DYSPHAGIA and PYROSIS
Gastrointestinal system has in human body 5 basic functions
1. uptake of informations from external enviroment a from gastrointestinal tract alone
2. uptake and process of sources of chemical energy, water, salts a biofactors
( = digestion and resorption)
3. transport of the gastrointestinal tract contain from the mouth to anal foramen
( = motority )
4. production of gastrointestinal hormons and modulators
5. immune role
For these 5 functions has gastrointestinal system it´s own equipment - it means
a) perceptive, secretory, motoric, endocrinne a immune apparatus
b) own GI nervous system with a large degree of autonomy on central regulatory
structures.
Function of upper alimentary ways
Activity of this part of alimentary system is
a) efficient part of alimentar behavior and
b) the first complex entrance of informations about food intake, which starts the whole
continuing complex sequence of processes ending by enter of nutriments, salts, water and
biofactors from the from the food and from the chyme to ECF.
Alimentar behavior is moved by basic food drive, food motivation with the hunger and taste
in background (hypothalamus).
This motivation chooses of the organismus´s behavioral repertoar those activities which
guide on the base of inborn and learned motorical programmes to finishing of alimentar drive.
During realization of these programmes takes part
a) corticospinal - voluntary - motor component and
b) vegetative motor component.
Striated musculature ( oral part till to first third of esophagus) in perfect central unison pass
on the activity to smooth musculature in the second and third thirds of esophageus.
Esophageal coordination (and it is phenomena of central coordination) consists in
1) harmony between the condition of upper and lower esofageal sphincter,
2) in succesive activation of both motor esophageal apparatuses and
3) the third exceptional serious fact is the esophageal-gastric phlux of food. It goes about
accurate coordination between esophageal pressure, intragastric pressure and condition of
lower esophageal sphincter.
This coordination certains in part dynamic, gradual filling of stomach by food, in part
esophago-gastric overpressure by open lower esophageal sphincter and finaly prevents again
acid chyme rephlux - lower esophageal mucosa has inadecvate protection again corrosion
influence of low pH.
Mechanism of esophageal motility disturbances
the lost of peristalsis
incorrect peristalsis
high resting tension of lower oesophageal sphincter
low resting tension of lower oesophageal sphincter
inadequate relaxation of lower oesophageal sphincter
lacks or incomplete relaxation of lower oesophageal sphincter
peristaltic wawes are supplied by unprogressive. simultaneous or tertiary concractions
Swalling system means: pharnyx, upper- cricopharyngeal sfincter of esophagus, esophageal
corpus and lower esophageal sphincter
Upper halve of esophageus and adjacent structures have striate musculature,
in distal part of esophageus and his lower sphincter is smooth musculature.
Dysphagia:
A subjective awareness of difficulty in swallowing due to impaired progression of matter
from pharynx to stomach. ( food „ gets stuck „ )
Pre-esophageal dysphagia: difficulty empting material from the oral pharnyx into the
esophagus
this symtpom occurs most often in patients with neurologic or muscular disorders
e.g. dermatomyositis, myasthenia gravis, muscular dystrophy, bulbar poliomyelitis,
amyotrophic lateral sclerosis, pseudobulbar palsy, other CNS lesions
Zenker´s diverticulum ( is an outpouching of the mucosa and submucosa posteriorly through
the cricopharyngeal muscle)
x ( traction diverticula - mediastinum lesions, motor disorders
epiphranic diverticulum - also probably of propulsive origin, accompanies esophageal motor
disturbance)
signs: nasal regurgitation
tracheal aspiration followed by coughing
cause: cricopharyngeal incoordination - the cricopharyngeal muscle remains closed
or opens in an uncoordinated way
e.g. Zenker´s diverticulum may lead to chronic lung disease
Esophageal dysphagia - difficulty passing food down the esophagus
1. Obstructive disorders :
extrinsic obstruction - compress aortic aneurysm, enlarged left atrium, aberrant subclavian artery (
dysphagia lusoria), substernal thyroid, bony exostosis, lung tumors,
mediastinal tumors
carcinoma of the esophagus - a) squamous cell carcinomas
conditions associated with an increased frequency : lye stricture,
achalasia, esophageal webs, people with tobacco or ethanol excess
b) adenocarcinoma - most frequently due to Barrett´s metaplasia = columnar
metaplastic epithelium that may occur in the lower esophagus following the
chronic injury of peptic esophagitis
c) other tumors
benign peptic stricture
Lower esophageal ring - Schatzki´s ring - a 2- to 4-mm mucosal structure, probably
congenital, causing ringlike narrowing of the distal esophagus at the squamocolumnar
junction ( intermitent dysphagia for solids when the lumen diameter is under 12 mm
Esophageal webs ( syndrom Plummer-Vinson or Paterson-Kelly, Sideropenic dysphagia
a thin, mucosal membrane that grows across the lumen of the esophagus, usually in the
esophageal upper part, , can be shown best on cinefilms , can be easily ruptured during
esophagoscopy
dysphagia lusoria - dysphagia due to compression of the esophagus by a congenital vascular
abnormality ( usually an aberrant right subclavia artery arising from the left side of the
aortic arch) - extrinsic compression in the high of Th 3 vertebra
2.
