Dysphagia, Dyspepsia, Hiccup Flashcards
Definition of Dysphagia
Difficult swallowing, distinct from odynophagia (painful swallowing)
Oropharyngeal dysphagia - difficulty initiating swallow
Esophageal dysphagia - food bolus failing to easily traverse the esophagus
Physiology of normal swallowing
- Oral phase (voluntary control) - mastication
- Transfer phase - solid or fluid bolus pushed back into the pharynx by the tongue. As the bolus enters the hypopharynx, the involuntary swallow process begins
- Involuntary phase - bolus enters hypopharynx, larynx is elevated and pushed anteriorly to open the UES and allow the tongue to push the bolus into the esophagus.
- Esophageal phase - LES relaxes as the bolus enters the esophagus and a primary peristaltic contraction begins. Secondary peristaltic actions occur due to esophageal distention.
Oropharyngeal dysphagia - pathophys/causes
Occurs due to difficult transferring a bolus from the mouth to the pharynx, or from the pharynx to the esophagus
Causes:
- Structural
- Malignancy
- Enlarged thyroid
- Zencker’s diverticulum - Neurological
- CVS, ALS, brain stem tumours, MS, Parkinsonism, neuropathy, dementia - Myopathic
- muscular dystrophy, polymysotisis, myasthenia, thyroid disease - Iatrogenic
- Meds causing myopathy (botox, amio, statins, vincristine)
- Meds inhibiting saliva (opioids, TCAs, atropine, phenothiazine)
- Rads to head and neck
- Surgery to head and neck - Poor dentition
- Anxiety
Effects of oropharyngeal dysphagia
Regurgitation, couching, choking.
High risk of aspiration, respiratory complications, malnourishment, dehydration.
Poor survival when compared to those without dysphagia
Aspiration - definition, outcome
- Passage of food or fluids through the vocal cords leading to pneumonia
- Severity of complications depends on type of aspirate and capacity to clear the pulmonary tree
- Aspirations of solid can lead to fatal airway obstruction
- Chemical pneumonia may occur if the aspirate is ascidic
- Bacterial pneumonia may occur due to the normal flora of the mouth/pharynx
Esophageal dysphagia - definition/pathophys
Due to:
- Narrowing of the lumen of the esophagus
- Impaired motor function
- Altered esophageal sensation
Causes:
1. Neuromuscular (achalasia, esophageal spasm, SLE, RA, IBD, scleroderma)
- Vascular (ischemic esophagus)
- Structural (stricture, diverticula, malignancy, external compression,
- Infectious: (mucosal injury secondary to infection - candidiasis, CMV, HIV)
- Meds: (causing mucusal injury - alendronate, NSAIDs, ascorbic acid, antibiotics)
- Eosinophilic esophagitis
Results in retention of the food or fluid bolus in the esophagus
Oropharyngeal dysphagia - prevalence
- Common in older population, affecting up to 50% of adults in residential care
- Not considered part of healthy ageing
- High risk in CVA (25-50% with acute unilateral stroke, 60% likely to die due to consequences of dsyphagia)
- Up to 80% in Alzheimers
- 50-80% in PD
- Esophageal CA
Epidemiology of esophageal cancer
- May cause dysphagia
- At diagnosis, 50% have incurable disease
Presentation of oropharyngeal dysphagia
- Difficulty initiating swallow
- Swallowing repeatedly to effect pharyngeal clearance
- Hoarse voice
- Nasopharyngeal regurgitation
- Coughing with swallowing
- Sensation of food being ‘stuck’ (note can occur in esophageal dysphagia as well)
- More trouble with thin fluids rather than swallowing
- Weight loss, recurrent RTIs, pna, malnutrition with slower onset
- With acute onset, more likely to be stroke
Presentation of esophageal dysphagia
- Symptoms localised to chest
- More likely to have difficulty with solids rather than thin liquids
- May have chest pain with swallowing (especially if due to structural abnormality with reflux, narrowing of the lumen due to a structural abnormality, or a disorder of peristalsis).
