2. INTRODUCTION
• Difficulty with swallowing.
• Classification:
• Pharyngeal dysphagia – patient develops cough or splutter while
swallowing as food enters the airway or stays in the mouth.
• Esophageal dysphagia - specified by “food getting stuck” in the
pathway.
• Can be progressive or intermittent.
• Can affect swallowing of solids and/or fluids.
• Can also be acute—due to foreign body impaction or acute
infection or chronic due to causes like stricture or carcinoma.
3. COMMON CAUSES
• GERD
• Ca esophagus – dysphagia is of short duration and progressive. 2/3 of the lumen should be
blocked by tumour to develop dysphagia.
• Foreign body impaction – causes acute dysphagia. Common in children and may be life
threatening.
• Carcinoma of pharynx or posterior 1/3rd of the tongue.
• Corrosive strictures – usually alkali stricture as the squamous mucosa is resistant to acid
effect to certain extent.
• Oesophageal candidial infection – common due to immunosuppressed patients. Presents with
dysphagia and odynophagia.
• Plummer-Vinson syndrome - Dysphagia occurs due to the presence of a postcricoid web that is
associated with IDA.
• Mediastinal swellings—primary tumours/nodal mass either lymphoma or secondaries or
tuberculosis.
4. RARE CAUSES
• Diffuse oesophageal spasm – incoordinated contractions of oesophagus causing chest
pain or dysphagia. It is common in distal 2/3rd of the oesophagus.
• Congenital anomalies – esophageal atresia (most common).
• Hiatal hernias – sliding hiatal hernias (most common).
• Achalasia – caused by loss of ganglion cells within the esophageal myenteric plexus.
• Esophageal diverticula – the most common being epiphrenic, hypopharyngeal
(Zenker’s), and mid-esophageal.
• A lower esophageal mucosal ring, also called a B ring , is a thin membranous
narrowing at the squamocolumnar mucosal junction.
• Web-like constrictions higher in the esophagus can be of congenital or inflammatory
origin.
5. • Boerhaave’s syndrome: It is vertical full thickness tear of
lower oesophagus due to vomiting with closed glottis. It is
often life threatening and emergency.
• Neurological causes like stroke, bulbar palsy, motor neuron
disease, Parkinson’s disease, etc.
• Drug-induced dysphagia: Drugs like KCl, quinine, NSAID
can cause dysphagia.
• Thyroid swelling – There will be always dyspnea when
dysphagia develops.
6.
7. CLINICAL CO-RELATES
• Esophageal strictures typically cause progressive dysphagia,
first for solids, then for liquids.
• Motility disorders often cause intermittent dysphagia for both
solids and liquids.
• Schatzki’s/B ring causes episodic dysphagia for solids,
typically at the beginning of a meal.
• Oropharyngeal motor disorders typically present with
difficulty initiating deglutition ( transfer dysphagia ) and
nasal reflux or coughing with swallowing; and achalasia may
cause nocturnal regurgitation of undigested food.
8. INVESTIGATIONS
• Dysphagia should always be investigated urgently.
• Endoscopy (Esophagoscopy) is the investigation of choice because it
allows biopsy and dilatation of strictures.
• Even if the appearances are normal, biopsies should be taken to look for
eosinophilic esophagitis.
• Barium swallow with videofluoroscopic swallowing assessment is
indicated to detect major motility disorders. They may show irregular
filling defect or extrinsic compression.
• Esophageal manometry It is the gold standard for the assessment of
oesophageal motor activity. It is not a primary investigation and should
be performed only when the diagnosis has not been achieved by history,
barium radiology or endoscopy.
9. • pH monitoring – 24-hour ambulatory monitoring uses a pH-
sensitive probe positioned in the lower oesophagus and is used
to identify acid reflux episodes (pH < 4) in situations of GERD.
• Endosonography can assess site, layers of the oesophagus,
nodes, spread, etc. properly. Different layers are seen as
alternating hyperechoic and hypoechoic bands.
• Chest X-ray often shows mediastinal mass lesion/foreign body.
• CT scan chest is very useful method to identify the anatomical
location of the cause (nodes/tumour/aorta/cardiac
cause/congenital). Extent, spread, nodal status, size and
operability of an extra-luminal tumour also well-assessed.
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17. TREATMENT
• Dependent on the cause.
• In GERD surgery is indicated in failure of drug treatment, sliding hernia,
Barrett’s ulcer, severe pain and presence of complications like
bleeding/stricture/shortening, respiratory problems. Fundoplication is the only
effective long-term beneficial therapy ideally available and considered now.
• Hernias are surgically repaired by excision of sac and repair of the defect.
• DES is treated nitrates, calcium channel blockers, bougie dilatation, long
oesophageal myotomy either video assisted or thoracotomy approach.
• Achalasia cardia is surgically treated with Modified Heller’s cardiomyotomy
with Toupet’s / Dor’s fundoplication.
• Symptomatic rings and webs are easily treated by dilatation.
18. • Treatment of diverticular is by surgical diverticulectomy
and cricopharyngeal myotomy or a marsupialization
procedure in which an endoscopic stapling device is used
to divide the cricopharyngeus.
• If it does not spontaneously resolve, impacted food is
dislodged endoscopically.
• Healing of more severe grades of caustic injury is
commonly associated with severe stricture formation and
often requires repeated dilatation.