Motor Disorders
Achalasia - a neurogenic esophageal disorder of unknown etiology causing impairment of
esophageal peristalsis and of lower esophageal sphincter relaxation.
The condition may be due to a malfunction of myenteric plexus of the esophagus that results
in denervation of esophageal muscle
dysphagia for boths solids and liquids is the major symptom,
onset is insidious and progresion is gradual over many months or years, at any age, but
usually between 20 and 4O
other symptoms: chest pain, regurgitation, nocturnal cough, bronchopneumonia,
bronchiectasia, , increased pressure of lower esophageal sphincter, esophageal dilatation
differential diagnosis: carcinoma, sclerodermia, peptic stricture
treatment: medicaments - nitrates, Ca-channel antagonists
instrumental - bougienage, , pneumatic dilatation, myotomy
Symptomatic diffuse esophageal spasm
( spastic pseudodiverticulosis, Rosary bead or Corkscrew esophagua)
A generalized neurogenic disorder of esophageal motility in which normal peristalsis is
replaced by phasic nonpropulsive contractions and, in some cases, by abnormal lower
esophageal sphincter function.
Over many years this disorder may evolve into achalasia
symptoms and signs: substernal chest pain, sometimes may occure in association with
exercise - diff. diagnosis - angina pectoris, dysphagia for both - solids and liquids
diagnosis: x rays, scintigraphy, esophageal manometry
treatment- nitrates, Ca-channel blockers,
diffuse esophageal spasm can be present by sclerodermy
Globus hystericus ( globus sensation) - is not true dysphagia it is subjective sensation of a lump or mass in the throat
the symptom is often relieved with eating or drinking, is unrelated to swallowing and occurs
without impaired transport
emotional etiology - ( stress factors , anxiety, grief )
Chest pain of esophageal origine:
Heartburn ( pyrosis) - a substernal burning pain that rises in the chest and may radiate into
the neck, throat, or even face, is caused by acidification of the esophagus by GER
Heartburn may be accompanied by hypersalivation = waterbrash = hypersalivation
secondary to acid stimulation of lower inflamed esophagus via the vagus nerve.
Odynophagia - pain during swallowing may occur without dysphagia and my be due to
mucosal destruction
e.g. esophagitis induced by GER, infections - mycotic, bacterial, viral, neoplasms,
chemicals, motility disorders
typical: pain as a burning sensation or a substernal tightness typically elicited by very hot or
very cold food or liquid. Onset is prompt on swallowing
Spontaneous esophageal chest pain may be severe and mimic angina pectoris in every way
Examination procedure:
ANAMNESIS - ( precisly detailing the patient´s symptoms should establish an accurate
diagnosis in about 80% of patients ! )
PHYSICAL EXAMINATION
X-RAYS - cinefluoroscopy ( swalling)
ENDOSCOPY
ESOPHAGEAL MANOMETRY
ESOPHAGEAL pH MONITORING
THE BERNSTEIN ( acid perfusion ) TEST ( 0.1 N HCl )
SCINTIGRAPHY
Gastroesophageal reflux disease ( G.B. GERD, USA: GORD)
GER - gastroesofageal reflux
reflux of gastric contents into the esophagus
40% of human population once a month has heartburn
main sign: heartburn, ,
less frequently :
regurgitation and ructus (belching)
substernal chest pain, foetor ex ore, vomiting, some times
recidive infections ( bronchitis, pneumonia , laryngitis, chronic coughing,
mediootitis,) dental caries, astma bronchiale,
dysphagia and odynophagia usually later, due to complications
obese women with short chest and hiatus hernia, pregnant women