botox
• enteral feeds

Weeks

• diet
• meds
• dilatation
• stenting

Days

• diet
• meds (PPI, H2, metoclopramide)

Question 25

Definition of dyspepsia

Answer 25

• epigastric pain
• burning
• post prandial fullness
• eary satiety

different from heartburn (retrosternal burning)

Question 26

Categories of dyspepsia

Answer 26

• functional
• secondary dyspepsia from
  
  • gerd
  • pud
  • gastric inflammation
  • UGI malignancy

Question 27

Stomach physiology

Answer 27

• stomach breaks down food
• proximal stomack relaxes via vagal stimulation after chewing
• distal stomach contracts to break down food
• liquid emptied into duodenum as entire stomach contracts and opens pylorus

Question 28

Pathophysiology of dyspepsia

Answer 28

• disorder of gastric motility
• changes in gastric emptying
• heterogenous sx

Question 29

Causes of dyspepsia **

Answer 29

• Functional
• secondary
  
  • GERD
  • esophagitis secondary to meds
  • FE, opioids, digoxin, CCB, nitrates, bisphosphonates, NSAIDS, steroids
  • PUD
  • malignancy
  • celiac

Question 30

Causes of dyspepsia- like symptoms (differential dx)

Answer 30

• Infection (giardia, tb)
• inflammatory (celiac, chrohn’s sarcoidosis, eosinophilic gastritis)
• Infiltrative (lymphoma, amyloid)
• gastric volvula
• gastric ischemia
• gastroparesis
  
  • drugs, DM, hypercalcemia
• paraneoplastic

Question 31

Clinical presentation dyspepsia : 4 cardinal symptoms

Answer 31

1. Post prandial fullness
2. early satiety
3. epigastric pain
4. epigastric burning

bloating, belching, n/vx

Question 32

History for dyspepsia

Answer 32

• IBS
• pain improved by food? PUD
• post prandial heartburn (GERD)
• meds
• weight changes
• changes to appetite
• vomiting of undigested food (gastroparesis)

Question 33

Investigations for dyspepsia

Answer 33

• history and physical
• upper EGD
• 24 hour esophageal pH monitoring
• H pylori assessment

Question 34

Management of dyspepsia

Answer 34

• lifestyle modifications:
  
  • small, frequent meals
  • avoid high fat
  • avoid triggers
• PPI if severe x 8 week trial
• TCA
• prokinetic

Question 35

Palliation of dyspepsia according to prognosis

Answer 35

Months-years

• treat underlying cause
• oral PPI/H@
• diet
• positioning
• prokinetics
• antidepressants

Weeks

• oral PPI, H2
• diet
• positioning
• prokinetics

EOL/days

• IV PPI, H2
• IV metoclopramide

Question 36

Hiccups definition

Answer 36

• SINGULTUS
• sharp, involuntary contraction of inspiratory muscles
• sharp inspiration and closure of glottis
• Sound is air column against closed glottis
• No physiological purpose

Question 37

Hiccups pathophysiology

Answer 37

• afferent limb
  
  • phrenic nerve
  • vagus
  • sympathetic chain
• central mediator
  
  • resp centre, medulla, hypothalamus
• Efferent limb
  
  • phrenic nerve to diaphragm and inspiratory muscles
  • recurrent laryngeal nerve to glottis

Question 38

Neurotransmitters involved in hiccups

Answer 38

• dopamine
• GABA

Question 39

Causes of hiccups

Answer 39

Central

• stroke
• tumour, abscess
• trauma
• encephalitis
• neurodegenerative (MS, PD)

Peripheral

• esophageal (dilation, achaclasia, tumour, food bolus)
• GI (distention, gastritis, GERD, SBO, ascites)
• Hepatic (liver mets, absecess, cholecystitis)
• Meds (steroids, benzos, opoiids, chemo)
• Respiratory (diaphragmatic irritation, pna, effusion)
• Toxic/metabolic (ARF, ETOH, lytes)
• Infectious (herpes zoster, GI candidiasis)
• Cardiac (MI)
• Psychological

Question 40

Hiccups clinical presentation

Answer 40

• 4-60 per minute
• high Pc02 slows frequency **
• minutes : “bout”
• > 48 hours “protracted”
• > 1 month “intractable”
• can cause:
  
  • distress, fatigue, sleep interruption, anxiety, anorexia, weight loss, vomiting, aspiration, pna

Question 41

Hiccups with a tracheostomy

Answer 41

• respiratory alkalosis secondary to hyperventilation
• life threatening

Question 42

Investigation of hiccups

Answer 42

• physical exam (neuro, abdo, resp, vitals)
• Cr, urea
• Lytes (hypona, hypoK, hypo Ca)
• liver enzymes
• imagining prn

Question 43

Medical palliation of hiccups

Answer 43

• treat underlying cause if possible
• First line:
  
  • BAclofen 5-10 mg po tid (smooth muscle relaxant)
  • Metoclopramide 10 mg po tid (dopamine antagonist)
  • Gabapentin 100 mg po tid
• Chlorpromazine 25 mg po tid
• haldol
• carbamazepine
• nifedipine
• midazolam
• dex, methyphenidate

Question 44

Non pharmalogical approaches to hiccups

Answer 44

• vagal nerve stimulation
• acupuncture
• glottic stimulation
  
  • q tip to palate or pharynx
• vagal nerve stimulation
  
  • gargling
  • ice water
  • valsalva
  • lift uvula with spoon
  • traction of tongue
• Increase PaCO2
  
  • breath holding
  • breathing into paper bag