This document discusses dysphagia, or difficulty swallowing. It defines two types - pharyngeal dysphagia involving coughing or food getting stuck in the mouth, and esophageal dysphagia where food gets stuck lower down. Common causes include GERD, esophageal cancer, foreign bodies, infections, and structural issues. Rare causes involve motility disorders, congenital anomalies, neurological issues, and injuries. Evaluation involves endoscopy, imaging, and functional testing. Treatment depends on the underlying cause but may include dilation, surgery, or medications.

1. DYSPHAGIA

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.

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.

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.

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