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Description : Check out this medical presentation on Aortic Aneurysm, which is titled "Dysphagia – Causes & Management", to know about dysphagia, its causes and management. Usually caused by nerve or muscle problems, dysphagia can be painful and is more common in older people and babies.

Tags : Aortic Aneurysm, Dysphagia, Causes, Management

Published on : Jun 02, 2021 | Views : 3805 | Downloads : 34

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Dysphagia – Causes & Management Dr.Nayana.V.G MBBS,MS Senior Resident Dept of ENT
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Esophagus BRIEF ANATOMY : Esophagus is a tubular structure about 10 inches continuous above with laryngeopharynx opposite 6th cervical vertebra passes through diaphragm at the level of 10th thoracic vertebra where it joins the stomach in the abdomen
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BLOOD SUPPLY OF ESOPHAGUS: upper 3rd middle 3rd lower 3rd Inferior thyroid artery Inferior thyroid vein azygos vein Descending thoracic aorta Left gastric artery left gastric vein
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AREAS OF NARROWING IN ESOPHAGUS: The aortic arch The left main bronchus The diaphragm
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Physiology of swallowing Oral Phase. Pharyngeal phase Closure of nasopharynx Closure of oral cavity Closure of larynx Pharyngeal contractions Esophageal Phase In resting both UES and LES are contracted to prevent reflux .
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DYSPHAGIA DEFINITION OF DYSPHAGIA: Medical term means any difficulty in swallowing regardless of the cause GRADES OF DYSPHAGIA: mild dysphagia: only solid things can't be swallowed moderate dysphagia: solid & semi solid thing can't be swallowed severe dysphagia: even liquids can't pass GRADES OF DYSPHAGIA: mild dysphagia: only solid things can't be swallowed moderate dysphagia: solid & semi solid thing can't be swallowed severe dysphagia: even liquids can't pass
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COMMON CAUSES OF DYSPHAGIA: CONGENITAL ACQUIRED
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1.CONGENITAL: esophageal atresia
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Pre esophageal etiologies ORAL PHASE Disturbances in mastication Disturbances in Lubrication Tongue disorders Palatal Defects Lesion of buccal cavity
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Pharyngeal Causes a)Obstructive lesion of pharynx b) Inflammatory condition c)Paralytic condition d)Spasmodic condition
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^ In the lumen Foreign body Food bolus strictues ^ In the wall Hyomobility disordes- Achalasia, Scleroderma Chagas’ disease Hyermobility Disorders Tumour of the esophagus GERD Plummer Vinson syndrome Pharyngeal pouch ^ Outside the wall Pressure of the enlarged lymph nodes Thoracic aortic aneurysm Bronchial carcinoma Retrosternal goitre ^ Neuromuscular disorders Myesthenia gravis Bulbar palsy Bulbar poiliomylitis ESOPHAGEAL
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Associated symptoms: Difficulty in chewing or bolus preparation Excessive drooling Chocking or regurgitation Food sticking Symptoms aggravated by : Aspiration pneumonia Weight loss Compromised nutritional status Or any combination of these
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Benign stricture Etiology – Trauma,Burns,Ulceration,surgery C/F – Dysphagia Invstigation – Ba.Swallow, OGD scopy Rx : BOUGIE Dilatation, Gastrostomy, surgery
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Hiatus Hernia 2 Types Sliding – reflux symptoms Paraesophageal – DOE Ba.swallow Rx:Surgery
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Plummer –Vinson syndrome “Patterson Brown kelly Syndrome” Sideropenic Dysphagia C/F : Anemia, Glossitis, Angular stomatits,Koilonychia,Achlorhydria, Splenomegaly,esophageal web
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Females , >40 yrs 10% a/w Sqcc of Post cricoid area Dx- Ba.Swallow and UGI scopy Rx: parenteral iron Esophageal Bougies
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Motility Disorders Hypermotility Disorders Cricopharyngeal Spasm: Failure of UES to relaxation B) Diffuse esophageal spasm- Non peristaltic contraction of body of esophagus with normal sphincteric contractions Corkscrew esophagus Manometry – NAD Rx: Dilatation : Surgery ( MYOTOMY from arch of aorta to LES)
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Corkscrew esophagus Manometry – NAD Rx: Dilatation : Surgery ( MYOTOMY from arch of aorta to LES)
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C) Nut Cracker Esophagus Strong high amplitude peristaltic esophageal contractions C/F : Dysphagia and substernal pain Diagnosis: Manometry; Ba.swallow – NAD Rx: Medical Treatment (CCB, Nitrates) Botulinum Toxin Surgery
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Definition Primary esophageal motility disorder characterized by: 1) Absence of peristalsis, 2) Elevated pressure of the LES, 3) Failure of the LES to relax during swallowing, Causing functional obstruction at the gastroesophageal junction. Achalasia cardia
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What is the most likely diagnosis? Achalasia of the Cardia WWW.MD4A.NET
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Clinical picture of Achalasia History Dysphagia (most common) Regurgitation Chest pain Heartburn Weight loss
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Details 25-50% report episodes of retrosternal chest pain. 80-90% experience spontaneous regurgitation. some patients may present with signs or symptoms of pneumonia or pneumonitis. Patients with achalasia are at increased risk for esophageal cancer Physical: Physical examination is noncontributory.
