SA GI Medicine 2 - Investigating and Managing Swallowing Disorders and Regurgitation Flashcards
Diagnostic investigations for swallowing disorders - blood tests.
Routine haematology and biochemistry (bilirubin) if suspect disease.
Electrolytes.
cPLi/fPLi if suspect pancreatitis leading to nausea.
Pre-GA profile in older patient if GA needed:
- full oral assessment, FB removal, flushing and debriding any wounds.
Diagnostic investigations for swallowing disorders - radiography.
Dental radiography.
Whole skull radiography/jaw radiography.
- bone lysis – osteomyelitis, neoplasia.
Neck radiography.
Thoracic radiography.
- Ideally 3 views for metastasis assessment.
Diagnostic investigations of swallowing disorders - ultrasound.
POCUS (TFAST & AFAST).
- trauma.
- effusions.
Assess organs.
- neoplasia.
- abnormalities on bloods.
Ultrasound-guided cystocentesis or FNA.
Diagnostic investigations for swallowing disorders - Advanced imaging.
CT - if available (or refer).
- reveals smaller thoracic metastases.
- 3D skull assessment.
- cellulitis/abscesses associated w/ FBs or retrobulbar disease.
- salivary gland assessment.
Diagnostic investigations for swallowing disorders - additional sampling.
FNA or biopsy of mass lesions and draining or local LN if palpable.
- excisional or incisional biopsy.
- put in formalin for histopathology.
- keep some fresh tissue (saline soaked swab in sterile plain tube.
US-guided.
Bacteriology/virology swabs if appropriate.
Investigation of gingivostomatitis.
Dental radiography and management.
Oral swabs for FHV, FCV (may get false negatives).
Blood tests for FIV/FeLV - snap test.
Biopsy lesions if proliferative, lysis or new bone on radiography.
- Diagnostic investigations for reflux and regurgitation - lab tests.
- Diagnostic investigations for reflux and regurgitation - survey neck and chest radiography.
- Haematology and serum biochemistry.
- to look for concurrent diseases. - chest radiographs must be conscious.
- perform survey radiographs prior to contrast study.
- referral possibly.
- chest radiographs must be conscious.
Diagnostic investigations for reflux and regurgitation - radiography.
Looking for problems in the oesophagus.
- dilation.
- structural changes.
- narrowing/stricture.
Oesophagus difficult to assess on x-ray.
- commonly missed.
Tracheal stripe sign:
- dorsal tracheal wall particularly clear
How should we remove an oesophageal FB?
Operator-dependent.
Can use instruments via endoscope to pull out through the mouth.
Can use endoscope to push FB into stomach and then perform gastrotomy.
Diagnostic investigations of reflux and regurgitation - contrast radiography.
Relatively contraindicated.
Barium mixed w/ food/liquid.
High risk of aspiration - causes lung injury.
Alternative imaging methods are preferable.
Investigating reflux and regurgitation - when to refer?
For advanced imaging.
Oesophagoscopy.
- to retrieve FB, evaluate for hiatal hernia (after other imaging), evaluate for/dilate stricture.
- NOT if megaoesophagus already shown.
Fluoroscopy “swallow study” - dynamic conscious x-ray (patient is conscious).
- swallowing – diagnosis of dysphagia/regurgitation.
- evaluation of intermittent pathology – e.g. sliding hiatal hernia.
- respiratory – diagnosis of airway collapse.
Specialist neurology assessment.
Functional assessment.
Management of swallowing disorders.
Dental treatments.
- Interferon for calicivirus.
Specific therapies for masticatory muscle disease.
Consider nutrition - we food/slurry? Feeding tubes?
Manage nausea e.g. antiemetics.
Management of regurgitation.
Correct underlying disease if known and possible.
- e.g. underlying neuromuscular or endocrine disease.
- hiatal hernias often managed successfully w/o surgery.
- consider referral:
– myasthenia gravis - anticholinesterase drugs (pyridostigmine).
– oesophageal FB –> endoscopic retrieval.
– oesophageal stricture –> balloon dilation.
– vascular ring anomaly –> Sx.
– BOAS – Sx?
Positional feeding e.g. elevated food bowls, steps up to food bowls, Bailey chair (essential for megaoesophagus (prokinetics do not work and LES drugs cause harm)).
Meds.
- Omeprazole:
– proton pump inhibitor (PPI).
– irreversibly binds H+/K+ATPase –> blocks gastric acid secretion.
– Off-L –> Non-PPIs e.g. H2 antagonists much less effective.
– most effective administered BID. - Cisapride:
– stimulates intestinal 5-HT4 receptors.
–> increase LES tone.
–> decrease pyloric tone, propulsive peristaltic waves throughout whole GIT
– Off-L.
– clinical uses in GERD, feline idiopathic megacolon, pro-motility agent in other spp.
– if not tolerated, metaclopramide (to facilitate gastric emptying) may be of value. - Sucralfate:
– complex sucrose octasulphate and aluminium hydroxide.
– available as tabs or suspension.
– precipitates and binds ulcerated tissue (oesophagus stomach).
–> chemical diffusion barrier.
– give at least 1hr before feeding.
– avoid direct co-administration w/ acid blockers (1-2hrs apart).
– impedes absorption of quinolones, tetracyclines, digoxin. - Pink Lady.
– referral.
– antacid and lidocaine.
Management of GERD?
Postural feeding - little and often.
– no closer than 2hrs to bedtime or exercise.
– low fat to facilitate gastric emptying.
– consider hydrolysed diet if concurrent chronic enteropathy.
Weight management.
Acid blockers.
- omeprazole.
LES drugs.
- cisapride.
