8.1 (10.1) Dysphagia, dyspepsia, and hiccup

Question 1

A patient presents with a sensation of food getting stuck in her throat and then coming out her nose. What are the two types of dysphagia and what type does she likely have?

Answer 1

oropharyngeal dysphagia - difficulty initiating swallow - as a result of difficulty transferring either food/fluid from either the mouth to the pharynx or from the pharynx to the oesophagus

Esophageal dysphagia - food bolus does not easily traverse upper esophagus - due to narrowing of the lumen of the oesophagus, impaired motor function, or altered oesophageal sensation.

Oropharyngeal dysphagia

Question 2

List four complications of oropharyngeal dysphagia

Answer 2

aspiration and respiratory complications*
malnourishment*
dehydration*
poorer survival
death*
airway obstruction
chemical pneumonia

Question 3

What are 2 phases of swallowing? Which is under voluntary control?

What types of muscles are located under the esophagus?

Answer 3

The initial phase (oral phase) is under voluntary control.
The next stage (transfer phase) where the tongue pushes solid/fluid bolus is pushed back into the pharynx. The involuntary swallow response is evoked when the bolus enters the hypopharnyx -> the larynx is elevated and pushed anteriorly, opening the upper esophageal sphincter. The lower esophageal sphincter relaxes and triggers peristaltic wave (2 purposes: clear residual bolus in the pharynx and propel bolus through the esophagus and into stomach).

Cervical esophagus -> striated muscle
Thoracic esophagus -> smooth muscle

Question 4

List four causes of oropharyngeal dysphagia

Answer 4

◆ Poor dentition
◆ Structural: malignancy, enlarged thyroid, Zencker’s diverticulum
◆ Myopathic: dermatophytosis, muscular dystrophy, polymyositis, myasthenia gravis, thyroid disease
◆ Iatrogenic: medications that must result in a myopathy (botulin toxin, procainamide, amiodarone, statins, vincristine), medications that inhibit saliva (opioids, tricyclic antidepressants, phenothiazines, atropine, hyoscine), radiotherapy, surgical procedures of head and neck
◆ Neurological: CVA, ALS, MS, dementia, Parkinson, brainstem tumours, bulbar poliomyelitis, neuropathy (diabetes, alcohol, cachexia)
◆ Anxiety

VINDICATE NP

Question 5

List 4 causes of esophageal dysphagia

Answer 5

◆ Structural: stricture secondary to reflux, diverticula, esophageal/gastric malignancy, benign tumours, external vascular compression, mediastinal masses, foreign body
◆ Mucosal injury due to: medications (NSAIDs, alendronate, ascorbic acid, ferrous sulphate, antibiotics, theophylline), infections (candidiasis, cytomegalovirus, HIV), allergic disorders (eosinophilic oesophagitis), skin disorders (pemphigus vulgaris, pemphigoid, epidermolysis bullosa dystrophica)
◆ Vascular: ischaemic oesophagus
◆ Neuromuscular: achalasia, oesophageal spasm, scleroderma, SLE, RA, IBD

FS

GAS (GERD, achlasia, stricture)
+
V - ischemia
I - infection (fungal)
N - cancer
D - strictures
I - meds - nsaids, iron
C
A - EE
T - trauma
E
N - achalasia, esophageal spasm
P

Question 6

How common is oropharyngeal dysphagia in older populations?

Answer 6

40-50% of aged care resident

Question 7

List 5 clinical presentations of oropharyngeal dysphagia and 2 of esophageal dysphagia.

What is the relationship between food/fluid thickness and how they cause problems in each type of dysphagia?

Answer 7

Oropharyngeal dysphagia:
(1) difficulty initiating swallow and then having to swallow repeatedly to effect pharyngeal clearance
(2) coughing on swallowing (typically due to aspiration)
(3) nasopharyngeal regurgitation
(4) hoarse voice
(5) sense of food being ‘stuck’ (both types)
More difficult to swallow thin fluids rather than solids

Esophageal dysphagia:
-symptoms localized to chest
-chest pains
-sense of food being ‘stuck’ (both types)
More difficult to swallow solids rather than liquids

Question 8

What are the three most useful investigations to assess dysphagia in a patient? What are other initial investigations to order?

