ppt is about dysphagia and its causes

1. APPROACHTODYSPHAGIA
Dr ABDUL SAMAD P

2. OBJECTIVES
• Anatomy of pharynx andesophagus
• Physiology of swallowing
• Typesof dysphagia
• Causesof dysphagia
• Approach to dysphagia

6. PHYSIOLOGY OF DEGLUTITION
• GITmotility
Neural : - Parasympathetic nervefibres
- Sympathetic nervefibres

7. NEUROGENIC
CONTROL OF
DEGLUTITION

8. ORAL PHASE

9. PHARYNGEAL PHASE
• Reflex process
• Receptors present at the posterior pharyngealwall
• UES relaxes
• Contraction of Superiorconstrictor
• Persistent elevation of soft palateand
tongue
• Vocalcords approximated
• Epiglottis closesthe inlet
• Larynxpulled upward andforward
• Relaxation of UES
• Peristaltic wave passesdownward

10. ESOPHAGEAL PHASE
• Primary peristaltic wave
• Secondary peristaltic wave
• Tertiary peristatic wave

11. What isdysphagia?
• DYSPHAGIA in Greek means Difficulty to eat.
• In common practice, dysphagia is a term encompassing the
sensations (short of pain) associated with abnormal bolus
transit from mouth to stomach as well as other signs or
symptoms accompanying abnormal transit.

12. TYPES
• Basedon location : - Oropharyngeal
- Esophageal - Extraluminal
- In the wall ofesophagus
- in the lumen
• Based on circumstances : - Structural
- Propulsive
• Basedon onset : -Acute
- Chronic
• Basedon progression : - Progressive
- Intermittent

14. • Oropharyngeal dysphagia
• typically complain of food
lodging or sticking in the back
of the throat or cervical
esophageal region
• Hesitation with swallowing,
frequent and repeated
swallowing attempts, and
throat clearing may accompany
dysphagia
• Esophageal dysphagia
• reflects disorders of the
esophageal body and
esophagogastric junction as well
as anatomical areas abutting
these regions, such as the
gastric cardia and mediastinum
• most telling feature differentiating
esophageal from oropharyngeal
dysphagia is the sensing of
abnormal bolus transit at a
retrosternal site

15. • Oropharyngeal dysphagia
• Related symptoms include
rough or dysphonic voice after
eating and hoarseness may
reflect the underlying
neuromuscular disorder.
• onset of dysphagia within 1 s of
swallowing, inability to swallow
any liquids or solids once a food
bolus is lodged, and
expectoration rather than
regurgitation of the bolus.
• Esophageal dysphagia
• In contrast to oropharyngeal
dysphagia, esophageal
dysphagia is not immediate.
• patients with esophageal
dysphagia regurgitate foamy,
bland secretions or ingested
liquids that have been retained
above the impacted food.

16. OROPHARYNGEAL DYSPHAGIA

17. Causes of
oropharyngeal
dysphagia

18. STRUCTURAL
ZENKER’S DIVERTICULUM
• Pharyngeal mucosa herniates through Kilian’s
dehiscence
• Dueto incoordinated contractions,spasm
• Clinical features : - Dysphagia
- Regurgitation
- Halitosis

19. NEOPLASM
• Carcinoma of posterior 1/3 oftongue
- Dysphagia
- Bleeding from mouth
- Hot potato voice
- Referred pain in ear
• Carcinoma tonsils / tonsillar fossa
• Carcinoma of posterior and lateralpharyngeal
wall

20. PROPULSIVE
NEUROGENIC
• Cerebrovascular accident
• Amyotropic lateral sclerosis
• Guillain Barre syndrome
• Parkinson’s disease

21. MYOGENIC
• Myasthenia gravis
• Poliomyelitis
• Myotonic dystrophy

22. APPROACH
TO
OROPHARYN
GEAL
DYSPHAGIA

23. ESOPHAGEAL DYSPHAGIA

24. Causes of esophageal dysphagia

25. • EXTRALUMINAL
• AORTICANEURYSM
• THYROIDENLARGEMENT(Malignancy)
• DYSPHAGIALUSORIA
- Dueto aberrant right subclavianartery
- C/f : dysphagia, chest pain, stridor,wheeze

26. • ROLLING HIATUS HERNIA
- Herniation of stomach fundus/colon/spleen through esophageal
opening
- c/f :
Abdominal, chestpain
Dysphagia
Palpitations
Shortness of breath

