Dysphagia - Clinicals, Diagnosis, and Management

Upper GI

Clinicals - History

Fact Explanation
Difficulty in swallowing (dysphagia) This can be classified according to the area of origin, it can be oropharyngeal or oesophageal. In oropharyngeal dysphagia, patient complains accumulation of food in the mouth without entering it into the oesophagus. In oesophageal dysphagia, there is food stuck after passing through the mouth. It can get stuck behind the neck, middle of the chest or even lower down in the chest. Oesophageal carcinoma causes dysphagia when it is large enough to obstruct the oesophageal lumen. Therefore dysphagia in the oesophageal carcinoma is presentation of advanced disease. Difficulty in swallowing (dysphagia)
This can be classified according to the area of origin, it can be oropharyngeal or oesophageal. In oropharyngeal dysphagia, patient complains accumulation of food in the mouth without entering it into the oesophagus. In oesophageal dysphagia, there is food stuck after passing through the mouth. It can get stuck behind the neck, middle of the chest or even lower down in the chest. Oesophageal carcinoma causes dysphagia when it is large enough to obstruct the oesophageal lumen. Therefore dysphagia in the oesophageal carcinoma is presentation of advanced disease.
Progression of dysphagia If the symptoms started as dysphagia for fluids and gradually progressing towards the solids, that might be an indicator of malignancy of the oesophagus. In conditions like achalasia cardia, and neuromuscular problems dysphagia is more towards the liquids. Duration of the dysphagia is also helpful to get an idea about the underlying pathology. Acute onset may be due to foreign body ingestion stricture or carcinoma. Long term history will suggests conditions like achalasia cardia, diffuse oesophageal spasms and nut cracker oesophagus like neuromuscular problems. Progression of dysphagia
If the symptoms started as dysphagia for fluids and gradually progressing towards the solids, that might be an indicator of malignancy of the oesophagus. In conditions like achalasia cardia, and neuromuscular problems dysphagia is more towards the liquids. Duration of the dysphagia is also helpful to get an idea about the underlying pathology. Acute onset may be due to foreign body ingestion stricture or carcinoma. Long term history will suggests conditions like achalasia cardia, diffuse oesophageal spasms and nut cracker oesophagus like neuromuscular problems.
Odynophagia This is painful swallowing which occurs due to the oral conditions like tonsilitis, candidiasis and thermal injuries etc, these can cause oropharyngeal dysphagia. Odynophagia
This is painful swallowing which occurs due to the oral conditions like tonsilitis, candidiasis and thermal injuries etc, these can cause oropharyngeal dysphagia.
Loss of weight, loss of appetite, hunger May be a feature of malignancy of the oesophagus. Compared to the oesophageal carcinoma, where hunger is prominent, gastric carcinoma will have marked loss of appetite. Loss of weight, loss of appetite, hunger
May be a feature of malignancy of the oesophagus. Compared to the oesophageal carcinoma, where hunger is prominent, gastric carcinoma will have marked loss of appetite.
Nasal regurgitation of the ingested materials, choking and coughing Ingestion of food is followed by these symptoms in oropharyngeal dysphagia. Nasal regurgitation of the ingested materials, choking and coughing
Ingestion of food is followed by these symptoms in oropharyngeal dysphagia.
History of stroke, guillen b'are syndrome, bulbar palsy or muscle weakness poliomyelitis Stroke can be a risk factor for the development of dysphagia. Most of the patients regain functional swallowing within the first month following stroke, but some will remain the dysphagia beyond that period. Incidence of dysphagia ismore wiyth the brainstem lesionsthan hemispheric lesions. History of stroke, guillen b'are syndrome, bulbar palsy or muscle weakness poliomyelitis
