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Flashcards in MISC - Dysphagia Deck (16)
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Causes of dysphagia
- oropharyngeal
- oesophageal

1. Usually neuromuscular dysfunction
•Head and neck surgery/radiotherapy
•Structural disorders
–Pharyngeal pouch or diverticulum

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


Likelihood of causes of dysphagia depending on time course
- sudden onset
- progressive weeks to months
- intermittent non progressive
- intermittent progressive

•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


How does liquid/solids dysphagia DDx?

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


What are some associated symptoms in dysphagia?

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


What are some relevant PMHx of dysphagia?

Reflux / CVA / neurologicaldisorders / caustic ingestion


Ix for dysphagia

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)


Describe pharyngeal pouch causing dysphagia
- pathology
- Px
- Dx
- Rx

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


Describe reflux related stricture as cause of dysphagia
- Dx
- Ix
- Rx

•History of reflux or heartburn

•Gastroscopy – confirms diagnosis / excludes malignancy

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


Describe large hiatus hernia as cause of dysphagia
- Dx
- Ix
- Rx

–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


Describe achalasia as cause of dysphagia
- Px
- Ix
- Rx

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

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

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


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

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

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


How do you Ix for GORD?

- 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)


Risks and benefits of Surgical Management of reflux Laparoscopic fundoplication

–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

–Inability to burp or vomit
–Increased flatus


Discuss Mx for malignant & benign stricture

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


Ix of achalasia

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


Mx of achalasia
- (3) medical
- (1) surgical

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

- Laparoscopic cardiomyotomy for division of lower esophageal sphincter

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