1. Raid Yousef, MD General/Trauma Surgery Surgical Critical Care
DYSPHAGIA
Raid Yousef, MD General/Trauma Surgery
Surgical Critical Care

2. Definition
Dysphagia is defined as having difficulty in swallowing which may affect any part of the swallowing pathway from the mouth to the stomach.

3. History and Examination
Patients complain that foods or liquids are no longer being swallowed easily and there is a sensation of food sticking.
Clinician must try to distinguish oropharyngeal from oesophageal dysphagia

4. Oropharyngeal vs.Oesophageal Dysphagia
In Oropharyngeal dysphagia, there is difficulty in preparing and transporting the food bolus through the oral cavity as well as initiating the swallow. This may be associated with aspiration or nasopharyngeal regurgitation.
In Oesophageal dysphagia, patients complain of food sticking in their lower throat, neck, retro-sternal discomfort or epigastrium.

5. Age: Possible causes
Children : Foreign body or congenital malformation
Middle aged patients: Reflux oesophagitis, hiatus hernia, anaemia, achlasia, globus syndrome.
Elderly patients: Malignancy, stricture formation from longstanding reflux, pharyngeal pouch, motility disorders associated with aging and neurological disorders.

6. History Onset. Duration Progression Severity of symptoms
Types of food intake that causes problems
Alleviating factors

7. Associated Symptoms Regurgitation Pain on swallowing
Hoarseness of voice
Otalgia
Coughing after eating
Frequent chest infections

8. Clinical Examination Complete Head and neck examination
Inspection of oral cavity
Dentition
Oropharynx
Nasolaryngoscopy
Cranial nerve examination ( tongue, gag and cough reflex, hoarseness, vocal cord mobility)
Neck for lymph nodes, neck masses, thyroid enlargement, loss of laryngeal crepitus and integrity of laryngeal cartilages.

9. Special Investigations
Blood tests to exclude anaemia (? Cause or effect)
ESR or C-Reactive Protein raised in malignancy or chronic inflammatory process
LFT, RFT along with S. Calcium when nutrition is impaired or metastasis is suspected
Thyroid function tests if dysphagia is caused by goiter or malignancy of thyroid

10. Special Investigations
Barium swallow
Chest radiograph
CT scan examination of neck, chest and abdomen.
MRI is indicated when there are neurological causes such as multiple sclerosis, cerebral tx, nasopharyngeal ca.
Rigid endoscopy
Flexible endoscopy
Manometry

11. Radiology
Plain x-ray neck & chest – for foreign bodies
DENTURES
PIN

12. Barium swallow Zenkers diverticulam Mid esophageal diverticulam
Epiphrenic diverticulam

13. Bird beak sign – Achalasia Sigmoid esophagus Achalasis
Barium Swallow
Bird beak sign – Achalasia
Sigmoid esophagus Achalasis
Nut Cracker Esophagus

14. Irregular filling defect
Barium Swallow
Stricture – caustic injury
Irregular filling defect –
carcinoma Esophagus
Sliding Hernia

15. Cine-radiography Dynamic assessment
Radiographic visualisation of food bolus movement from oral cavity to
hypophyrnx

16. Endoscopy Rigid Flexible Diagnostic visual biopsy Therapeutic
foreign bodies removal
Stenting Dilations

17. Esophagial diverticulam
Barret’s Esophagitis
Schzkati ring
Esophagitis
Esophagial diverticulam

18. Paraesophageal hernia retro flexion view
Foreign body – bone
Carcinoma Esophagus
Corrosive stricture

19. Manometery Indications Types Stationary Manometery
Achalasia cardia
diffuse esophageal spasm
Nutcracker esophagus
hypertensive esophageal sphincter
Types
Stationary Manometery
High Resolution manometery

20. Manometery Normal peristalsis Achalasia Nutcracker esophagus
Diffuse esophageal spasm

21. 24-Hour Ambulatory pH Monitoring
The most direct method of measuring increased REFLUX (esophageal exposure to gastric juice ) is by an indwelling pH electrode, or more recently via a radio- telemetric pH monitoring capsule that can be clipped to the esophageal mucosa.

23. Endoscopic ultrasound
Used for dysphagia due to carcinoma esophagus
for T , N staging
Biopsy can also be taken
tumor confined to the esophageal wall
an advanced esophageal carcinoma penetrating through all layers

24. HISTOLOGY
Barret’s esophagitis
Squamous cell carcinoma
Adenocarcinoma