General oto esophageal dysphagia Flashcards
In a patient with dysphagia, how can you differentiate oropharyngeal from esophageal dysphagia based on symptoms?
● Esophageal dysphagia: Food gets stuck after the swallow
is completed because of structural or neuromuscular
pathology; the problem is in the esophageal body or
lower esophageal sphincter.
● Oropharyngeal dysphagia: Difficult to complete swallow;
disorders involve the oropharynx, hypopharynx, and
upper esophageal sphincter.
How does the differential diagnosis change if a
patient with esophageal dysphagia complains of symptoms with solids only versus both solids and
liquids?
Mechanical obstruction usually causes difficulty with solids (but it may progress to involve liquids later on). Motility disorders commonly result in concurrent solid and liquid dysphagia.
What are the most common diagnoses in a patient
with solid-food esophageal dysphagia?
● Esophageal ring (intermittent)
● Peptic stricture (progressive)
● Malignancy (progressive)
What is the most common cause of acute
esophageal dysphagia?
Food impaction (meat); results in saliva expectoration
What disease process is characterized by decreased or absent lower esophageal sphincter relaxation and decreased or absent esophageal
peristalsis?
Achalasia (Greek: “does not relax”)
Eagle syndrome is associated with what anatomical abnormality?
Elongated styloid process (about > 3 cm) and/or ossification
or calcification of part or all the stylohyoid ligament. This syndrome was described in 1937 by Dr. Wyatt Eagle.
Dysphagia lusoria is associated with what anatomical anomaly?
Aberrant right subclavian artery
What histopathologic findings support the diagnosis of achalasia?
Decrease in total ganglion cells within the myenteric plexus,
the presence of T cell, eosinophil, and mast cell infiltration,
and increased neural fibrosis
What is the general age group most commonly
affected by achalasia?
20 to 60 years
What are the primary complaints associated with loss of lower esophageal sphincter relaxation and esophageal aperistalsis (achalasia)?
Solid and liquid dysphagia, weight loss, chronic cough,
chest pain, hiccups, regurgitation, heartburn, and globus
What three associations are often included in
triple A syndrome (Allgrove syndrome), which is
most commonly found in children?
● Achalasia
● Adrenal insufficiency
● Alacrima
What infectious disease can lead to clinical
manifestations of achalasia?
Chagas disease
What management strategy can be used to reverse or stop the progression of achalasia?
None. The goal of management is to decrease lower
esophageal sphincter tone and manage reflux.
What is first-line therapy for patients with severe
achalasia?
Surgical dilation or myotomy unless the patient is a poor
operative candidate
What medical options are available for patients
with achalasia?
Nitrates and calcium channel blockers with the goal of
decreasing lower esophageal sphincter tone
What surgical interventions are available for
achalasia?
Good operative candidates may undergo pneumatic dilation or myotomy. Poor operative candidates may undergo dilation with a bougie or botulinum toxin injection.
What pathogen is associated with Chagas disease?
Parasite Trypanosoma cruzi
What is the vector for Trypanosoma cruzi?
Reduviid bugs
Describe the esophageal manifestations of Chagas disease?
● Megaesophagus with dilation and muscular hypertrophy
● Reduction in the number of neurons in the myenteric
plexus
What is the most common condition associated
with chronic Chagas disease?
● Cardiomyopathy
● Arrhythmias
● Conduction blocks
What are the clinical manifestations of scleroderma?
Skin tightening, hyperpigmentation, and hypopigmentation
of skin, sclerodactyly, Raynaud phenomenon, GERD,
arthralgias, myalgias, Sicca syndrome, and dysphagia
How common is esophageal involvement in
patients with scleroderma?
90%; 50% experience significant symptoms
The progressive fibrosis and atrophy within the
smooth muscle of the esophagus associated with
scleroderma manifest with what classic finding on
esophageal manometry and barium esophagram?
● Manometry: Progressive loss of esophageal body peristalsis in distal two-thirds and decreased lower esophageal sphincter pressure
● Barium esophagram: Dilated esophagus, patulous gas-
troesophageal (GE) junction, and uninhibited reflux
events into the distal esophagus
What are common complications noted in patients
with scleroderma and GERD?
Barrett esophagus, esophagitis, and strictures
What laboratory test is most sensitive and specific
for dermatomyositis?
Creatine kinase
How is dermatomyositis commonly treated?
Systemic steroid therapy and potentially immunosuppres-
sive and cytotoxic therapy, including methotrexate, aza-
thioprine, and cyclophosphamide
Describe the potential head and neck manifestations of dermatomyositis.
Heliotrope discoloration of upper eyelids, malar rash,
dysphonia, dysphagia, scaly scalp, and hair loss
What part of the aerodigestive tract is affected by
polymyositis?
Hypopharynx and upper third of the esophagus
What is the cause of diffuse esophageal spasm?
Neural and muscular defects triggered by reflux events,
stress, extreme temperature variability in food or drink,
carbonation, or particular smells
What symptoms are associated with diffuse
esophageal spasm?
Intermittent esophageal dysphagia, noncardiac chest pain,
reflux/heartburn
What are the classic esophageal manometric
findings in patients with diffuse esophageal
spasms?
Two or more uncoordinated contractions during 10 consecutive swallows, aperistalsis in more than 30% of wet swallows, and a fifth of contractions being simultaneous
