DYSPHAGIA
FAISAL GHANI SIDDIQUI
MBBS; FCPS; MCPS (HPE); PGD (BIOETHICS)
faisal@lumhs.edu.pk
www.lumhs.edu.pk/faculties/surgery/gsurgery/about-dr.faisalghani.html
PREAMBLE
DYSPHAGIA & ITS TYPES?
NORMAL SWALLOWING REFLEX
DIAGNOSTIC PROTOCOL
DYSPHAGIA
DIFFICULTY IN SWALLOWING
RESULTS FROM ANY PATHOLOGY
THAT INTERFERES WITH THE
NORMAL SWALLOWING
MECHANISM
SWALLOWING REFLEX -3 PHASES
ORAL
PHARYNGEAL
OESOPHAGEAL
ORAL PHASE
FOOD BOLUS ROLLED BACK BY THE
TONGUE INTO THE PHARYNX
PHARYNGEAL PHASE
FOOD PASSES THROUGH THE
PHARYNX INTO THE OESOPHAGUS
OESOPHAGEAL PHASE
FOOD PASSES THROUGH THE
OESOPHAGUS INTO THE STOMACH
TYPES OF DYSPHAGIA
HIGH
(OROPHARYNGEAL)
DYSPHAGIA OCCURING AT OR ABOVE
CRICOPHARYNGEUS
LOW
(OESOPHAGEAL)
DYSPHAGIA OCCURING BELOW
CRICOPHARYNGEUS
DYSPHAGIA -CAUSES
HIGH (OROPHARYNGEAL) DYSPHAGIA
NEUROLOGICAL /
NEUROMUSCULAR
•
•
•
•
•
MECHANICA / STRUCTURAL
• PHARYNGEAL POUCH
• TUMOURS
CVA
PARKINSON’S DISEASE
MULTIPLE SCLEROSIS
MYSTHAENIA GRAVIS
BULBAR / PSEUDOBULBAR PALSY
DYSPHAGIA -CAUSES
LOW (OESOPHAGEAL) DYSPHAGIA
PRIMARY MOTILITY DISORDERS
• ACHALASIA
• DIFFUSE OESOPHAGEAL SPASM
• NUTCRACKER OESOPHAGUS
SECONDARY MOTILITY
DISORDERS
MECHANICAL (INTRINSIC
DISEASES)
• CHAGA’S DISEASE
MECHANICAL (EXTRINSIC
DISEASES)
•
•
•
•
• OESOPHAGEAL CARCINOMA
• BENIGN STRICTURE
BRONCHOGENIC CARCINOMA
THORACIC AORTIC ANEURYSM
GOITRE
DYSPHAGIA LUSORIA
DYSPHAGIA -DIAGNOSIS
HISTORY
PHYSICAL EXAMINATION
INVESTIGATIONS
HISTORY
HIGH (OROPHARYNGEAL)
DYSPHAGIA
ASSOCIATED WITH CHOKING OR COUGHING
IMMEDIATELY AFTER SWALLOWING
SWALLOWING SOLIDS EASIER THAN LIQUIDS
HISTORY
DYSPHAGIA DUE TO
OESOPHAGEAL CARCINOMA
SHORT DURATION (< 3 MONTHS)
PROGRESSIVE
ASSOCIATED WEIGHT LOSS
HISTORY
DYSPHAGIA DUE TO
MOTILITY DISORDERS
LONG HISTORY
INVOLVES BOTH SOLIDS AND LIQUIDS
DYSPHAGIA MAY DISAPPEAR, BEING REPLACED
WITH REGURGITATION & NOCTURNAL COUGH
PHYSICAL EXAMINATION
OFTEN UNREWARDING
MOVEMENTS OF TONGUE, PALATE, &
MUSCLES OF FACIAL EXPRESSION
CERVICAL LYMPHADENOPATHY
WEIGHT LOSS
INVESTIGATIONS
ENDOSCOPY
BARIUM SWALLOW
MANOMETRY
EUS
ENDOSCOPY
PATIENTS WITH HIGH DYSPHAGIA
WITH NO OBVIOUS NEUROLOGICAL
CAUSE SHOULD BE REFERRED TO
ENT SPECIALIST
FLEXIBLE LARYNGOSCOPY
FLEXIBLE NASOENDOSCOPY
RIGID ENDOSCOPY
ENDOSCOPY
OESOPHAGEAL DYSPHAGIA
BIOPSIES TO DIFFERENTIATE
MALIGNANT & BENIGN STRICTURES
THERAPEUTIC; DILATATION OF BENIGN
STRICTURES / MOTILITY DISORDERS
STENTING IN INOPERABLE TUMOURS
BARIUM SWALLOW
OESOPHAGEAL DYSPHAGIA
Demonstrates different structural
pathologies
Hiatus hernia | Strictures
Achalasia | Tumours
MANOMETRY
PATIENTS WITH NO STRUCTURAL
ABNORMALITY ON ENDOSCOPY
REQUIRE FURTHER INVESTIGATION
WITH MANOMETRY
TO EXCLUDE
MOTILITY DISORDERS
ENDOSCOPIC ULTRASOUND
USED FOR STAGING OF
HISTOLOGICALLY PROVEN
OESOPHAGO-GASTRIC CARCINOMA
WALL PENETRATION
LYMPH NODE INVOLVEMENT
EXTRINSIC OESOPHAGEAL COMPRESSION
HIGH
DYSPHAGIA
HISTORY SUGGESTIVE OF
NEUROLOGICAL CAUSE
NO
ENT REFERRAL
OROPHARYNGOLARYNGOSCOPY
YES
VIDEOFLOUROSCOPY &
MANOMTERY