This document provides information on dysphagia (difficulty swallowing). It discusses the anatomy and physiology of swallowing, types of dysphagia based on location and cause, common causes of oropharyngeal and esophageal dysphagia such as neurological conditions, tumors, and achalasia. The approach to a patient with dysphagia involves taking a thorough history, examination, and investigations like barium swallow, endoscopy, and manometry. Treatment depends on the underlying cause, and may include procedures like dilatation for strictures or myotomy for achalasia.

1. DYSPHAGIA
Kabilan. S
Karthigalakshmi. S

2. OBJECTIVES
• Anatomy of pharynx and esophagus
• Physiology of swallowing
• Types of dysphagia
• Causes of dysphagia
• Approach to dysphagia
• Management

6. PHYSIOLOGY OF DEGLUTITION
• GIT motility
Neural : - Parasympathetic nerve fibres
- Sympathetic nerve fibres

7. ORAL PHASE

8. PHARYNGEAL PHASE
• Reflex process
• Receptors present at the posterior pharyngeal wall
• UES relaxes
• Contraction of Superior constrictor
• Persistent elevation of soft palate and
tongue
• Vocal cords approximated
• Epiglottis closes the inlet
• Larynx pulled upward and forward
• Relaxation of UES
• Peristaltic wave passes downward

10. ESOPHAGEAL PHASE
• Primary peristaltic wave
- Contraction of superior constrictor
- 5 to 10 s
• Secondary peristaltic wave
• Tertiary peristatic wave

11. What is dysphagia?
Difficulty in swallowing, problems with the transit of food or
liquid from mouth to hypopharynx or through esophagus

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

13. OROPHARYNGEAL DYSPHAGIA

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

15. NEOPLASM
• Carcinoma of posterior 1/3 of tongue
- Dysphagia
- Bleeding from mouth
- Hot potato voice
- Referred pain in ear
• Carcinoma tonsils / tonsillar fossa
• Carcinoma of posterior and lateral pharyngeal
wall

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

17. MYOGENIC
• Myasthenia gravis
• Poliomyelitis
• Myotonic dystrophy

18. ESOPHAGEAL DYSPHAGIA

19. EXTRALUMINAL
• AORTIC ANEURYSM
• THYROID ENLARGEMENT (Malignancy)
• DYSPHAGIA LUSORIA
- Due to aberrant right subclavian artery
- C/f : dysphagia, chest pain, stridor, wheeze

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

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

22. CAUSES IN THE WALL OF ESOPHAGUS
• CARCINOMA ESOPHAGUS
- 2/3 of lumen should be occluded
- Substernal/abdominal pain
- Anorexia

23. • CORROSIVE STRICTURE OF ESOPHAGUS
ingestion of alkali
liquefaction, saponification, thrombosis of vessels
fibrosis and stricture

24. • GASTRO ESOPHAGEAL REFLEX DISEASES (GERD)
- Pathological reflex from the stomach into esophagus
- C/f : Chest pain , pyrosis
Dysphagia
Regurgitation

25. • ACHALASIA CARDIA
- Dysphagia, regurgitation, weight loss
- Heart burn

26. • PLUMMER VINSON SYNDROME
- Dysphagia
- Iron deficiency anemia
- Esophageal webs
- Glossitis
- SCHATZKI’S RINGS

28. • TRACHEO ESOPHAGEAL FISTULA

29. CAUSES IN THE LUMEN
• Atresia
• Foreign bodies

30. OROPHARYNGEAL DYSPHAGIA
STRUCTURAL PROPULSIVE
- Zenker’s diverticulum
- Neoplasm
NEUROGENIC MYOGENIC
- CVA
- Amyotropic Lateral Sclerosis
- GBS
- Parkinson’s
- Myasthenia gravis
- Myotonic dystrophy
- Poliomyelitis

31. ESOPHAGEAL DYSPHAGIA
EXTRALUMINAL IN THE LUMENIN THE WALL
- Aortic aneurysm
- Thyroid enlargement
- Dysphagia Lusoria
- Rolling hiatus hernia
- Mediastinal swelling
- CA esophagus
- Strictures
- GERD
- Achalasia cardia
- PV syndrome
- Congenital anomalies
- Atresia
- Foreign bodies

32. APPROACH TO DYSPHAGIA

33. HISTORY
• Age, sex
• Onset
• Progression
• Pain
• Cough
• Past history

34. EXAMINATION
• General examination
• Mouth and pharynx
• Neck
• Cranial nerves, motor system

35. INVESTIGATION AND
TREATMENT

36. Evaluation of a patient with dysphagia
• Proper history
• Hematocrit
• Chest x ray often shows mediastinal mass lesion/foreign body
• Oesophagoscopy:-
once lesion is detected, it is treated accordingly. Biopsy from
lesion, endotheraphy if needed carried out (like foreign body removal,
stricture dilatation, sclerotheraphy)

