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

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

3. 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.

4. 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

5. Swallowing
Oral phase
Pharyngeal phase
Esophageal phase

6. 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

7. 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

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

9. 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

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

11. 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

12. 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

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

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

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

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

18. Biopsies
Dilatation
Stenting / laser ablation

22. Investigations for Staging
CT or MRI
EUS
Staging laparoscopy

23. Manometry -patients with no structural abnormality on endoscopy

24. Normal Swallow

25. 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

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

27. 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

29. Achalasia Tracing

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

33. Odinophagia