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Sem 4, case 1 (oesophageal cancer) > oral, pharyngeal and oesophageal physiology and dysphagia (lecture) > Flashcards

oral, pharyngeal and oesophageal physiology and dysphagia (lecture) Flashcards

1
Q

What are the 3 normal phases of swallowing ?

A
  1. oral
  2. pharyngeal
  3. oesophageal
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2
Q

What type of muscle is used at each phase of swallowing ?

A
  1. oral = striated
  2. pharyngeal = striated
  3. oesophageal = striated/smooth
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3
Q

Where does the neural control stem from in each phase of swallowing ?

A
  1. oral = cortex/medulla (CN 5, 7, 12)
  2. pharyngeal = medulla (CN 9, 10, 11)
  3. oesophageal = medulla/enteric NS (CN V3, 9, 10, 12)
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4
Q

Say whether each phase of swallowing is under voluntary control or not …

A
  1. oral = voluntary control
  2. pharyngeal = some voluntary control
  3. oesophageal = no voluntary control
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5
Q

What are the main components of the oral phase of swallowing that prepare the bolus ?

A
  1. chewing = prepares solid food (teeth + mass water muscles)
  2. salivation = lubricates bolus and starts digestion (enzymes + water)
  3. movement of bolus = delivers prepared bolus to oropharynx (tongue)
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6
Q

Which muscular structure protects against laryngo-oesophageal reflux ?

A

upper oesophageal sphincter

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7
Q

Which zone is the most high-pressure zone in the oesophagus ?

A

upper oesophageal sphincter (100 mmHg)

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8
Q

What structures define the boundaries of the oesophagus?

A
  • The upper oesophageal sphincter
  • The lower oesophageal sphincter
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9
Q

Which cranial nerves are involved in swallowing ?

A
  • 5 (trigeminal)
  • 7 (facial)
  • 9 (glossopharyngeal)
  • 10 (vagus)
  • 12 (hypoglossal)

accessory nerve (11) also has small input

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10
Q

Which brainstem nuclei are primarily involved in the afferent relay pathways of swallowing ?

A
  • Nucleus solitarius (X)
  • Nucleus of the spinal tract of trigeminal (V)
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11
Q

Which of the brainstem nuclei are the main efferent pathways of swallowing ?

A
  • dorsal motor nucleus
  • nucleus ambiguous
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12
Q

Damage to which brainstem nucleus would result in severe dysphasia ?

A

Nucleus ambiguous (the main efferent nucleus of swallowing)

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13
Q

Does taste have any influence on the swallowing system ?

A

taste system is integrated with the swallowing system

stronger taste = stronger swallow

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14
Q

What are the characteristics of oropharyngeal dysphasia ?

A
  • abnormal bolus transfer to the oesophagus
  • difficulty initiating a swallow
  • only one manifestation of the primary disease (e.g stroke)
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15
Q

What type of MRI has been used to image swallowing ?

A

FMRI

functional MRI

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16
Q

What did FMRI show about blood flow during swallowing ?

A

Increased blood flow

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17
Q

What are the characteristics of oesophageal dysphasia ?

A
  • Abnormal bolus transport through oesophagus
  • Food stops after initiation of swallow
  • Oesophagus is the location of the primary disease (e.g achalasia)
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18
Q

What are some causes of neurological dysphasia ?

A
  • stroke (main)
  • parkinson’s
  • motor neurone disease
  • neuro-degenerative disease
  • head injury
  • MS
  • others
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19
Q

What is the most common method of imaging oropharyngeal dysphasia ?

A

Videofluoroscopy (VFS)

swallow barium then study dynamic images over time

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20
Q

What are the 2 main methods of imagine swallowing ?

A
  • VFS (videofluoroscopy)
  • FEES (Fiberoptic endoscopic examination of swallowing)
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21
Q

What is the method of FEES (fiberoptic endoscopic examination of swallowing) ?

A
  • insert tube with camera on it through the nose
  • look at base of tongue, pharynx and larynx
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22
Q

What % of stroke victims experience dysphasia as a result ?

A

about 50%

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23
Q

What type of dysphasia is most common after a stroke ?

A

oropharyngeal

24
Q

What is the most important complication of oropharyngeal dysphasia following a stroke ?

A

Aspiration

foreign objects - e.g food - getting directed into the lungs

25
Q

Does dysphasia after a stroke usually correct itself naturally or via surgery?

A

Natural recovery in most

26
Q

What type of therapy can help recovery of dysphasia after a stroke?

A

SALT

speech and language therapy

27
Q

What is the increased risk of death if a patient suffers aspiration due to dysphasia following a stroke ?

A

~ 3x increased mortality

28
Q

What is acahlasia ?

