undergraduate lecture about dysphagia and achalasia

1. Dysphagia
PROF. DR. MOHAMED-NAGUIB WIFI
PROFESSOR OF MEDICINE AND
HAPATOGASTROENTEROLOGY
CAIRO UNIVERSITY

2. Dysphagia & Odynophagia
A- Oro-
pharyngeal
Esophageal
I- Neuromuscular: Pseudo and true bulbar palsy,
motor neurone disease, Guillain-Barre Syndrome,
myasthenia gravis, polymyositis and some
myopathies and muscular dystrophies.
II- Compression: Zenker’s diverticulum,
cricopharyngeal bar, cervical spondyulosis, thyroid
enlargement and retropharyngeal abscess.
III- Iatrogenic: surgery and radiation
IV- Infectious: pharyngitis.
V- Webs: Plummer-vinson syndrome
VI- Strictures: Peptic, corrosive and post-radiation.
VII- Tumors: Carcinoma, sarcoma and lymphoma.
I- Structural: circumferential lesions like:
Schatzki’s rings.
II- Infectious and inflammatory:
cytomegalovirus esophagitis, monilial
esophagitis, Eosinophilic esophagitis
III- Strictures: Peptic, corrosive strictures and
post-radiation.
IV- Propulsive disorders: abnormality in
peristalsis: diffuse esophageal spasm, achalasia,
and scleroderma.
V- Tumors: Carcinoma. sarcoma, lymphoma and
subepithelial tumours e.g. leiomyoma.
Definition: It is difficulty (i.e. taking more time and effort) in swallowing (It
should be distinguished from Odynophagia which is painful swallowing and
Globus which is sensation of a lump in the throat).

3. Achalasia
• Achalasia originates from the Greek
word a-khalasis, meaning lack of
relaxation = Failure to relax
• It is a rare disease caused by loss of
ganglion cells within the esophageal
myenteric plexus a hypertonic lower
esophageal sphincter which fails to
relax in response to the esophageal
swallowing wave.

4. Pathophysiology of Achalasia
•As the disease progresses, the obstructed lower esophagus
dilates and peristalsis becomes less powerful.
•Longstanding achalasia is characterized by progressive
dilatation and sigmoid deformity of the esophagus with
hypertrophy of the LES.
•This presents in late middle age with episodic chest pain
which may mimic angina, sometimes accompanied by
transient dysphagia.

5. • It can be diagnosed by: barium swallow X-ray and/ or high
resolution manometry (HRM)
Diagnosis
Parrot peak
HRM: absent esophageal peristalsis
pathognomonic for achalasia

6. 1. Previously treated with
pneumatic dilatation
2. But currently the treatment
options are either:
I. Surgery (Heller’s myotomy)
or
II. Endoscopically (Per-oral
esophageal myotomy
(POEM)).
Treatment Options

7. Approach to a pt. with Ach.
• (A) History:
- Age: Cancer in middle and old age, Achalasia in middle and ole age, post-
corrosive in young.
- Type of food: dysphagia only to solids in mechanical causes while to both
solids and liquids in motor dysphagia.
- Duration and Course: transient and of short duration in inflammatory
conditions, progressive in cancer and intermittent in functional disorders.
-Associated symptoms:
• Nasal regurgitation in pharyngeal paralysis.
• Loss of weight in cancer.
• Long preceding heart burn in peptic stricture.

8. Approach to a pt. with Ach.
• (B) Physical Examination:
- Neurological examination: for associated neurological disease.
- Neck: for lymph node and thyroid enlargement.
• (C) Diagnostic Procedures:
- Endoscopy: to exclude mechanical obstruction
- Barium swallow.
- Esophageal manometry studies for functional disorders.