Associate Prof. Dr. Meltem Ergun Dysphagia Associate Prof. Dr. Meltem Ergun Yeditepe University Department of Gastroenterology

Learning Objectives What is dysphagia? What are types of dysphagia? What are the causes of dysphagia? How to investigate a patient with dysphagia?

Difficulty in swallowing=dysphagia Dysphagia suggests the presence of an organic abnormality in the passage of solids or liquids from the oral cavity to the stomach. Patients' complaints range from the inability to initiate a swallow to the sensation of solids or liquids being hindered during their passage through the esophagus into the stomach.

Dysphagia is an alarm symptom that warrants immediate evaluation to define the exact cause and initiate appropriate therapy. Dysphagia in older adult subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities, which are rarely symptomatic

Swallowing Oral phase Pharyngeal phase Esophageal phase

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

Oropharyngeal dysphagia Oropharyngeal dysphagia is characterized by difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. It is a transfer problem caused by impaired ability to transfer food from mouth to upper esophagus impaired oral preparatory phase Clinical presentation: food sticking in the throat difficulty initiating a swallow nasal regurgitation coughing during swallowing They may also complain of dysarthria nasal speech because of associated muscle weaknesses Other Neurological clinical findings

Oropharyngeal Dysphagia Neuromuscular CVA Parkinson’s disease MS Mysthania gravis Muscular dystrophy Bulbar / pseudobulbar palsy

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

Diffuse oesophageal spasm Esophageal Dysphagia Motility disorders Achalasia Diffuse oesophageal spasm Chaga’s disease

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

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

Dysphagia Odynophagia Globus (pain in swallowing=odinophagia) Globus= something in my throat

Stable, intermittent, progressive History Duration Stable, intermittent, progressive Speed of progression Liquids or solids

Alendronate (for Osteoporosis) History Hx of drugs Tetracycline Alendronate (for Osteoporosis) Kostic injury

Diagnostic laparoscopy Investigations Diagnostic Endoscopy Barium swallow Manometry Staging CT Diagnostic laparoscopy EUS

Biopsies Dilatation Stenting / laser ablation

Investigations for Staging CT or MRI EUS Staging laparoscopy

Manometry -patients with no structural abnormality on endoscopy

Normal Swallow

Esophageal Motility Disorders Achalasia-Etiology A primary esophageal motility of unknown cause characterized by insufficient LES relaxation and loss of esophageal peristalsis hereditary, degenerative, autoimmune, and infectious factors as possible causes

Oesophageal Motility Disorders Achalasia - Symptoms Dysphagia – usually slowly progressive Regurgitation Chest pain and dysphagia Reflux symptoms

Oesophageal Motility Disorders Achalasia-Manometric features Normal to raised LOS resting pressures LOS fails to relax to gastric baseline Raised residual pressures Raised oesophageal baseline pressures Absent or chaotic low amplitude simultaneous peristalsis

Achalasia Tracing

Oesophageal Motility disorders Achalasia-Treatment Pneumatic dilatatation Risks Patient selection Botox injection Surgery Gastro-oesophageal reflux a significant complication

Odinophagia