Answer 8

barium videofluoroscopy (i.e. barium swallow) - visualize all phases of swallowing, risk of aspiration

flexible endoscopic evaluation of swallow - viewing pharynx and larynx, not as comprehensive and cannot see oral phase of swallowing

esophageal manometry - quantify pharyngeal swallowing strength and whether upper esophageal sphincter relaxes appropriately, should be used in combination of above 2 tests

initial investigations: BWK to assess malnutrition/dehydration, CT/MRI if acute onset, CXR to exclude pneumonia

Question 9

2 investigations specific to esophageal dysphagia

Answer 9

Gastro-esophageal endoscopy - allows visualization of mucosa, allows biopsies to be taken and dilatation/stent placement; main risk of perforation

Esophageal pH monitoring - best tool to diagnose reflux

Question 10

What cranial nerves should be assessed when examining a patient with dysphagia

Answer 10

V and VII-XII

Question 11

3 main assessments/clarifications needed to create management plan for dysphagia

Answer 11

1. Oropharyngeal or esophagus issue
2. Acute or chronic
3. Overall patient prognosis

Question 12

A patient with a long prognosis is found to have non-reversible dysphagia. A discussion is undertaken about a PEG placement. The patient wants to know three complications of malnourishment if PEG is not placed.

Answer 12

Deteriorating performance status
anaemia
increased risk of pressure sores
impaired wound healing
accelerated osteoporosis

Inadequate hydration also places people at risk of metabolic complications and aspiration, increasing the risk of pneumonia (salivary flow may be reduced therefore altering the normal flora of the oropharynx)

Question 13

What are 4 general management techniques for OROPHARYNGEAL dysphagia when life is measured in months to years

Answer 13

◆ Oral hygiene - regular mouth wash and artificial salvia

◆ Diet changes: pureed diet (avoid hard or chewy foods), thickened
fluids, nutritional support, adequate fluid intake to maintain hydration

◆ Modification of swallowing behaviours: sitting upright, increasing number of chews/swallows, taking fluids from a spoon, turning the head to one (stronger) side to swallow, ensuring residual food is removed from the oral cavity

◆ Avoid medications likely to contribute to a dry mouth

◆ SLP to provide targeted exercise routine to improve swallowing safety - lip, tongue, jaw, vocal cord adduction exercises

◆ Electrical stimulation - along with exercise

◆ Compensatory techniques

◆ Surgery - laryngeal closure, laryngotracheal separation-diversion

◆ Parenteral or enteral feeding

FS:l
(1) Tx underlying condition (eg meds, surgery)

(2) Tx symptoms
- diet changes
- good oral hygiene
- position/ swallowing / SLP

(3) Tx complications
- enteral / parenteral feeds

Question 14

What are 4 general management techniques for OROPHARYNGEAL dysphagia when life is measured in weeks

Answer 14

Tx source:
◆ Avoidance of medications likely to contribute to sedation

Tx symptoms:
◆ Positioning
◆ Diet modification
◆ Oral care (cleaning after meals, improve dry mouth)

Question 15

What are 3 general management techniques for OROPHARYNGEAL dysphagia in the final stages of life

Answer 15

◆ Diet as tolerated.
◆ Oral hygiene
◆ Family education and reassurance

FS:
Tx underlying (meds)

Tx symptoms
- diet modification
- education
- Mouth care
- Position

Question 16

What are 4 general management techniques for ESOPHAGEAL dysphagia when life is measured in months to years

Answer 16

General
◆Diet modification
◆Enteral feeds

Treating underlying cause
◆GERD: PPI, H2 blockers, antacids, sulcrate, maxeran/domperidone
◆Stricture: Stenting, dilation
◆Achalasia: Botox