Stroke can be a risk factor for the development of dysphagia. Most of the patients regain functional swallowing within the first month following stroke, but some will remain the dysphagia beyond that period. Incidence of dysphagia ismore wiyth the brainstem lesionsthan hemispheric lesions.
Easy fatiguebility Myasthenia gravis is a disease where the problem is in the neuromscular junction. Easy fatiguebility
Myasthenia gravis is a disease where the problem is in the neuromscular junction.
Heart burn and regurgitation These are symptoms of gastrooesophageal reflux disaese (GORD). GORD can produce strictures in the oesophagus. GORD and Barrett’s esophagus (migration of squamo- columnar junction) are risk factors for esophageal adenocarcinoma. Heart burn and regurgitation
These are symptoms of gastrooesophageal reflux disaese (GORD). GORD can produce strictures in the oesophagus. GORD and Barrett’s esophagus (migration of squamo- columnar junction) are risk factors for esophageal adenocarcinoma.
Chest pain Can be a feature of achalasia or GORD. Achalasis is a neuromuscular disorder of the oesophagusdue to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing. Chest pain
Can be a feature of achalasia or GORD. Achalasis is a neuromuscular disorder of the oesophagusdue to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing.
History of corrosive, vinegar ingestion or exposure to radiation Can cause strictures. History of corrosive, vinegar ingestion or exposure to radiation
Can cause strictures.
History of foreign body ingestion These can lodge in the oesophagus causing dysphagia. Most common ones are food boluses, batteries etc. History of foreign body ingestion
These can lodge in the oesophagus causing dysphagia. Most common ones are food boluses, batteries etc.
Fever and productive cough As the ingested materials are unable to go through the obstruction, there is accumulation above the obstruction. These patients are vulnerable for the recurrent aspiration and entrance of swallowed materials into the airway results in aspiration pneumonia. Fever and productive cough
As the ingested materials are unable to go through the obstruction, there is accumulation above the obstruction. These patients are vulnerable for the recurrent aspiration and entrance of swallowed materials into the airway results in aspiration pneumonia.
History of traumatic brain injury This is a neurological cause for dysphagia. Mostly due to the prolonged disturbance of consciousness. Impairment of the swallowing is mainly affects the voluntary component of swallowing such as oral dysphagia. History of traumatic brain injury
This is a neurological cause for dysphagia. Mostly due to the prolonged disturbance of consciousness. Impairment of the swallowing is mainly affects the voluntary component of swallowing such as oral dysphagia.
History of parkinson’s disease Repeated tongue pumping movements, delayed triggering of the pharyngeal phase, delayed onset of laryngeal elevation, are some of the suggested factors contributing to the dysphagia. History of parkinson’s disease
Repeated tongue pumping movements, delayed triggering of the pharyngeal phase, delayed onset of laryngeal elevation, are some of the suggested factors contributing to the dysphagia.
Betal chewing, smoking These are risk factors for the development of squamous cell carcinoma of the oesophagus which mainly affecs the upper two thirds of the oesophagus. Betal chewing, smoking
These are risk factors for the development of squamous cell carcinoma of the oesophagus which mainly affecs the upper two thirds of the oesophagus.

