Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Y3 Oxford Cases > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

When a patient describes “swallowing difficulty” what could this mean

A

Dysphagia - difficulty, initiating (high) or food getting stuck (low)
Odynophagia - pain on swallowing
Globus - sensation of having a lump in the throat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is high and low dysphagia and what are their general cause

A

high - oropharyngeal and upper oesophagus
low - lower oesophageal
High dysphagia is more likely to be due to a generalised neuromuscular disease
Low dysphagia is more likely to be due to a local obstructing lesions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the functional causes of high dysphagia

A 
Stroke
Parkinson's 
Myasthenia gravis
MS
Myotonic dystrophy 
MND
Inadequate saliva production (Sjrogens, anticholinergics)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the structural causes of high dysphagia and are they luminal, mural or extrinsic

A

Cancer - mural
Pharyngeal pouch - mural
Cricopharyngeal bar - mural

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the functional causes of low dysphagia

A 
Achalasia 
Chagas disease
Nutrcracker oesophagus 
Diffuse oesophageal spasm 
Limited cutaneous scleroderma (CREST)
Infective oesophagitis 
Eosinophilic oesophagitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the structural causes of low dysphagia and are they luminal, mural or extrinsic

A 
Foreign body - luminal
Cancer - mural
Stricture (caustic or inflammatory) - mural
Plummer-vinson syndrome - mural
Schatzki ring - mural
Congenital atresia - mural
Mediastinal mass - extrinsic
Retrosternal goitre - extrinsic
Bronchial carcinoma - extrinsic
Thoracic aortic aneurysm - extrinsic
Ortner's syndrome - extrinsic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the red flag for carcinoma in terms of dysphagia

A

New-onset dysphagia in middle-aged to elderly patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What questions should be asked about the swallowing

A

Duration of symptoms - short history (day-week) suggests cancer, months- years suggests chronic motility

Dysphagia progressive or intermittent - progressive suggests stricture, intermittent suggests motility disorder

To solids, fluids or both

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What can information about what kind of foods they have difficulty swallowing tell you

A

solids that they feel are sticking: mechanical osbtruction e.g. stricture
Fluids more than solids: motility disorder e.g. achalasia
Absolute dysphagia: large piece of food that is stuck

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What associated symptoms should be asked about in the history

A

Any coughing related to eating
Do they suffer with halitosis (pharyngeal pouch)
Any gurgling (pharyngeal pouch)
Dysphonia/hoarsensess (vocal cord dysfunction due to recurrent laryngeal nerve involvement
Heartburn or waterbrash: reflux disease
Weight loss: red flag for oesophageal cancer
Neuro symptoms: for anyone with functional D
Rheumatological symptoms: CREST

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the association between dysphagia and coughing

A

Coughing immediately after: stroke and parkinsons
Sometimes after: pharyngeal pouch regurgitation, aspiration of food in a dilated oesophagus (achalasia) or FORD
Nocturnal cough - achalasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What symptoms are associated with CREST

A 
Calcinosis 
Raynaud's
Esophageal dysmotility (dysphagi)
Sclerodactyly
Tengiectasia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What past medical history is relevant in dysphagia

A

GORD and peptic ulcers are important to enquire about.
GORD - predisposes adenocarcinoma and non-malignant strictures. Any surgery to tighten the lower sphincter (fundoplication) may cause dysphagia
Peptic ulcers - leads to scarring and strictures

MS or parkinson’s also useful

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What in the drug history should be enquired about for dysphagia

A

CCBs and nitrates (relaxes smooth muscle) can cause or exacerbate reflux symptoms
NSAIDs, aspirin, steroids and bisphosphonates predispose to peptic ulceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What should be emphasised/prioritised on physical examination for dysphagia

A

Cranial nerve pathology: bulbar palsy may be present in functional dysphagia
GI malignancy signs: cachetic, Virchow’s node, palpable carcinoma, hepatomegaly in metastasis
Neck mass: pharyngeal pouch which may gurgle, goitre, cervical lymphadenopathy (due to head and neck cancers)
Features of CREST: calcinosis, Raynaud’s, Sclerodactyly and tenlengiectasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What investigations can be done for dysphagia

A

Barium swallow
Endoscopy
Videofluroscopy
Manometry

17
Q

Describe the barium swallow

A

Monitors the passage of a bolus of barium contrast through a supine patient to the lower sphincter and not further
Lesions often have a characteristic appearance
They may also swallow an effervescent agent to produce a double-contrast study for mucosal lesions

18
Q

What do the following appearances on barium swallow suggest:

A

See notes in Presentations

19
Q

Describe endoscopy for dysphagia

A

Visualisation of luminal and mural lesions
Opportunity to biopsy and treat lesions
Stricture dilatation, stent insertion, laser coagulation and botox can all be done this way
More sensitive and specific than the double-contrast barium swallow
Often first line for low dysphagia

