MISC - Dysphagia

Question 1

Causes of dysphagia

• oropharyngeal
• oesophageal

Answer 1

Oropharyngeal: 
1. Usually neuromuscular dysfunction
•Stroke
•Head and neck surgery/radiotherapy
•Structural disorders
–Stricture
–Web
–Pharyngeal pouch or diverticulum

Oesophageal causes
1. Stricture
•Reflux disease
•Malignant
•Extrinsic compression
2. Functional
•Achalasia
•Dysmotility – diffuse oesophageal spasm/scleroderma
•Pouches/diverticula

Question 2

Likelihood of causes of dysphagia depending on time course

• sudden onset
• progressive weeks to months
• intermittent non progressive
• intermittent progressive

Answer 2

• Sudden event - ?bolus obstruction / CVA
• Progressive weeks to months – malignancy / stricture / achalasia
• Intermittent non-progressive – benign stricture / web / hiatus hernia
• Intermittent progressive – functional eg achalasia / scleroderma / spasm

Question 3

How does liquid/solids dysphagia DDx?

Answer 3

• Solids likely a structural problem eg malignancy / pouch pharyngeal or oesophageal
• Liquids – functional disorder eg achalasia

Question 4

What are some associated symptoms in dysphagia?

Answer 4

• Weight loss suggests malignancy / achalasia
• Long term reflux – peptic stricture
• Associated disease – scleroderma / CVA
• Aspiration – neuromuscular issues eg CVA / achalasia

Question 5

What are some relevant PMHx of dysphagia?

Answer 5

Reflux / CVA / neurologicaldisorders / caustic ingestion

Question 6

Ix for dysphagia

Answer 6

Oropharyngeal dysphagia
–Video swallow: Provides functional information
•Can identify a pharyngeal pouch

Oesophageal dysphagia
–Gastroscopy: Can identify structural abnormality eg Cancer / web / stricture / extrinsic compression. May be therapeutic eg dilate stricture / remove foreign body
–Barium swallow: Uncommonly required but may be useful for achalasia or if pharyngeal pouch suspected
–CT scan: May be useful for assessment of large hiatus hernia or extrinsic compression
–Oesophageal manometry: Assessment of achalasia or diffuse oesophageal spasm
– Endoscopic Ultrasound: Can characterise lesions in the wall such as Gastrointestinal Stromal Tumours (GIST)

Question 7

Describe pharyngeal pouch causing dysphagia

• pathology
• Px
• Dx
• Rx

Answer 7

•Cause
–dysfunction / spasm of upper oesophageal sphincter
•History
–Gurgling in neck
–Brings up previously eaten foods
•Diagnosis
–Barium swallow
•Treatment: cricopharyngeal myotomy via
a. open procedure in the neck or
b. endoscopic transoral myotomy

Question 8

Describe reflux related stricture as cause of dysphagia

• Dx
• Ix
• Rx

Answer 8

–Diagnosis
•History of reflux or heartburn

–Investigation
•Gastroscopy – confirms diagnosis / excludes malignancy

–Treatment
•Dilate stricture at the time of the gastroscopy
•Treat the cause
–PPI
–Anti-reflux operation - fundoplication

Question 9

Describe large hiatus hernia as cause of dysphagia

• Dx
• Ix
• Rx

Answer 9

–Diagnosis
•History 
–usually lengthy
–May have intermittent symptoms
–May not have heartburn but may have vomiting/regurgitation
•Examination: Maybe normal

–Investigations: Gastroscopy, CT/Barium swallow

–Treatment: If symptomatic in a fit patient - laparoscopic repair. If asymptomatic in elderly or unfit patient - conservative management

Question 10

Describe achalasia as cause of dysphagia

• Px
• Ix
• Rx

Answer 10

–History
•Often lengthy and diagnosis missed
•Progressive to solids and liquids
•Associated weight loss

–Investigations
•Gastroscopy to exclude cancer
•Oesophageal manometry – diagnostic
•Barium swallow may be helpful

–Treatment
•Laparoscopic cardiomyotomy (divide lower oesophageal sphincter)
•Oesophageal dilation can occasionally be used

Question 11

When (4) should you consider antireflux surgery in oesophagitis? What Ix should you do before the op?

Answer 11

–Failed medical therapy
–Complications despite adequate Rx
–Preference to avoid drugs
–Intolerance of therapy

Ix: esophageal function test (pH testing, oesophageal manometry)

Question 12

How do you Ix for GORD?

Answer 12

• Naso-oesophageal pH monitor: Check for pH less than 4 over 24hrs for less than 4% of this period
• Bravo pH capsule can be clipped side of oesophagus to measure pH for 48 hours
• esophageal manometry (pressure of LES)

Question 13

Risks and benefits of Surgical Management of reflux Laparoscopic fundoplication

Answer 13

–Available for 10 years
–Advantages of laparoscopic surgery
–Mortality rate 0.2%
–Morbidity rates lower than open surgery
–Results are affected by surgeon experience

Outcomes: 80-90% good long term outcomes

SE:
–Inability to burp or vomit
–Increased flatus
–Bloating

Question 14

Discuss Mx for malignant & benign stricture

Answer 14

On gastroscopy, if BENIGN stricture:

1. dilate
2. PPI
3. consider fundoplication

On gastroscopy, if MALIGNANT stricture:

1. staging investigations
2. if EARLY disease: surgery +/- neo adjuvent chemotherapy
3. if ADVANCED disease: Chemo/radiotherapy

Question 15

Ix of achalasia

Answer 15

• Gastroscopy – exclude malignancy
• Manometry – gold standard test
• Barium study

Question 16

Mx of achalasia

• (3) medical
• (1) surgical

Answer 16

Medical:
1. 17C dilatation using whalebone - associated with high mortality!!!

2. 20C balloon dilatation
•Post op contrast study
•Perforation 2-12%
•55-70% success single dilatation
•90% success multiple dilatations
•Significant perforation rates unsatisfactory

3. BOTOX temporary relief only

Surgical:
- Laparoscopic cardiomyotomy for division of lower esophageal sphincter