Apporach to Dysphagia - PowerPoint Presentation

Slide1

Apporach

to Dysphagia

And benign

esophgeal

diseases

Presented by;

Lina

bani

hamad

Slide2

dysphagia

The physiology of swallowing

Definition

Epidemology

Slide3

There are

two forms of

dysphagia

Oropharyngeal dysphagia (transfer

dysphagia)

:

There's problem in initiating the

swallowing occurs

in patients with

neurologic

conditions or muscular disorders that affect skeletal muscles

.

It will be associated with cough-

ing

, chocking, nasal regurgitation

Esophageal

dysphagia

relates to intrinsic functional (motor) and anatomic abnormalities of the esophagus that result in swallowing

difficulties

.

May associated with history of food impaction and food sticking of the chest

Slide4

Oropharyngeal dysphagia

Neurologic

•

Stroke

•

Parkinson's disease • Multiple sclerosis • motor neuron disorders ( progressive bulbar palsy, pseudobulbar palsy) • Bulbar poliomyelitis Muscular • Myasthenia gravis • Dermatomyositis • Muscular dystrophy • Cricopharyngeal incoordination

Esophageal dysphasia

Motility disorder

•

Achalasia

•

Diffuse esophageal spasm

•

Systemic sclerosis(scleroderma)

•

Eosinophilic

esophagitis

Mechanical

obstruction

Peptic stricture

•

Esophageal cancer

•

Lower esophageal rings(

Schatzki's

ring)

•

Caustic ingestion

Slide5

SIGNIFICANCE AND COMPLICATIONS

points to a serious underlying

pathology

Aspiration

can

cause acute

pneumonia

recurrent aspiration may eventually lead to chronic lung disease.inadequate nutrition and weight loss.death

Slide6

Apporach

to the patient

-History

age

Onset

Duration

Intermittent or progressive

Solids or liquids Level of stuck OdynophagiaHx pf caustic ingestion ,GERD,PUDFever, weight loss,anorexia,fatigue

Slide7

Immunocomprised

pt

(

DM,steriods

) why?

Chest pain ,cough (

pneumoina)Hx of neck massHx of cardiac problems Drugs (anticholingeric,doxycyclin)Family hx

Slide8

PHYSICAL EXAMINATION

General examination(

nutritional status

,skin, lymph nodes, signs of

sleroderma

Neck examination

The abdomen is checked for masses, tenderness, and

organomegalycomplete neurologic examinationMuscles are inspected for wasting and fascicula- tions and are palpated for tenderness (dermatomy-sitis, myopathy).

Slide9

Diagnostic

Tests

the

barium swallow

is

the

ideal first test as it is readily available, cost effective, and rapidly performed.anatomic relations, esophageal transit patterns, and the

presence or

absence

of mass

lesions

and

diverticula

.

.

Upper endoscopy allows for

a visual

assessment

of

mucosa

after

caustic

ingestion

or due to an infectious etiology

Other tests for specific causes are done as

sug-gested

by findings.

Slide10

When

reflux

disease

is suspected,

extended pH monitoring

is invaluable in assessing the presence and severity of

GERD.Motility disorders are best diagnosed using

manometric

techniques

.

In

cases where

extrinsic

compression

is suspected

or demonstrated,

cross-sectional imaging using

computed tomography

(

CT

) or magnetic resonance imaging (

MRI

) may be useful in identification of malignant masses

or

vascular anomalies (aberrant

subclavian

vessels, aortic aneurysms

Slide11

Treatment

Treatment is directed at the specific cause.

emergent upper endoscopy If com-

plete

obstruction

occurs

careful endoscopic dilation is performed. If a stricture, ring, or web is

foundPatients with severe dysphagia and re-current aspiration may require a gastrostomy tube.

Slide12

Esophagus

eso

Slide13

Anatomy

25 cm long. It has cervical

(

5 cm),

tho-racic

(18 cm)

and

abdominal (2 cm)Blood supply lymphatic drainge

Slide14

PHYSIOLOGY

The main function of the

esophegus

is to transfer food from the mouth to the stomach in a

coordi-nated

fashion and prevents stomach acid and con-tent reflux

upward

USE: antaomical sphincter LES: fuctional sphincter

Slide15

Assessment

of esophageal function:

Structural

-Radiology

-Endoscopy(rigid, flexible)

Functional

Stationary

manometry24 Hours pH monitoring

Slide16

GERD:

it is chronic problem that

occur when acid from the stomach washes up into the esophagus. it is a common dis-ease that accounts for approximately two thirds of esophageal pathology

.

