Dyspahagia

Question 1

1- Oropharyngeal Hi dysphagia

Functional (neuromuscular)
Stroke
Parkinsons disease
Cranial nerves palsy , Bulbar palsy
Multiple sclerosis
Myesthenia gravis

Answer 1

Structural (mechanical )

1 - Mural
Throat cancers
Pharyngeal pouch (Zenker diverticulum)
Structural (mechanical )

Extrinsic compression

Lymphadenopathy
retropharyngeal abscesses

Question 2

2- Oesophageal low dysphagia
Functional (neuromuscular)
Achalasia
Chagas disease
Diffuse esophageal spasm Webs
Nutcracker esophagus
Scleroderma

Answer 2

Structural (mechanical )
Mural
Extrinsic compression
(Achalasia)
Malignant stricture = Cancer esophagus /stomach cardia
Thyroid Goiter
(Chagas disease)
Benign stricture
Mediastinum : LN
(Diffuse esophageal spasm Webs) = Plummer-Vinson syndrome
Lung Ca
(Nutcracker esophagus)
Rings = Peptic rings

Heart: Mitral Stenosis & Lt. Atrial hypertrophy

(Scleroderma)
Post-surgical ( stenotic anastomosis or fundoplication)
Vascular: Thoracic aortic aneurysm dysphagia aortica. Anomalies: right subclavian artery passes between esophagus and spine (Dysphagia lusoria ).

Question 3

malignant esophageal strictures: Cancer Of The Oesophagus

Answer 3

Malignancy is likely if there is:
• Old age ( >60 ).
• Rapidly progressive dysphagia ( short duration < 4 months).
• Dysphagia more for solid initially then for both solid & liquid as
tumor grows.
• Weight loss , chest pain, odynophagia, anemia, anorexia &
Hematemesis .
• Presence of risk factors: Smoking, Alcohol, Achalasia, Webs and
rings, Barrett oesophagus.
• Squamous cell or adenocarcinoma

Question 4

Benign esophageal strictures

Answer 4

peptic stricture due to Gastroesophageal reflux disease (GERD):
• It is the most common cause of benign strictures.
• Gastric juice “Reflux” back into esophagus
• Represents a failure of lower esophageal sphincter due to Decrease in LES tone
• Chronic & Prolonged contact with gastric acid  Acid destroys mucosa  replaced by fibrous tissue and scarring.
• occurs at the squamocolumnar junction at the lower esophagous and extend in longer segment.
• Risk factors include: alcohol, smoking, obesity, fatty foods, caffeine, hiatal hernia
• Symptoms : slowly progressive dysphagia to solid associated with Heartburn, water brash: Sour taste and a gush of
saliva, Retrosternal “burning” sensation After meals, or when lying flat, Painful esophagitis, Respiratory due to Reflux
into respiratory tract, Asthma (adult onset), Cough, Dyspnea, Damage of teeth

Question 5

Zenker’s Diverticulum

Answer 5

Acquired, pulsion type, mucosal & submucosa outpouching
pseudodiverticulum through muscular layer at junction of
esophagus and pharynx. • Located at Killian’s Triangle between oblique fibers of the
thyropharyngeus muscle and the horizontal fibers of the
cricopharyngeus muscle Just proximal to upper esophageal
sphincter. • Most common esophageal diverticulum • Caused by ↑ intraluminal pressure in the pharynx due to
failure relaxation of the cricopharyngeus muscle during the
swallowing.
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asymptomatic when small. • When they grow progressively due to retained food they
compress the oesophagus & cause dysphagia • passive regurgitation (supine position) a patient may
wake up choking & coughing • halitosis, & if they aspirate they will have recurrent
pneomonia. • Noisable swallowing (gurgling ). • When it reaches a significant size it might be felt as a
soft neck lump.

Question 6

Esophageal Rings And Webs

Answer 6

Mucosal bands protruding into the esophageal lumen • Asymptomatic if lumen diameter >12 mm • Obstructs movement of food  intermittent dysphagia to solids
 Ring = circumferential narrowing (lower esophagus)  Web = partial occlusion (upper esophagus)
• Pre-malignant for Squamous cell carcinoma .

Question 7

Esophageal Rings:
Schatzki ring :

Answer 7

Due to GERD. • located at GEJ ( squamo-columnar junction). • Commonly found in association with hiatus
hernia. • Covered with squamous epithelium above
and columnar epithelium below.

Question 8

Esophageal Webs:
Plummer-Vinson or Patterson-Kelly syndrome:

Answer 8

Rare syndrome • common in middle-aged to elderly white women. • it is associated with iron-deficiency anaemia. • Intermittent dysphagia to solids • atrophic glossitis (smooth red tongue) • cheilosis (cracks at the corner of the mouth) • koilonychia

Question 9

Achalasia Cardia

Answer 9

Most common type of esophageal motility disorders. • characterized by incomplete relaxation of the lower
esophageal sphincter (LES) and aperistalsis of the
esophageal smooth muscle resulting in functional
obstruction of the esophagus. • Autoimmune, progressive inflammatory destruction of
ganglion cells in Auerbach’s (myenteric) plexus. • Auerbach’s (myenteric) plexus provides motor innervation
to the esophagus . • Causes:
– Often idiopathic – Chagas Disease (Protozoa: Trypanosoma cruzi)
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of ganglion cells of Auerbach’s (myenteric) plexus which results in:
1. Progressive loss of peristalsis in the esophageal body & distal esophagus
2. Incomplete/failure of relaxation of the LES smooth muscles with swallowing.
3. Increased resting tone of the LES.
↑ of intraluminal oesophageal pressure,
oesophageal dilatation