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Dysphagia

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seminar presented on dysphagia by our unit on 4/2/2016 @ pmch

Published in: Health & Medicine
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Dysphagia

  1. 1. DYSPHAGIA Dr (PROF.) A B SINGH UNIT Department of general surgery Patna medical college & Hospital
  2. 2. CONTENTs • Definition • Swallowing mechanism • Clinical presentation • Grading of dysphagia • Etiology • Investigations • Management
  3. 3. DYSPHAGIA • The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). • Eating becomes unenjoyful. • It refers to the sensation of food being obstructed in the food passage anywhere from the mouth to the stomach. • The basic impairment behind dysphagia are 1)neurological 2)mechanical / obstructive
  4. 4. SWALLOW MECHANISM • The act of swallowing requires the passage for food and drink from the mouth into the stomach. • From mouth to hypopharynx covers 1/3rd of passage (distance) while 2/3rd is covered by the esophagus . • The swallowing center in brain stem is located in the floor of fourth ventricle and adjacent regions of medulla. From here it is connected to cerebral cortex, vomiting and respiratory centre. • All these areas works in coordinated manner to provides voluntary as well the involuantary control of swallowing. • An adult swallow approximately 580 times daily and the act goes on unconsciously . • Swallowing phase – Oro-Pharyngeal phase( voluntary phase) – Esophageal phase( involuntary phase)
  5. 5. OROPHYRANGEAL PHASE
  6. 6. ELEVATION OF TOUNGE POSTERIOR MOVEMENT OF TOUNGE ELEVATION OF SOFT PALATE ELEVATION OF HYOID ELEVATION OF LARYNX TILTING OF EPIGLOTTIS
  7. 7. Esophageal Phase • Food bolus is propelled through the esophagus by an involuntary wave of contraction mediated by the enteric nervous system. • Pressure gradient speeds the movement of food from the hypopharynx into the esophagus when the cricopharyngeus muscle relaxes. • The primary peristaltic contraction which is initiated by a swallowing , moves down the esophagus at the rate of 2 to 4 cm/s and reaches the distal esophagus about 9 seconds . • This duration varies from 8 to 20 seconds
  8. 8. Clinical presentation • Pain and difficulty in swallowing. • Sensation of food being stuck into throat or chest. • Coughing or gagging while swallowing. • Nasal regurgitation • Dysarthria • Nasal speech because of associated muscle weaknesses • Frequent burning sensation in chest. • Having food or stomach acid back up into the throat. • Unexpectedly losing weight.
  9. 9. FUNCTIONAL GRADES OF DYSPHAGIA There are 6 grades of dysphagia • GRADE 1 : Complains of dysphagia but still eating normally • GRADE 2 : Requires liquid with Meals • GRADE 3 : able to take semisolid ,but unable to take any solids • GRADE 4 : able to swallow liquids only • GRADE 5 : unable to swallow liquid, but able to swallow saliva • GRADE 6 : unable to swallow saliva also
  10. 10. Etiology Dyspahgia has been classified broadly into two types on the basis of site. Oropharyngeal Esophageal
  11. 11. Abnormalities Causing Oropharyngeal Dysphagia • Inability to initiate the act of swallowing. Etiology (1) Neuromuscular Diseases • Central nervous system (CNS) • Cerebral vascular accident involving the brain stem. • Parkinson disease • Wilson disease • Multiple sclerosis • Brain stem tumor • Peripheral nervous system • poliomyelitis • Peripheral neuropathies (e.g. diphtheria, tetanus rabies, diabetes mellitus) • Motor end plate • Myasthenia gravis
  12. 12. CONTINUED ........................ • Muscle • Oculopharyngeal muscular dystrophy • Primary myositis • Metabolic myopathy (e.g., glycogen storage disease, lipid storage disease) (2) mechanical or obstructive Lesions 1) Inflammatory • Pharyngitis • Abscess ( peri-tonsillar , paraphryngeal/retrophryngeal ) • Tuberculosis • Syphilis 2) Neoplastic 3) Plummer-Vinson syndrome 4)Extrinsic compression • Thyromegaly( hashimoto’s thyroiditis) • cervical osteophytes • Lymphadenopathy