Clinicals - Examination

Fact Explanation
Pallor May be due to malnutrition, malignancy of the oesophagus or Plummer winson syndrome/ Paterson-Brown-Kelly syndrome where there is a combination of upper esophageal webs, postcricoid dysphagia, and iron deficiency anemia. Long-term, iron deficiency anemia is the cause for the disease. Pallor
May be due to malnutrition, malignancy of the oesophagus or Plummer winson syndrome/ Paterson-Brown-Kelly syndrome where there is a combination of upper esophageal webs, postcricoid dysphagia, and iron deficiency anemia. Long-term, iron deficiency anemia is the cause for the disease.
Icterus Disseminated malignancy into the liver can produce jaundice. Icterus
Disseminated malignancy into the liver can produce jaundice.
Wasting Due to malnutrition and loss of weight in malignancy. Wasting
Due to malnutrition and loss of weight in malignancy.
Koilonoychia, glossitis There are associated nutritional deficiencies due to the poor intake result in iron, vitamin B 12 deficiency. Plummer-Vinson syndrome is also associated with iron deficiency. Koilonoychia, glossitis
There are associated nutritional deficiencies due to the poor intake result in iron, vitamin B 12 deficiency. Plummer-Vinson syndrome is also associated with iron deficiency.
Fatiguebility Seen in myasthenia gravis, ocular muscles can be used to demonstrate the fatiguebility. Fatiguebility
Seen in myasthenia gravis, ocular muscles can be used to demonstrate the fatiguebility.
Focal neurological signs, facial nerve palsy Stroke is a risk factor for the dysphagia. They will have limb weakness, abnormalities in the muscle tone, power, abnormal gait(hemiplegic gait) and cranial nerve palsies. Focal neurological signs, facial nerve palsy
Stroke is a risk factor for the dysphagia. They will have limb weakness, abnormalities in the muscle tone, power, abnormal gait(hemiplegic gait) and cranial nerve palsies.
shuffling gate, involuntary tremor, dyskinesia (slowing of the moments) These are seen in parkinson disease. shuffling gate, involuntary tremor, dyskinesia (slowing of the moments)
These are seen in parkinson disease.
Lymphadenopathy In conditions like lymphoma, there can be large intra thoracic lymphoid masses compressing the oesophagus. Lymphadenopathy
In conditions like lymphoma, there can be large intra thoracic lymphoid masses compressing the oesophagus.
Sunken eyes, reduced skin turgor, reduced tearing These are features of dehydration due to the poor intake. Sunken eyes, reduced skin turgor, reduced tearing
These are features of dehydration due to the poor intake.
Palmar and plantar thickening These are found in tylosis A, which is associated with oesophageal carcinoma. Palmar and plantar thickening
These are found in tylosis A, which is associated with oesophageal carcinoma.
Enlarged tonsils, bad breath Due to the tonsillitis causing oropharyngeal dysphagia. Enlarged tonsils, bad breath
Due to the tonsillitis causing oropharyngeal dysphagia.

Investigations - Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy Upper gastrointestinal endoscopy is the key investigation for the diagnosis of dysphagia. It can visualize the growths like malignancy in the walls of the oesophagus, ulcers and strictures. Ulcer, typical of friable hyperemic mucosa with necrotic debris with a tendency for easy to touch bleeding can be found in injuries to the mucosa due to hot beverages. Endoscopy has diagnostic advantages such as biopsy and therapeutic advantages such as insertion of synthetic tubes and dilatation. Upper gastrointestinal endoscopy
Upper gastrointestinal endoscopy is the key investigation for the diagnosis of dysphagia. It can visualize the growths like malignancy in the walls of the oesophagus, ulcers and strictures. Ulcer, typical of friable hyperemic mucosa with necrotic debris with a tendency for easy to touch bleeding can be found in injuries to the mucosa due to hot beverages. Endoscopy has diagnostic advantages such as biopsy and therapeutic advantages such as insertion of synthetic tubes and dilatation.
Barium swallow This will show a core of an apple appearance in malignancy of the oesophagus due to the malignant growth, bird's beak appearance is seen in achalasia cardia, corkscrew appearance in diffuse oesophageal spasm and stasis of barium in the pyriform sinuses is in globus pharyngeus. This can not do the biopsy. Barium swallow
This will show a core of an apple appearance in malignancy of the oesophagus due to the malignant growth, bird's beak appearance is seen in achalasia cardia, corkscrew appearance in diffuse oesophageal spasm and stasis of barium in the pyriform sinuses is in globus pharyngeus. This can not do the biopsy.
Oesophageal manometry Used for the diagnosis of gastro oesophageal reflux disease. Oesophageal manometry
Used for the diagnosis of gastro oesophageal reflux disease.
Edrophonium test Acetylcholine esterase inhibitor is given and the amount of acetylcholine is increased at the neuromuscular junction, that produces short term improvement of the fatigability. Edrophonium test
Acetylcholine esterase inhibitor is given and the amount of acetylcholine is increased at the neuromuscular junction, that produces short term improvement of the fatigability.
Serum iron and ferritin studies Plummer Vinson syndrome is due to the long term iron deficiency anemia, that need evaluation of iron levels in the body. Serum iron and ferritin studies
Plummer Vinson syndrome is due to the long term iron deficiency anemia, that need evaluation of iron levels in the body.

