Mechanical problems with swallowing and their assessment

Question 1

Epidemiology of dysphagia problems, GORD with dysphagia

Answer 1

• 13.5% of people have dysphagia

- 29% people have GORD in the UK, 30% of these also have dysphagia

Question 2

How you go about diagnosing a oesophageal swallowing problem

Answer 2

• always begin with endoscopy or barium swallowing study (150-200 mL barium, image taken every 1, 2 and 5 minutes). This will tell you if there is anything structurally wrong with the oesophagus, such as diverticulitis or a tumour
• for some non-functional causes of obstruction, such as eosinophilic oesophagitis, endoscopy may not be sufficient (17% of patients don’t have unusual structural pathology) therefore a biopsy is needed (histology)
• for functional issues endoscopy/biopsy won’t help, but useful to just exclude cancer etc.
• to assess function, need to do manometry screening- which is where a thin catheter is placed through the nose and down the oesophagus, which has pressure sensors (36). 10 water swallows are done, and average pressure at each locus is taken and plotted in a spatiotemporal clouse plot, whereby low pressure is blue and high pressure is red. This gives diagnosis of functional problems

Question 3

Structure of the oesophagus

Answer 3

• 18-22cm long
• gastro-oesophageal junction: lower oesophageal sphincter + diaphragm
• has both circular (inside) and longitudinal (outside) muscle, with myenteric plexus nerve between them
• top of the oesophagus has striated muscle (voluntary, 1/3 of the way down, the smooth muscle starts

Question 4

Normal function of the oesophagus

Answer 4

• peristaltic wave of excitation
• normally, as rest, deglutatative inhibition of the smooth muscle via nitric oxide (just relaxed and sphincter closed)
• once bolus gets to smooth muscle get waves of excitation and contraction via cholinergic conduction
• excitation moves down oesophagus in waves, followed by progressively larger inhibitory peaks
• then get to lower oesophageal sphincter and the bolus is pushed through

Question 5

Chicago classification 3.0 of major motor disorders

Answer 5

• oesophageal gastric junction issues (i.e. achalasia) + spasm (no inhibition of neurons and multiple contractions
• aperistalsis (no contraction)
• hypercontractability (increased contraction, inhibition normal)

Question 6

Achalasia: definition, subtypes, prevalence, diagnosis

Answer 6

• definition: where the inhibitory neurons in the myenteric plexus die meaning the lower oesophagus cannot relax
• subtypes: achalasia I (big, baggy oesophagus and non-relaxing lower oesophageal sphincter), achalasia II (the process before subtype I, oesophagus not big yet, most treatable), achalaisa III (lumen obstructing spastic contractions)
• affects 1 in 100,000 people, equal distribution across men and women
• barium swallow diagnosis 60-70% of patients and endoscopy only 30%, therefore manometry needed

Question 7

Eosinophilic oesophagitis (non-functional cause of obstruction): definition, progression, prevalence, clinical features (adults + children), diagnosis

Answer 7

• definition: T-cell mediated mediated allergic response to food which activates eosinophils and cytokine cascade
• progression: from inflammation to fibrosis which restricts the lumen
• prevalence: 4% of people with GORD have EoE. Peaks at ages 20-50 years, predominantly men (78%)
• clinical features in adults: respiratory GORD, dysphagia (intermittent), chest pain, food impaction
• clinical features in children: failure to thrive, feeding intolerance, heart burn, vomiting, dysphagia, food impaction
• diagnosis: need endoscopy with HISTOLOGY (>15 eos/hpf)

Question 8

Hiatus hernia: definition, subtypes

Answer 8

• definition: opposite of obstruction, too much relaxation
• type I: sliding hiatus hernia. Most common, where the OGJ moves up and some of the stomach pouches up with it
• type II: Pure para-oesophageal hernias. where OGJ stays in place, but the fundus comes up
• type III: mix of both types I and II
• type IV: where another GI organ, such as intestine, comes up above OGJ

Question 9

Minor motor disorders

Answer 9

• these may or may not have symptoms, if they do, just managing the symptoms and not the condition itself
• hypo-contraction
• hypersensitive oesophagus
• frequent failed swallows
• in 5 years, 70% spontaneously get better anyway, for those that don’t, may need the biopsychosocial model so they can get better