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?
How is dysphagia treated?

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. The Normal Swallow
Innate ability which is present in the developing fetus
Necessary to maintain nutrition and hydration
Adults swallow approximately 580 times daily unconsciously
Swallowing is a four-phase process:
Oral preparatory phase
Oral phase
Pharyngeal phase
Esophageal phase

6. Oral Preparatory Phase
Begins as food or liquid enters the mouth
Containing, manipulating, and preparing the food or liquid into a bolus
Chewing (mastication) occurs to grind solid bolus into manageable texture
Requires coordination of lips, tongue, teeth, mandible, and cheeks
Duration: variable depending on substance
Respiration: normal through the nose (mouth closed)

7. Oral Phase Bolus is propelled to the back of the mouth
“stripping action” by the tongue
Tension in the cheeks (buccal muscles)
Duration: seconds
Respiration: normal through the nose

8. Pharyngeal Phase
Begins as the bolus reaches the tonsils (faucial pillars)
Pharygeal swallow reflex is triggered:
Pharyngeal wall and back of tongue move together and pharyngeal muscles squeeze to move bolus down through the pharynx
Upper esophageal sphincter opens to allow passage of bolus into esophagus
Time: 1 second
Respiration: briefly halted (apneic moment)
During bolus transit, risk of food or liquid entering the airway

9. Pharyngeal Phase – Protective Mechanisms
Soft palate elevates to stop bolus from flowing upward into nasal area
Larynx moves forward and higher in the neck to reduce risk of entrance into airway
Epiglottis forms a cover over the larynx
Vocal folds come together to close the entrance into the larynx
If material does enter the larynx, reflexive cough to expel it will occur

10. Esophageal Phase
Bolus is propelled through the esophagus by an involuntary wave or contraction
Moves from the upper esophageal sphincter through the lower esophageal sphincter and into the stomach
Time: 8-20 seconds, can be influenced by age (often increase in duration in elderly population)
Respiration: normal through nose and mouth

11. Disordered Swallow: Dysphagia
Impairment can occur in one, some, or all of the four phases of swallowing
Some persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway)
Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutrition
Some persons require an enteral feeding tube for nutritional maintenance

12. 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

13. 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

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

15. 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

16. Case Study 1 45-year old man diagnosed with ALS 18 months ago
Unable to work, on a puree diet with thin liquids, has lost 10 kg in past two months, just recovered from severe aspiration pneumonia
Severe oral and pharyngeal dysphagia with aspiration
What should be the treatment?

17. Case Study 2 35- year-old woman presented with dysphagia
Lab: Hb 8,6 Fe: TIBC: Ferritin:

18. Plummer Vinson sd.

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

20. 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

21. 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

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

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

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

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

27. Biopsies
Dilatation
Stenting / laser ablation

31. Investigations for Staging
CT or MRI
EUS
Staging laparoscopy

32. Manometry -patients with no structural abnormality on endoscopy

33. Normal Swallow

34. Oesophageal Motility Disorders Achalasia-Aetiology
Idiopathic- 98 %
Primary
Secondary
Familial
Associated with other congenital defects
Associated with degenerative neurological disease

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

36. 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

38. Achalasia Tracing

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

42. OESOPHAGEAL MOTILITY DISORDERS NUTCRACKER OESOPHAGUS
Most common cause of NCCP in those patients with an oesophageal motility disorder.
Average distal pressures > 180 mm Hg.
Peristalsis is normal so Ba studies usually normal.
90% present with chest pain.

43. Normal Swallow

44. Nutcracker Oesophagus

45. OESOPHAGEAL MOTILITY DISORDERS DIFFUSE ESOPHAGEAL SPASM
Intermittent dysphagia with occasional chest pain 90% present with chest pain. (Corkscrew esop)
DES is characterized by the findings of simultaneous contractions greater than 30% of water swallows, with the presence of normal peristalsis.
Other associated manometric findings may include repetitive contractions (>2 peaks),
Prolonged contractions (>6 s),
High-amplitude contractions (>180 mm Hg),
Spontaneous contractions

51. DYSPHAGIA CONCLUSIONS
The symptom of dysphagia does not always indicate a physical obstruction
Oesophageal motility disorders account for the majority of cases of dysphagia
A normal endoscopy or Ba study does not exclude a motility disorder - role of oesophageal manometry
Importance of mucosal biopsies of macroscopically normal mucosa