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MD2 ENT > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

What word is used to describe pain on swallowing?

A

Odynophagia

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2
Q

How might a patient’s impression of the level of pharyngeal/oesophageal obstruction differ from the actual level of obstruction?

A

Level of obstruction is generally lower than indicated

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3
Q

List 3 causes of oropharyngeal dysphagia

A

Stroke
Head and neck surgery/radiotherapy
Structural disorders: stricture, web, pharyngeal pouch or diverticulum

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4
Q

List 3 stricturing and 3 functional causes of oesophageal dysphagia

A

Stricture: reflux disease, malignancy, extrinsic compression
Functional: achalasia, dysmotility (diffuse oesophageal spasm/scleroderma), pouches/diverticula

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5
Q

What is globus hystericus?

A

The sensation of having a “lump” in one’s throat, associated with anxiety

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6
Q

What does a sudden onset of symptoms suggest about the underlying cause of a dysphagia?

A

?bolus obstruction or CVA

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7
Q

What does a progressive course of dysphagia imply about the underlying aetiology?

A

Suggests malignancy, stricture or achalasia

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8
Q

What does an intermittent non-progressive course of dysphagia imply about the underlying aetiology?

A

Benign stricture, web or hiatus hernia

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9
Q

What does an intermittent progressive course of dysphagia imply about the underlying aetiology?

A

Functional (e.g. achalasia, scleroderma, spasm)

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10
Q

What does a dysphagia of liquid vs solids imply about the underlying aetiology?

A

Solids: likely structural problem (e.g. malignancy, pharyngeal or oesophageal pouch)
Liquids: functional disorder (e.g. achalasia)

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11
Q

What does a dysphagia with weight loss suggest in terms of the underlying cause?

A

Malignancy

Achalasia

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12
Q

What does a dysphagia associated with long term reflux suggest about the underlying cause?

A

Peptic stricture

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13
Q

What does a dysphagia associated with aspiration suggest about the underlying cause?

A

Neuromuscular issues (e.g. achalasia, CVA)

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14
Q

What signs MAY be observed on examination in the setting of dysphagia?

A

General inspection: wasted (?malignancy)
Periphery: scleroderma (CREST syndrome)
Head and neck: LNs, previous Sx, gurgling pouch in the neck
Neurological function

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15
Q

What Ix can be ordered for oropharyngeal dysphagia?

A

Video swallow (provides functional information; can identify a pharyngeal pouch)

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16
Q

What Ix can be ordered for oesophageal dysphagia?

A 
Gastroscopy
Barium swallow
CT scan
Oesophageal manometry
Endoscopic U/S
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17
Q

What is the aim of performing a gastroscopy in the setting of oesophageal dysphagia?

A

Can identify structural abnormality (e.g. cancer, web, stricture, extrinsic compression)
Can be therapeutic (e.g. stricture dilation, removal of foreign body)

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18
Q

When might a barium swallow be useful in the context of dysphagia?

A

Uncommonly required but may be useful for achalasia or if pharyngeal pouch suspected

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19
Q

What information may be supplied by a CT scan in the setting of dysphagia?

A

May be useful for assessment of large hiatus hernia or extrinsic compression

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20
Q

What information may be supplied by oesophageal manometry in the setting of dysphagia?

A

Assessment of achalasia or diffuse oesophageal spasm

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21
Q

What information may be supplied by endoscopic U/S in the setting of dysphagia?

A

Can characterise lesions in the wall such as GI stromal tumours (GIST)

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22
Q

What is the cause of a pharyngeal pouch?

A

Dysfunction/spasm of upper oesophageal sphincter

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23
Q

Describe the natural Hx of a pharyngeal pouch

A

Gurgling in the neck

Brings up previously eaten foods

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24
Q

How is pharyngeal pouch diagnosed?

A

Barium swallow

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25
Q

How is pharyngeal pouch treated?

A

Cricopharyngeal myotomy either via an open procedure in the neck OR endoscopic transoral myotomy

26
Q

List 5 staging Ix which may be indicated for oesophageal cancer

A

Endoscopy and biopsy
CT scan chest/abdomen (to look for metastatic or locally advanced disease)
Staging laparoscopy
Bronchoscopy (for mid-oesophageal tumours)

27
Q

How is oesophageal cancer treated? What is the principle aim of treatment?

A

Surgery
Chemoradiotherapy
Aim: to resect if not locally advanced and no metastatic disease

28
Q

What Ix should be performed in suspected reflux-related stricture causing dysphagia?

A

Gastroscopy (confirms Dx, excludes malignancy)

29
Q

How is a reflux-related stricture treated?

A

Dilation (at time of gastroscopy)

Treat underlying cause (PPI, anti-reflux operation called fundoplication)

30
Q

Describe features on Hx which would be consistent with the Dx of a large hiatus hernia

A

Usually lengthy Hx
May have intermittent symptoms
May not have heartburn but may have vomiting/regurgitation
Examination may be normal

31
Q

What Ix should be performed in suspected large hiatus hernia?

A

Gastroscopy

CT/barium swallow

32
Q

How is a large hiatus hernia treated?

