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RC Study > Dysphagia, Dyspepsia, Hiccup > Flashcards

Dysphagia, Dyspepsia, Hiccup Flashcards

1
Q

What is dysphagia

A
  • difficult swallowing
  • oropharyngeal : difficulty initiating swallowing
  • Esophageal swallowing : difficulty of food bolus traversing esophagus
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2
Q

Physiology normal swallowing

A
  1. Oral phase (voluntary)
    1. mastication
  2. Transfer Phase
    1. bolus pushed back by tongue to hypopharynx
  3. Involuntary phase
    1. larynx elevated
    2. UES opens
    3. tongue pushes food into esophagus
  4. Esophageal phase
    1. LES relaxes
    2. primary peristalsis
    3. secondary peristalsis from esophageal distention
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3
Q

Causes of OROPHARYNGEAL dysphagia

A

difficult transfer of food bolus from mouth to pharynx or pharynx to esophagus

Causes:

  • Structural
    • malignancy
    • thyroid large
    • Zencker’s diverticulum
  • Neurological
    • CVS
    • ALS
    • Brain stem tumour
    • MS
    • Parksinons
    • Neuropathy
    • Dementia
  • Myopathic
    • muscular dystrophy
    • polymyositis
    • thyroid dz
    • myasthenia
  • Iatrogenic
    • meds (botox, amio, statins, vincristine)
    • anticholingergics (TCA, atropine, opioids)
    • radiation rx
    • surgery head and neck
  • Poor dentition
  • Anxiety
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4
Q

Causes of ESOPHAGEAL Dysphagia

A

Narrowing of lumen of esopahgeal. Impaired motor function, altered esophageal sensation

Causes:

  1. Neuromuscular
    1. achalasia, esophageal spasm, SLE, RA, IBD, scleroderma
  2. Vascular
    1. ischemic esophagus
  3. Structural
    1. stricture, diverticula, malignancy, external compression
    2. foreign body, medistinal masses
  4. Infectious
    1. candidiasis, HIV, CMV
  5. Medications
    1. alendronate, NSAIDS, ascorbic acid, antibiotics, steroids
  6. Eosinophilic esophagitis
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5
Q

Clinical presentation of dysphagia

A
  • Oropharyngeal :
    • repeated swallowing
    • regurgitation
    • choking
    • aspiration
    • hoarse voice
    • coughing on swallowing
    • weight loss
    • malnurtrition
    • pneumonia
    • liquids > solids more difficult
  • Esophageal:
    • chest pain
    • solids > liquids more difficult
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6
Q

What is aspiration?

A
  • passage of food/fluid through vocal cords
  • causes pneumonitis, pneumonia
  • solids - fatal airway obstruction
  • bacterial pna - normal flora of mouth
  • chemical pna - acidic aspiration
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7
Q

Physical exam for dysphagia

A
  • nutritional status
  • hydration
  • mental status
  • dysphonia/dysarthria
  • oral cavity : dentition/ candidiasis
  • Neuro exam (CN V< VII-XII)
    • symmtery, strength, sensation of lips
    • midline uvula
    • gag reflex
    • tongue for wasting, deviation towards side of lesion
    • cough
  • swallowing test
    • open/closes mouth
    • clear mouth after swallowing
    • changes with fatigue
    • drooling, cough, wet hoarse voice
  • respiratory exam
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8
Q

Investigations for dysphagia

A
  • CBC, albumin
  • CT/MRI if ? stroke
  • Cxray (pna?)
  • Barium swallow
    • all phases of swallow
    • patient has to be able to sit up
    • risk of aspiration
  • Endoscopy
    • direct visualization of larynx and pharynx
    • esophagus (biopsy, dilation, stent)
    • esophageal pH monitoring
    • not as comprehensive as barium swallow
    • no risk of aspiration
    • oral phase of swallowing cannot be assessed
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9
Q

Management of oropharyngeal dysphagia

A
  • lifestyle
    • pureed diet
    • increased numbers of chews/swallows
    • thickened fluids
    • SLP for swallowing exercises
    • SLP for safe swallowing
    • surgery rare - long life expectancy
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10
Q

Principles / goals of palliative management of dysphagia

A
  • maximize swallowing function
  • maintain adequate nutrition as appropriate
  • allow people to participate socially in meals
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11
Q

