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Approach%20to%20the%20patient%20with

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Dysphagia Dysphagia in elderly subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities,which are rarely ... – PowerPoint PPT presentation

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Title: Approach%20to%20the%20patient%20with


1
  • Approach to the patient with
  • Dysphagia
  • Dr Ehsani
  • Gastroenterologist/internist

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Dysphagia
  • Definition sensation of sticking or obstruction
    of the passage of food through the
    mouth ,pharynx,or esophagus.
  • Aphagia
  • Odynophagia
  • Phagophobia
  • Feeling of fullness in the epigastrium

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Dysphagia
  • Dysphagia is a subjective sensation
    that suggests the presence of an organic
    abnormality in the passage of liquids or solids
    from the oral cavity to the stomach.
  • Dysphagia is considered to be an alarm
    symptom,indicating the need for an immediate
    evaluation to define the exact cause and initiate
    appropriate therapy.

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Dysphagia
  • Dysphagia in elderly subjects should not be
    attributed to normal aging.
  • Aging alone causes mild esophageal motility
    abnormalities,which are rarely symptomatic.

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Dysphagia
  • The normal transport of an ingested bolus
    through the swallowing passage depends on the
    size of the ingested bolus,the luminal diameter
    of the swallowing passage , the force of
    peristaltic contraction,the deglutitive
    inhibition,including normal relaxation of UES,LES
    during swallowing

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Dysphagia
  • Classification
  • Mechanical (large bolus,luminal narrowing)
  • Motor (weakness of peristaltic contractions
    ,impaired deglutitive inhibition causing
    nonperistaltic contractions , impaired sphincter
    relaxation)

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Dysphagia
  • classification
  • Oropharyngeal dysphagia
  • Esophageal dysphagia
  • Functional dysphagia

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Dysphagia
  • Medical history
  • the cornestone of evaluation
  • Distinguish from odynophagia globus sensation
  • Determine the types of food that produce
    symptoms
  • Progressive or intermitent symptoms
  • Others symptoms or findings

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Approach to the patient with dysphagia
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Dysphagia,esophagealDifferential diagnosis
  • Peptic stricture
  • in 10 of patients with GERD ,in older age, male
    gender,longer duration of reflux symptoms.
  • In scleroderma,Z-E syndrom,NG tube, Heller
    myotomy.
  • Infectious esophagitis,post surgical,caustic
    injury,pill induced esophagitis,radiation
    exposure.

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Dysphagia,esophagealDifferential diagnosis
  • Esophageal rings and webs
  • Thin,fragile structures that partially or
    completely compromise the esophageal lumen.
  • Webthin mucosal fold,covered with squamous
    epithelium,in anterior cervical esophagus,
    causing focal narrowing in the postcricoid area.

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Dysphagia,esophagealDifferential diagnosis
  • Esophageal rings and webs
  • RingsSchatzki ,mucosal structures at the GE
    junction , smooth,thin,(lt4mm).covered with
    squamous mucosa above and columnar epithelium
    below.
  • Pathogenesis,mucosal,muscular,GERD
  • Changing the caliber during peristaltism.

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Dysphagia,esophagealDifferential diagnosis
  • Esophageal rings and webs
  • DiagnosisBarim swallow,EGD
  • Symptomsacute(steak house syndrome)
    ,intermittent,with chest discomfort
  • Plummer-vinson or paterson-kelly syndrom

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Dysphagia,esophagealDifferential diagnosis
  • Carcinoma
  • Esophagus,gastric cardia
  • History,others symptoms,age
  • Histologic type
  • Risk factors
  • incidence

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Dysphagia,esophagealDifferential diagnosis
  • Cardiovascular abnormalities
  • Compressing the esophagus
  • Complete vascular ring double aortic arch, R.
    aortic arch with retroesophageal
    L. subclavian artery and L. ligamentum
    arteriosum,R. aortic arch with mirror-imaging
    branching and L. ligamentum arteriosum
  • Incompleteretroesophageal R.aberrent subclavian
    artery and L.pul artery

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Dysphagia,esophagealDifferential diagnosis
  • Cardiovascular
  • Severe atherosclerosis in elderly
  • Large aneurysm of the thorasic aorta
  • Enlargement of the left atrium

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Dysphagia,esophagealDifferential diagnosis
  • Radiation injury
  • Acute esophagitis
  • Chronicgt2 months after radiotherapy
    (ulceration or strictures)
  • Location
  • Motility disorder

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Dysphagia,esophagealDifferential diagnosis
  • Achalasia
  • Etiology
  • Symptoms
  • Manometric abnormalities
  • Secondary achalasia

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High-resolution esophageal pressure topography
,conventional manometry normal swallow
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Classic achalasia
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Achalasia with compression
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Spastic achalasia
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  • Secondry achalasia

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Dysphagia,esophagealDifferential diagnosis
  • Spastic motility disorders
  • DES,nutcracker esophagus,hypertensive LES ,non
    specific spastic esophageal motility disorders
  • Pathophysiology
  • Symptoms
  • diagnosis

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Variants of esophageal spasm spastic nutcracker
(left) and diffuse esophageal spasm (right)
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Dysphagia,esophagealDifferential diagnosis
  • Connective tissue disorders
  • Sclerodermaesophageal involvement in up to 90
    of patients
  • sjogrens syndromdysphagia up to 74

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  • sclroderma

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Dysphagia,esophagealDifferential diagnosis
  • Functional dysphagia
  • Is a diagnosis of exclusion
  • Complete diagnostic evaluation is needed.
  • No structural abnormality or motility
    disturbance,no reflux.
  • At least 12 weeks in the preceding 12 months of a
    sense of having solid and/or liquid food
    sticking,lodging,or passing abnormally through
    the esophagus.

