Dysphagia & Regurgitation

Question 1

history questions for dysphagic patients

Answer 1

1. solids or liquids?
2. intermittent or progressive?
3. temporal pattern? (which phase of swallowing is affected)
4. recent general anesthesia?
5. age of onset
6. dysphonia?
7. odynophagia?
8. recent medications?

Question 2

ddx for dysphonia

Answer 2

• myopathy
• neuropathy
• junctionopathy

ex. GOLPP (geriatric onset laryngeal paralysis + polyneuropathy)

Question 3

localizing dysphagia

Answer 3

1. oropharyngeal - oral, pharyngeal, cricopharyngeus muscle
2. esophageal
3. gastroesophageal

Question 4

BOAS

Answer 4

brachycephalic obstructive airway syndrome

• hypoplastic trachea
• elongated soft palate
• hypertrophic tongue
• stenotic nares
• everted laryngeal saccules

predisposes brachycephalics to hiatal hernia due to increased negative intrathoracic pressure

Question 5

diagnostics for dysphagic/regurgitating patients

Answer 5

1. observation
2. PE
3. neuro exam
4. minimum database
5. radiographs
6. esophagram vs video fluoroscopy

Question 6

what type of radiographs are indicated

Answer 6

3 view thoracic
1 lateral cervical

Question 7

esophagram vs video fluoroscopy

Answer 7

esophagram - static image at time intervals after swallowing barium bolus

video fluoroscopy - dynamic imaging of barium bolus moving throughout the swallow

Question 8

masticatory muscle myositis

Answer 8

immune mediated attack on the muscles of mastication

targets the 2M myofibers

Question 9

clinical signs of MMM

Answer 9

inability to open jaw

acute: inflammation + pain
chronic: fibrosis + scarring

Question 10

diagnosis of MMM

Answer 10

2m antibody ELISA
muscle biopsy (if chronic)

Question 11

treatment of MMM

Answer 11

immunosuppression
- corticosteroids
- cyclosporine

can NOT treat chronic cases when muscles already fibrosed down

Question 12

cricopharyngeus muscle dysfunction

Answer 12

failure of the UES to open or open at the correct time

two forms:
- achalasia
- asynchrony

Question 13

CMD achalasia

Answer 13

failure of the UES to open

mini long hair dachshunds
toy breeds

Question 14

CMD asynchrony

Answer 14

failure of the UES to open at the same time as pharyngeal contraction

young golden retrievers

Question 15

clinical signs of CMD

Answer 15

• regurgitation immediately after swallowing
• WORSE with water
• nasal reflux

Question 16

diagnosis of CMD

Answer 16

video fluoroscopy

can NOT do static imaging

Question 17

treatment of CMD

Answer 17

ALWAYS modify water texture - ice, thickening agents

surgical: open myotomy of CP muscle

medical:
- botox of CP muscle
- pneumonic dilation of UES

Question 18

megaesophagus

Answer 18

dilation and loss of motility of the esophagus (primary or secondary)

primary: idiopathic
secondary:
- myasthenia gravis
- NM disease
- esophageal foreign body
- vascular ring anomaly
- esophageal neoplasia
- Addison’s disease

Question 19

clinical signs of megaesophagus

Answer 19

acute onset dysphagia
regurgitation
ptyalism
dysphonia

Question 20

esophageal achalasia like syndrome

Answer 20

common cause of megaesophagus

hypertonic LES preventing the bolus from entering the stomach

Question 21

types of treatment for megaesophagus

Answer 21

1. management (for primary idiopathic ME)
2. medical (for EALS)
3. surgical (for EALS)

Question 22

management of primary idiopathic megaesophagus

Answer 22

• modify diet (wet food)
• elevated feeding (Bailey chair)

Question 23

medical treatment for EALS

Answer 23

• botox of the LES
• sildenafil (viagra)

temporary - only lasts 3-4 months

Question 24

surgical treatment for EALS

Answer 24

• pneumonic dilation
• heller myotomy + fundoplication

Question 25

heller myotomy + fundoplication

Answer 25

heller myotomy: incising into the LES and pulling the mucosa through the incision to release tension of hypertonic muscle fundoplication: wrapping the fundus around the base of the esophagus in order to resolve potential reflux from heller myotomy alone

Question 26

myasthenia gravis

Answer 26

muscle weakness and fatigue caused by deficient Ach receptors congenital vs acquired

Question 27

congenital myasthenia gravis

Answer 27

deficient Ach receptors at the NM junction occurs in YOUNG PUPPIES signs: - exercise intolerance - generalized weakness - megaesophagus diagnosis: muscle biopsy

Question 28

acquired myasthenia gravis

Answer 28

immune mediated attack on Ach receptors occurs in ADULTS signs: - megaesophagus alone - ME + generalized weakness diagnosis: Ach receptor antibody test - normal <0.6 - if Ab > 0.3 with acute clinical signs --> retest in 3-6 weeks

Question 29

hiatal hernia

Answer 29

stomach pushes through the diaphragm at the hiatus common in brachycephalics due to BOAS and pyloric hypertrophy

Question 30

clinical signs of hiatal hernia

Answer 30

regurgitation dysphagia hypersalivation

Question 31

diagnosis of hiatal hernia

Answer 31

video fluoroscopy to ID esophageal dysmotility

Question 32

treatment of hiatal hernia

Answer 32

ALWAYS treat the BOAS before doing surgical hernia repair - can often resolve the hernia surgical management is ideal - L sided gastropexy, esophagopexy, diaphragmatic hiatal plication medical: PPIs, cisapride, LF diet

Question 33

esophagitis

Answer 33

inflammation of the esophagus

Question 34

common causes of esophagitis

Answer 34

1. general anesthesia 2. medication induced 3. chronic vomiting 4. foreign body 5. ingestion of caustic material

Question 35

anesthesia induced esophagitis

Answer 35

occurs 1 week after anesthesia drugs used for anesthesia + loss of swallow reflex/LES tone while unconscious --> reflux --> acidic contents remain in esophagus during duration of procedure

Question 36

what medications can cause esophagitis

Answer 36

doxycycline clindamycin

Question 37

treatment of esophagitis

Answer 37

PPIs, H2 blockers sucralfate cisapride, metoclopramide LF diet

Question 38

esophgeal strictures

Answer 38

narrowing of the lumen following esophagitis common consequence of esophagitis caused by anesthesia, trauma, foreign body, etc

Question 39

treatment of esophgeal strictures

Answer 39

esophageal balloon dilation + antifibrotics