Physical exam for dsphagia
Observation
- Mental status (alertness, orientation)
- Dysphonia or dysarthria (signs of motor dysfunction)
Oral cavity
- Dentition (increased risk of asp pna)
- Candidiasis
Neurologic exam (CN V, VII - XII)
- Symmetry, strength, sensation of lips
- Midline uvula
- Gag reflex (stroke pharyngeal mucosa and ensure palatal retraction is symmetric - if abnormal, suggests bulbar pathology)
- Tongue for wasting, fasciculations, deviation (deviates TOWARD lesion)
- Cough
Observed swallowing test
- How the patient opens their mouth, closes their mouth while taking fluid or solids
- How well they are able to clear their mouth after swallowing
- Whether the swallow changes with fatigue
- Red flags (drooling, delayed swallow, coughing, wet or hoarse voice)
Respiratory exam
Investigation of oropharyngeal dysphagia
- Nutrition parameters (albumin, CBC)
- CT or MRI head if sudden onset
- CXR (check for pna)
Barium video-fluoroscopy (swallow)
- Localize the site of the swallowing difficulty
- Visualizes all phase of swallowing and provides information to recommend the safest diet
- Pt must be able to sit upright
- Risk of aspiration
Flexible endoscopic evaluation of swallowing
- Direct visualisation of the larynx and pharynx
- Not as comprehensive as barium swallow, but no risk of aspiration
- Oral phase of swallowing cannot be assessed
Investigation of esophageal dysphagia
- Endoscopy for visualization of the esophagus, as well as biopsies, dilatation, and stent (Risk of perforation as a complication of biopsies or stent insertion)
- Esophageal pH monitoring for reflux disease
Management of oropharyngeal dysphagia
Lifestyle changes
- pureed diet (oral phase issues, food being pocketed in the buccal recesses, or pharyngeal retention of chewed solid food)
- increasing number of chews and swallows per bolus
- Thickened fluids
- SLP for swallowing exercises (e.g. tongue to help with food bolus management, lips to help stop drooling, vocal cords to limit aspiration)
- SLP for safe swallowing techniques (e.g. voluntary glottis closure, maneuvers)
- Surgery in cases where life expectency is long and the case is pchronic
Principles of palliative management of dysphagia
- Maximize swallowing function
- Maintain adequate nutrition as appropriate to stage of life (particularly important when prognosis is long)
- Allow people to participate in the social activities of eating/drinking
Prevention of aspiration pneumonia in dysphagia
- Maintain nutrition and hydration (decreases risk of serious complications from aspiration pneumonia, particularly when immunocompromised or with impaired cough)
- Ensuring good oral hygiene
When to consider enteral or parenteral feeds
- When interventions are inadequate or inappropriate and a patient cannot maintain hydration or nutrition safely
- Generally inserted for progressive debilitating conditions
Consider:
- Reversibility of the swallowing problem
- Degree to which underlying problem can be modified with less invasive interventions
- Individual wishes of the patient
- Risks
NG insertion - indications, risks, benefits
- Least invasive (no sedation required), simplest
- Recommended for situations where the need for enteral feeds are short or as a temporary measure
Risks:
- bleeding, trauma, misplacement of the tube, esophageal perforation
- Over time, discomfort, nasal ulceration, chronic sinusitis, reflux, aspiration pna
Oro-esophageal tube (indications)
- Temporary placement of a narrow bore feeding tube only during a feed, then removed.
- Useful for patients who do not have a gag reflex and decline other approaches to feeding
- Requires compliance and time commitment
PEG tube - indications, risks
Percutaneous gastrostomy tube - tube inserted through the anterior abdominal wall
Surgical gastrostomy - requires general anesthetic
Percutaneous gastrostomy - sedation
Insertion complications:
- bleeding, infections, peritonitis, perforation of other organs
Risks:
- Aspiration may still be a concern
- Infections, tube leakage or displacement, bleeding, metabolic/biochemical consequences, microbial contamination of feeds
- Survival at 12 months after starting enteral feeds is 40-50%
Contraindicated in patients with a short life expectancy
Treatment of esophageal strictures (dilatation)
- Most commonly caused by reflux
Simple strictures (straight, less than 2cm, easily passed by scope) - Dilatation alone
Complex strictures (longer than 2 cm, more tortuous, more difficult to pass the scope) - Dilatation (commonly requires more than 3). If 7 attempts, may be stented
Risks of dilatation (rare - <1%)
- Perforation
- Bleeding
- Bacteremia