Case 1 - swallowing and dysphagia

Question 1

what are the three phases of normal swallowing

Answer 1

oral phase
pharyngeal phase
oesophageal phase

Question 2

what is included in the oral phase

Answer 2

striated muscle
neural control is by the cortex and the medulla
full voluntary control

Question 3

what is included in the pharyngeal phase

Answer 3

striated muscle
medulla neural control
some voluntary control

Question 4

what is included in the oesophageal phase

Answer 4

striated/smooth muscle
medulla/ENS neural control
no voluntary control

Question 5

what occurs in the oral phase

Answer 5

components for the preparation of bolus and initiation of swallowing

Question 6

what is chewing

Answer 6

prepares solid food for transfer through the pharynx

the effectors are the teeth, jaws, and masseter muscles

Question 7

what is salivation

Answer 7

lubricates bolus and begins digestion

the effectors are mucus, amylase, lipase, water and HCO3-

Question 8

what is the movement of bolus

Answer 8

delivers prepared bolus to oropharynx

the effectors are the tongue

Question 9

bolus transfer from the mouth to the oesophagus

Answer 9

Question 10

what are the boundaries of the sphincters defined by and what do they prevent

Answer 10

defined by sphincters and these sphincters prevent influx of air and reflux of gastric contents into the oesophagus

Question 11

what is the atmospheric pressure

Answer 11

0mmHg

Question 12

what is the upper oesophageal sphincter pressure

Answer 12

100mmHg

Question 13

what is the intraoesophageal pressure

Answer 13

-5mmHg

Question 14

what is the lower oesophageal sphincter pressure

Answer 14

20mm

Question 15

what is the intragastric pressure

Answer 15

5mmHg

Question 16

what prevents reflux

Answer 16

the lower oesophageal sphincter having a higher pressure than the intragastric one

Question 17

neuroanatomy of swallowing diagram

Answer 17

Question 18

what is the nucleus solitarious

Answer 18

primary an afferent relay centre in the medulla

Question 19

what is the nucleus of trigeminal

Answer 19

output from this system and have the dorsal motor nucleus and nucleus ambigous

Question 20

what is the the nucleus ambiguous to do with

Answer 20

swallowing

Question 21

what is transcranial magnetic stimulation used for

Answer 21

to oversee this action and tell us about the integrity of this system

Question 22

what is oropharyngeal dysphagia

Answer 22

abnormal bolus transfer to the oesophagus

difficulty initiating a swallow

only one manifestation of the primary disease e.g stroke

Question 23

what is oesophageal dysphagia

Answer 23

abnormal bolus transport through the oesophagus
Food stops after initiation of swallow
Oesophagus is the location of the primary disease e.g achalasia

Question 24

what are the methods used to look at swallowing

Answer 24

VFS
fiberoptic endoscopic examination of swallowing

Question 25

dysphagia after a stroke

Answer 25

common - 50% of all stroke victims Usually oropharyngeal 30% increased risk of mortality Aspiration most important complication Natural swallowing recovery in majority Decisions about alternative feeding difficult Optimal timing Method of delivery treatment options limited SALT

Question 26

what side of the brain takes on the swallowing mechanism after a stroke

Answer 26

the non-dominant side of the brai

Question 27

what allows pressure to be used to measure the swallow in the oesophagus and the sphincters

Answer 27

manometry

Question 28

what is manometry

Answer 28

More precise measurement of upper GI motility Catheters with multiple sensors <2cm apart (24+ arrays) Spatiotemporal or topographic plot of pressure data (Clouse Plots) Evolutionary technology

Question 29

what is Clouse plot

Answer 29

display method can Improve accuracy and speed of recognition of motility disorders even in manometry-naive individuals It is a coloured plot We get location, temporal and pressure information

Question 30

what is achalasia

Answer 30

failure of a ring of muscle fibres such as a sphincter of the oesophagus, to relax

Question 31

what gene is achalasia associated with

Answer 31

HLA-DQw1

Question 32

what suggests that alchasia may be autoimmune

Answer 32

circulating antibodies to enteric neurone s

Question 33

what is the prevalence of achalasia

Answer 33

annual incidence of approx 1 case per 100,000 Men = women Onset before adolescence unusual Usually diagnosed between the ages of 25 and 60 years

Question 34

what is used to diagnose achalasia

Answer 34

clinical history Endoscopy Radiology Manometry In one series of 87 consecutive patients with newly diagnosed achalasia, the mean duration of symptoms was 4.7 years

Question 35

what would endoscopy reveal

Answer 35

may reveal a dilated oesophagus containing residual material May appear normal Oesophageal stasis predisposes to candida infection that may be apparent

Question 36

what would be the radiology findings

Answer 36

barium swallow diagnostic accuracy around 95% Dilated oesophagus with beak like narrowing Dilation may be so profound that the oesophagus assumes a sigmoid shape Fluoroscopy reveals the absence of peristalsis Purposeless, spastic contractions can be observed - some radiologist call this vigorous achalasia

Question 37

what would manometry show

Answer 37

manometric examination is usually required for confirmation Three primary findings: Elevated resting LES pressure - above 45mmHg Incomplete LES relaxation - this manometric finding distinguishes achalasia from other disorders associated with aperistalsis aperistalsis - in the smooth muscle portion of the body of the oesophagus. For most patients, low amplitude; in some cases, however, the simultaneous oesophageal contractions have higher amplitudes (>60mmHg) such patients are said to have vigorous achalasia.

Question 38

what is botulinum toxin

Answer 38

endoscopic injection of BT (type A) into the lower oesophageal sphincter.

Question 39

mechanism of action of botulinum toxin

Answer 39

inhibits the calcium dependent release of acetylcholine from nerve terminals, thereby countering the effect of the selective loss of inhibitory neurotransmitters

Question 40

is botulinum toxin effective

Answer 40

it is initially effective in relieving symptoms, in about 85% of patients. symptoms recur in more than 50% of patients within 6 months, possibly because of regeneration of the affected receptors

Question 41

what is pneumatic dilation

Answer 41

most effective non-surgical treatment for achalasia involves placing a balloon across the lower oesophageal sphincter, which is then inflated to a pressure adequate to tear the muscle fibres of the sphincter

Question 42

what is Hellers Myotomy

Answer 42

involves carrying out an anterior myotomy across the lower oesophageal sphincter however, whether myotomy should be combined with an antireflux procedure is a cause for debate

Question 43

how are myotomies usually carried out

Answer 43

laparoscopically through the abdomen with a 1-2c distal myotomy onto the stomach

Question 44

what is the major complication of Hellers myotomy

Answer 44

uncontrolled gasto-oesophageal reflux in 10% of patients