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MD2 ENT > Dysphagia > Flashcards

Dysphagia Flashcards

(60 cards)

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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
How is pharyngeal pouch treated?
Cricopharyngeal myotomy either via an open procedure in the neck OR endoscopic transoral myotomy
26
List 5 staging Ix which may be indicated for oesophageal cancer
Endoscopy and biopsy CT scan chest/abdomen (to look for metastatic or locally advanced disease) Staging laparoscopy Bronchoscopy (for mid-oesophageal tumours)
27
How is oesophageal cancer treated? What is the principle aim of treatment?
Surgery Chemoradiotherapy Aim: to resect if not locally advanced and no metastatic disease
28
What Ix should be performed in suspected reflux-related stricture causing dysphagia?
Gastroscopy (confirms Dx, excludes malignancy)
29
How is a reflux-related stricture treated?
Dilation (at time of gastroscopy) | Treat underlying cause (PPI, anti-reflux operation called fundoplication)
30
Describe features on Hx which would be consistent with the Dx of a large hiatus hernia
Usually lengthy Hx May have intermittent symptoms May not have heartburn but may have vomiting/regurgitation Examination may be normal
31
What Ix should be performed in suspected large hiatus hernia?
Gastroscopy | CT/barium swallow
32
How is a large hiatus hernia treated?
If symptomatic in a fit patient: laparoscopic repair | Asymptomatic in elderly or unfit patient: conservative Mx
33
Describe features on Hx which would be consistent with a Dx of achalasia
Often lengthy and Dx often missed Progressive to solids and liquids Associated weight loss
34
What Ix should be performed in a suspected case of achalasia?
Gastroscopy to exclude cancer Oesophageal manometry (gold standard, diagnostic) Barium swallow may be helpful
35
How is achalasia treated?
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
65 year old man presents with long Hx of heartburn, recent onset of dysphagia and weight loss of 4kg First Ix?
Gastroscopy!
37
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?
Ix: if no evidence of malignancy, no further Ix required at this stage Best first line treatment: PPI
38
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?
If patient has failed medical therapy, has complications despite adequate Rx, preference to avoid drugs or intolerance of therapy, consider antireflux surgery
39
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?
Yes; oesophageal function tests (pH testing, oesophageal manometry)
40
What oesophageal function tests are there?
pH testing | Oesophageal manometry
41
What is the aim of naso-oesophageal pH monitoring?
Check for pH
42
What is an alternative to the use of a naso-oesophageal pH monitor to test oesophageal pH?
Bravo pH capsule (clipped to side of oesophagus and measures pH for 48 hour period)
43
What information does oesophageal manometry provide?
Pressure wave in oesophagus
44
What are the advantages of laparoscopic fundoplication for management of reflux?
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
What does fundoplication aim to achieve?
Fundal mobilisation Hiatal closure Can be achieved with a 360 degree wrap, or a partial fundoplication ??
46
What % of patients have good long term outcomes from anti-reflux surgery?
80-90%
47
List 3 possible side effects of anti-reflux surgery
Inability to burp or vomit Increased flatus Bloating
48
Describe the different "decision trees" for malignant vs benign strictures found on gastroscopy
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
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?
Hiatus hernia
50
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?
Achalasia
51
What is the cause of achalasia?
Neural abnormality (specific cause unknown)
52
What is the typical age of onset for achalasia?
30-60 years
53
What is the prevalence of achalasia?
1 per 100,000
54
Describe the natural Hx of achalasia
Intermittent but progressive
55
List 7 typical symptoms of achalasia
``` Progressive dysphagia Pain (odynophagia; vigorous achalasia) Postural regurgitation Profound weight loss Poor nutrition ```
56
What must be performed post-20C balloon dilatation for achalasia?
Contrast study
57
What is one of the possible complications of 20C balloon dilatation for the Mx of achalasia? What is the prevalence of this complication?
Perforation (2-12%)
58
What % of patients experiencing successful relief with a single 20C balloon dilatation for Mx of achalasia vs those who have multiple?
Single: 55-70% Multiple: 90%
59
How is laparoscopic cardiomyotomy performed?
Oesophagogastric junction is identified Plane for cardiomyotomy is developed here LOS is divided
60
Gastroscopy spot Dx | IMAGE
ANSWER IMAGE

MD2 ENT (10 decks)

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