  13. 13. CONTINUED......................... 5) Disorders of the Upper Esophageal Sphincter (UES) It is related to the abnormal UES relaxation or opening • Incomplete relaxation cricopharyngeal achalasia oculopharyngeal muscular dystrophy • Inadequate opening cricopharyngeal bar Zenker diverticulum • Delayed relaxation familial dysautonomia
  14. 14. Esophageal Dysphagia Patients usually complains of feeling of food getting stuck several seconds after swalloing and will point towards the suprasternal notch or behind the sternum. ETIOLOGY 1) Neuromuscular (Motility) Disorders • Most common – Achalasia – Diffuse esophageal spasm • Other motility abnormalities – Nutcracker esophagus – Hypertensive lower esophageal sphincter – motility disorders secondary to Scleroderma collagen disorders Chagas disease
  15. 15. CONTINUED ........ (2) Mechanical or obstructive i) Esophagitis:dysphagia is due to mucuosal edema or benign stricture • Gastroesophageal reflux disease (GERD) • Infectious esophagitis HIV , H. pylori, Herpes, Candidiasis • Medication-induced esophagitis NSAIDs , quinidine, potassium, vitamins (B. complex), Iron sulphate • Radiation treatment • Caustic injury ii) Disorders of wall Esophageal stricture Zenker diverticulum Epiphrenic diverticula
  16. 16. CONTINUED............ (iii) Disease causing external compression Hiatus hernia ( mainly paraesophageal hernia ) Cervical osteophytes Mediastinal growth Vascular ring (dysphagis lusoria) (iv)Luminal obstruction: Foreign bodies Esophageal webs Schatzki rings Carcinoma esophagus
  17. 17. Associated symptoms and possible etiologies Condition Diagnosis to consider Difficulty in initiating swallow Oropharyngeal dysphagia Food sticks after swallow in chest Esophageal dysphagia Progressive dysphagia Neuro muscular dysphagia, carcinoma Sudden dysphagia Foreign body, esophagitis Intermittent dysphagia Rings and webs, Diffuse esophageal spasm, Nutcracker esophagus Cough: Early in swallow Late in swallow Neuromuscular dysphagia Obstructive dysphagia Weight loss: In elder patient With regurgitation Carcinoma Achalasia Pain after swallowing Esophagitis Dysphagia related to: solid foods only Solid and liquid both Obstructive dysphagia Neuromuscular dysphagia Regurgitation of old food and halitosis Zenkers diverticulum Dysphagia relieved with repeated swallow Achalasia
  18. 18. Evaluation of dysphagia • History • Clinical examination • Blood investigations Hb % , TC ,DC ,serum iron • Radiology – plain x-ray , barium meal , CECT thorax / Neck • Upper GI endoscopy • laryngoscopy • Manometery • 24 hr pH monitoring • Endoscopic ultrasound • Histopathology
  19. 19. Radiology • Plain x-ray neck & chest – for foreign bodies DENTURES PIN
  20. 20. Barium swallow Mid esophageal diverticulam Epiphrenic diverticulam Zenkers diverticulam
  21. 21. Barium Swallow Bird beak sign – Achalasia Sigmoid esophagus Achalasis Nut Cracker Esophagus
  22. 22. Barium Swallow Stricture – caustic injury Sliding Hernia Irregular filling defect – carcinoma Esophagus
  23. 23. Cine-radiography • Dynamic assessment • Radiographic visualisation of food bolus movement from oral cavity to hypophyrnx
  24. 24. Endoscopy • Rigid • Flexible • Diagnostic visual biopsy • Therapeutic foreign bodies removal Stentings Dilations
  25. 25. Barret’s Esophagitis Schzkati ring Esophagitis Esophagial diverticulam
  26. 26. Corrosive stricture Carcinoma Esophagus Foreign body – bone Paraesophageal hernia retro flexion view
  27. 27. Manometery • Indications - Achalasia cardia - diffuse esophageal spasm - Nutcracker esophagus - hypertensive esophageal sphincter Types • Stationary Manometery • High Resolution manometery
  28. 28. Manometery Normal peristalsis Achalasia Nutcracker esophagus Diffuse esophageal spasm
  29. 29. 24-Hour Ambulatory pH Monitoring • The most direct method of measuring increased REFLUX (esophageal exposure to gastric juice ) is by an indwelling pH electrode, or more recently via a radio- telemetric pH monitoring capsule that can be clipped to the esophageal mucosa.