Investigations - Management

Fact Explanation
Upper gastrointestinal endoscopy Periodic testing with endoscopy is indicated as this is a premalignant condition. Aim is to detect the carcinoma at an curable early stage. Upper gastrointestinal endoscopy
Periodic testing with endoscopy is indicated as this is a premalignant condition. Aim is to detect the carcinoma at an curable early stage.
Full blood count Anaemia with low haemoglobin is found in malignancy, achalasia like chronic diseases and Plummer Vinson syndrome due to iron deficiency. Full blood count
Anaemia with low haemoglobin is found in malignancy, achalasia like chronic diseases and Plummer Vinson syndrome due to iron deficiency.
Lung function tests, chest x-ray and echocardiogram Oesophagectomy is a major surgery involving the thorax. On the other hand most of the elderly patients are having severe cardio respiratory co morbidities. So pulmonary functions need to be assessed before the surgery. Lung function tests, chest x-ray and echocardiogram
Oesophagectomy is a major surgery involving the thorax. On the other hand most of the elderly patients are having severe cardio respiratory co morbidities. So pulmonary functions need to be assessed before the surgery.
Echocardiography Left atrial dilatation may be a cause for the dysphagia. Echocardiography
Left atrial dilatation may be a cause for the dysphagia.
Endoluminal ultrasound scan This is used to stage the tumours of the oesophagus and gastro-oesophageal junction. Endoluminal ultrasound scan
This is used to stage the tumours of the oesophagus and gastro-oesophageal junction.
Computer tomography Is used for the preoperative assessment of oesophageal carcinoma. CT is used for the staging, assessment of the lymph nodes, liver involvement, and peritoneal deposits. Computer tomography
Is used for the preoperative assessment of oesophageal carcinoma. CT is used for the staging, assessment of the lymph nodes, liver involvement, and peritoneal deposits.
Laparoscopy Combined thoracoscopy/laparoscopy has >90% accuracy rate in staging. Laparoscopy
Combined thoracoscopy/laparoscopy has >90% accuracy rate in staging.
Bone scan Done if there are symptoms of bone involvement of bone due to metastasis. Bone scan
Done if there are symptoms of bone involvement of bone due to metastasis.

Management - Supportive

Fact Explanation
Postural adjustments to prevent aspiration Changes in body and head posture may be recommended reduce aspiration as this may the affects the speed and flow direction of a food or liquid bolus. Postural adjustments to prevent aspiration
Changes in body and head posture may be recommended reduce aspiration as this may the affects the speed and flow direction of a food or liquid bolus.
Swallow maneuvers These are are changes in the the normal swallowing to produce safe or efficient swallowing. Eg:- supraglottic and super supraglottic swallow techniques- voluntary breath holding, related to laryngeal closure to protect the airway during swallowing.
Mendelsohn maneuver to extend opening or relaxation of the upper esophageal sphincter.
Swallow maneuvers
These are are changes in the the normal swallowing to produce safe or efficient swallowing. Eg:- supraglottic and super supraglottic swallow techniques- voluntary breath holding, related to laryngeal closure to protect the airway during swallowing.
Mendelsohn maneuver to extend opening or relaxation of the upper esophageal sphincter.
Diet modifications If the person is unable to swallow the solids, it has to be replaced with liquids. Thickened liquids are a important compensatory intervention in long term caring to supply adequate nutrition. Diet modifications
If the person is unable to swallow the solids, it has to be replaced with liquids. Thickened liquids are a important compensatory intervention in long term caring to supply adequate nutrition.
Nutrition Poor nutrition causes problems such as poor wound healing, deterioration of cognitive status and immune system. Therefore provision of adequate nutrition by oral or non oral routes is mandatory. Nutrition
Poor nutrition causes problems such as poor wound healing, deterioration of cognitive status and immune system. Therefore provision of adequate nutrition by oral or non oral routes is mandatory.
Swallow rehabilitation This focuses on improving physiology of the swallowing. Eg:- Expiratory muscle strength training (EMST), Shaker head lift exercise. Swallow rehabilitation
This focuses on improving physiology of the swallowing. Eg:- Expiratory muscle strength training (EMST), Shaker head lift exercise.
Transcranial magnetic stimulation This is a new technique for the post stroke dysphagia. The treatment is applied for 20 minutes daily for 5 days and it improves swallow reaction time and decreases aspiration scores. Transcranial magnetic stimulation
This is a new technique for the post stroke dysphagia. The treatment is applied for 20 minutes daily for 5 days and it improves swallow reaction time and decreases aspiration scores.
Iron replacement This is recommended for patients with Plummer Vinson syndrome which is due to iron deficiency anemia. Iron replacement
This is recommended for patients with Plummer Vinson syndrome which is due to iron deficiency anemia.