A

If symptomatic in a fit patient: laparoscopic repair

Asymptomatic in elderly or unfit patient: conservative Mx

33
Q

Describe features on Hx which would be consistent with a Dx of achalasia

A

Often lengthy and Dx often missed
Progressive to solids and liquids
Associated weight loss

34
Q

What Ix should be performed in a suspected case of achalasia?

A

Gastroscopy to exclude cancer
Oesophageal manometry (gold standard, diagnostic)
Barium swallow may be helpful

35
Q

How is achalasia treated?

A

Laparoscopic cardiomyotomy (divide lower oesophageal sphincter)
Oesophageal dilation can occasionally be used: 17C dilatation using whalebone (associated with high mortality!), 20C balloon dilatation
Botox for temporary relief

36
Q

65 year old man presents with long Hx of heartburn, recent onset of dysphagia and weight loss of 4kg
First Ix?

A

Gastroscopy!

37
Q

65 year old man presents with long Hx of heartburn, recent onset of dysphagia and weight loss of 4kg
Gastroscopy shows evidence of oesophagitis
Are more Ix required?
What is the best treatment at this stage?

A

Ix: if no evidence of malignancy, no further Ix required at this stage
Best first line treatment: PPI

38
Q

65 year old man presents with long Hx of heartburn, recent onset of dysphagia and weight loss of 4kg
Gastroscopy shows evidence of oesophagitis
In the longer term reflux symptoms persist despite adequate PPI - what is the next step?

A

If patient has failed medical therapy, has complications despite adequate Rx, preference to avoid drugs or intolerance of therapy, consider antireflux surgery

39
Q

65 year old man presents with long Hx of heartburn, recent onset of dysphagia and weight loss of 4kg
Gastroscopy shows evidence of oesophagitis
Are any further Ix required if surgery planned?

A

Yes; oesophageal function tests (pH testing, oesophageal manometry)

40
Q

What oesophageal function tests are there?

A

pH testing

Oesophageal manometry

41
Q

What is the aim of naso-oesophageal pH monitoring?

A

Check for pH

42
Q

What is an alternative to the use of a naso-oesophageal pH monitor to test oesophageal pH?

A

Bravo pH capsule (clipped to side of oesophagus and measures pH for 48 hour period)

43
Q

What information does oesophageal manometry provide?

A

Pressure wave in oesophagus

44
Q

What are the advantages of laparoscopic fundoplication for management of reflux?

A

Available for 10 years
Advantages of laparoscopic surgery
Mortality rate low (0.2%)
Morbidity rates lower than open surgery (but results affected by surgeon experience)

45
Q

What does fundoplication aim to achieve?

A

Fundal mobilisation
Hiatal closure
Can be achieved with a 360 degree wrap, or a partial fundoplication
??

46
Q

What % of patients have good long term outcomes from anti-reflux surgery?

A

80-90%

47
Q

List 3 possible side effects of anti-reflux surgery

A

Inability to burp or vomit
Increased flatus
Bloating

48
Q

Describe the different “decision trees” for malignant vs benign strictures found on gastroscopy

A

Malignant: staging Ix, followed by chemo/radiotherapy for advanced disease, OR surgery +/- neo-adjuvent chemotherapy for early disease
Benign: dilation, then give PPI and consider fundoplication

49
Q

78 year old lady presents with several years of swallowing difficulties, worse recently with some LOW
Local GP has done a CXR
What cause of oesophageal dysphagia, consistent with this Hx, might be seen on this CXR?

A

Hiatus hernia

50
Q

35 year old female presents with progressive dysphagia and recent vomiting of old food
Associated features: 6kg LOW, “offensive burps”, occasional chest pains
LMO has done a barium swallow which shows a characteristic “bird-beak” sign
What underlying disease process is this indicative of?

A

Achalasia

51
Q

What is the cause of achalasia?

A

Neural abnormality (specific cause unknown)

52
Q

What is the typical age of onset for achalasia?

A

30-60 years

53
Q

What is the prevalence of achalasia?

A

1 per 100,000

54
Q

Describe the natural Hx of achalasia

A

Intermittent but progressive

55
Q

List 7 typical symptoms of achalasia

A 
Progressive dysphagia
Pain (odynophagia; vigorous achalasia)
Postural regurgitation
Profound weight loss
Poor nutrition
56
Q

What must be performed post-20C balloon dilatation for achalasia?

A

Contrast study

57
Q

What is one of the possible complications of 20C balloon dilatation for the Mx of achalasia? What is the prevalence of this complication?

A

Perforation (2-12%)

58
Q

What % of patients experiencing successful relief with a single 20C balloon dilatation for Mx of achalasia vs those who have multiple?

A

Single: 55-70%
Multiple: 90%

59
Q

How is laparoscopic cardiomyotomy performed?

A

Oesophagogastric junction is identified
Plane for cardiomyotomy is developed here
LOS is divided

60
Q

Gastroscopy spot Dx

IMAGE

A

ANSWER IMAGE

MD2 ENT (10 decks)

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