ICL 3.4: Swallowing and Dysphagia Flashcards
(39 cards)
what are the 2 types of dysphagia?
- oropharyngeal dysphagia
initiating swallowing problem; patients will say they cough/aspirate/choke a lot or the food comes out of their nose –> diagnose with videofluoroscopy
- esophageal dysphagia
food sticks after swallowing –> diagnose with endoscopes and biopsy
what are the structural causes of oropharyngeal dysphagia?
- Zenker’s diverticulum
- neoplasm
- cervical web
what are the motility causes of oropharyngeal dysphagia?
- CVA
- multiple sclerosis
- ASL
- Parkinson’s
- dermatomyositis
- myasthenia gratis
what are the structural causes of esophageal dysphagia?
intermittent
1. Schatzki’s ring/web
- eosinophilic esophagitis
progressive
3. neoplasms
- stricture
variable
5. extrinsic compression
- radiation esophagitis
what are the motility causes of esophageal dysphagia?
- achalasia
- scleroderma
- DES
- Jackhammer
A 65-year old woman with a 6-month history of amyotrophic lateral sclerosis is evaluated for a 1-month history of difficulty swallowing. She experiences choking and coughing while attempting to swallow solids and liquids and has intermittent nasal regurgitation of liquids. Two weeks ago she was treated for pneumonia.
On physical examination, vital signs are normal. Tongue fasciculations and jaw clonus are present and there is definite weakness of the masseter muscle. There is weakness of the proximal arms of the intrinsic muscles of the hands, but deep tendon reflexes are preserved.
Which of the following is the most appropriate initial diagnostic test to evaluate this patient’s swallowing disorder?
A. endoscopy
B. esophageal manometry
C. upper gastrointestinal series
D. videofluoroscopy
D. videofluoroscopy
this is because she has an oropharyngeal dysphagia! she’s having a problem with upper swallowing
what are some of the causes of oropharyngeal dysphagia?
- brain = CVA, head injury, Parkinson’s, brainstem disease, MS, motor neuron disease, phenothiazine
- muscle or nerve = dermatomyositis, poliomyelitis, MD, MG
- cricopharyngeal dysfunction = Zenker’s diverticulum, reduced muscle compliance
A 46-year-old woman comes to the office due to dysphagia. The patient has had difficulty swallowing both liquid and solid foods as well as frequent episodes of regurgitation and cough while eating. She has also had weakness in her extremities and a rash. The patient has no prior medical problems and takes no medications. Vital signs are within normal limits. Physical examination shows an erythematous eruption on the upper eyelids. The oropharynx is clear and cardiopulmonary and abdominal examinations are unremarkable. She has difficulty lifting her arms above her head and standing from a sitting position.
- Which of the following is the most likely cause of this patient’s dysphagia?
A. Atrophy and fibrous replacement of the distal esophageal muscularis propria
B. Diffuse eosinophil-predominant inflammation of esophageal mucosa
C. Inflammation and degeneration of the esophageal myenteric plexus
D. Outpouching of hypopharyngeal mucosa through weakened muscle
E. Perifascicular atrophy of muscle fibers in the proximal esophageal muscularis propria
F. Fibrous replacement of the muscularis in the lower esophagus
E. Perifascicular atrophy of muscle fibers in the proximal esophageal muscularis propria
aka she has dermatomyositis! this is a stiratal muscle problem so it’s oropharyngeal dysphagia
A. scleroderma
B. eosinophilic esophagitis
C. achalasia
D. Zenker diverticulum
F. scleroderma
An 80-year-old man comes to the office due to six months history of difficulty swallowing, choking spells, and cough. He has also had recurrent episodes of pneumonia. He smokes 1 pack of cigarette /day. His other medical problems include mild congestive heart disease. The patient has foul-smelling breath, but his oropharyngeal and neck examinations are normal. A barium swallow study is performed and reveals an abnormality in the upper esophagus, as shown in the image below.
which of the following mechanisms is the most likely cause of
his symptoms?