Management - Specific

Fact Explanation
Surgery Radical esophagectomy with radical lymph node dissection is the gold standard surgery for oesophageal squamous cell carcinoma. Patients with advanced, inoperable tumor stages and severe comorbidities may not be suitable for surgery. Stage 0 or I disease is usually treated with surgery alone. Stage II and III disease is treated with surgery, with or without neoadjuvant therapy. Techniques of resection will be Ivor-Lewis, a thoracoabdominal approach, transhiatal that involves the abdomen and neck without thoracotomy the transabdominal, that is mainly for the lower gastroesophageal junction and thoracoscopic/laparoscopic, which is a minimally invasive approach. Surgery
Radical esophagectomy with radical lymph node dissection is the gold standard surgery for oesophageal squamous cell carcinoma. Patients with advanced, inoperable tumor stages and severe comorbidities may not be suitable for surgery. Stage 0 or I disease is usually treated with surgery alone. Stage II and III disease is treated with surgery, with or without neoadjuvant therapy. Techniques of resection will be Ivor-Lewis, a thoracoabdominal approach, transhiatal that involves the abdomen and neck without thoracotomy the transabdominal, that is mainly for the lower gastroesophageal junction and thoracoscopic/laparoscopic, which is a minimally invasive approach.
Ivor-Lewis oesophagectomy Ivor-Lewis, involves a thoracoabdominal approach, where abdominal incision is made to mobilize stomach with preserving the gastroepiploic vessels and then thoracotomy to approach the oesophagus. This provides a better access to the oesophagus, lymph node dissection is possible, but there is a risk of mediastinitis as the thoracotomy is involved.
This approach is advantageous in decreasing the recurrent
nerve lesion and other complications associated with a cervical dissection.
Ivor-Lewis oesophagectomy
Ivor-Lewis, involves a thoracoabdominal approach, where abdominal incision is made to mobilize stomach with preserving the gastroepiploic vessels and then thoracotomy to approach the oesophagus. This provides a better access to the oesophagus, lymph node dissection is possible, but there is a risk of mediastinitis as the thoracotomy is involved.
This approach is advantageous in decreasing the recurrent
nerve lesion and other complications associated with a cervical dissection.
Mc Keown oesophagectomy This is an extension of Ivor Lewis method, where there are abdominal incision, thoracotomy and third neck incision. This is three stage approach with a cervical anastomosis that reduces the risk of mediastinitis. But this also has the thoracotomy associated morbidity. Mc Keown oesophagectomy
This is an extension of Ivor Lewis method, where there are abdominal incision, thoracotomy and third neck incision. This is three stage approach with a cervical anastomosis that reduces the risk of mediastinitis. But this also has the thoracotomy associated morbidity.
Transhiatal/Oringers oesophagectomy Transhiatal/Oringers that involves the abdomen and neck without thoracotomy. Oesophagus is then connected to the stomach via cervical esophagogastric anastomosis. As there is no thoracotomy involved, this is a blind dissection and is suitable for middle and lower oesophageal malignancies. Complications will be thoracic or pulmonary complications such as pneumothorax, pleural effusions, pneumonias, empyemas, and respiratory failure and anastomotic leak. Transhiatal/Oringers oesophagectomy
Transhiatal/Oringers that involves the abdomen and neck without thoracotomy. Oesophagus is then connected to the stomach via cervical esophagogastric anastomosis. As there is no thoracotomy involved, this is a blind dissection and is suitable for middle and lower oesophageal malignancies. Complications will be thoracic or pulmonary complications such as pneumothorax, pleural effusions, pneumonias, empyemas, and respiratory failure and anastomotic leak.
Video assisted thoracoscopic surgery Laparoscopic and thoracoscopic techniques has been used as the the treatment of esophageal disorders such as oesophageal malignancy, achalasia and gastroesophageal reflux disease (GERD). Shorter hospital stay, less postoperative complications , and early recovery are the advantages of this laparoscopic and thoracoscopic techniques. Video assisted thoracoscopic surgery