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INVESTIGATIONS Lab Studies Laboratory studies are noncontributory. Imaging Studies Ba.Swallow: Bird’s Beak. EGD: Normal or dilated esophagus. Manometry The radiologic examination of choice in the diagnosis of achalasia is a barium swallow study performed under fluoroscopic guidance.
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Normal Barium Swallow Birds bak xray Bird’s Beak
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Diagnosis of achalasia supported by the results of radiologic studies must always be confirmed by 1) Performing (EGD) to rule out cancer of the gastroesophageal junction or fundus, and 2) Esophageal manometry.
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The goal of therapy for achalasia is to relieve symptoms by eliminating the outflow resistance caused by the hypertensive and nonrelaxing LES. Medical Management Surgical Management MANAGEMENT
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Medical Management Botulinum toxin: intrasphincteric injection Only 30% of patient's treated endoscopically still have relief of dysphagia 1 year after treatment. (50% re-treat in 9 months vs 10% balloon)
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b) Pharmacologic therapy: relax the smooth muscle of the LES. Calcium channel blockers - Nifedipine and verapamil Anticholinergic agents - Cimetropium bromide Nitrates - Isosorbide dinitrate Opioids - Loperamide
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Surgical Management Pneumatic dilatation: Dilation of LES with a bougie ( flexible cylindrical instrument ) Most commonly performed by using pneumatic balloons. The success rate is 70-80%, and the perforation rate is approximately 5%.
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Approximately one half of patients experience recurrent symptoms within 5 years. Complications Failures Perforation Gastro esophageal reflux
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b) Esophageal (Heller) myotomy: ^ Heller myotomy – cardiomyotomy and dividing the muscle of the lower end of the esophagus and the upper stomach down the mucosa. ^ Heller myotomy is the appropriate treatment for patients in whom pneumatic dilatation fails. ^ The laparoscopic approach appears to be most appropriate.
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Under general anesthesia, make a controlled division of the muscle fibers (myotomy) of the lower esophagus (5 cm) and proximal stomach (1.5 cm) followed by a partial fundoplication to prevent reflux . Patients in whom surgery fails may need a dilatation, a second operation, or removal of the esophagus (ie, esophagectomy).
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Esophageal Tumor Benigh Tumors: * LIOMYOMA * POLYP Malignant Tumors
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Benign Tumors RARE The commonest is LIOMYOMA. Dysphagia , bleeding. Remove it .
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What you see ??
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?
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Esophageal Carcinoma Oesophageal carcinoma is becoming more common, unlike the trend observed in gastric carcinoma. Squamous carcinoma typically arises in the upper 2/3 of the oesophagus Adenocarcinoma usually arises in a region of specialised columnar epithelium (SCE) metaplasia in the lower 1/3 of the oesophagus - Barrett's oesophagus.
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Clinical Features Dysphagia is the most frequently presented feature of oesophageal carcinoma : Patient may recount a short history of progressive dysphagia, initially affecting solids only, but gradually affecting the swallowing of fluids.
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Clinical Features The level at which difficulty in swallowing is encountered may be identifiable by the patient. Short history of dysphagia in an elderly male is almost certainly carcinoma of the oesophagus or the cardia of the stomach.
