Dysphagia

Prestented by: Mais Al.Shboul B2 6th year Supervised by :Dr.Ghazi Qasaimah 30.Jan.2013 wed

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Anatomy of Esophagus
The esophagus is a muscular tube around 25 cm long It begins at the inferior border of the cricoid cartilage, opposite vertebra CVI, and ends at the cardiac opening of the stomach, opposite vertebra TXI. 2cm below diaphragm descends on the anterior aspect of the bodies of the vertebrae in a midline position , but As it approaches the diaphragm, it moves anteriorly and to the left esophageal hiatus T10 Smooth muscle except upper third: skeletal
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Anatomy of Esophagus
narrowed by surrounding structures at four locations These constrictions have important clinical consequences. (swallowed object lodge at a constricted area. An ingested corrosive substance. Also ,present problems during the passage of instruments) 15 , 25 , 40 .

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Innervation
preganglionic parasympathetic fibers (visceral efferents) from the vagus nerve that synapse in the myenteric and submucosal plexuses in the esophageal wall. peristalsis

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Physiology of swallowing
Oral phase Pharyngeal phase Esophageal phase Swallowing reflex is a complex neurological event Any defect dysphagia

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Dysphagia
Difficulty swallowing Specifically ascribes the problem to esophagus Obstructive vs. Motility disorder Intra Luminal , Mural , Extra luminal , Neuromuscular Preesophageal (oropharynx) Esophageal Post esophageal (esophageogastric) Para esophageal (extrinsic dysphagia)
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Types
pharyngeal

Motor
75% of cases UES dysfunction CVA , Parkinson's , peripheral neuropathy , MG, myopathy DES Achalasia ;Vigorous Achalasia Scleroderma DM (with neuropathy)

Physical (organic)
Oropharyngeal carcinoma cong. Web Zenckers diverticulum Painful mouth ulcer Throat infection FB or Food bolus Esophageal carcinoma (Peptic\Candida) stricture Reflux esophagitis Schatski ring Plummer Vinson Irradiation Gastric ca Stricture

Esophageal

Esophageogastric

Achalasia

Para esophageal

cervical spine disease, Goiter , left atrial enlargement (MS) , post. surgical scar, mediastinal\cervical lymphadenopathy\ca -thoracic aortic aneurysm. Page 7 -Para esophageal (rolling) HH.

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A. Extaluminal 1.Congenital
-esophageal atresia.

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Esophageal Atresia.
THE newborn baby will show dribbling of saliva, inability to swallow feeds, production of frothy mucus, choking attacks, cyanotic attacks and chest infections, obvious respiratory compromise (aspiration pneumonia), gastric distention as air enters the stomach directly from the trachea. VACTERL 10% Treatment: -suction (NPO), upright position ,prophylactic antibiotic - surgical correction. Within 1-2 day of birth The two most feared complications are pneumonia and leakage from anastomosis

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2. Esophageal diverticulum
Outpouching of esophageal mucosa through a defect in muscular layer. Characterized by location: Pharyngoesophageal ( Zenkers) Midesophageal (true diverticula) Epiphrenic Most are pulsion diverticula cause by increased esophageal pressure. Traction diverticula are less common and usually due to granulomatous disease like TB and histoplamosis.
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Pharyngeal pouch
ZENKERS DIVERTICULUM : Pharyngoesophageal diverticulum; a false diverticulum containing mucosa and submucosa at the UES at the pharyngeoesophageal junction (posteriorly above the cricopharyngeous sphincter trough the natural weak point between the oblique and horizontal fibers of the inferior pharyngeal constrictor muscle.)
Most common esophageal diverticulum Clinical presentation :

Dysphagia, neck mass, halitosis, food regurgitation, choking & aspiration Dx by : Barium swallow Endoscopy is dangerous due to risk of perforation Treatment : Diverticulectomy Cricopharyngeus myotomy, if > 2 cm

1. 3.

2. Diverticulopexy

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ZENKERS DIVERTICULUM

Front View with Barium: One can easily appreciate the Zenker's Diverticulum pouch with fluid halfway filling the pouch. The patient's chin is seen at the top

Side View with Barium: A side view showing the Zenker's Diverticulum

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B. Luminal
1-The most common impacted material is food (meat bolus& bones ) may be the first presentation of a benign stricture or a malignant tumor (signifies underlying disease). 2-button batteries and coins may be a troublesome problem in children (be aware). 3-false teeth.