27. • MEDIASTINAL SWELLINGS
- Primary tumors
- Nodal mass: Lymphoma or Tuberculosis

28. INTRAMURAL CAUSES
• CARCINOMA ESOPHAGUS
- 2/3 of lumen should beoccluded
- Substernal/abdominal pain
- Anorexia

29. • CORROSIVE STRICTURE OFESOPHAGUS
ingestion of alkali
liquefaction, saponification, thrombosis ofvessels
fibrosis andstricture

30. • GASTRO ESOPHAGEALREFLEXDISEASES (GERD)
- C/f : Chestpain ,
pyrosis Dysphagia
Regurgitation

31. • ACHALASIACARDIA
- Dysphagia, regurgitation, weight loss
- Heart burn

32. • PLUMMER VINSONSYNDROME
- Dysphagia
- Iron deficiencyanemia
- Esophageal webs
- Glossitis

33. SCHATZKI’S
RING

34. INTRALUMINAL CAUSES
• Atresia
• Foreign bodies

35. OROPHARYNGEALDYSPHAGIA
STRUCTURAL PROPULSIVE
- Zenker’s diverticulum
- Neoplasm
NEUROGENIC MYOGENIC
- CV
A
- Amyotropic Lateral Sclerosis
- GBS
- Parkinson’s
- Myasthenia gravis
- Myotonic dystrophy
- Poliomyelitis

36. ESOPHAGEALDYSPHAGIA
EXTRALUMINAL INTHELUMEN
INTHEWALL
- Aortic aneurysm
- Thyroid enlargement
- DysphagiaLusoria
- Rolling hiatus hernia
- Mediastinal swelling
- CAesophagus
- Strictures
- GERD
- Achalasia cardia
- PVsyndrome
- Congenital anomalies
- Atresia
- Foreignbodies

37. APPROACH
TO
ESOPHAGEAL
DYSPHAGIA

38. CLASSIFICATION
OF
ESOPHAGEAL
DYSFUNCTION

39. APPROACHTODYSPHAGIA

40. HISTOR
Y
• Age, sex
• Onset
• Progression
• Pain
• Cough
• Pasthistory

41. EXAMINATION
• General examination
• Mouth andpharynx
• Neck
• Cranial nerves, motor system

42. APPROACH
TO
DYSPHAGIA

43. INVESTIGATIONAND
TREATMENT

44. Evaluation of apatient with dysphagia
• Proper history
• Hematocrit
• Chestxray often shows mediastinal masslesion/foreign body
• Oesophagoscopy:-
once lesion is detected, it is treated accordingly. Biopsyfrom
lesion, endotheraphy if needed carried out (like foreign body removal,
stricture dilatation, sclerotheraphy)

45. DIAGNOSTICPROCEDURES
• Barium swallow:-It may show irregular filling defect orextrinsic
compression
CONTRASTSTUDYOFOESOPHAGUS
1.Barium swallow using barium suphate
2.Using water soluble contrast like GASTROGRAFIN

46. •Indications:-
1.Barium swallow
-Dysphagia due to motility disorder like achalasia cardia,diffuse
esophageal spasm
-Dysphagia due to mechanical causeslike carcinoma, benign strictures
and neoplasms, external compression
-Pharyngeal pouch and other diverticula.
-Gastro esophageal reflux disease

47. • Important findings in bariumswallow:-
Achalasia cardia-BIRD BEAKappearance asthe esophagus is
dilated above an apparent narrowing at thecardia.
In long standing cases-SIGMOIDOESOPHAGUS

48. • Diffuse oesophageal spasm-CORCKSCREWappearance

49. • GORD-Showsreflux when done in Trendelenburg's position

50. • Esophagealcarcinoma-irregular steno sing lesion with
shouldering(‘RATTAIL’)is fluoroscopic finding

51. • Pharyngeal pouch-demonstration of the pouch
• External compression-indentation of barium column by superioror
posterior mediastinal mass,enlarged left atria asin mitralstenosis

52. • 2.Water –soluble contrast radiograph
-in suspected pharyngeal perforation
-leaking esophageal anastomosis

53. • CTscan:- It is very useful to identify the anatomical lesion ofthe
cause(nodes/tumor/aorta/cardiac cause/congenital).
Extent,spread,nodal status,size and operabilityof tumor also cn be
assessed.

