79 YEAR OLD GENTLEMAN WITH PROGRESSIVE DYSPHAGIA MBBS

79 -YEAR OLD GENTLEMAN WITH PROGRESSIVE DYSPHAGIA ………………………………………………………………………………………………………………. MBBS; FAISAL GHANI SIDDIQUI FCPS (GENERAL SURGERY); PG DIPLOMA-BIOMEDICAL ETHICS; MCPS-HPE; FICLS; (MHPE) HEAD, SURGICAL UNIT-I PROFESSOR OF SURGERY CHAIRMAN, DEPARTMENT OF SURGERY & DIRECTOR, DEPARTMENT OF MEDICAL EDUCATION L I A Q U A T U N I V E R S I T Y O F M E D I C A L S C I E N C E S faisalghani@lumhs. edu. pk & H E A L T H

CASE REPORT A 79 -year-old retired teacher was admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially could swallow soft diet but now can tolerate fluids only • Weight loss of 5 kg in last one month On examination, he appears cachectic WHAT IS THE MOST LIKELY DIAGNOSIS?

DIAGNOSIS CARCINOMA ESOPHAGUS

WHAT IS THE DIFFERENTIAL DIAGNOSIS?

STAGES OF SWALLOWING

DYSPHAGIA -difficulty in the progression of bolus from the mouth to the stomach due to dysfunction of: • oropharynx • esophagus

DIFFERENTIAL DIAGNOSIS OF DYSPHAGIA OROPHARYNGEAL DYSPHAGIA DISEASES OF CNS • • CVA PARKINSON’S DISEASES ALZHEIMER'S DISEASE MULTIPLE SCLEROSIS DISEASES OF PERIPHERAL NERVOUS SYSTEM • MYASTHENIA GRAVIS OBSTRUCTIVE LESIONS IN OROPHARYNX • • ZENKER’S DIVERTICULUM ENT TUMOURS ESOPHAGEAL DYSPHAGIA ESOPHAGEAL MOTILITY DISORDERS • ACHALASIA CARDIA • DIFFUSE ESOPHAGEAL SPASM • NUTCRACKER ESOPHAGUS EXTRINSIC COMPRESSION • LYMPHADENOPATHY • RETROSTERNAL GOITRE OBSTRUCTIVE LESIONS • PEPTIC / CORROSIVE STRICTURES • FOREIGN BODY • CARCINOMA ESOPHAGUS

CARCINOMA OF THE OESOPHAGUS PATHOLOGY

CARCINOMA ESOPHAGUS –INCREASE IN INCIDENCE

3 TIMES MORE COMMON IN MALES

TYPES OF CARCINOMA ESOPHAGUS 25 % CARCINOMA OF OESOPHAGUS 75 % ADENOCARCINO MA SQUAMOUS CELL CARCINOMA

SPREAD OF CARCINOMA OESOPHAGUS DIRECT INVASION TO THE REGIONAL LYMPH NODES ACROSS THE WALL LONGITUDINAL LY THROUGH SUBMUCOSAL LYMPHATICS LYMPHAT ICS BLOOD • LIVER • LUNGS • BONE

Carcinoma Esophagus disseminates early! Symptoms are often absent until tumour becomes advanced poor prognosis at the time of diagnosis!

WHY ME? RISK FACTORS

SQUAMOUS CELL CARCINOMA • • • SMOKING ALCOHOL HOT BEVERAGES CORROSIVE INJURY ACHALASIA CARDIA RISK FACTORS ADENOCARCINO MA • OBESITY --> REFLUX • SMOKING

CASE REPORT A 79 -year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic HOW WILL YOU INVESTIGATE THIS PATIENT?

HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 ENDOSCO PY 3 INVESTIGATI ONS FOR STAGING 2 BLOOD TESTS FOR FITNESS

ENDOSCOPY • First-line investigation • Site/size/extent/ histology of lesion • Disadvantage: only mucosal surfaces biopsied

NORMAL MUCOSA OF THE ESOPHAGUS SQUAMOUS CELL CARCINOMA OF THE MID ESOPHAGUS

HISTOPATHOLOGY SHOWS SQUAMOUS CELL CARCINOMA WHAT NEXT?

HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 Local tumour and regional nodes (T, N) ENDOSCO PY • Endoscopic ultrasound Metastases (M) • CT / PET scan (lung; liver; bones; distant nodes) • Laparoscopy (peritoneal metastases) 3 INVESTIGATI ONS FOR STAGING 2 INVESTIGATI FOR FITNESS ONS • Anemia • Tests for malnutrition

MANAGING A PATIENT WITH SUSPICIOUS SYMPTOMS ENDOSCOPY & BIOPSY DIAGNOSIS OF CARCINOMA MADE ASSESS PATIENT’S FITNESS FOR SURGERY FIT UNFIT STAGING INVESTIGATIONS PALLIATIO N CURATIVE TREATMENT ADVANCED

EARLY DISEASE T 1/T 2, N 0 LOCALLY ADVANCED DISEASE T 3/T 4, N 1 INCURABLE DISEASE Any T, N 2/N 3, M 0

TREATMENT EARLY DISEASE RADICA T 1/T 2, N 0 L SURGE RY NEOADJUVA LOCALLY NT ADVANCED CHEMO DISEASE THERAP T 2/T 3, NO Y+ INCURABLE DISEASE Any T, N 2/N 3, M 0 SURGE RY PALLIATI ON

IVOR-LEWIS TWO PHASE ESOPHAGECTOMY

MCKEOWN THREE PHASE ESOPHAGECTOMY

TREATMENT EARLY DISEASE RADICA T 1/T 2, N 0 L SURGE RY NEOADJUVA LOCALLY NT ADVANCED CHEMO DISEASE THERAP T 2/T 3, NO Y+ INCURABLE DISEASE Any T, N 2/N 3, M 0 SURGE RY PALLIATI ON

SELF-EXPANDING METAL STENT

CASE REPORT A 79 -year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic CONCLUSION: This case report demonstrated the importance of a timely upper endoscopy. It carries major impact on primary care physicians who serve as the first tier in managing patients with ‘red flag’ features.

. . . IN SUMMARY • Squamous cell affects the upper two-thirds; adenocarcinoma affects the lower third • Common etiological factors are tobacco and alcohol (squamous cell), GORD and obesity (adenocarcinoma) • Dysphagia is the most common presenting symptom • Accurate pretreatment staging is essential in patients thought to be fit to undergo ‘curative’ treatment