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Dysphagia,esophageal
  • Specific testing
  • Should be based upon the medical history
  • Early referral for EGD
  • Barium swallow in proximal esophageal lesion
  • Esophageal motility study

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Acute dysphagia
  • Require immediate evaluation and intervention
  • Annual incidence13/100,000
  • M/F1.7/1-increase with age.
  • Commonly have an underlying component of
    mechanical obstraction
  • Food impaction is the most common cause in adults.

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Dysphagia,oropharyngealphysiology of swallowing
  • Normal swallowing consist of 3 phases (oral
    preparatory , pharyngeal , esophageal)
  • Up to 600 times/day
  • Once begin , it takes less than 1 second for a
    bolus to reach the esophagus,and an additional
    10-15 seconds to complete the swallow
  • Involve more than 30 muscles

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Sagittal and diagrammatic views of the
musculature (involved in enacting oropharyngeal
swallowing)
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Dysphagia,oropharyngealphysiology of swallowing
  • Oral preparatory phase
  • The bolus is processed by mastication to an
    appropriate size,shape and consistency
  • The tongue is a critical part for controlling the
    food so that proper chewing can occur and for
    directing the bolus to its proper position for
    swallowing.
  • Voluntary control/cranial nerve V,VII,XII.

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Dysphagia,oropharyngealphysiology of swallowing
  • Pharyngeal phase
  • The bolus is advanced through the pharynx and
    into the esophagus by pharyngeal peristalsis
  • Is controlled reflexively
  • Cranial nerve V,X,XI,XII
  • Respiration is inhibited centrally.

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Dysphagia,oropharyngealphysiology of swallowing
  • Esophageal phase
  • In this phase , peristaltic contractions in
    the body of the esophagus combined with
    simultaneous relaxation of the LES propel the
    bolus into the stomach

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Dysphagia,oropharyngealpathogenesis
  • Disturbance in oral preparatory or pharyngeal
    phase
  • Arise from diseases of the upper esophagus ,
    pharynx ,UES dysfunction

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Dysphagia,oropharyngealpathogenesis
  • Disorders of the oral preparatory phase
  • Poor dentition
  • Decrease in salivary flow
  • Neurologic disorders such as stroke, parkinsons
    dis(weakness of muscles, decrease in
    coordination)
  • Disruption of the oropharyngeal mucosa

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Dysphagia,oropharyngealpathogenesis
  • Disorders of the pharyngeal phase
  • a normal phase requires neuromuscular
    coordination for propulsion of the bolus, an
    unobstructed lumen , and normal relaxation of the
    UES.
  • Neuromuscular discoordination(CNS disorders
    egstroke,motor neuron dis eg ALS,peripheral
    neuron dis egmyastenia

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Dysphagia,oropharyngealpathogenesis
  • Continue..
  • Obstructions within the oropharynx malignancies
    (the most common), cervical rings or webs,
    cervical osteophytes
  • Poor compliance of the UES (parkinsons dis)

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Dysphagia,oropharyngealhistory
  • Specific clues in the history can help establish
    the cause of the dysphagia
  • Older patients,particularly those with a history
    of alcohol abuse,smoking or weight loss
    malignant cause must be R/O
  • Repositioning during the swallowingdifficulte in
    transfer of bolus
  • History of dry mouth or eye

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Dysphagia,oropharyngealhistory and physical exam
  • Continue
  • Changes in speech(neuromuscular dysfunction,vocal
    cord paralysis,)
  • Food regurgitation,halitosis,a sensation of
    fullness in the neck,or a history of pneumonia
    Zenkers diverticulum
  • Pain upon swallowing inflammation,infection,malig
    nancy

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Dysphagia,oropharyngealclinical manifestations
  • Pointing toward the cervical region
  • Symptoms occur almost immediately after
    swallowing
  • Feelig of an obstruction in the neck,
    coughing,chocking,drooling and regurgitation
  • Differentiation with globus sensation,dysphagia
    related to distal esophageal dis,such as peptic
    stricture.

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Dysphagia,oropharyngealphysical examination
  • Oral cavity,head and neck,supraclavicular region
    must be examed carefully
  • Neurologic examination should include testing of
    all cranial nerves,especially those involved in
    swallowing (sensory components of V, IX, X, and
    motor components of V, VII, X, XI, XII).

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Dysphagia,oropharyngealdiagnostic testing
  • Barium radiography
  • Videofluroscopy
  • Upper endoscopy
  • Fiberoptic nasopharyngeal laryngoscopy
  • Esophageal manometry
  • The choice of specific testing depends upon
    the clinical presentation and available expertise.

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Dysphagia,oropharyngealtherapy
  • The goals of treatment are to improve food
    transfer and to prevent aspiration.
  • The approach chosen depends in part upon the
    cause of dysphagia
  • Neoplasms resection , chemotherapy or radiation
    therapy

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Dysphagia,oropharyngealtherapy
  • Following stroke , head or neck trauma, surgery ,
    or in degenerative neurologic diseases
    rehabilitation is recommended
  • Therapeutic endoscopy for esophageal webs or
    strictures
  • Surgical myotomy
  • Botulinium toxin injection (alternative to
    cricopharyngeal myotomy)

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