Approach to Dysphagia

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Approach to Dysphagia:

Dr. R. Sakthivel , MD PG (Internal Medicine) Approach to Dysphagia

Definitions:

Definitions Dysphagia : “Sticking”/Obstruction of passage of food through mouth, pharynx or esophagus Aphagia : complete obstruction; bolus impaction Odynophagia : painful swallowing “Difficulty in initiating swallow”: disorders of voluntary phase of swallowing Globus pharyngeus Phagophobia : refusal to swallow – hysteria, rabies, tetanus, pharyngeal paralysis, painful lesions

Physiology of swallowing:

Physiology of swallowing Voluntary oral phase – preparatory phase and transfer phase Deglutition reflex Centrally mediated reflex Propel food through pharynx/esophagus and prevents entry into airway

PowerPoint Presentation:

Primary peristalsis Contraction in response to swallow Deglutitive inhibition + peristaltic contraction Secondary peristalsis Local distension of esophagus from residual food Mm of oral cavity, pharynx, UES, cervical esophagus – STRIATED Mm Thoracic esophagus/LES – SMOOTH Mm

PowerPoint Presentation:

Oral cavity and tongue Mm – V, VII, XII Pharyngeal Mm – IX, X UES Constrictor: cricopharyngeus , inferior constrictor – X Dilator: suprahyoid Mm – XII & V, VII Stays closed d/t elastic properties and neurogenic tonicity of cricopharyngeus Opening of UES: inhibition of vagal excitatory activity relaxing cricopharyngeus and contraction of dilator Mm

PowerPoint Presentation:

Peristalsis in CERVICAL ESOPHAGUS d/t sequential activation of vagal motor Nn in nucleus ambiguus Thoracic esophagus/LES Excitatory/inhibitory Nn in eso . myenteric plexus Preganglionic fibers in X CN arising from dorsal motor nucleus Closed at rest d/t intrinsic myogenic tone Peristalsis d/t patterned activation of inhibitory f/b excitatory pathways  deglutitive inhibition f/b contraction

PowerPoint Presentation:

LES relaxes, with deglutitive inhibition, at the onset of peristalsis External LES = striated muscle of diaph crura

Pathophysiology:

Pathophysiology Normal swallow – size of ingested bolus/lumen - MECHANICAL Deglutitive inhibition – UES/LES relaxn Force of peristaltic contraction Oral dysphagia drooling/overstay/diff initiating swallow rx Premature spillage into pharynx/aspiration Pharyngeal dysphagia d/t poor propulsion and obstruction at UES Nasal regurgitation and laryngeal aspiration MOTOR

PowerPoint Presentation:

Video Fluoroscopic Swallow Study (VFSS) Fully conscious patient Detection and analysis abnormalities of oropharyngeal fn Pharyngeal contraction waves and opening of UES with swallow monitored Manometric study Amplitude of pharyngeal contraction Decreased UES pressure w/o further fall in Pr on swallowing

PowerPoint Presentation:

Trained swallow therapist Feeding by NG tube/ endoscopically placed gastrostomy /FJ tube

Esophageal dysphagia:

Esophageal dysphagia Lumen distension upto 4 cm < 1.3 cm: dysphagia is always present Diseases affecting striated Mm common to both oropharyngeal Mm and cervical esophagus Diseases affecting smooth Mm involve thoracic eso and LES Dysphagia when peristalsis are weak/absent and failure of LES relaxation

BARIUM SWALLOW:

BARIUM SWALLOW

Approach to the patient:

Approach to the patient History Site of dysphagia described by the patient Asso symptoms Nasal regurg /aspiration with swallowing: pharyngeal paralysis, TEF Unrelated to swallowing: achalasia , Zenker’s , GERD Hoarseness following dysphagia : RLN inv by eso ca Hoarseness preceding dysphagia : primary larynx lesion Hoarseness: secondary laryngitis d/t GERD Hiccups: distal eso lesion U/L wheeze with dysphagia : mediastinal mass inv eso /larynx

PowerPoint Presentation:

Type of food Mechanical cause (ca): SOLIDS  SOLIDS + LIQUIDS Motor cause ( achalasia , DES): SOLIDS AND LIQUIDS from the onset Duration and course Transient- inflammation Progressive-carcinoma Episodic-lower esophageal ring Chest pain with dysphagia : DES/large bolus

PowerPoint Presentation:

Stricture  h/o heart burns: peptic stricture NG intubation, pills ingestion, radiation AIDS/ immunocompromised patients Candida, HSV, CMV, KS, Lymphoma

PowerPoint Presentation:

PHYSICAL EXAMINATION Oropharyngeal dysphagia Signs of bulbar/ pseudobulbar palsy Neck- thyromegaly /spine Mouth and pharynx exam Pulmonary complication Esophageal dysphagia Skin exam (collagen vascular disease) Lymphnode /liver mets

Thank You!:

Thank You!

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