Laparoscopic and thoracoscopic techniques has been used as the the treatment of esophageal disorders such as oesophageal malignancy, achalasia and gastroesophageal reflux disease (GERD). Shorter hospital stay, less postoperative complications , and early recovery are the advantages of this laparoscopic and thoracoscopic techniques.
Endoscopic dialatation Can be used for the peptic strictures Endoscopic dialatation
Can be used for the peptic strictures
Insertion of stent Stents are inserted in non operable patients with malignancy . This can relieve dysphagia in 90% of patients. Stent can give rise to complications such as stent migration, blocking of the tube, perforation and infection. Self expanding metal stents are beneficial as it is associated with less complications and easy insertion. Insertion of stent
Stents are inserted in non operable patients with malignancy . This can relieve dysphagia in 90% of patients. Stent can give rise to complications such as stent migration, blocking of the tube, perforation and infection. Self expanding metal stents are beneficial as it is associated with less complications and easy insertion.
Neoadjuvant or definitive chemoradiotherapy Chemotherapy, radiotherapy , and chemoradiotherapy can be combined with the surgery for the better outcome. Preoperative neoadjuvant radiotherapy is used to down stage the tumour. Chemotherapy is with bleomycin, vindesine, 5-flurouracil or combination of these. These are used specially for the treatment of squamous cell carcinoma. This has shown to improve the survival compared with surgery alone. Neoadjuvant or definitive chemoradiotherapy
Chemotherapy, radiotherapy , and chemoradiotherapy can be combined with the surgery for the better outcome. Preoperative neoadjuvant radiotherapy is used to down stage the tumour. Chemotherapy is with bleomycin, vindesine, 5-flurouracil or combination of these. These are used specially for the treatment of squamous cell carcinoma. This has shown to improve the survival compared with surgery alone.
Laser ablation therapy Good as a palliative method. This procedure is expensive, Repeated treatments are needed for the success, it also as serious adverse effects. Laser ablation therapy
Good as a palliative method. This procedure is expensive, Repeated treatments are needed for the success, it also as serious adverse effects.
Brachytherapy, photodynamic therapy or immunotherapy Used to downstage the tumor in some patients. Brachytherapy, photodynamic therapy or immunotherapy
Used to downstage the tumor in some patients.
Management of gastroesophageal reflux disease The main agents available for patients with GORD are antacids, H2-receptor antagonists, and proton pump inhibitors such as pantoprazole, omeprazole etc. Chronic relapsing GORD requires long-term maintenance treatment. Management of gastroesophageal reflux disease
The main agents available for patients with GORD are antacids, H2-receptor antagonists, and proton pump inhibitors such as pantoprazole, omeprazole etc. Chronic relapsing GORD requires long-term maintenance treatment.
Surgical resection of pharngeal pouch Surgical resection of pharyngeal pouch will relieve the symptoms. Surgical resection of pharngeal pouch
Surgical resection of pharyngeal pouch will relieve the symptoms.
Management of food bolus/foreign body Ingested foreign body if stays at one place for a longer time needs extraction or moving it into the stomach via endoscopy. Management of food bolus/foreign body
Ingested foreign body if stays at one place for a longer time needs extraction or moving it into the stomach via endoscopy.
Management of achalasia cardia Medical therapies for the achalasia are calcium antagonists or sildenafil with the aim of relaxing the smooth muscle of the lower oesophageal sphincter (LOS). Pneumatic dilatation using endoscope and injection of botulinum toxin provide short term improvement. Surgical management is cardiomyotomy that is to divide the muscle of the LOS longitudinally via transabdominal, transthoracic or thoracoscopic routes. Management of achalasia cardia
Medical therapies for the achalasia are calcium antagonists or sildenafil with the aim of relaxing the smooth muscle of the lower oesophageal sphincter (LOS). Pneumatic dilatation using endoscope and injection of botulinum toxin provide short term improvement. Surgical management is cardiomyotomy that is to divide the muscle of the LOS longitudinally via transabdominal, transthoracic or thoracoscopic routes.

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