A

A motility disorder of the oesophagus

= impaired ability to push food down the oesophagus due to failure of the sphincter muscles

29
Q

What are the methods of testing for achalasia ?

A
  • conventional manometry (pressure monitoring system using catheterisation during swallowing)
  • high resolution manometry (more precise measurement than conventional)
  • spatiotemporal (clouse) plot (pressure, time and distance travelled by the bolus plotted on a graph)
30
Q

What are the potential causes of achalasia ?

A
  • potentially a HLA association (genetic)
  • potentially autoimmune due to circulating antibodies to enteric neurones
  • potentially result of a chronic infection e.g herpes, measles (unconfirmed)
31
Q

What is the prevalence of achalasia ?

A

1 in 100,000 cases

32
Q

Is achalasia more common in men it women?

A

The same!

Men = Women

33
Q

What is the most common age range for receiving a diagnosis of achalasia ?

A

25 - 60

childhood or adolescence is unusual

34
Q

What are the symptoms of achalasia ?

A
  • dysphasia
  • difficulty belching
  • weight loss
  • coughing
  • chest pain
  • regurgitation
  • reflux/heartburn
  • sensation of fullness
35
Q

What are the main steps of diagnosing achalasia ?

A
  • History
  • Endoscopy
  • Radiology (fluoroscopy)
  • Manometry
36
Q

What might endoscopy reveal if achalasia is present ?

A
  • dilated oesophagus
  • build up of fluid
  • oesophageal candiditis
  • could appear normal !
37
Q

Which is the most effective method of diagnosis achalasia ?

A

radiology (fluoroscopy)

swallow barium and use x-ray imaging to watch it travel through system

95% success rate

38
Q

What is the classic sign of achalasia called in radiology/fluoroscopy ? What is the physiology behind this presentation ?

A

bird-beak sign

= creates a bulge in the lower oesophagus because the lower oesophageal sphincter isn’t opening properly so the liquid cannot pass into stomach

39
Q

What is the gold standard method of confirming a diagnosis of achalasia ?

A

Manometry

40
Q

What are the 3 primary findings in Manometry that indicate achalasia ?

A
  1. elevated resting LES pressure
  2. incomplete LES relaxation
  3. aperistalsis = loss of peristalsis

LES = Lower oesophageal sphincter

41
Q

What reading is considered elevated LES pressure in manometry, and therefore indicative of achalasia ?

A

above 45 mmHg

42
Q

Which manometric finding distinguishes achalasia from other disorders presenting with aperistalsis ?

A

The incomplete LES relaxation

43
Q

Where does aperistalsis occur in the GI tract if achalasia is present ?

A

in the smooth muscle portion of the body of the oesophagus

44
Q

How many subtypes of achalasia are there ?

A

3

Type I
Type II
Type III

45
Q

What feature of achalasia occurs through all subtypes ?

A

incomplete relaxation of the LES

LES = lower oesophageal sphincter

46
Q

What % of achalasia-related deaths are attributable to oesophageal cancer ?

A

19%

47
Q

What are treatment options for achalasia ?

A
  • Botox injection into LES
  • Pneumatic dilation = balloon across LES, inflated to tear the muscle of the sphincter
  • Hellers myotomy = surgical incision into the LES to widen the sphincter to allow for passage of food etc

LES = lower oesophageal sphincter

48
Q

What is the MOA of botulinum toxin (botox) ?

A

inhibits acetylcholine release to relax muscle

inhibits Ca dependent release of acetylcholine from nerve terminals, thereby counteracting the effect of the selective loss of inhibitory neurotransmitters

49
Q

How effective is botox at relieving symptoms of achalasia ?

A

effective in about 85% of cases

50
Q

How frequently do symptoms recur in achalasia patients that were treated with botox ?

A

50% of patients within 6 months of their first treatment

51
Q

What is the most effective non-surgical treatment for achalasia ?

A

pneumatic dilation

52
Q

What is the process of pneumatic dilation ?

A
  • place a balloon over the LES
  • inflate it to a pressure great enough to tear the muscles of the sphincter
53
Q

What % of achalasia patients gain good-to-excellent symptom relief from pneumatic dilation?

A

50 - 93%

54
Q

How/where is Hellers myotomy performed ?

A

Laparoscopically, through the abdomen

= surgical procedure of the lower oesophageal sphincter

55
Q

What % of achalasia patients experience good-to-excellent symptom relief from myotomy ?

A

80 - 100%

56
Q

What is the main complication of myotomy ? How common is this complication?

A

uncontrolled gastro-oesophageal reflux

seen in about 10% of patients

Sem 4, case 1 (oesophageal cancer) (6 decks)

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