From Makerere University

1. DYSPHAGIA
NKWASIIBWE JUSTUS MBChB V
NAMUTEBI FLORENCE MBChB V
Tutor: Dr. KABUYE RONALD

2. OUTLINE
● Definition
● Anatomy
● Physiology of swallowing
● Classification of dysphagia
● Causes of dysphagia
● Approach to a patient with dysphagia
● Management Principles

3. Definition.
● Dysphagia is defined as difficulty with swallowing which may be
associated with ingestion of solids or liquids or both. It may
coexist with heartburn or vomiting but should be distinguished
from both globus sensation ( in which anxious people feel a lump
in the throat without organic cause) and odynophagia ( pain
during swallowing)
What is Dysphagia?

4. Anatomy
● Esophagus is a tubular muscular structure about 25cm
long that starts from the oral pharynx at the lower edge of
cricoid cartilage(C6) , passes through the diaphragm at
level of T10 vertebra, ends in abdomen at cardiac orifice
of the stomach at T11 vertebra.
● Divided into cervical, thoracic and abdominal parts.
In the neck, it commences in the midline in front of
prevertebral fascia; laterally related to the lobes of the
thyroid gland and anteriorly in touch with the trachea and
recurrent laryngeal nerves, Inclines slightly to the left of the
midline and enters thoracic inlet.

5. Anatomy Continued
●In the thorax, it passes downward and to the left through the superior and then the
posterior mediastinum. At the level of T5 vertebra it returns to the midline but at T7
vertebra deviates again to the left to pass in front of descending aorta. It pierces the
diaphragm 2.5cm to the left of midline at the level of 7th costal cartilage.
●In superior mediastinum; crossed by arch of aorta on its left and vena azygos on its
right. Through out its length, trachea is in direct anterior relation.
●In posterior mediastinum, just below the bifurcation of the trachea, its crossed anteriorly
by left main bronchus and the right pulmonary artery.
●Its wall is comprised of the mucosa, sub mucosa, muscularis propria, adventitia and no
peritoneal lining save for the short intra-abdominal segment.
●Muscularis propria is composed of striated muscle in the upper third, striated and
smooth in the middle third and smooth muscle in the lower third.

6. Areas of anatomic narrowing
● Cervical constriction; at the level of
cricopharyngeal sphincter (narrowest point of
GIT), 15cm from upper incisor. It is an important
site for foreign body impaction.
● Broncho-aortic constriction; at the level of T-4,
25cm from upper incisor. Important site for
endoscopic perforation
● Diaphragmatic constriction; where the esophagus
traverses the diaphragm, at the level of T-10,
40cm from upper incisor.

7. Blood supply, drainage and innervation of
esophagus
● Arterial supply – inferior thyroid artery 1(1/3), esophageal branches of descending aorta 2(1/3),
branches from the left gastric artery 3(1/3)
● Venous drainage – by inferior thyroid vein 1(1/3), azygos vein 2(1/3) and left gastric vein
3(1/3)(tributary of the portal vein)
● Lymph drainage – deep cervical nodes 1(1/3), superior and posterior mediastinal nodes 2(1/3),
the lower third drains into nodes along the left gastric blood vessels, and the celiac nodes.
● Nerve supply – esophagus is innervated by both sympathetic and parasympathetic efferent and
afferent fibers via vagi and sympathetic trunks. It has got mainly Auerbach’s plexus between the
longitudinal and circular muscle layers.

8. Physiology of swallowing
●Swallowing/deglutition is the process that allows food or liquid bolus to be transported
from the mouth to the pharynx and esophagus, through which it enters the stomach.
●Usually is a smooth, coordinated process that involves a complex series of voluntary
and involuntary neuromuscular contractions
●Divided into three distinct phases:
1. Oral phase
2. Pharyngeal phase
3. Esophageal phase

9. Phases of Swallowing
a) Oral (voluntary) phase
Divided into two;
● Oral preparatory phase, the process of mastication to render the bolus easy to swallow.
● Oral propulsive/transit phase; propelling of food from the oral cavity into the oropharynx.
a) Pharyngeal phase (involuntary)
● Involves a rapid sequence of overlapping events; the soft palate rises, the hyoid bone and larynx
move upward and forward, the vocal folds move to the midline, the epiglottis folds backwards to
protect the airway and then the tongue, together with the pharyngeal walls push the bolus
downwards.
● The Upper sphincter (Cricopharyngeus muscle) relaxes and is pulled open by the forward
movement of hyoid bone and larynx

10. Phases of Swallowing
c) Esophageal phase (involuntary)
● The bolus is propelled downward by a peristaltic movement, the LOS relaxes at initiation of
swallowing and this persists until the food bolus has been propelled into the stomach.
● Unlike the Upper Sphincter, the LOS is not pulled open by extrinsic musculature, rather closes
after the bolus enters the stomach. It is a physiological sphincter.

