Presentation: Dysphagia Flashcards
What is achalasia?
Achalasia is the failure of oesophageal peristalsis and relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus. The LOS is contracted, and the oesophagus above is dilated.
Who is typically affected by achalasia?
Achalasia typically presents in middle-age and is equally common in men and women.
What are the clinical features of achalasia?
Clinical features include dysphagia of both liquids and solids, variation in severity of symptoms, heartburn, regurgitation of food, and may lead to cough or aspiration pneumonia.
What are the potential complications of achalasia?
Achalasia may lead to cough, aspiration pneumonia, and malignant change in a small number of patients.
What is the most important diagnostic test for achalasia?
Oesophageal manometry is considered the most important diagnostic test, showing excessive LOS tone that does not relax on swallowing.
What does a barium swallow show in achalasia?
A barium swallow shows a grossly expanded oesophagus with a fluid level and a ‘bird’s beak’ appearance.
What does a chest x-ray reveal in achalasia?
A chest x-ray may show a wide mediastinum and fluid level.
What is the preferred first-line treatment for achalasia?
Pneumatic (balloon) dilation is increasingly the preferred first-line option due to being less invasive and having a quicker recovery time than surgery.
When should surgical intervention be considered for achalasia?
Surgical intervention with a Heller cardiomyotomy should be considered if there are recurrent or persistent symptoms.
What is the role of botulinum toxin in treating achalasia?
Intra-sphincteric injection of botulinum toxin is sometimes used in patients who are at high surgical risk.
What is the role of drug therapy in achalasia treatment?
Drug therapy (e.g., nitrates, calcium channel blockers) has a role but is limited by side effects.
What is dysphagia?
Dysphagia is difficulty swallowing. New-onset dysphagia is a red flag symptom requiring urgent endoscopy.
What are the characteristics of dysphagia caused by oesophageal cancer?
Dysphagia may be associated with weight loss, anorexia, or vomiting during eating.
Past history may include Barrett’s oesophagus, GORD, excessive smoking, or alcohol use.
What symptoms are associated with oesophagitis?
There may be a history of heartburn and odynophagia, but no weight loss and the patient is systemically well.
What are the risk factors for oesophageal candidiasis?
There may be a history of HIV or other risk factors such as steroid inhaler use.
What are the symptoms of achalasia?
Dysphagia of both liquids and solids from the start, heartburn, and regurgitation of food, which may lead to cough and aspiration pneumonia.
What is a pharyngeal pouch?
A pharyngeal pouch is more common in older men and represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles.
Typical symptoms include dysphagia, regurgitation, aspiration, chronic cough, and occasionally halitosis.
What features may be present in systemic sclerosis?
Other features of CREST syndrome may include calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia.
What are the symptoms of myasthenia gravis related to dysphagia?
Dysphagia with liquids as well as solids, and other symptoms may include extraocular muscle weakness or ptosis.
What is globus hystericus?
Globus hystericus may have a history of anxiety, with symptoms often intermittent and relieved by swallowing, usually painless.
The presence of pain should warrant further investigation for organic causes.
What are the classifications of causes of dysphagia?
Causes of dysphagia can be classified as extrinsic, intrinsic, and neurological.
What are examples of extrinsic causes of dysphagia?
Examples include mediastinal masses and cervical spondylosis.
What are examples of intrinsic causes of dysphagia?
Examples include tumours, strictures, oesophageal web, and Schatzki rings.
What are examples of neurological causes of dysphagia?
Examples include CVA, Parkinson’s disease, multiple sclerosis, brainstem pathology, and myasthenia gravis.
What investigations are required for dysphagia?
All patients require an upper GI endoscopy unless there are compelling reasons not to perform it. A full blood count should also be performed.
What additional studies may be required for motility disorders?
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.