-plain radiography are often useful. (modern denture material

are not always radiopaque) -Treatment: flexible endoscopy. If food bolus then we break it up by given fluid or by endoscopy. -We should know the cause of impaction after treatment

-(stricture , tumor..etc)

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C. Mural
1. 2. 3. 4. Webs & Rings Stricture : (peptic) Reflux esophagitis (consequence of GERD ) A caustic stricture Candidal esophagitis Malignant stricture

Esophageal Carcinoma
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1. Webs & rings

Plummer Vinson

Schatzkis ring

Dx : Barium Esophagram Tt : dilation procedures Page 16

Plummer Vinson
Patterson Kelly syndrome

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Schatzki ring

Schatzki ring. Prone, single-contrast barium esophagogram demonstrating a thin, ringlike narrowing (arrows) in the lower esophagus just above a hiatal hernia.

Endoscopic image of Schatzki ring, seen in the esophagus with the gastro-esophageal junction in the background.
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2. Stricture
A. Peptic stricture

GERD - Any significant symptomatic clinical condition or

histopathological changes resulting from reflux of gastric contents to the esophagus as a result of LES incompetence

very common condition: 3% of population experience heartburn daily 7% frequently 15% weekly 25% monthly -Most common in pregnant women: 80% -Common in obese and smokers.
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GERD
Mechanism of GERD Transient LES relaxation (Hypotensive LES) Sliding Hiatus hernia Impaired salivation Decreased esophageal acid clearance Symptoms : worse when supine \ after meals HEARTBURN Substernal Chest pain. REGURGITATION Nausea and vomiting Water brash Belching Hicough Dysphagia Exraesophageal symtoms. (pol)
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GERD
Diagnosis: Clinical picture. UGI endoscopy. 24 hour pH monitoring Manometry Barium swallow (show stricture)

Complication: Reflux esophagitis Stricture formation

Barretts epithelium Adenocarcinoma
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GERD
Treatment 1-lifestyle modification. avoid smoking and alcohol Weight loss . Tilting the bed . Small multiple meals

2-pharmacology (antacid, H2 blocker, PPI).

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GERD
3-Surgery: -Nissen:360 degree fundoplication; wrap fundus of stomach all the way around the esophagus.
*Indications for surgery: 1. Failed medical therapy 2. Esophageal stricture 3. Progressive Pol. Insufficiency due to nocturnal aspiration 4. Barretts esophagus

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B. Inflammatory stricture

Candidal esophagitis fungal infections -such as Candida

albicans- are common in immunocompromised ; AIDS , patient taking steroid & chemotherapy. -endoscopy shows numerous white plaque that cant be removed. -Biopsy is diagnostic. -Treatment: topical antifungal agent.

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3. Esophageal CA
The 9th most common cancer Disease of mid to late adulthood, usually above 50 Squamous cell carcinoma usually affect upper twothirds and adenocarcinoma on the lower third. Incidence of adenocarcinoma is increasing due to Barretts esophagus Males > females Black Over 50% of patients have unresectable or metastatic disease at presentation. 5 year survival rate is poor, about 5%
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Esophageal CA
Risk factor: Environmental: Tobacco Alcohol Food additives (nitrates in smoked and pickles : china ) Esophageal disorders: GERD/Barrets Achalasia (Adenocarcinoma ) History of radiation to mediastinum Signs and symptoms: Early: Non specific GI symptoms like dyspepsia Late: dysphagia for solid, weight loss, hoarsness, palpable lymph node, back pain signs of distant mets.
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Esophageal CA
Growth patterns: Fungating mass (60%) Ulcerating lesion (25%) Infiltrating the whole esophagus (15%) The spread of the cancer: 1. Lymphatic spread Cervical esophagus cervical lymph nodes. Thoracic esophagus mediastinal lymph nodes. Abdominal esophagus celiac lymph nodes. 2. Direct invasion : may invade the bronchus constant cough & hemoptysis this indicate broncho-esophageal fistula in-operable 3. .Hematogenous spread
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Esophageal CA
Work up : 1. UGI series (barium swallow ) 2. EGD for visualization and biopsy 3. Transesophageal ultrasound (TEU) for evaluation of depth of tumor and presence of lymphadenopathy 4. CT scan of chest/abdomen , LFT , bone scan for staging Asymptomatic patients occasionally identified by surveillance endoscopy to have Barrets esophagus.
Staging is dependent on wall penetration and lymph node spread.

