This lecture was conducted during the Nephrology Unit Grand Ground by a Sub-intern under Nephrology Division, Department of Medicine in King Saud University. Nephrology Division is NOT responsible for the content of the presentation for it is intended for learning and /or education purpose only.

APPROACH TO DYSPHAGIA Mashari Alzahrani

Dysphagia Dysphagia: * Sensation of obstruction of food passage. * Difficulty in swallowing

Classified as Oropharyngeal Esophageal

Oropharyngeal dysphagia Arises from : Upper esophagus Pharynx Upper esophageal sphincter

Orpharyngeal dysphagia: * Motor neuron diseases. * CVA * Myasthenia gravis * Polymyositis

Esophageal dysphagia arises from: Esophageal body Lower esophageal sphincter Cardia of the stomach

Esophageal dysphagia classify to A) Mechanical dysphagia my be due to: 1. Large food bolous. 2. Instrinsic narrowing. e.g. i) Esophagitis (viral/ fungal) ii) Stricture (benign) iii) Tumor iv) Web/ rings

3.Extrinsic compression e.g. i) Enlarge thyroid. ii) Diverticulum. iii) Left atrial enlargement.

B) Motor dysphagia : Smooth muscles disorder: * Scleroderma * Achalasia * Esophageal spasm

Questions to ask patients with dysphagia: 1. Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after swallowing? 2. Do you cough or is food coming back through your nose after swallowing? 3. Do you have problem swallowing solids, liquids, or both? 4. How long have you had problems swallowing and have your symptoms progressed, remained stable, or are they intermittent?

Questions to ask patients with dysphagia: (cont…) 5. Could you point to where you feel food is getting stuck? 6. Do you have other symptoms such as loss of appetite, weight loss, nausea, vomiting, regurgitation of food particles, heartburn, vomiting fresh or old blood, pain during swallowing, or chest pain? 7. Do you have medical problems such as diabetes mellitus, scleroderma, Sjorgen syndrome,AIDS, neuromuscular disorder (myasthenia gravis, muscular dystrophy), Chagas’ disease or others?

Questions to ask patients with dysphagia: (cont…) 8- Have you had surgery on your larynx, esophagus, stomach, or spine? 9- Have you received radiation therapy in the past? 10- What medications are you using now?

4 cardinal Q Oropharyngeal or esophageal Solid or solid and liquid Intermittent or progressive Associated symptoms

Signs And Symptoms of Dysphagia Oral or pharyngeal dysphagia : Coughing or choking with swallowing Difficulty initiating swallowing Food sticking in the throat Sialorrhea Change in voice or speech (wet voice) Nasal regurgitation Esophageal dysphagia include the following: Sensation of food sticking in the chest or throat Oral or pharyngeal regurgitation

Diagnosis of dysphagia Difficulty initiating a swallow Associated with coughing, Choking or nasal regurgitation Sensation of food getting stuck In the esophagus (seconds after initiating a swallow) Oropharyngeal dysphagia Solids and/or liquids Chronic heartburn Solids Progressive Mechanical obstruction Motor disorder Intermittent Esophageal ring Elderly, Significant Weight loss And/ or anemia Esophageal dysphagia Intermittent Progressive DES NEMD Chronic heartburn Scleroderma Regurgitation and/or Respiratory symptoms and/ or weight loss Peptic Stricture Achalasia cancer

Investigation : FBC. For anemia and luekocytosis ( bleeding – infection ) ESR. (inflamation)

Investigation : Basic imaging techniques may include : Chest and neck x-ray CT (Computed Topography) These investigations may illustrate : Consolidated areas of the lung due to pneumonia may arise as a result of aspiration.pneumonia Structural abnormalities or masses that may be responsible for dysphagia.

Investigation : Specialist investigations may include : Barium swallow and chest X-ray Barium swallow and videofluoroscopy (also known as a modified barium swallow, videofluoroscopy swallow study or videoesophagography) These investigations provide dynamic images to assist with identifying any obstructions or dilated areas as is seen in achalasia.

Investigation : Swallowing electromyography Manometry These investigations are used to assess muscle activity, either with oropharynx or esophagus, to assess impairment of pharyngeal or esophageal motility.

Investigation : Transnasal laryngoscope Upper GI endoscopy These investigations allow the doctor intraluminal visualization to assess the lining of the pharynx and esophagus. Other specific tests, like : Cranial CT or MRI (if neurological signs). Others like : Acetylcholine (ACh) receptor antibodies For MG 24-Hour esophageal pH test

Thank you