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Clinical Features Other local features may include : Regurgitation of food or blood-stained vomit Aspiration pneumonia Pain : classically, retrosternally and in the interscapular region it may radiate to the jaws and arms
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Clinical Features General manifestations of malignant disease may include : Loss of Weight Anorexia Anemia Coughing Secondary deposits occur in: lymph nodes liver causing jaundice
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Diagnosis The diagnosis of oesophageal carcinoma is made on : History and examination Barium swallow Endoscopy and biopsy CT scan USG Bronchoscopy
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WWW.MD4A.NET
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Investigations
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Management Management of oesophageal carcinoma is dependent on the level of the lesion and the stage of the disease. Upper third lesion Middle third lesion Lower third lesion
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Management Upper third lesion: high dose radiotherapy is indicated for lesions up to 5 cm long. Vital structures in the mediastinum closely related to the upper third make surgical clearance and resection very difficult. Middle third lesion : Early tumours are resectable. Again, radical radiotherapy may be indicated if the lesion is up to 5 cm long . Lower third lesion : most accessible surgically; adenocarcinomas are radioresistant
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Management Extensive disease requires palliation of dysphagia: endoscopic laser surgery for lesions less than 8 cm long oesophageal stenting e.g. with a Celestin tube - if longer than 8 cm alternatives include: oesophago-gastrostomy or oesophago-jejunostomy short course radiotherapy
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(GERD) Gastroesophageal reflux disease
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Episodes of gastroesophageal reflux occurs normally in asymptomatic individuals However excessive duration and frequency of reflux events lead to symptomatic illness referred to as (GERD) BUT The clinical features of GERD occur only when the anti-reflux mechanisms fail.
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PATHOGENESIS LOS tone is reduced Frequent Transient LOS relaxations increased mucosal sensitivity to gastric acid & reduced esophageal clearance of acid The LOS tone fails to increase when intra-abdominal pressure is increase.
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CLINICAL FEATURES Symptoms:- Heart burn Acid regurgitation Dysphagia Extraesophageal symptoms:- Asthma Recurrent pneumonia Chronic cough Angina like chest pain Laryngitis (horseness) Signs:- Usually absent
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Complications Peptic stricture Barrett's esophagus Adenocarcinoma WWW.MD4A.NET
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INVESTIGATION Specific investigations:- CBC to rule out anaemia due to blood loss. Endoscopy with biopsy: best way to diagnosis mucosal injuries, hiatal hernia, peptic stricture & Barrett's oesophagus & may be used to dilate peptic strictue
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INVESTIGATION Esophageal Manometry: Used to assess LOS pressure & peristalsis WWW.MD4A.NET
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INVESTIGATION Esophageal PH monitoring:- To measure esophageal PH as to differentiate between physiological and pathological esophageal acid exposure. Usually when the PH < 4 its pathological
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INVESTIGATION BARIUM SWALLOW:- To identify Hiatal Hernia & Strictures
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Management of GRED Aims of therapy: Relive symptoms. Heal esophageal mucosa. Prevent & manage complications. Maintain remission. Treatment of GRED is a stepwise approach starting with: General measures. Drugs. Surgery.
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Pharmacological therapy Group H2blockers e.g ranitidine PPI e.g omeprazole Prokinitic e.g cisapride - Action . Decrease acid reflux \\ \\ \\ \\ Increase LES tone Increase esoph. Peristalsis Increase gastroesoph. Motility .
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Surgical management Indication : Unresponsiveness to medical Rx Apnoeic spells Repeated attack of asipration Persistent reflux & stricture of esophagus MR or brain damage .
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SURGERY Fudoplication; A- Nissen----- fundus of stomach is wrapped complete around lower esophagus B- belsey ----- thoracic procedure in which esoph. Is sutured to diaphragm & to fundus of the stomach C- hill ---- cardia is tightend & fixed to peraortic fascia . This is mainly in adult , b\c children keep growing
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Assesment Of Dysphagia in breif HISTORY: Onset Progression Continous/ Intermittent Solid/ liquid Intolerence to acid food
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Clinical Examination: Examination of oral cavity and oropharynx Examination of neck , chest Neurological examination
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Laboratary investigation Haemogram Nutritional assesment of patient RADIOGRAPHY Xray Chest Xray Lat view of neck Ba. Swallow with fluoroscopy
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Manometry and pH studies Motility disorders GERD ESOPHAGOSCOPY And Biosy Flexible or Rigid scopy and biopsy
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Other Investigations Bronchoscopy Cardiac catheterization Thyroid scan
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Thank you