A. degenerative changes of the myenteric plexus
B. squamous cell carcinoma of the upper esophagus
C. cricopharyngeal motor dysfunction
D. increased intraluminal pressure in the esophagus
E. Schatzki’s ring
F. Esophageal diverticulum
C. cricopharyngeal motor dysfunction
aka he has Zenger’s diverticulum = herniation between the oblique fibers of the thyropharngeal muscle and the horizontal fibers of the cricopharyngeal muscle
Shatski’s ring is lower!
what is the treatment for Zenker’s diverticulum?
surgical treatment
they cut the septum between the diverticulum and esophagus
what are esophageal webs?
thin membranes (2-3mm) of normal esophageal tissue consisting of mucosa and submucosa that can partially protrude/obstruct the esophagus
cause of esophageal dysphagia
usually in the upper esophagus while Schatzki’s ring is in the lower esophagus –> treat by cutting ring or balloon dilation
what is esophagitis? what are the different causes?
- eosinophilic
- GERD/Barrett’s
- infectious
- pill induced (kid starts on doxy for acne and then they get dysphagia)
- caustic (kid drinks bleach or suicide attempt)
- radiation (breast, lung lymphoma)
what is eosinophilic esophagitis?
inflammation of the esophagus only, NOT systemic! so it’s a chronic immune/antigen-mediated esophageal disease
diagnosed via biopsy = 15+ eosinophils per high power field
presentation is dysphagia; severity depends on size of food bolus
more common in males
which of the following is the common food trigger identified for patients with eosinophilic esophagitis?
- milk**
- wheat*
- nuts
- seafood
- eggs
- soy
what are the approached to diet therapy for eosinophilic esophagitis?
- elemental diet: amino acid based formula
- direct elimination diet: skin prick testing
- empiric elimination of milk, wheat, soy, egg, peanut, seafood
how do you manage eosinophilic esophagitis?
- diet management
- topical steroids
- esophagus dilation
- proton pump inhibitors
what are the esophageal motility disorders?
normal high resolution manometry!
peristalsis and LES both have to work to get the food down the esophagus!
A 56-year-old woman is evaluated for a 3-year history of progressive dysphagia for solids and liquids; she has had a 6.8 kg (15 lb) weight loss during this time. The dysphagia was initially intermittent, but recently swallowing almost all food or drink causes a feeling of chest tightness and discomfort with increasing frequent regurgitation of undigested food. The dysphagia is sometimes alleviated by standing upright and her medications include Lisinopril and a multivitamin.
On physical examination, the patient appears uncomfortable and restless; she is thin but does not have thenar wasting, she is afebrile; the blood pressure is 142/92 mm Hg. the pulse rate is 96/min, and the respiration is 22/min. the BMI is 23.
EGD shows a dilated esophagus and a tight lower esophageal sphincter, which allowed passage of the endoscope without significant difficulty. Esophageal manometry showed the following tracings with no contractions aka no peristalsis and no LES relaxation
which of the following is the most likely diagnosis?
A. achalasia
B. diffuse esophageal spasm
C. peptic stricture
D. scleroderma esophagus
E. cricopharyngeal dysfunction
A. achalasia
no peristalsis and no relaxation of LES!
what is achalasia?
failure of relaxation of lower esophageal sphincter (LES) & lack of peristalses
loss of inhibitory ganglia cells in myenteric plexus leads to imbalance of NO and ACh
what are the primary and secondary causes of achalasia?
PRIMARY
idiopathic = increased risk of squamous cell carcinoma
SECONDARY
1. chagas disease
- paraneoplastic achalasia
what are the symptoms of achalasia?
- dysphagia (solid/liquid)
- regurgitation/heartburn
- chest pain
- weight loss
how do you diagnose achalasia?
Symptoms
EGD: NL mucosa, stasis, dilated esophagus, “pop-in sign”
Esophogram: Bird’s beak
Manometry: absent of peristalsis & non-relaxing LES
for a patient (with Achalasia), Injection of which of the following into the patients LES would most likely help relieve her symptoms?
A. Botulinum toxin B. Corticosteroids C. Neostigmine D. Phenylephrine E. Pilocarpine
A. Botulinum toxin
it would inhibit contraction!!
how do you treat achalasia?
Endoscopic:
1. botulinum toxin injection of LES
- Pneumatic dilation of LES
Surgical:
1. Heller’s myotomy (usually with anti-reflux fundoplication)