FS
Tx underlying condition (GAS above)

Tx symptoms
- diet
- position*

Tx complication
- feeds

Question 17

What are 4 general management techniques for ESOPHAGEAL dysphagia when life is measured in weeks

Answer 17

Tx source
◆Medication
◆Dilatation
◆Stenting

Tx symptoms
- Diet modification

Question 18

What are 2 general management techniques for ESOPHAGEAL dysphagia in the final stages of life

Answer 18

◆Diet
◆Medication

Question 19

For esophageal strictures - when to dilate versus to stent

Answer 19

Dilate if:
- simple stricture (< 2 cm long, straight and endoscope can pass easily)
(Common for pts to need 3 min dilatations, if more than 7 attempts - considered resistant)

Stent if:
- complex stricture

Question 20

What are 3 general approaches to the management of BENIGN esophageal strictures?

Answer 20

dilatation
stent placement
treat underlying cause

Question 21

What are 4 general approaches to the management of MALIGNANT esophageal strictures?

Answer 21

dilatation - if life expectancy is VERY short

stent placement - offered alone if prognosis <3months

treat underlying cause

+ adjuvant radiotherapy or brachytherapy <3 month prognosis

Question 22

Stenting MALIGNANT esophageal stricture - what % of patients are likely to develop problems within first 2 months? What % of these patients will have successful re-stenting?

Answer 22

40%

90% of the 40%

Question 23

How is percutaneous gastrostomy tube inserted through the abdo wall?

Answer 23

1. Surgical gastrostomy (requires general anesthetic)
2. Endoscopic gastrostomy (requires sedation)
3. Image-guided gastrostomy insertion by IR (will need NG tube to inflate stomach so that it is visible on Xray)

Question 24

What are 3 acute complications from feeding tube insertion?

What are 4 longer term complications from having a feeding tube insitu?

What percentage of patients won’t survive 12 months following PEG tube placement?

What is an absolute contraindication to PEG tube placement?

Answer 24

Feeding tube insertion complications
- bleeding
- infections
- peritonitis
- perforation of other abdominal organs.

PEG tube complications
- aspiration/asp PNA/chemical PNA (10%)*
- tube leakage
- tube removal, displacement or migration*
- bleeding*
- gastric mucosal overgrowth or ulceration
- metabolic and biochemical complications such as re-feeding syndrome*
- GI side effects
- microbial contamination of the feeds*

Approximately 50–60% of people are unlikely to survive 12 months after enteral feeding is commenced.

Short life expectancy is absolute contraindication (FS: BO?)

Question 25

A patient has a stent placed for an esophageal stricture. What are 3 possible complications you will warn them about?

Answer 25

pain*

stent migration*

stent obstruction (benign overgrowth, malignant overgrowth, food)

reflux (complicated by asp pna)

fistula formation (esp if proximal stricture)*

difficulty removing the stent*

Question 26

A patient has brachytherapy (passing applicator to the esophagus) for a malignant stricture. What are 3 possible complications you would warn them about?

Answer 26

esophagitis
fistula formation
stricture formation

Question 27

List 3 management strategies of eosinophilic esophagitis

Answer 27

identifying allergen
trial of inhaled steroids
oral steroids

Question 28

List 4 treatments for management of esophageal spasm

Answer 28

botulism toxin injection

Smooth muscle relaxants (buscopan)

TCA

calcium channel blockers (nitrate)

sildenafil (phosphodiesterase 5 inhibitor aka viagra) - complicated by headache and vertigo

Question 29

Other than the use of PPI and H2 blockers, what are 3 adjuvant treatments for GERD and 1 non-pharm management

Answer 29

antacids - during intermittent exacerbations (e.g. almagel, tums, pepto bismol)

sucralfate - barrier therapy

prokinetic agents (maxeran, domperidone)

baclofen - inhibiting reflux

avoid foods that impair gastric emptying

Question 30

What are up to four cardinal features of dyspepsia?