20
Q

Describe videofluoroscopy for dysphagia

A

Modified barium swallow where patients are given barium in liquids, solid or semi-solid form.
Speech therapist modifies the swallowing technique throughout the study
Most suited for those with functional high dysphagia

21
Q

Describe manometry for dysphagia

A

Assesses the pressures in the lower oesophageal sphincter and peristaltic wave in the rest of the oesophagus
Key investigation for diagnosing a motility disorder and distinguishing between the different types of motility disorder e.g. achalasia and nutcracker

22
Q

How may an oesophageal adenocarcinoma be staged

A 
Spiral CT chest/abdomen - for initial staging, checks for metastases
PET scan - assess whether lesion of lymph node on CT is hot or cold
Endoscopic ultrasound (EUS) - done if no evidence of disease on CT/PET and patient is a candidate for surgery (most accurate modality for locoregional staging)
Laparoscopy - Done if no evidence of metastatic disease and there is a distal oesophageal tumour, used to exclude peritoneal deposits
23
Q

What assessment must be done in those who are suitable for treatment for oesophageal adenocarcinoma

A

Fitness assessment for surgery with combination of lung function tests, ECG, exercise tolerance test +/- echo

24
Q

What is the prognosis for oesophageal cancer

A

Usually poor
Stage-dependent
5 year survival for cancer caught at stage 1 is 50%
Lymph node involvement (70%) - 5 year survival 15%4

25
Q

27F with 2 year history mild dysphagia to both solids and liquids. No problems coordinating a swallow but feels food is sticking. No choking or gurgling and no weight loss.
Complains to GP about heartburn and nocturnal cough and the treatment given did not work.
Exams are unremarkable
Barium swallow shoes beak-like terminal narrowing.
Manometry shows elevated lower oesophageal sphincter pressure + incomplete relaxation of the sphincter + aperistalsis
What is the diagnosis and treatment options?

A

Achalasia

Options:
Pneumatic balloon dilatation
Surgical (Heller's) myotomy 
Botox injections
Drugs: CCBs/nitrates to relax the sphincter
26
Q

64M with 5 week progressive dysphasia to solids. Feels food getting stuck. No choking, gurgling, heartburn, or waterbrash
Coughs day and night has recently been associated with episodes of haemoptysis. Lost 4 kg and has felt increasingly lethargic.
No significant PMH, no drinking, 40 pack years
Cachetic, hepatomegaly, palpable lymph nodes in left supraclavical fossa, neuro and resp exam unremarkable
CXR shows widened mediastinum and hilar lymphadenopathy
CT shows mediastinal mass + biopsies come back as small cell lung cancer
What is the mechanism of dysphasia

A

Caused by extrinsic compression of the oesophagus by the lung cancer + mediastinal lymph nodes.

27
Q

Describe Barrett’s oesophagus

A

Metaplasia of squamous epithelium of the lower oesophagus into columnar epithelium
Associated with inflammation and ulceration of the distal oesophagus
Endoscopically visible as “velvety” epithelium
Caused by persistent irritation by GORD
Precursor lesion to adenocarcinoma (risk increases 30-40x)

28
Q

What are the risk factors for squamous cell oesophageal cancer

A 
Alcohol
Smoking
Dietary nitrosamines
Aflatoxins
Achalasia
Plummer-Vinsons syndrome
hereditary tylosis 
Coeliac disease
29
Q

What are the risk factors for oesophageal adenocarcinoma

A

Barrett’s

Smoking and alcohol intake (not as important as for squamous cell)

30
Q

What is Plummer-Vinsons syndrome

A

Collection of features that include atrophic glossitis, cheilosis, koilonychia, dysphagia associated with iron deficiency anaemia

31
Q

What is the pathophysiology of achalasia

A

Absence of ganglion cells in the myenteric plexus (Auerbach’s) of the oesophagus.
Failure of relaxation of the lower sphincter and aperistalsis in the oesophageal body
Chagas will result in identical pathophysiology and infiltrating carcinoma may produce a pseudo-achalasia.

32
Q

What is Hirschprung’s disease

A

Complete absence of myenteric plexus ganglion cells

33
Q

A dysphagic patient presents with hoarse voice and bovine cough. What pathology may account for both of these.

A

Characteristic of recurrent laryngeal nerve pathology.
Nerve + dysphagia - either infiltration by primary malignancy of the oesophagus or mediastinal malignancy
OR
Ortner’s syndrome - compression by the cardiovascular system (left atrial dilatation secondary to mitral stenosis)

34
Q

How can oesophageal cancer present

A 
Dysphagia
Weight loss
GI reflux
Odynophagia
Dyspnoea 
Less common: GI bleeding, fatigue due to anaemia, hoarseness, cough, facial flushing due to SVC obstruction
35
Q

What are the complications after oesophagectomy

A 
Breakdown of anastomosis 
Pneumonia
Cardiac arrhythmia
Recurrent laryngeal nerve injury 
Chylothorax/chyle leak.

Y3 Oxford Cases (29 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions