Week 2: Dysphagia Flashcards
Types of dysphagia
3 listed
- Mechanical
- dysmotility
- or both
How long is the esophagus?
20-22 cm long muscular tube
Which muscular layer is most superficial?
outer longitudinal layer
Inner circular layer
Categories of causes of oropharyngeal dysphagia
Neuromuscular or Structural causes
Neuromuscular causes of oropharyngeal dysphagia
8 listed
- CVA/stroke
- ALS
- Brain tumor
- Poliomyelitis
- Myasthenia gravis
- Muscular dystrophies
- Polymyositis and dermatomyositis
- UES dysfunction
Structural causes of oropharyngeal dysphagia
- Pharyngitis
- Radiation injury
- Cervical osteophyte
- Head and Neck cancer
- Thyromegaly/Goiter
- Zencker’s diverticulum
What is dysphagia?
Symptoms that result from the slowing or cessation of a food or liquid bolus passing through the esophagus
nervous structure of the esophagus
Myenteric plexus
Oropharyngeal dysphagia presentation
8 listed
- Difficulty initiating swallow
- Double swallowing
- Drooling
- Cough, choking sensation “Can’t breathe”
- Nasal regurgitation
- Aspiration -> Pneumonia
- Dysarthria and voice changes/weakness
- Localization in throat or high neck
Categories of causes of Esophageal dysphagia
Structural
motility
Structural causes of Esophageal dysphagia
7 listed
Benign stricture
GERD
Eosinophilic esophagitis
Infectious esophagitis
Foreign bodies
Extrinsic compression
Esophageal CA
Motility causes of Esophageal dysphagia
5 listed
- Achalasia disorders
- Scleroderma
- Esophageal spastic disorders
- Chagas disease
- Non-relaxing lower esophageal sphincter
Presentation of Esophageal dysphagia
4 listed
- Food sticking retrosternally
- Regurgitation or vomiting
- Chest pain
- Localization at sternal notch or below
Associated symptoms of dysphagia
6 listed
- Slow eating
- careful eating
- Sips of beverage with solid food bolus
- Walking around while eating
- Avoiding restaurants and social meals
- Restricted diet
Causes of sudden mechanical Dysphagia
- Foreign body
- Eosinophilic esophagitis
Causes of intermittent mechanical Dysphagia
- Schatzki’s ring (reflux driven obstruction)
- Webs (fibrous strands)
- Ext. Compression (Mass or vascular structure)
Causes of progressive mechanical Dysphagia < 50 years old
- Heartburn
- GERD Stricture
- Caustic, med-induced, radiation
Causes of progressive mechanical Dysphagia > 50 years old
Carcinoma
Overview of historical causes of mechanical obstruction dysphagia
Causes of recent neuromuscular or infectious dysphagia
- Immunosuppression
- Antibiotics
- HIV infection
- Candida
- CMV
Causes of intermittent neuromuscular or infectious dysphagia
Chest pain?
Motility disorder
Causes of progressive neuromuscular or infectious dysphagia
- Achalasia
- Scleroderma
Overview of historical causes of neuromuscular or infectious dysphagia
Physical exam for dysphagia
Types of tests for dysphagia
- Barium swallow
- Endoscopy
Barium swallow capabilities for dysphagia
Endoscopy capabilities for dysphagia
Describe diffuse esophageal spasm via barium swallow
spastic “Corkscrew appearance”
Describe eosinophilc esophagitis via barium swallow
corrugated appearance from furrows that form from the scarring from eosinophilic infiltration
What is depicted by barium swallow?
Diffuse Esophageal Spasm
What is depicted by barium swallow?
Eosinophilic Esophagitis
Describe esophagitis via endoscopy
breaks in mucosa (represents esophageal injury
What is depicted via endoscopy?
Achalasia
What is depicted via endoscopy?
Adeno Carcinoma
What is depicted via endoscopy?
Candida
What is depicted via endoscopy?
Esophagitis
What is depicted via endoscopy?
Schatzki ring
What is depicted via endoscopy?
Peptic stricture
What is depicted via endoscopy?
Diffuse Esophageal spasm
What is depicted via endoscopy?
Eosinophilic Esophagitis
Describe peptic stricture via endoscopy
scarred down
needs to be dilated or stretched out
Describe Schatzski ring via endoscopy
doesnt expand any further
can be broken up by biopsy cuts to open it up
Describe adenocarcinoma via endoscopy
lumen is narrowed by neoplasm
Describe Candida via endoscopy
growth of fungus
Describe eosinophilic esophagitis via endoscopy
corrugated rings or could be linear corrugation
Describe achalasia via endoscopy
the sphincter is super tight
Describe Diffuse eosphageal spasm via endoscopy
“corkscrew” spasming
Approach to dysphagia
What is a high-resolution manometry catheter?
basically an EKG of esophagus
High-resolution manometry catheter data
Normal swallow under High-resolution manometry catheter
Describe Achalasia by barium swallow
HRM AKA
High-resolution manometry catheter
HRM of type II Achalasia
Failure of LES to relax
Subtypes of achalasia
Upper endoscopy of Achalasia
Describe Type I Achalasia HRM
Absent peristalsis
No peristaltic waves, no movement
Describe Type II Achalasia HRM
Panesophageal pressurizations occur after a swallow but could keep going
Describe Type III Achalasia HRM
Hypercontraction but not a productive peristaltic spasm
food still gets trapped and patient still feels bolus stuck
Why does achalasia occur?
- Loss of myenteric neurons such as by immune-mediated neuronal death
- Imbalance between excitatory and inhibitory forces
Describe achalasia by loss of myenteric neurons
Describe achalasia by excitatory/inhibitory imbalance
Achalasia type I causation
loss of myenteric nerves
Achalasia type II causation
Loss of myenteric neurons
Achalasia type III causation
Excitatory/inhibitory force imbalance
Pharmacological therapy of Achalasia
(botox is kind of the go to)
Surgical interventions of achalasia
- Pneumatic dilation (balloon)
- Heller Myotomy (cut the circular muscle fibers)
Response rates of achalasia treatments
POEM for achalasia
POEM outcomes
Achalasia means?
“Failure to relax”
The predominant feature of achalasia
poorly relaxing LES
Symptoms of Achalasia
- Dysphagia
- Regurgitation
- Heatburn
- CP
- Cough
- Choking
- Aspiration pneumonia
- Weight loss
Achalasia Manometric abnormalities
- Abnormal LES residual pressure
- No normal peristalsis
Is achalasia ever cured?
What treatments are there?
Never cured and treatment is aimed at reducing the pressure across the LES
- Pneumatic dilation
- Heller Myotomy
- POEM
- Botox, CCB, nitrates
What is pseudoachalasia?
Dysphagia workup pathway
What is the patient’s diagnosis?
Pseudoachalasia
Is this achalasia
EGD pseudoachalasia
