Approach to dysphagia Definition of Dysphagia The word

Approach to dysphagia

Definition of Dysphagia The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). It specifically refers to the sensation of food being hindered in its normal passage from the mouth to the stomach.

CLASSIFICATION Two distinct syndromes Oropharyngeal dysphagia Produced by abnormalities affecting the finely tuned neuromuscular mechanism of the striated muscle of the mouth, pharynx, and UES Esophageal dysphagia Caused by the variety of disorders affecting the smooth muscle esophagus

Oropharyngeal dysphagia n Inability to initiate the act of swallowing. n It is a transfer problem caused by n n n impaired ability to transfer food from mouth to upper esophagus impaired oral preparatory phase Clinical presentation: n food sticking in the throat n difficulty initiating a swallow n nasal regurgitation n coughing during swallowing n They may also complain of n dysarthria n nasal speech because of associated muscle weaknesses n Other Neurological clinical findings

Abnormalities Causing Oropharyngeal Dysphagia n Neuromuscular Diseases n Central nervous system (CNS) n n n n Cerebral vascular accident (e. g. , brain stem or pseudobulbar palsy) Parkinson disease Wilson disease Multiple sclerosis Amyotrophic lateral sclerosis Brain stem tumors Tabes dorsalis Miscellaneous congenital and degenerative disorders of CNS

Abnormalities Causing Oropharyngeal Dysphagia n Neuromuscular Diseases n Peripheral nervous system n n n Motor end plate n n Bulbar poliomyelitis Peripheral neuropathies (e. g. , diphtheria, botulism, rabies, diabetes mellitus) Myasthenia gravis Muscle n n n Muscular dystrophies Primary myositis Metabolic myopathy (e. g. , thyrotoxicosis, myxedema, steroid myopathy) Amyloidosis SLE

Abnormalities Causing Oropharyngeal Dysphagia n Local Structural Lesions n Inflammatory n n Pharyngitis Abscess Tuberculosis Syphilis n Neoplastic Congenital webs Plummer-Vinson syndrome n Extrinsic compression n n n Thyromegaly cervical spine hyperostosis Lymphadenopathy Surgical resection of the oropharynx

Abnormalities Causing Oropharyngeal Dysphagia n Disorders of the Upper Esophageal Sphincter (UES) n Hypertensive UES (i. e. , spasm, possibly in globus, or gastroesophageal reflux n Hypotensive UES (e. g. , esophagopharyngeal regurgitation or aspiration) n Abnormal UES relaxation or opening n n n Incomplete relaxation (e. g. , cricopharyngeal achalasia CNS lymphoma, oculopharyngeal muscular dystrophy) Inadequate opening (e. g. , cricopharyngeal bar, Zenker diverticulum) Delayed relaxation (e. g. , familial dysautonomia)

Etiology Of Esophageal Dysphagia Neuromuscular (Motility) Disorders n Most common n n Other associated motility abnormalities n n n Achalasia Scleroderma Diffuse esophageal spasm Nutcracker esophagus Hypertensive lower esophageal sphincter Vigorous achalasia Nonspecific esophageal dysmotility Other secondary motility disorders n n Other collagen disorders Chagas disease

Etiology Of Esophageal Dysphagia Mechanical Lesions, Intrinsic n Most common n n Peptic stricture Lower esophageal (Schatzki) ring Carcinoma Other n n Esophageal webs Esophageal diverticula Benign tumors Foreign bodies

Etiology Of Esophageal Dysphagia Mechanical Lesions, Extrinsic Vascular compression n Mediastinal abnormalities n Cervical osteoarthritis n

Esophageal Dysphagia n Three important questions are particularly crucial. n n What kind of food (i. e. , liquid or solid) produces the symptom? Is the dysphagia intermittent or progressive? Is there associated heartburn? Physical examination is usually not revealing in patients with esophageal dysphagia, with the exception of scleroderma.

Diagnosis n n n History Examination CBC Cx. R Barium studies Endoscopy Computed tomography scanning Endoscopic ultrasound Endoscopy Esophageal Manometry Esophageal p. H studies