Approach to dysphagia

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Approach to dysphagia
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Definition of Dysphagia

• The word dysphagia is derived from the Greek
  phagia (to eat) and dys (with difficulty). It
  specifically refers to the sensation of food
  being hindered in its normal passage from the
  mouth to the stomach.

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CLASSIFICATION

• Two distinct syndromes

Oropharyngeal dysphagia
Esophageal dysphagia
Produced by abnormalities affecting the finely
tuned neuromuscular mechanism of the striated
muscle of the mouth, pharynx, and UES
Caused by the variety of disorders affecting the
smooth muscle esophagus
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Oropharyngeal dysphagia

• Inability to initiate the act of swallowing.
• It is a transfer problem caused by
• impaired ability to transfer food from mouth to
  upper esophagus
• impaired oral preparatory phase
• Clinical presentation
• food sticking in the throat
• difficulty initiating a swallow
• nasal regurgitation
• coughing during swallowing
• They may also complain of
• dysarthria
• nasal speech because of associated muscle
  weaknesses
• Other Neurological clinical findings

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Abnormalities Causing Oropharyngeal Dysphagia

• Neuromuscular Diseases
• Central nervous system (CNS)
• Cerebral vascular accident (e.g., brain stem or
  pseudobulbar palsy)
• Parkinson disease
• Wilson disease
• Multiple sclerosis
• Amyotrophic lateral sclerosis
• Brain stem tumors
• Tabes dorsalis
• Miscellaneous congenital and degenerative
  disorders of CNS

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Abnormalities Causing Oropharyngeal Dysphagia

• Neuromuscular Diseases
• Peripheral nervous system
• Bulbar poliomyelitis
• Peripheral neuropathies (e.g., diphtheria,
  botulism, rabies, diabetes mellitus)
• Motor end plate
• Myasthenia gravis
• Muscle
• Muscular dystrophies
• Primary myositis
• Metabolic myopathy (e.g., thyrotoxicosis,
  myxedema, steroid myopathy)
• Amyloidosis
• SLE

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Abnormalities Causing Oropharyngeal Dysphagia

• Local Structural Lesions
• Inflammatory
• Pharyngitis
• Abscess
• Tuberculosis
• Syphilis
• Neoplastic
• Congenital webs
• Plummer-Vinson syndrome
• Extrinsic compression
• Thyromegaly
• cervical spine hyperostosis
• Lymphadenopathy
• Surgical resection of the oropharynx

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Abnormalities Causing Oropharyngeal Dysphagia

• Disorders of the Upper Esophageal Sphincter (UES)
• Hypertensive UES (i.e., spasm, possibly in
  globus, or gastroesophageal reflux
• Hypotensive UES (e.g., esophagopharyngeal
  regurgitation or aspiration)
• Abnormal UES relaxation or opening
• Incomplete relaxation (e.g., cricopharyngeal
  achalasia CNS lymphoma, oculopharyngeal muscular
  dystrophy)
• Inadequate opening (e.g., cricopharyngeal bar,
  Zenker diverticulum)
• Delayed relaxation (e.g., familial dysautonomia)

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Etiology Of Esophageal Dysphagia

• Neuromuscular (Motility) Disorders
• Most common
• Achalasia
• Scleroderma
• Diffuse esophageal spasm
• Other associated motility abnormalities
• Nutcracker esophagus
• Hypertensive lower esophageal sphincter
• Vigorous achalasia
• Nonspecific esophageal dysmotility
• Other secondary motility disorders
• Other collagen disorders
• Chagas disease

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Etiology Of Esophageal Dysphagia

• Mechanical Lesions, Intrinsic
• Most common
• Peptic stricture
• Lower esophageal (Schatzki) ring
• Carcinoma
• Other
• Esophageal webs
• Esophageal diverticula
• Benign tumors
• Foreign bodies

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Etiology Of Esophageal Dysphagia

• Mechanical Lesions, Extrinsic
• Vascular compression
• Mediastinal abnormalities
• Cervical osteoarthritis

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Esophageal Dysphagia

• Three important questions are particularly
  crucial.
• What kind of food (i.e., liquid or solid)
  produces the symptom?
• Is the dysphagia intermittent or progressive?
• Is there associated heartburn?
• Physical examination is usually not revealing in
  patients with esophageal dysphagia, with the
  exception of scleroderma.

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Diagnosis

• History
• Examination
• CBC
• CxR
• Barium studies
• Endoscopy
• Computed tomography scanning
• Endoscopic ultrasound
• Endoscopy
• Esophageal Manometry
• Esophageal pH studies