What is dyspepsia a disease of?

Answer 30

epigastric pain
epigastric burning
postprandial fullness
early satiety

It is a disease of gastric motility

Question 31

What are two major categories of etiology for dyspepsia

Answer 31

1. functional - patients present with complex symptoms of pain, burning, early saties, fullness but no clearly identifiable cause
2. secondary to underlying condition

Question 32

List four secondary causes of dyspepsia

Answer 32

Secondary:
◆ Esophagitis secondary to medications: Iron, NSAIDs, steroids, opioid, theophylline, digoxin, antibiotics, calcium channel blockers, nitrates, bisphosphonates
◆ GERD
◆ Peptic ulcer disease: H. pylori, NSAIDS
◆ Malignancy: oesophageal cancer, gastric cancer
◆ Coeliac disease

Dyspepsia like symptoms
◆ Infection/inflammatory
◆Infiltrative
◆gastroparesis (drugs, diabetes, metabolic, cancer)
◆other (idiopathic, post-surgical, paraneoplastic)

FS:
V
I
N - esophageal, gastric cancer
D -
I - meds that cause esophagitis - NSAIDs, steroids or decrease motility - anticholinergic
C
A - esophagitis
T
E - diabetes
N - stroke, Parkinson
A - GERD, achalasia, stricture, GOO, PUD, adhesions, ascites
P - psych

Question 33

What 3 minimum investigations to order to exclude secondary causes of dyspepsia (suggesting functional dyspepsia)?

Answer 33

◆ Upper GI endoscopy
◆ H pylori assessment
◆ 24h Esophageal pH monitoring

Question 34

A patient is found to have functional dyspepsia. What are 3 diet recommendations?

Answer 34

• smaller more frequent meals
• avoid foods with high fat
• avoid foods that aggravate symptoms

Question 35

A patient is diagnosed with functional dyspepsia. What are three meds you would consider trying?

Answer 35

PPI*

prokinetic - metoclopramide, domperidone*

Mirtazapine*

TCA

buspirone - anti anxiety, to relax gastric fundus

acotiamide - muscarinic receptor antagonist, cholinesterase inhibitor

Question 36

What are 3 medications and 3 non-pharm recommendations for functional dyspepsia when life is measured in months-years?

Answer 36

◆ Oral PPIs or H2 antagonists for pain or burning
◆ Prokinetics when early satiety is a feature
◆ Antidepressants

◆ Dietary advice
◆ Positioning
◆ Supportive counselling

Question 37

What are four recommendations for dyspepsia when life is measured in weeks?

Answer 37

◆ Dietary advice
◆ Positioning
◆ Oral PPI or H2 antagonists for pain or burning
◆ Prokinetics.

Question 38

What are two treatments for dyspepsia when life is measured in hours

Answer 38

◆ Parenteral PPI, H2 antagonists
◆ Parenteral metoclopramide

Question 39

What is a hiccup? What is the hiccup reflex arc?*

Answer 39

Hiccup = sharp involuntary contractions of inspiratory muscles -> sudden sharp inspiration + closure of the glottis (sound is caused from column of air evoked by diaphragmatic contraction hitting closed glottis)

Hiccup reflex arc = afferent limb, efferent limb and central component
◆Afferent limb - phrenic nerve, vagus nerve, sympathetic chain
◆Central component - connections to 4th cerebral ventricle, resp centre in brainstem, medial reticular formation, hypothalamus, phrenic nerve nuclei
◆Efferent limb - phrenic nerve to diaphragm,

made up of 3 parts : afferent limb, central component ( Midbrain connections) and the efferent limb= carrying motor fibers to the diaphragm and IC muscles .