54. • Oesophageal manometry:
-It is used to measure the function of the lower oesophageal
sphincter(the valve prevents the reflux of gastric acid intooesophagus)
and the muscle of theoesophagus.
-This test will tell your doctor if the oesophagus is able to move
food to your stomachnormally.
-It is useful to rule outachalasia cardia/GERD

56. • 24 hours monitoring:-
-It is ideal and most accurate forGERD
Procedure:-
-small pHprobe(transnasal catheter) is passedinto oesophagus 5cm
proximal to lower oesophagealsphincter
-probe is connected to digital recorder worn by the patient for 24 hrs
-record is analysed using a computer
If pH<4more than 4%of total 24 hrsperiod
Pathological reflux

58. -It is often assessedby scoringsystem
-Radio-telemetry pHprobes aeused now without any nasal tube
-It is placed and passedon the oesophageal wall usingendoscope

59. • Endosonography:-
-Endoscopic sonography
-can assesssite ,layers of the oesophagus,nodes,spread etc
-Different layers are seenasalternating hyperechoic bands and
hypoechoic bands.
Endoscopyis combined with ultrasound to obtain images ofthe
internal organs(insertion of probe into holloworgan)
-It is performed with the patientsedated
-The endoscope is passedthrough the mouth and advance through the
oesophagus

60. -useful method of finding and assessinginvolvement
or pathology of different layers of esophagus especially in carcinoma
• -It shows all layers clearly and distinctly and soinvasion canbe
better made Staining using is labelled iodine
• Normal mucosal cells contain glycogen which takes up iodine andso
stains brown
• Carcinoma cells will not take up iodine and somucosa appearspale

61. • Ultrasound Abdomen to seeabdominal nodes/liver/ascites.
• MRI study

62. • Oesophagoscopy
Indications:-
Diagnostic
1.T
oidentify the lesion and to take biopsy in carcinoma
oesophagus 2.for diagnosing other oesophageal conditions
Therapeutic:-
1.T
oremove foreign body
2.T
odilate stricture
3.T
oplace endostents for inoperable carcinoma oesophagus
4.T
oinject sclerosants for varices

63. • TYPES:-
• Rigid osophagascope(Negus type)
-It is done underanesthesia
-Head is extended and head end of the table is tiltedupwards,
scope is passedbehind the epiglottis and cricoid through the
cricopharyngeal opening.
-this is the most difficult part inoesophagoscopy
-after that negotiating through the oesophagus iseasier
-The lesion is identified and biopsy is taken if required.
COMPLICATION:-perforation (at the level of cricopharyngeus ismost
common) and bleeding

65. • Fibreoptic flexible oesophagoscopy
-It canbe under localanesthesia
-Reflux and hiatus are well identified
-Stomach also canbe visualized
-easyto passand perforation isunlikely
Drawbacks:
-Tissue taken for biopsy issmaller
-Removal of foreign body is alsodifficult

67. • Third spaceendoscopy:-
-It is anewer method wherein submucosal and intramural spewhich
is called as3rd space(1stbeing luminal spaceand 2nd being peritoneal
space)

68. TREATMENT
Depend on cause–modified heller’s myotomy:-
it is a surgical procedure in which muscles of the cardia(lower
oesophageal sphincter are cut, allowing food and liquids to pass the
stomach.
used to treat achalasiacardia

69. • Procedure
Thepatient is put under anesthesia
5or6 small incision are made in the abdominal wall andlaparoscopic
instruments are inserted
The myotomy is lengthwise cut along the oesophagus, starting above
the LES and extending down onto the stomach alittle way
the oesophagus is made of several layers and the myotomy only cuts
through the outside muscle layers which are squeezing it shut, leaving
the inner mucosal layerintact.
Small risk of perforation is there duringmyotomy

70. • OESOPHAGEALRESECTION:-
it is the surgical removal of oesophagus, nearby lymphnodes and
sometimes aportion of the stomach
TYPES:-
ESOPHAGECTOMY:-it is the surgical removal of oesophagusor
cancerous portion of the esophagus and nearby lymphnodes
ESOPHAGOGASTRETOMY:-Itis the removal of lower esophagus and the
upper part of stomach that connects to the esophagus

72. • OESOPHAGEALDILATATION:-
Therapeutic endoscopic procedure that enlarges the lumen ofthe oesophagus.
Types:-
Mercury-weighted bougies
Bougie over guidewire dilators
Pneumatic dilation or balloondilatation
COMPLICATIONS:-
-Hematemesis
-oesophageal perforation
-Mediastinitis

74. THANKYOU