Approach to dysphagia &benign esophageal - PowerPoint Presentation

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Approach to dysphagia &benign esophageal disease

Done by: Thaer Omar Alqatish

Slide2

Definitions:

 

Dysphagia

?

 

Aphagia

?

Odynophagia 

?

Phagophobia

 

?

Slide3

Classifications for dysphagia 

1-

Oral and Pharyngeal (Oropharyngeal)

Dysphagia ?

2-

Esophageal

Dysphagia ?

Slide4

DDx

1-

Oropharyngeal

Dysphagia

:

Iatrogenic

 causes include surgery and radiation,

Neurogenic

 

:

from cerebrovascular accidents, Parkinson’s disease, and amyotrophic lateral sclerosis

Structural

 lesions causing dysphagia include 

Zenker’s

diverticulum

, 

cricopharyngeal

bar, and 

neoplasia

.

2-

Esophageal

Dysphagia:

 

S

tructural:

 

 

Schatzki’s

rings

, 

eosinophilic esophagitis

, and 

peptic strictures

.

Neuromascular

:

DES

,

achalasia

, scleroderma

Slide5

Clinical approach

History 

?

Physical Examination 

Investigations

Treatment

Slide6

History 

1-  

localization 

of

dysphagia,

 

2- other

symptoms 

associated 

with dysphagia

,

3- The 

type of

food

 causing

dysphagia

4- dysphagia 

progression

.

5- 

accompanying

 

odynophagia

??,

6- A 

history of

  ;

* A history of prolonged nasogastric intubation, esophageal or head and neck surgery, ingestion of caustic agents or pills, previous radiation or chemotherapy,

Slide7

Physical Examination

1- M

outh

and pharynx

?

2- Neck ?

3-

Changes

in the

skin ?

4-

Signs of

 neuromuscular

disease?

Slide8

Investigations

1-

start with

 

barium

swallow

study

2- For suspected esophageal dysphagia, 

upper endoscopy

 (& 

mucosal biopsies)

 is the single most useful test

.

3-

 

Esophageal

manometry

4- In specific cases, computed tomography (CT) examination and endoscopic ultrasonography may be useful.

Slide9

Treatment

1- conservative measures:

changing

 postures or maneuvers

 

 altering the

consistency

of ingested food and liquid

 severe and persistent cases may require gastrostomy and enteral feeding

.

2-

 medical treatment 

3- Dilators & Surgical

intervention

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Zenker’s

Diverticulum

Definition

:

is a diverticulum (outpouching) of the mucosa of the pharynx, just above the

cricopharyngeal

muscle (i.e. above the upper sphincter of the esophagus). It is a 

pseudo diverticulum

 (not involving all layers of the esophageal wall).

Pathophysiology:

If

swallowing is Uncoordinated so that the

cricopharyngeus

does not relax, the week unsupported

area above

these fibers bulges out. 

(Killian’s dehiscence)

Clinical Features:

Signs and Symptoms:

1-

Dysphagia

2-

Halitosis

(bad smell)

3- Food regurgitation.

4- Posterior neck mass.

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Diagnosis:Barium swallow.

**

Endoscopy and NG tube are contraindicated

 (due to the risk of perforation)

Treatment:

Surgical

resection

1.

One stage

cricopharyngeal

myotomy

and

diverticulectomy

2.

Other options are

cricopharyngeal

myotomy

and

diverticulopexy

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Esophageal Webs

Definition

:

Thin protrusion of esophagus mucosa, most often in the 

upper esophagus

 (hypopharynx

).

Etiology

 

⸎Plummer-

vinson

syndrome, due to iron deficiency

anemia

(IDA).

Clinical Features:

Signs and Symptoms:

Dysphagia:

➢ Intermittent and not progressive. ➢ For solids only.

Complications

: slightly increased risk for esophageal CA.

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Daignosis:

1- Barium swallow.

2- endoscopy

Treatment:

E

sophageal

dilatation

, using

bougie

or balloon

dilators.

Treat IDA

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Schatzki ring

Definition

: Lower esophageal ring, usually at the 

squamo-columner

junction.

{

lower esophagus

}

⸎ almost

always associated with esophageal hiatal hernia

Clinical Features

:

1- Dysphagia:

➢ Intermittent and not progressive.

➢ For solids only, especially meat and fibers

.

Daignosis

:

1- Barium swallow (the ring should be >13 mm to cause symptoms)

2- endoscopy

Treatment:

treat it like esophageal webs, by dilatation..

➢ The patients are placed on PPI after

diltation

.

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Esophageal stricture ( peptic stricture )

Definition

: Narrowing of the esophagus.

Etiology

:

➢ Long history of incompletely treated reflux.

➢ Prolonged NG tube placement.

➢ Lye (bleaching agent) ingestion decades ago (alkali is worse than acids)→ erosive esophagitis.

Pathophysiology

:

Prolonged/severe

Esophageal

irritation→erosion

of the mucosa→ fibrosis (stricture).

Slide20

Clinical Features:

Signs

and Symptoms:

1-

Dysphagia

:

➢ Constant, 

slowly 

progressive.

➢ For solids then liquids

.

Daignosis

:

Barium

swallow.

Treatment

:

Dilation

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Achalasia

Definition

: a failure of smooth muscle fibers to relax, which can cause a sphincter to remain closed and fail to open when needed.

Etiology

:

⸎Of unknown

etiology

.

⸎

pseudoachalasia

/secondary achalasia:

1.

Esophageal

CA.

2. Lymphoma

3. Chagas disease (

trypanosoma

cruzi

infection).

4. Eosinophilic esophagitis

5. Neurodegenerative diseases.

Pathophysiology:

Loss

of

intralumenal

neurons →

inc.