Question 40

What are two neurotransmitters most likely implicated in neuromodulation of hiccups

Answer 40

dopamine + gamma-aminobutyric acid (GABA)

Question 41

List four central (CNS) causes of hiccups

Answer 41

◆ Vascular: cerebral aneurysm, ischaemic stroke, haemorrhagic
stoke
◆ Space-occupying lesion: cerebral tumours, cerebral abscess
◆ Head trauma
◆ Encephalitis
◆ Neurodegenerative: multiple sclerosis, Parkinson’s disease.

VINDICATE NP

Question 42

List three terms that categorize hiccups by duration

Answer 42

less than a few minutes - bout
>48h - protracted
> 1 month - intractable

Question 43

Investigations of protracted hiccups

What could be abnormal on bwk?

Answer 43

BWK: renal failure, uremia, low Na, low K, low Ca

Imaging per differential

Question 44

List five peripheral causes of hiccups

Answer 44

◆◆◆ Oesophageal: oesophageal dilatation, achalasia, food impaction, tumours

◆◆◆ GI: gastric distension, gastritis, reflux, peritoneal traction, SBO, ascites

◆◆◆ Respiratory: diaphragmatic irritation (pneumonia, pleural effusion, malignancy), subphrenic abscess

◆◆◆ Hepatic: liver metastases, primary liver cancers, hepatic abscess, cholecystitis

◆◆◆ Cardiovascular: myocardial ischaemia

◆ Toxic/metabolic: renal failure, alcohol intoxication, electrolyte disturbances, hypoadrenalism

◆ Infectious: herpes zoster, gastrointestinal candidiasis

◆ Iatrogenic: benzodiazepines, opioids, corticosteroids, chemotherapy (e.g. cisplatinum)

◆ Perioperative: intubation, general anaesthesia, mechanical
ventilation

◆ Psychological: anxiety, distress

FS:
Dyspepsia causes + lung + liver + heart

Question 45

What is the relationship between arterial CO2 and hiccup frequency? What is the implication for this in terms of treatment

Answer 45

Hiccup frequency slows when arterial CO2 is high

Hold your breath/breath into a paper bag and stop hiccups (increase PaCO2)

Question 46

After how many hours of hiccups would you consider initiation of pharmacotherapy

Answer 46

Protracted - >48h

Question 47

What are four complications from intractable hiccups

Answer 47

sleep disturbances*
daytime drowsiness
cognitive dysfunction
worsen fatigue*
skeletal muscle fatigue

interfere with capacity to eat and drink*
vomiting
aspiration and pneumonia
in a patient with a tracheostomy may lead to respiratory alkalosis secondary to hyperventilation

mood disturbance - anxiety/depression*
significant distress and anxiety to pt and family/informal caregivers*

Question 48

List five pharm tx for hiccups (see table 8.1.2 for rationale)

Answer 48

Dopamine antagonists: Chlorpromazine, Haloperidol, Metoclopramide

Ca-channel blockers: Gabapentin (Ca-channel blocker)

Anti-convulsants: Phenytoin, Sodium valproate, Carbamazepine

Antispasmodics: Baclofen

Corticosteroid: Dexamethasone

Anti-arrhythmia: Nifedipine (Ca-channel blocker), IV lidocaine (Na-channel blocker)

Benzodiazepines: Midazolam

Nebulized lidocaine

Neurostimulant: Methylphenidate

Question 49

How is gabapentin proposed to treat hiccups

Answer 49

Inhibiting calcium channel -> increasing GABA release -> modulates diaphragmatic excitability

inhibiting the inspiratory muscles mediated by endogenous GABA or [17] by reducing the calcium influx to the muscles.

Question 50

List four non pharm strategies for hiccups

Answer 50

Traction on the tongue *

Stimulation of the palate or pharynx with a cotton applicator *

Lifting the uvula with a spoon

Gargling or drinking ice water *

——-

Performing a Valsalva manoeuvre *

Breath holding *

Breathing into a paper bag *

—-

Digital rectal massage*

—-

Sudden fright

Vagal nerve stimulation using nerve stimulator

Acupuncture