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EUS

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Staging

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Esophageal CA
Treatment (depend on stage & site)
Localized: Surgical resection: for symptoms control Radiotherapy: shrink tumor but not palliate dysphagia Pre/post chemotherapy Combination of all is now common Advanced: Chemotherapy to shrink tumor and palliate symptoms Post-op complications: common Fistula (TE), abscess and respiratory complication

Stage 1 & 2 esophagectomy with gastric pull-up or colon interposition Stage 3 & 4 palliative only : Endoscopic : dilation stent , alcohol injection , plastic tube , laser electrocoagulation, photodynamic laser therapy
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Esophagectomy
2 stages esophagectomy (Ivor-Lewis esophagectomy) Abdominal & thoracic : The site of anastomosis of this operation is below the clavicle, so the most dangerous thing about this operation is if this anastomosis leaks mediastinitis & death

3 stages esophagectomy

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D. Motility disorders 1. Achalasia

Failure of LES to relax during swallowing due to : 1) Complete absence of peristalsis in esophageal body 2) impaired relaxation of LES 3) Increased resting tone of LES (ganglionic degeneration of Auerbachs plexus, vagus nerve, or both ) Clinical presentation: Dysphagia for both solids and liquids Regurgitation Severe halitosis Weight loss Esophageal carcinoma secondary to food stasis
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Achalasia
Diagnosis: Chest x-ray: dilated esophagus Barium swallow: dilated esophageal body with narrowing inferiorly ; Birds beak sign Manometry: increased pressure in the LES and failure of the LES to relax during swallowing Endoscopy: found tight cardia, exclude sticture and for biopsy Complication : Squamous carcinoma Aspiration & recurrent resp. Infections
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Achalasia

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Achalasia
Treatment: Medical: Nitrogylcerin, Ca channel blocker, botulinum toxin. Endoscopic dilatation: Inserting a balloon tearing the smooth muscle and decrease LES competency Higher risk of esophageal rupture Surgery: Esophagomyotomy Hellers myotomy Done thoracoscopically or trans abdominal laparoscopically. Tunica muscularis of the esophagus is incised distally with extension to LES. 0 Necessitates antireflux procedure: 270 fundoplication. DDx: Benign stricture of esophagus Carcinoma Diffuse esophageal spams
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2. Nutcracker Esophagus
A condition in which peristaltic pressures of more than 180mmHg develop. i.e Very strong peristaltic waves
Diagram of esophageal motility study in nutcracker esophagus. The disorder shows peristalsis with high pressure esophageal contractions exceeding 180 mmHg and contractile waves with a long duration exceeding 6 seconds.
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3.Diffuse Esophageal Spasm

Strong uncoordinated large amplitude rapid nonperistaltic contractions of smooth muscle of the esophageal body; sphincter function is usually normal Could be associated with Gastroesophageal reux S\S : Dysphagia for both solids and liquids Substernal chest pain similar to myocardial infarction Dx : Esophageal manometry: Motility studies reveal repetitive, high- amplitude contractions with normal sphincter response Upper GI may be normal, but 50% show segmented spasms or corkscrew Esophagus Endoscopy: to rule out stricture and mass Tt : Medical (antireux measures, calcium channel blockers, nitrates) Long esophagomyotomy in refractory cases Page 39

DES corkscrew

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ACHALASIA
Signs and symptoms: Dysphagia Regurgitation Weight loss Severe halitosis cough Failure of LES to relax

DES
Dysphagia Diffuse chest pain

Pattern of contraction:

Swallow induce large wave of esophageal contraction, Normal LES pressure

Barium swallow Birds beak Absence gastric bubble

Cork screw

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Systemic causes of Dysphagia

Connective tissue disease Scleroderma Neuromuscular Stroke Multiple sclerosis Myasthenia gravis Amyotrophic lateral sclerosis Parkinsons disease Muscular dystrophy Others Aging Globus hystericus
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How to approach ?
History Physical exam Investigations

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History taking
Do you have Difficulty Swallowing ? Solid only vs. solid & liquid? Can you localize ? Progressive vs. intermittent ? For how long ? Associated pain? heartburn? Thyromegaly ? W8 loss? Chest pain ? Choke or cough ? Also When not swallowing ? Alcohol , smoking , radiation ? Coustic material ingestion ?

Neuro diseases : CVA , MS , Parkinson's , GBS , DM MG Prev. surgery , radiation , trauma Drug hx : steroids ? Family hx Social hx

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Physical exam
General : w8 , voice quality Head & neck : tongue , uvula , oropharynx , Goiter gurgling voice Abdominal exam : gastric mass Neuro Exam : Cranial nerve

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Investigations
Plain films :FB Barium swallow Endoscopy +\- biopsy Manometry 24 h Ph monitoring

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Thank You
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