Prevention of aspiration pneumonia in dysphagia

A
  • maintain nutrition
  • hydration
  • good oral hygiene (altered colonization risk)
    • mouthwash, artificial saliva
      *
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12
Q

Parenteral / enteral feeds : considerations

A
  • progressive debilitating conditions
  • reversibility of underlying problem
  • can it be improved with less invasive interventions
  • individual wishes of patient
  • risks
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13
Q

NG Tubes

A
  • least invasive
  • simple
  • temporary
  • short feeds
  • risks: bleeding, trauma, esophageal perforation
  • nasal ulceration, discomfort, sinusitis, reflux, pna
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14
Q

Oroesophageal tube for feeds

A
  • temp tube only during feed
  • no gag reflex
  • requires compliance and time
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15
Q

PEG tube for feeding

A
  • Percutaneous gastrostomy tube
  • placed under sedation
  • risks: bleeding, infection, perforation, perforation of other organs
  • aspiration still a risk (10%)
  • infections, tube leakage, blockage,metabolic derangements
  • low survival
  • NOT for short life expectancy
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16
Q

Esophageal strictures

A
  • most common cause Reflux
  • Simple strictures (straight, < 2 cm)
    • dilatation alone
  • Complex strictures (> 2cm, tortuous)
    • dilatation (multiple)
    • stent

Risks of dilations: perforation, bleeding, infection

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17
Q

Esophageal stents

A
  • Risks:
  • Mid distal stents
    • stent migration
    • obstruction
    • reflux
  • Proximal stents
    • food obstruction
    • fistula
    • aspiration

40% need re-stent. it works 90% of the time

CANNOT stent a stricture above or crosses UES

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18
Q

Malignant esophageal strictures

A
  • dilatation
    • < 3 months prognosis
  • stent
    • >3 months prognosis
  • adjuvant RT
  • brachytherapy
    • usually longer prognosis
19
Q

Eosiniphilic esophagitis

A
  • inhaled allergens
  • ID allergen
  • inhaled or systemic corticosteroids
20
Q

Esophageal spasm

A
  • diltiazem
  • TCA
  • botox
  • sildafenil
21
Q

Management of oropharyngeal dysphagia when life is measured in months - years

A
  • diet changes
  • thin fluids
  • puree
  • thickened fluids
  • nutritional support
  • hydration
  • modification of swallowing (sitting, fluids from spoon, turning head to one side)
  • oral hygiene
  • avoid meds dry mouth
  • targeted exercises
  • electrical stimulation
  • surgery
  • parenteral/oral feeding
22
Q

Management oropharyngeal dysphagia in life measured in weeks

A
  • diet
  • positioning
  • avoidance of dry mouth meds
  • oral care
23
Q

Managing oropharyngeal dysphagia with days prognosis/EOL

A
  • oral hygiene
  • diet as stolerated
24
Q

Managing esophageal dyspahgia : based on prognosis

A

Months- years

  • diet
  • surgery
  • stenting
  • bracy/radiotherapy
  • PPI /H2 blocker
  • baclofen
  • metoclopramide
  • sucralfate
  • botox
  • enteral feeds

Weeks

  • diet
  • meds
  • dilatation
  • stenting

Days

  • diet
  • meds (PPI, H2, metoclopramide)
25
Q

Definition of dyspepsia

A
  • epigastric pain
  • burning
  • post prandial fullness
  • eary satiety

different from heartburn (retrosternal burning)

26
Q

Categories of dyspepsia

A
  • functional
  • secondary dyspepsia from
    • gerd
    • pud
    • gastric inflammation
    • UGI malignancy
27
Q

Stomach physiology

A
  • stomach breaks down food
  • proximal stomack relaxes via vagal stimulation after chewing
  • distal stomach contracts to break down food
  • liquid emptied into duodenum as entire stomach contracts and opens pylorus
28
Q

Pathophysiology of dyspepsia

A
  • disorder of gastric motility
  • changes in gastric emptying
  • heterogenous sx
29
Q

Causes of dyspepsia **

A
  • Functional
  • secondary
    • GERD
    • esophagitis secondary to meds
    • FE, opioids, digoxin, CCB, nitrates, bisphosphonates, NSAIDS, steroids
    • PUD
    • malignancy
    • celiac
30
Q

Causes of dyspepsia- like symptoms (differential dx)