Common symptoms

– esophageal crises heartburn: substernal burning-type discomfort beginning in the epigastriumand radiating upwards. Aggrevated post prandial, spicy,smoking Regurgitation: The effortless return of acid or bitter gastric contents into the chest , pharynx or mouth.Atypical symptoms – respiratory crisesChest pain and dysphagia

Slide17

Human

antireflux

mechanisms

:

High pressure zone at GE junction

Specialized thickening

Collar sling and clasp

fibresReceptive relaxation

Slide18

Association with HH:

Repeated gastric distension

GEJ ( upside down funnel-shaped )

Progressive opening of the angel of His )

Stretching of

phrenico

esophageal ligament

Enlargement of hiatal openingAxial herniation

Slide19

DIAGNOSIS

History

Barium study

a hiatus hernia, the

presence of

severe ulceration, benign strictures

Endoscopy

confirm reflux if esophagitis is seen and allow taking biopsies to detect complications (Barrett’s esophagus 24 Ph monitoringthe gold standard in establishing the diagno-sis of acid reflux

Slide20

GERD treatment:

High doses of PPIs

If symptoms return …….Endoscopy

Surgery:

a

nti-reflux

surgery -

Nis-sen’s fundoplicationAdvice on:Change of life style(advice against weight loss, smoking, excessive consump-tion of alcohol, tea or coffee.)Dietary measures25-50% persistent or progressive disease

Slide21

Anti reflux Surgery:

create a new anti reflux valve at

GEJ,while

preserving the patient ability to swallow normally and

to belch

to relieve the gaseous distension.( Nissen fundoplication)

Slide22

COMPLICATIONS

BARRETT'S ESOPHAGUS

Barretts

esophagus (BE ):

10-20% of GERD

Defined as the presence of columnar mucosa extending at least 3

cms

into the esophagusComplicated by:UlcerationStrictureDysplasia-cancer sequenceRespiratory complications

Slide23

Hiatus Hernias (HH ):

Types

:

Sliding: type 1m.c

Para esophageal (PEH) Rolling

type 11

Combined

type111Sliding is 7 times more than PEHPEH are more in elderly womenManifestationsUsually GERD in type 1But in PEH ( pressure symptoms ) Significant incidence of catastrophic life-threateningComplications risk of strangulations )Diagnosis: lateral Erect CXR; fluids above diaphragm in PEH Barium study: determine which the type Fiberoptic esophagoscopyTreatment:Life style changes Surgery

Slide24

Slide25

Slide26

Scleroderma:

80

% of patients have

esophageal motility

abnormalities

Result from vascular compromise due to collagen

deposition -Smooth

muscle atrophyIn general Motility Disorders:Manifested by dysphagiaPain, chokes or vomits with eating,Require liquids with eating,The last to finishDiagnosis is by manometry

Slide27

Zenkers

Diverticulum:

Occur in

proxmial

part of esophagus

Elderly

Dysphagia with spontaneous

regurge ( bland )Repeated Respiratory tract infectionsDiagnosed by Barium swallow and endoscopyTreated surgically by diverticulopexy or diverticulectomy acc to the size

Slide28

Motility disorders of the esophagus:

Abnormalities in

Propulsive pump action

Relaxation of LES

Primary, or

Generalised

:

Neural, Muscular, Collagen depositFour categories:1. Achalasia2. diffuse esophgeal spasms3. Nutcracker esophagus4. HH , lower esophgeal spasm

Slide29

Achalasia:

Failure of

lES

to relax during propulsive foods –stick foods in

esophgus

–dilation of proximal esophagus

Esophageal dilatation ( bird peak and air fluid level ) it is common 1 : 100 000

Slide30

Treatment

involves either balloon dilatation of the lower

oesophageal

sphincter

surgical

myotomy (Hellers myotomy; division of the muscles over the lower esophagus and proximal stomach).

Slide31

Diverticula of the

esophagus

Location : in the body of the esophagus

May present with dysphagia or pressure symptoms

Pathophysiology ;

-

Pulsion

; increase in pressure in esophagus wall due to any motilty disorders – push esophagus wall outside-true divericula (zenker diverticulum)traction: normal esohagus wallThe wall pulled outside by inflamed l.n in hilum of the lung -TB

Slide32

Thank

you