  30. 30. Endoscopic ultrasound tumor confined to the esophageal wall an advanced esophageal carcinoma penetrating through all layers Used for dysphagia due to carcinoma esophagus for T , N staging Biopsy can also be taken
  31. 31. HISTOLOGY Barret’s esophagitis Squamous cell carcinoma Adenocarcinoma
  32. 32. TREATMENT • Life style modification • Drug therapy • Therapeutic endoscopy • Dilation • Stentings • Chemo-radiation • Surgery
  33. 33. LIFE STYLE MODIFICATION • These include – avoidance of precipitating foods(fatty foods, alcohol, caffeine) – Oral hygine – avoidance of recumbency postprandially – elevation of the head of the bed – smoking cessation – weight reduction.
  34. 34. • Inflammatory lesion Antibiotics Antifungal Incision & Drainage – for abscess Neuromuscular dysphagia Maintenance of oral hygine Chew well Semisolid /liquid diet Eat small meals more frequently Thermal tactile stimulation For grade 4-6 dysphagia – cricomyotomy
  35. 35. Drug therapy for esophageal dysphagia • H2 Blocker • Antacids • PPI • Metaclopromide/ Domperidon • Nitrates • Calcium channel Blockers • sildenafil • Botox injection • Steroids • Vinegar, lemon, orange juice - Alkali ingestion • Milk, egg white, Antacid - Acid ingestion Reflux esophagitis Motility disorders Caustic injuries
  36. 36. Therapeutic Endoscopy • Foreign body / food bolus extraction Graspers Food bolus extracted endoscopically
  37. 37. Dilation • Upto 40- 60 F ( Hydrostatic / pneumatic ) • Indications -Strictures, Schatki rings Achalasia Anastomotic stenosis , Pneumatic Dilator
  38. 38. Stents • Self expanding metal stents • Indication – grade 4 -6 dysphagia in ca esophagus ( not resectable )  Types - covered , uncovered stents  Complication - stent blockage , stent migration , erosion  Blockage can be removed by coring using laser or cryo ablation Non-covered stents Stent in situStent delivery system
  39. 39. Chemo-radiation • Indications Grade 1-3 dysphagia in case of ca esophagus ( neo adjuvent ) Grade 4-6 dysphagia in case of ca esophagus ( palliative ) Cisplatin+5FU + 60Gy radiation over 8 weeks
  40. 40. Surgery • Diverticulotomy/diverticulopexy + myotomy - esophagial diverticulum • Myotomy – motility disorders neuronal dysphagia • Fundoplication – reflux esophagitis • Hernia repair (crural repair) - Hiatus hernia • Esophageal resection and reconstruction Malignancy long standing Achalasia caustic injuries
  41. 41. Zenker’s diverticulum repair • Open Cricomyotomy + diverticulopexy/diverticulectomy • Dohlam’s procedure trans oral approach Dohlam’s procedure
  42. 42. Motility disorder • Long esophageal myotomy Indications Diffuse esophageal spasm Nutcracker esophagus Scleroderma Epiphrenic diverticulum • Heller’s myotomy ( modified ) indications Achalasia chagas disease These myotomy are done in conjunction with partial fundoplication – Dor , Toupet , Nissen
  43. 43. Reflux esophagitis • Fundoplication indications failure of medical treatment structurally defective LES ( lower esophageal spintcher ) stricture Barrets esophagitis in conjunction with myotomy or hiatus hernia repair Types : Nissen’s fundoplication Dor fundoplication Toupet fundoplication Besely fundoplication
  44. 44. Esophageal resection • Indications Carcinoma esophagus ( with two /three field lymphadenectomy ) long standing achalasia Extensive corosive injury • Surgical Approach  Open – Trans-hiatal (Orringer) Laprotomy + Trans thoracic (Ivor-lewis ) Three phase (Mc Keown)  Laproscopic Laproscopic Ivor lewis procedure Laproscopic Tran-hiatal  VATS (video assited transthoracic surgery)  Robotic
  45. 45. Ivor- lewis operation Trans-Hiatal approach Mc Keown three phase – post op patient
  46. 46.  Reconstruction stomach colon jejenuum ( pedicle / free ) Gastroesophageal Anastomosis at Orthotropic site

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