Dysphagia & Regurgitation Flashcards
history questions for dysphagic patients
- solids or liquids?
- intermittent or progressive?
- temporal pattern? (which phase of swallowing is affected)
- recent general anesthesia?
- age of onset
- dysphonia?
- odynophagia?
- recent medications?
ddx for dysphonia
- myopathy
- neuropathy
- junctionopathy
ex. GOLPP (geriatric onset laryngeal paralysis + polyneuropathy)
localizing dysphagia
- oropharyngeal - oral, pharyngeal, cricopharyngeus muscle
- esophageal
- gastroesophageal
BOAS
brachycephalic obstructive airway syndrome
- hypoplastic trachea
- elongated soft palate
- hypertrophic tongue
- stenotic nares
- everted laryngeal saccules
predisposes brachycephalics to hiatal hernia due to increased negative intrathoracic pressure
diagnostics for dysphagic/regurgitating patients
- observation
- PE
- neuro exam
- minimum database
- radiographs
- esophagram vs video fluoroscopy
what type of radiographs are indicated
3 view thoracic
1 lateral cervical
esophagram vs video fluoroscopy
esophagram - static image at time intervals after swallowing barium bolus
video fluoroscopy - dynamic imaging of barium bolus moving throughout the swallow
masticatory muscle myositis
immune mediated attack on the muscles of mastication
targets the 2M myofibers
clinical signs of MMM
inability to open jaw
acute: inflammation + pain
chronic: fibrosis + scarring
diagnosis of MMM
2m antibody ELISA
muscle biopsy (if chronic)
treatment of MMM
immunosuppression
- corticosteroids
- cyclosporine
can NOT treat chronic cases when muscles already fibrosed down
cricopharyngeus muscle dysfunction
failure of the UES to open or open at the correct time
two forms:
- achalasia
- asynchrony
CMD achalasia
failure of the UES to open
mini long hair dachshunds
toy breeds
CMD asynchrony
failure of the UES to open at the same time as pharyngeal contraction
young golden retrievers
clinical signs of CMD
- regurgitation immediately after swallowing
- WORSE with water
- nasal reflux
diagnosis of CMD
video fluoroscopy
can NOT do static imaging
treatment of CMD
ALWAYS modify water texture - ice, thickening agents
surgical: open myotomy of CP muscle
medical:
- botox of CP muscle
- pneumonic dilation of UES
megaesophagus
dilation and loss of motility of the esophagus (primary or secondary)
primary: idiopathic
secondary:
- myasthenia gravis
- NM disease
- esophageal foreign body
- vascular ring anomaly
- esophageal neoplasia
- Addison’s disease
clinical signs of megaesophagus
acute onset dysphagia
regurgitation
ptyalism
dysphonia
esophageal achalasia like syndrome
common cause of megaesophagus
hypertonic LES preventing the bolus from entering the stomach
types of treatment for megaesophagus
- management (for primary idiopathic ME)
- medical (for EALS)
- surgical (for EALS)
management of primary idiopathic megaesophagus
- modify diet (wet food)
- elevated feeding (Bailey chair)
medical treatment for EALS
- botox of the LES
- sildenafil (viagra)
temporary - only lasts 3-4 months
surgical treatment for EALS
- pneumonic dilation
- heller myotomy + fundoplication
heller myotomy + fundoplication
heller myotomy: incising into the LES and pulling the mucosa through the incision to release tension of hypertonic muscle
fundoplication: wrapping the fundus around the base of the esophagus in order to resolve potential reflux from heller myotomy alone
myasthenia gravis
muscle weakness and fatigue caused by deficient Ach receptors
congenital vs acquired
congenital myasthenia gravis
deficient Ach receptors at the NM junction
occurs in YOUNG PUPPIES
signs:
- exercise intolerance
- generalized weakness
- megaesophagus
diagnosis: muscle biopsy
acquired myasthenia gravis
immune mediated attack on Ach receptors
occurs in ADULTS
signs:
- megaesophagus alone
- ME + generalized weakness
diagnosis: Ach receptor antibody test
- normal <0.6
- if Ab > 0.3 with acute clinical signs –> retest in 3-6 weeks
hiatal hernia
stomach pushes through the diaphragm at the hiatus
common in brachycephalics due to BOAS and pyloric hypertrophy
clinical signs of hiatal hernia
regurgitation
dysphagia
hypersalivation
diagnosis of hiatal hernia
video fluoroscopy to ID esophageal dysmotility
treatment of hiatal hernia
ALWAYS treat the BOAS before doing surgical hernia repair - can often resolve the hernia
surgical management is ideal - L sided gastropexy, esophagopexy, diaphragmatic hiatal plication
medical: PPIs, cisapride, LF diet
esophagitis
inflammation of the esophagus
common causes of esophagitis
- general anesthesia
- medication induced
- chronic vomiting
- foreign body
- ingestion of caustic material
anesthesia induced esophagitis
occurs 1 week after anesthesia
drugs used for anesthesia + loss of swallow reflex/LES tone while unconscious –> reflux –> acidic contents remain in esophagus during duration of procedure
what medications can cause esophagitis
doxycycline
clindamycin
treatment of esophagitis
PPIs, H2 blockers
sucralfate
cisapride, metoclopramide
LF diet
esophgeal strictures
narrowing of the lumen following esophagitis
common consequence of esophagitis caused by anesthesia, trauma, foreign body, etc
treatment of esophgeal strictures
esophageal balloon dilation + antifibrotics