A
  • Infection (giardia, tb)
  • inflammatory (celiac, chrohn’s sarcoidosis, eosinophilic gastritis)
  • Infiltrative (lymphoma, amyloid)
  • gastric volvula
  • gastric ischemia
  • gastroparesis
    • drugs, DM, hypercalcemia
  • paraneoplastic
31
Q

Clinical presentation dyspepsia : 4 cardinal symptoms

A
  1. Post prandial fullness
  2. early satiety
  3. epigastric pain
  4. epigastric burning

bloating, belching, n/vx

32
Q

History for dyspepsia

A
  • IBS
  • pain improved by food? PUD
  • post prandial heartburn (GERD)
  • meds
  • weight changes
  • changes to appetite
  • vomiting of undigested food (gastroparesis)
33
Q

Investigations for dyspepsia

A
  • history and physical
  • upper EGD
  • 24 hour esophageal pH monitoring
  • H pylori assessment
34
Q

Management of dyspepsia

A
  • lifestyle modifications:
    • small, frequent meals
    • avoid high fat
    • avoid triggers
  • PPI if severe x 8 week trial
  • TCA
  • prokinetic
35
Q

Palliation of dyspepsia according to prognosis

A

Months-years

  • treat underlying cause
  • oral PPI/H@
  • diet
  • positioning
  • prokinetics
  • antidepressants

Weeks

  • oral PPI, H2
  • diet
  • positioning
  • prokinetics

EOL/days

  • IV PPI, H2
  • IV metoclopramide
36
Q

Hiccups definition

A
  • SINGULTUS
  • sharp, involuntary contraction of inspiratory muscles
  • sharp inspiration and closure of glottis
  • Sound is air column against closed glottis
  • No physiological purpose
37
Q

Hiccups pathophysiology

A
  • afferent limb
    • phrenic nerve
    • vagus
    • sympathetic chain
  • central mediator
    • resp centre, medulla, hypothalamus
  • Efferent limb
    • phrenic nerve to diaphragm and inspiratory muscles
    • recurrent laryngeal nerve to glottis
38
Q

Neurotransmitters involved in hiccups

A
  • dopamine
  • GABA
39
Q

Causes of hiccups

A

Central

  • stroke
  • tumour, abscess
  • trauma
  • encephalitis
  • neurodegenerative (MS, PD)

Peripheral

  • esophageal (dilation, achaclasia, tumour, food bolus)
  • GI (distention, gastritis, GERD, SBO, ascites)
  • Hepatic (liver mets, absecess, cholecystitis)
  • Meds (steroids, benzos, opoiids, chemo)
  • Respiratory (diaphragmatic irritation, pna, effusion)
  • Toxic/metabolic (ARF, ETOH, lytes)
  • Infectious (herpes zoster, GI candidiasis)
  • Cardiac (MI)
  • Psychological
40
Q

Hiccups clinical presentation

A
  • 4-60 per minute
  • high Pc02 slows frequency **
  • minutes : “bout”
  • > 48 hours “protracted”
  • > 1 month “intractable”
  • can cause:
    • distress, fatigue, sleep interruption, anxiety, anorexia, weight loss, vomiting, aspiration, pna
41
Q

Hiccups with a tracheostomy

A
  • respiratory alkalosis secondary to hyperventilation
  • life threatening
42
Q

Investigation of hiccups

A
  • physical exam (neuro, abdo, resp, vitals)
  • Cr, urea
  • Lytes (hypona, hypoK, hypo Ca)
  • liver enzymes
  • imagining prn
43
Q

Medical palliation of hiccups

A
  • treat underlying cause if possible
  • First line:
    • BAclofen 5-10 mg po tid (smooth muscle relaxant)
    • Metoclopramide 10 mg po tid (dopamine antagonist)
    • Gabapentin 100 mg po tid
  • Chlorpromazine 25 mg po tid
  • haldol
  • carbamazepine
  • nifedipine
  • midazolam
  • dex, methyphenidate
44
Q

Non pharmalogical approaches to hiccups

A
  • vagal nerve stimulation
  • acupuncture
  • glottic stimulation
    • q tip to palate or pharynx
  • vagal nerve stimulation
    • gargling
    • ice water
    • valsalva
    • lift uvula with spoon
    • traction of tongue
  • Increase PaCO2
    • breath holding
    • breathing into paper bag

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