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    PPT PPT Presentation Transcript

    • A Multidisciplinary Approach to Esophageal Dysphagia: Role of the SLP Darlene Graner, M.A., CCC-SLP, BRS-S Sharon Burton, M.D.
    • What is the role of the SLP?
      • Historically
        • SLPs the preferred providers for evaluation and treatment of oral and pharyngeal stage dysphagia
        • Assessment of the esophagus was not always included in the evaluation
    • ASHA Guidelines
      • Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004)
      • Issue: Pharyngoesophageal considerations
      • While it is the responsibility of appropriately trained physicians to evaluate and diagnosis esophageal stage dysphagia…. Clinicians should be aware that oropharyngeal swallowing function is often altered in patients with esophageal motility disorders and dysphagia. …SLP have knowledge and skills to recognize patient signs and symptoms..associated with esophageal phase dysphagia.
    • ASHA Policy Statement
      • Knowledge and Skills Needed by Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004)
      • B. Skills required
      • 7. If esophageal screening is completed, describe any suspected anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow, deferring to radiology for diagnostic statements
    • ASHA Position Statement
      • Instrumental Diagnostic Procedures for Swallowing (1991)
      • The results of the VFSS may suggest that referral to a radiologist/gastroenterologist for an upper GI series or air contrast esophagram may be needed to view the esophagus. SLPs should have sufficient knowledge to make an appropriate referral and plan cooperative management.
    • ACR Appropriateness Criteria
      • Abnormalities of the mid or distal esophagus or gastric cardia can cause referred dysphagia to the upper chest or pharynx
      • Therefore, a combined radiographic evaluation of the pharynx, esophagus and gastric cardia is recommended in patients with unexplained pharyngeal dysphagia
    • Goals
      • Review normal esophageal anatomy and physiology and how we evaluate them
      • Demonstrate anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow and produce dysphagia symptoms
      • Present unknown case examples
    • Normal Esophagram
      • Double Contrast
        • High density barium
        • “ thick”
        • Fizzies
      • Goal: Mucosal detail
        • Esophagitis
        • Neoplasm
    • Single Contrast Phase
      • Low density barium
        • “ thin”
        • Single swallows for peristalsis
        • Multiple swallows for detection of
          • Rings
          • Strictures
          • Hernia
    • Esophageal Dysphagia
      • Structural Causes
        • Diverticula
        • Web
        • Ring
        • Stricture
        • Hernia
        • Neoplasm
      • Motility Disorders
        • Achalasia
        • Scleroderma
        • Diffuse spasm
        • Non-specific esophageal dysmotility (NEMD)
    • Cervical Web
      • 1 - 2 mm, anterior wall
      • Hemispheric and circumferential webs (rings) cause solid food dysphagia
      • Associations:
        • GE reflux, Plummer-Vinson syndrome
    • GE Reflux
      • Fluoroscopic evaluation is limited for detection of GER
      • 24-hour ambulatory pH testing is the most accurate way to document reflux
      • Evaluate patient for complications of GERD
    • Peptic Esophagitis
      • Abnormal Motility
      • Granular mucosa
      • Thickened folds > 3mm
      • Nodularity
      • Ulceration
      • Better detected with endoscopy
    • Peptic Strictures
      • Distal esophagus
      • Hiatal hernia in > 90%
      • Fluoroscopy better than EGD for ring and stricture detection
        • 95% sensitivity
      • EGD for biopsy and dilatation
    • Barrett Esophagus
      • Columnar metaplasia
      • Occurs in 10-15% of patients with reflux esophagitis
      • Premalignant
      • High stricture or ulcer, reticular pattern
    • Eosinophilic Esophagitis
      • Esophageal biopsies:
        • Many intraepithelial eosinophils (80/high power field)
      • Associated with food allergies
      • Treatment:
        • Oral steroid (Fluticasone) therapy
        • 220 mcg two puffs a day
    • Hiatal Hernias
      • Sliding
      • Paraesophageal
      • Mixed
      • Intrathoracic stomach
    • Esophageal Cancer Risk factors for squamous cell carcinoma: Smoking ETOH Achalasia Chronic GERD Barrett esophagus Adenocarcinoma
    • Achalasia
      • Primary
        • Idiopathic
        • Progressive dysphagia
        • Dilated esophagus
        • Birdbeak
      • Secondary
        • Neoplasm of distal esophagus or gastric cardia
        • Chagas disease
    • Achalasia
        • Aperistaltic esophagus
        • Failure of relaxation of lower esophageal sphincter
        • Treatment options
        • Dilatation
        • Heller myotomy and fundoplication
        • Botox injection
    • Scleroderma
      • Motility pattern
        • Proximal 1/3 striated muscle
          • normal peristalsis
        • Distal 2/3 smooth muscle
          • impaired motility
      • Patulous GE junction
        • GE reflux can cause distal stricture
      • Chest pain
      • Intermittent dysphagia
      • Segmental nonperistaltic contractions
      • Corkscrew esophagus
      • Muscular hypertrophy
      Diffuse Esophageal Spasm (DES)
    • References
      • Adler, D. G., Romero, Y., Primary esophageal motility disorders. Mayo Clin Proc. 2001;76:195-200.
      • Crescenzo, D. G., Trastek, V. F., Allen, M. S., Deschamps, C., Pairolero, P. C. Ann Thorac Surg. 1998; 66:347-350.
      • Martin, R. E., Letsos, P., Taves, D. H., Inculet, R. I., Johnston, H., Preikasaitis, H. G., Oropharygeal dysphagia in esophageal cancer before and after transhiatal esophagectomy, Dysphagia. 2001; 16:23-31.
      • Philippsen, L. P., Weisberger, E. C., Whiteman, T. S., Schmidt, J. L., Endoscopic stapled diverticulotomy: Treatment of choice in Zenker’s diverticulum. The Laryngoscope. 2000; 110:1283-1286.
      • Sofer, E., Murray, J. A., Schulze-Delrieu, K., Esophagoscopy and tests of esophageal function. In Perlman, A. L. and Schulze-Delrieu, K. (eds) Deglutition and its Disorders. Singular Publishing Group: San Diego. 1998.
    • Reference Links
        • Levine M.S., Rubesin S.E. Diseases of the Esophagus: Diagnosis with Esophagography. Radiology 2005; 237:414-427.
        • http://radiology.rsnajnls.org/cgi/content/full/237/2/414?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=levine&fulltext=esophagus&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
        • ACR Appropriateness Criteria: Dysphagia http:// www.acr.org/s_acr/bin.asp?CID =1207&DID=11772&DOC=FILE.PDF