37. DIAGNOSTIC PROCEDURES
• Barium swallow:-It may show irregular filling defect or extrinsic
compression
CONTRAST STUDY OF OESOPHAGUS
1.Barium swallow using barium suphate
2.Using water soluble contrast like GASTROGRAFIN

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

39. • Important findings in barium swallow:-
Achalasia cardia-BIRD BEAK appearance as the esophagus is
dilated above an apparent narrowing at the cardia.
In long standing cases-SIGMOID OESOPHAGUS

40. • Diffuse oesophageal spasm-CORCKSCREW appearance

41. • GORD-Shows reflux when done in Trendelenburg's position

42. • Esophageal carcinoma-irregular steno sing lesion with
shouldering(‘RAT TAIL’) is fluoroscopic finding

43. • Pharyngeal pouch-demonstration of the pouch
• External compression-indentation of barium column by superior or
posterior mediastinal mass, enlarged left atria as in mitral stenosis

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

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

46. • Oesophageal manometry:
-It is used to measure the function of the lower oesophageal
sphincter(the valve prevents the reflux of gastric acid into oesophagus)
and the muscle of the oesophagus.
-This test will tell your doctor if the oesophagus is able to move
food to your stomach normally.
-It is useful to rule out achalasia cardia/GERD

48. • 24 hours monitoring:-
-It is ideal and most accurate for GERD
Procedure:-
-small pH probe(transnasal catheter) is passed into oesophagus 5cm
proximal to lower oesophageal sphincter
-probe is connected to digital recorder worn by the patient for 24 hrs
-record is analysed using a computer
If pH<4 more than 4% of total 24 hrs period
Pathological reflux

50. -It is often assessed by scoring system
-Radio-telemetry pH probes ae used now without any nasal tube
-It is placed and passed on the oesophageal wall using endoscope

51. • Endosonography:-
-Endoscopic sonography
-can assess site ,layers of the oesophagus,nodes,spread etc
-Different layers are seen as alternating hyperechoic bands and
hypoechoic bands.
Endoscopy is combined with ultrasound to obtain images of the
internal organs(insertion of probe into hollow organ)
-It is performed with the patient sedated
-The endoscope is passed through the mouth and advance through the
oesophagus

52. -useful method of finding and assessing involvement
or pathology of different layers of esophagus especially in carcinoma
• -It shows all layers clearly and distinctly and so invasion can be
better made Staining using is labelled iodine
• Normal mucosal cells contain glycogen which takes up iodine and so
stains brown
• Carcinoma cells will not take up iodine and so mucosa appears pale

53. • Ultrasound Abdomen to see abdominal nodes/liver/ascites.
• MRI study

54. • Oesophagoscopy
Indications:-
Diagnostic
1.To identify the lesion and to take biopsy in carcinoma oesophagus
2.for diagnosing other oesophageal conditions
Therapeutic:-
1.To remove foreign body
2.To dilate stricture
3.To place endostents for inoperable carcinoma oesophagus
4.To inject sclerosants for varices

55. • TYPES:-
• Rigid osophagascope(Negus type)
-It is done under anesthesia
-Head is extended and head end of the table is tilted upwards,
scope is passed behind the epiglottis and cricoid through the
cricopharyngeal opening.
-this is the most difficult part in oesophagoscopy
-after that negotiating through the oesophagus is easier
-The lesion is identified and biopsy is taken if required.
COMPLICATION:- perforation (at the level of cricopharyngeus is most
common) and bleeding

57. • Fibreoptic flexible oesophagoscopy
-It can be under local anesthesia
-Reflux and hiatus are well identified
-Stomach also can be visualized
-easy to pass and perforation is unlikely
Drawbacks:
-Tissue taken for biopsy is smaller
-Removal of foreign body is also difficult

59. • Third space endoscopy:-
-It is a newer method wherein submucosal and intramural spe which
is called as 3rd space(1st being luminal space and 2nd being peritoneal
space)

60. 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 achalasia cardia

61. • Procedure
The patient is put under anesthesia
5or6 small incision are made in the abdominal wall and laparoscopic
instruments are inserted
The myotomy is lengthwise cut along the oesophagus, starting above
the LES and extending down onto the stomach a little 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 layer intact.
Small risk of perforation is there during myotomy

62. • OESOPHAGEAL RESECTION:-
it is the surgical removal of oesophagus, nearby lymph nodes and
sometimes a portion of the stomach
TYPES:-
ESOPHAGECTOMY:- it is the surgical removal of oesophagus or
cancerous portion of the esophagus and nearby lymph nodes
ESOPHAGOGASTRETOMY:-It is the removal of lower esophagus and the
upper part of stomach that connects to the esophagus

64. • OESOPHAGEAL DILATATION:-
Therapeutic endoscopic procedure that enlarges the lumen of the oesophagus.
Types:-
Mercury-weighted bougies
Bougie over guidewire dilators
Pneumatic dilation or balloon dilatation
COMPLICATIONS:-
-Hematemesis
-oesophageal perforation
-Mediastinitis

66. THANK YOU