Dysphagia Flashcards
(33 cards)
differential diagnosis of dysphagia to solids
1-Mechanical causes
SCORE-WE” –
S – Stricture (peptic stricture from GERD)
C – Carcinoma (esophageal cancer)
O – Obstruction (external compression: mediastinal mass, thyroid, etc.)
R – Ring (Schatzki ring)
E – Eosinophilic esophagitis
W – Web (Plummer-Vinson syndrome)
E – Esophagitis (especially infectious or corrosive)
differential diagnosis of dysphagia to solids
2- Motility disorders
SAD”:
S – Scleroderma
A – Achalasia
D – Diffuse esophageal
A 56-year old male with long history of heart burn and acid regurgitation presented with 4
weeks history of difficult swallowing of solid. He was able to swallow liquids. During this
duration, he has loss of appetite with 3 Kg weight loss. He has hypertension, DM and IHD
with history of myocardial infarction 3 years ago. Cardiac catheter was done with
insertion of 3 coronary stents. He has a history of heavy smoking for 30 years.
A-Discuss differential diagnosis with prioritization.
Differential diagnosis is
Dysphagia to solids
قولهم…..
1-Esophageal Adenocarcinoma (Most likely)
Why?
*Long-standing GERD → risk of Barrett’s esophagus → risk of adenocarcinoma.
*Progressive dysphagia (solids first) and weight loss are classic red flags.
*Smoking is a significant risk factor.
Likely location: lower third of esophagus (common site for adenocarcinoma).
2-Esophageal Squamous Cell Carcinoma but less suspect than esophageal adenocarcinoma
Why?
Strong association with smoking and alcohol.
More commonly affects the upper and middle thirds of the esophagus.
Dysphagia and weight loss are typical presentations.
3-Esophageal Stricture (Benign Peptic Stricture)
Why?
Chronic GERD.
4-Achalasia
*Dysphagia to both solids and liquids is typical.
*Rarely presents with late-onset dysphagia at this age.
Not supported by history (GERD usually not a feature).
A 36-year-old, otherwise healthy woman with a 6-year history of progressive solid food dys-
phagia is referred to you for evaluation. Her dysphagia has progressed to the point that she can
eat only small meals. Barium esophagram reveals an oblique defect at the upper thoracic level just
above the aortic arch.
▶ What is the patient’s most likely diagnosis?
A. Median arcuate ligament syndrome
B. Dysphagia lusoria
C. Thoracic outlet syndrome
D. Aortic aneurysm
E. Spinal osteophyte
Dysphagia lusoria
A 17-year-old girl, who is a recent immigrant from Mexico, presents with dysphagia for
solids and liquids. The symptoms began 3 months ago. She recalls swelling around her left eye prior to the onset of symptoms. She had been living in a thatched roof hut in Mexico.
Chagas disease
. A 72-year-old man presents with recent-onset dysphagia for solids and liquids. This came
“nearly overnight.” He also has new-onset constipation. He has never before suffered
either dysphagia or constipation. He has a 50-pack-per-year smoking history, and recently
noticed an increasingly hoarse voice.
Paraneoplastic achalasia
40-year-old woman complains of paroxysmal bouts of severe chest pain. She is unable to
swallow any liquid or solid during these attacks. Between attacks she is fine, and does not
suffer from dysphagia. Her cardiac evaluation has been totally normal.
DES
A 50-year-old woman presents with progressive dysphagia for solids and liquids. She has
difficulty standing from a seated position, and describes a violaceous rash, like a “shawl,”
at the nape of her neck.
Dermatomyositis
. A 50-year-old man presents with progressive weakness and atrophy of his lower extremity
musculature, along with progressive dysphagia for solids and liquids. He had childhood
polio at the age of 15.
Post polio syndrome
. A 32-year-old woman presents with progressive dysphagia, first for solids, then for solids
and liquids. She has a “megaduodenum” on small bowel follow-through, and has recurrent
bouts of small intestinal bacterial overgrowth.
Systemic sclerosis
An 83-year-old man presents with longstanding dysphagia. He explains that solid food is
intermittently stuck in the “back of his throat,” just as he’s trying to swallow. There is no
dysphagia to liquids. He has a history of osteoarthritis, along with repetitive traumatic
neck injuries.
Cervical osteophytes
A 72-year-old woman presents with longstanding dysphagia to solids, but not liquids. The
dysphagia has not been progressive. She remembers symptoms going back for at least a
decade. She has no unintentional weight loss, no vomiting, no early satiety, and no signifi-
cant constitutional symptoms. She has no oropharyngeal symptoms of note. Her primary
care physician ordered a barium swallow study, which revealed a normal radiographic
motility pattern and transit of the barium column to the stomach. However, there was evi-
dence of a structural abnormality appearing as a “shelf” impinging on the barium column
at the level of the upper esophageal sphincter. The patient now presents to you for further evaluation
Cricopharyngeal bar
A 58-year-old man is referred from his primary care physician for progressive dysphagia. The
dysphagia began 3 months ago, and at first was associated only with solid foods. He subsequently
developed increasingly severe symptoms, and 1 month ago developed intolerance of liquids as well
as solids. He lost 18 pounds unintentionally over the 3 months since developing dysphagia. He
also noted dramatic thickening of the skin on both his hands and the soles of both feet at about
the time his dysphagia began.
On examination, he is thin, has temporal wasting, and appears cachectic. Oral exam reveals
leukoplakia on the buccal mucosa. He is noted to have keratoderma on both hands and the soles
of both feet. Stool was heme positive.
▶ What is this condition?
Tylosis (Howel-Evan Syndrome)
▶ Is this inherited?
Yes,autosomal dominant
▶ What is the GI association?
Oseophegeal adenocarcinoma
▶ What is endoscopy likely to reveal?
Keratoderma of palms and soles + Dysphagia =
Tylosis with esophageal squamous cell carcinoma
Dysphagia + Living under a thatched roof hut
Chagas disease
New-onset bowel paralysis in a smoker =
Think paraneoplasia
(Paraneoplastic achalasia
Red eyes or neck + Dysphagia =
Think dermatomyositis
Dysphagia years after polio =
Post polio syndrome
Dysphagia + Megaduodenum + Pneumatosis intestinalis =
Systemic sclerosis
Dysphagia + Cervical arthritis =
Think cervical osteophyte
Dysphagia + Cervical “shelf” on UGIS =
Cricopharyngeal bar
DES
DES
Dysphagia (to both solids and liquids , intermittent)
+
*Spasm in wall and lower esophygeal sphincter
+
Chest pain
+
Corkscrew esophagus on barium swallow
*Simultaneous contractions on manometry
*Peristalsis absent orp disordered
Treatment
Ccb
Sublingual nitrate
Ppi
Surgical
Tylosis
=Thick skin + cancer osophegus
A 28-year-old woman is referred to you for recurrent bouts of epigastric pain. The pain is
always postprandial, typically within minutes of food ingestion. It lasts for several minutes and
then improves. There are no symptoms between meals. The pain is severe, and she now has devel-
oped a progressive fear of eating, to the point of unintentionally losing 30 pounds over the past
3 months. She is often nauseous with the bouts of epigastric pain, but she does not vomit. There
is no diarrhea, melena, or hematochezia. There is no history of hypertension, diabetes, or obesity.
Examination reveals a bruit over the epigastrium. The patient is thin, and the abdominal aorta
is palpable. However, there is no lateral expansion of the abdominal aorta evident on palpation.
Abdominal ultrasound is negative.
What is the most likely diagnosis?
Median arcuate ligament syndrome
▶ What is the next diagnostic step to confirm this diagnosis?
Ct,MRI with angiography