11. Classification of dysphagia
1. Depending on onset;
Acute (foreign body impaction, acute infection etc.)
Chronic (carcinoma, stricture etc.)
1. Depending on its progression;
Progressive
Intermittent
2. Depending on location;
Oropharyngeal
Esophageal

12. Causes of dysphagia
Common causes
● Gastroesophageal reflux disease; (GERD/hiatus hernia)
● Ca esophagus; the dysphagia is of short duration and progressive, since 2/3 of the lumen has to be
blocked by tumor to develop dysphagia.
● Ca pharynx or posterior 1/3rd of tongue
● FB esophagus; common in children, include coin, bone piece, denture etc.
● Corrosive strictures; usually alkali stricture (the squamous mucosa is resistant to acids to some
extent)
● Esophageal candidial infection
● Plummer-Vinson syndrome; Triad of Iron deficiency anemia, Post-cricoid Dysphagia & Upper
Esophageal webs

13. Rare causes
● Diffuse esophageal spasms; common in distal 2/3rd
● Esophageal diverticula, Chagas disease
● Dysphagia lusoria; a congenital vascular anomaly of aortic root. In this, patients have got an
aberrant right subclavian artery in a transposed position arising from descending aorta that
course posterior to esophagus.
● Thyroid swelling; always there is dyspnea when dysphagia develops
● Boerhaave’s syndrome; a vertical full thickness tear of lower esophagus due to vomiting
with closed glottis. Always life threatening
● Neurological causes; stroke, bulbar palsy, motor neuron disease, Parkinson’s disease etc.
● Congenital anomalies of the esophagus.
● Drug-induced dysphagia; quinine, NSAIDs, KCl
● Mediastinal fibrosis

14. Causes of dysphagia depending on site

15. Causes of Dysphagia Continued

16. Clinical presentations
⮚ Oropharyngeal dysphagia
● Usually due to neuromuscular cause
rather than obstructive
● Cough or chocking with swallowing
● Difficulty initiating swallowing
● Sialorrhea
● Food sticking in the throat-rare
● Change in dietary habits
● Hoarseness of voice
● Recurrent pneumonia
⮚ Esophageal dysphagia
● Sensation of food sticking in the
chest/throat-commonest
● Recurrent pneumonia
● Symptoms of GERD, including
heartburn, belching, sour
regurgitation, and water brash
● Change in dietary habits.

17. Approach to a patient with dysphagia
Proper history
taking:
● Age, sex
● Onset
● Progression
● Intermittence
● Associated pain
● Cough, fever, DIB
● Past history
● Weight loss
● Hemoptysis
● Hematemesis

18. Examination
● General examination(vitals, nutritional status, virchow’s
node, pallor, scleral icterus, dehydration)
● Mouth and pharynx(obvious masses)
● Neck(masses, nodes)
● Motor system/cranial nerves

19. Investigations
● CBC-anemia
● Electrolytes- loss in vomitus
● CXR – often shows mediastinal mass lesion/foreign body, consolidation
● Esophagoscopy/endoscopy – it is both diagnostic and/or therapeutic. Biopsy can be taken
as well. Endotherapy if needed e.g. FB removal, stricture dilatation, sclerotherapy can be
done.
● Barium swallow – it may show irregular filling defect or extrinsic compression, shouldering
,bird beak sign, cock-screw appearance etc.
● Esophageal manometry – in suspected motility disorders e.g. achalasia cardia.

20. ● 24 hour pH studies – for GERD.
● Chest CT scan – very useful to identify anatomical location of the cause (nodes, tumor, aorta,
cardiac or congenital cause)
● Endosonography – it can assess site, layers of esophagus, nodes, spread etc.
● Abdominal ultrasound – to analyze abdominal nodes, liver, ascites.
● MRI study

21. Management
★ Goals of management;
- To maintain adequate nutritional intake for the patient.
- To maximize airway protection.
The following are the various management modalities.
● Lifestyle modification
● Nutritional evaluation and support
● Drug therapy
● Dilation
● Stenting
● Chemo-radiation
● Surgery

22. Lifestyle modification
● Avoidance of precipitating foods(fatty foods, alcohol, caffeine)
● Oral hygiene
● Avoidance of recumbency postprandially
● Elevation of the head of the bed
● Smoking cessation
● Weight reduction
● Semi solid or liquid diet
● Eating small meals more frequently
● Chewing well

23. Drug Therapy
● Reflux esophagitis – H-2 blocker, anti-acids, PPIs, anti-emetics
● Motility disorders – nitrates, calcium channel blockers, botulinum (Botox)
● Caustic injuries – steroids, milk, anti-acids etc.
● Plummer-Vinson syndrome – ferrous sulphate, with vitamins, IV/IM iron
therapy.

24. Surgery
● Zenker’s diverticulum – diverticulectomy/diverticulopexy + myotomy
● Motility disorders/Neurological dysphagia – myotomy
● Reflux esophagitis – fundoplication
● Hiatus hernia – hernia repair/crural repair
● Malignancy/long standing achalasia/caustic injuries – esophageal
resection and reconstruction.
● Achalasia cardia/ Chagas disease – modified Heller’s myotomy

25. Complications of dysphagia
● Aspiration pneumonia and other RTI’s
● Malnutrition
● Dehydration
● Weight loss
● Depression, anxiety and social isolation
Lourita is an adorable girl.

26. References
1.M Sriram Bha-SRB manual of Surgery 5th Edition
2.Principles and practice of Surgery 6th Edition
3.Bailey and Love’s Short Practice of Surgery 25th Edition
4.Snell’s Clinical Anatomy
5.Medscape
Thank you