LES tone (failure of relaxation)→Dilation of the Distal

esophagus

.

No

esophageal

peristalsis

.

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Diagnosis:

1. Barium swallow: (best initial test) → 

bird’s beak appearance

 

?

2. Upper endoscopy+ biopsy

: why ?

3.

Esophageal

manometry

: (the definitive diagnosis)

?

Treatment:

1-

P

neumodilatation

:

 (BEST initial therapy)

➢ 3-4 diameter

ballon

is inflated in the LES→ produce higher pressure.

➢ Effective in 85% of patients.

➢ 5% risk of perforation

.

**

Pneumodilatation

effective only for short duration of weeks , best to mix it with

botox

2- Botox

 (botulinum toxin injection)

➢ Effective in 65% of patients.

➢ Requires repeating therapy within 6-12 months

.

3- Surgical

myotomy

.

➢ ”Heller”

myotomy

.

➢

Incision

of circular muscle layer of LES

. (cut through the muscle to relief the tension )

➢ High risk of GERD

4- Medical

treatment 

(CCB and nitrates) is not that

effective.

Slide23

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Diffuse esophageal

spasm

Definition

:

Idiopathic abnormality in neuromuscular activity of the

esophagus

, resulting in

non-peristaltic contractions

with high amplitudes causing pain and dysphagia. { sphincter function is usually

normal }

Etiology

:

Idiopathic.

Clinical Features:

1. Dysphagia:

➢ For both solids and liquids

.

2. Atypical chest pain

.

➢ May mimic MI.

➢ Inc. With cold liquids.

Slide25

Diagnosis:1- 

ECG 

to role out MI

.

2- 

Barium swallow 

:

➢ 

Corkscrew appearance

 (see picture).

3- 

Manometry

 

(

most accurate test

):

➢ High intensity, intermittent, disorganized contractions.

Treatment

:

Medical (

antireflux

measures, calcium channel blockers, nitrates)

Long

esophagomyotomy

in refractory

cases (a cut through the muscle )

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Nutcracker Esophagus ???

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Gastroesophageal reflux disease (GERD)

Definition

:

also

known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications

.

Pathophysiology:

⸎Loss

of anti-reflux mechanisms

:

1. 

Loss of LES tone &/or peristalsis

; due to smoking, alcohol, peppermint, Chocolate, CCB & nitrates. Or 

hiatal

hernia

2.

 Inc. Gastric volume

; due Diabetic gastroparesis or pyloric stenosis

.

3. 

Inc. Gastric pressure

; due to Ascites or pregnancy.

Slide29

Signs and Symptoms:

1. 

Heartburn

/ sore throat.

2. 

Water brush.

3. Epigastric/substernal pain (the most common cause of non-cardiac chest pain is GERD).

4. Bad, metal-like taste in mouth.

5. Cough, wheezing or hoarseness (it may exacerbate asthma

).

Alarming

signs:

1. Dysphagia/odynophagia

2. Wight loss/ anorexia/

anemia

/ blood in stool.

3. Family history of peptic ulcer disease.

4. Failure to respond to PPI.

5. Long duration of symptoms

.

Slide30

Complications:

1. Exacerbation of asthma.

2.

Esophageal

ulcers

3. Strictures,

4. bleeding

5.

 Barrett

esophagus

?

Treatment

:

1

. Life style modification.

??

2

.

Antacids

3

. H2

blockers or PPI

⸎Surgical

:

( indications ?? )

1. Lap

Nissen

2. 

Belsey

Mark

IV

3. 

Hill

4. 

Toupet

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➢ Indications for surgery:1. Failure of medical treatment.

2. Respiratory problems.

3. Severe esophageal injury

Slide32

1. 

Lap

Nissen

• It’s 360 fundoplication – 2 cm Laparoscopically. 

** how does it work ??

• It works through improving lower esophageal sphincter function; 

Increasing LES tone

, 

Elongates LES by 3 Cm

, 

Returning LES into abdominal cavity

.

Effective in 85% (70% to 95%)

• Post-op complications:

1. 

Gas-bloating syndrome

 (Inability to burp or vomit)

2. Strictures

3.

Esophageal

perforation.

4. Pneumothorax.

5. Spleen injury requiring splenectomy.

Slide33

Other surgical options

2. 

Belsey

Mark IV

: 240 to 270 fundoplication through thoracic approach.

3. 

Hill

: Arcuate ligament repair (close large

esophageal

hiatus) +

gastropexy

(suture stomach to diaphragm).

4. 

Toupet

: laparoscopic Incomplete Wrap (200)

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 Barrett esophagus

Definition

:

 It’s an intestinal metaplasia of lower

esophageal

mucosa (change from stratified squamous epithelium into simple columnar epithelium with goblet cells

).

➢ Risk factors are smoking and

GERD

10% patients

with GERD develops Barrett’s

esophagus.

7% (5% to 10%) of

patients with Barrett’s esophagus will develop

adenocarcinoma.

Diagnosed:

 by

edoscopy

&

B

x.

Slide37

 Management is by PPI, resection

and follow up

:

i

. No dysplasia → 3-5 years

ii. Low-grade dysplasia→ 6-12 months

iii. High-grade dysplasia → 3

months

** from

Dr.

Mansour :

(in

high grade dysplasia

we

don’t wait and follow the

pt

instead of that, we go and

remove the

esophagus

as if

it was a case of

esophageal

CA)

Resection options:

endoscopic mucosal resection and photodynamic

therapy,

radiofrequency ablation

, and

cryoablation

Slide38

Other medical disorders

1-

Scleroderma

esophagus

2- Pill-induced esophagitis

3-

Infective

esophagitis

4-

Eosinophilic (allergic) esophagitis

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