DISFAGIA

Dr.Rista D.Soetikno, Sp.Rad.(K), M.Kes.

DYSPHAGIA
= difficulty swallowing
Epidemiology
- Occur in all age groups
- The incidence of dysphagia is higher in the elderly
- Resulting from congenital abnormalities, structural damage,
and/or medical conditions
- It is classified into :
1. Oropharyngeal dysphagia
2. Esophageal dysphagia
- No organic cause for dysphagia can be found
functional dysphagia

DYSPHAGIA:
1. Oropharyngeal Dysphagia
2. Esophageal Dysphagia

Oropharyngeal Dysphagia
Arises from abnormalities of upper esophagus, pharynx,
& oral cavity.
Symptoms & signs
Swallowing difficulties (=dysphagia) include:
- Inability to recognize food
- Difficulty placing food in the mouth
- Inability to control food/saliva in the mouth
- Difficulty initiating a swallow
- Coughing
- Choking
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Symptoms & signs

- Frequent pneumonia
- Unexplained weight loss
- Gurgly/wet voice after swallowing
- Nasal regurgitation
- Swallowing difficulty
Complication
- Aspiration pneumonia
- Malnutrition
- Dehydration

Etiology
- Stroke
- Neurodegenerative diseases:
Parkinsons disease & Alzheimers disease
- Mechanical obstruction: malignancies
- Surgical procedures

Assessment of adults
- A Speech Language Pathologist
- Electromyography (EMG)
- Electroglottography (EGG)
- Cervical auscultation
- Pharyngeal manometry
- Imaging studies:
A modified Barium Meal, ultrasound, scintigraphy
- A Videoendoscopy

Treatment
- Feeding instructions, including posture while eating,
swallowing maneuvers, consistency of food,
& size of mouthfuls
- Environmental modification
- Oral sensory awareness techniques
- Vitalstim therapy/electrical stimulation (E-stim)
- Prosthetics
- Surgical treatments

Esophageal Dysphagia
Arises from the body of the esophagus, lower
esophageal sphincter, or cardia of the stomach.
Symptoms & signs
1.
A motility problem:
dysphagia to both solids & liquids
2.

A mechanical obstruction:
dysphagia initially to solids but progresses to involve
liquids
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Etiology
1. A motility problem (solids & liquids)(neuromuscular)
1.1. Intermittent: Diffuse Esophageal Spasm (DES)
1.2. Progressive: Scleroderma or achalasia
2. A mechanical obstruction (solids only)
2.1. Intermittent: Lower esophageal ring
2.2. Progressive: Esophageal stricture or esophageal cancer

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Diagnostic Tools
- A barium meal:
any suspicion of a proximal lesion
- A manometry:
if achalasia suspected on barium swallow
- An upper endoscopy:
if a stricture is suspected
if there is no suspicion of any of the above

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Diffuse Esophageal Spasm (DES)

Background:
It can be subdivided into 2 distinct entities:
1. Diffuse esophageal spasm (DES)
2. Nutcracker esophagus
Frequency:
- In the US
: True incidence cannot be determined.
- Internationally: True incidence is not known.
Mortality/Morbidity:
- Mortality is very rare
- Morbidity arises from an inability to eat

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Race: More common in whites.

Sex : More common in women
Age :
- Rare in children
- Incidence increases with age
History:
- Noncardiac chest pain (80%)
- Globus
- Dysphagia
- Regurgitation
- Heartburn (20%)

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Causes: Unknown
Imaging Studies:
Barium meal
- The best imaging study to aid in the diagnosis
- A characteristic appearance :
multiple simultaneously contractions (a corkscrew appearance)
CT
- Thickening of the esophagus (Normal < 3 mm)

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Diffuse Esophageal Spasm

a corkscrew appearance

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Scleroderma
Frequency:
- In the US: 14 cases per million.
- Internationally: Estimated incidence is 20 cases per million
Morbidity:
It is involved in 50-90% of patients
Pathophysiology:
Progressive atrophy of smooth muscle with replacement
by fibrosis.

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Sex: Male :Female = 1 : 3

Age: Symptoms manifest in the 4th-6th decades
History:
- Often asymptomatic
- May be required to eat/drink in sitting/erect position
Complication:
- Reflux esophagitis
- Barrett metaplasia
- Carcinoma

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Imaging Studies:
Barium meal
- Normal stripping wave in the upper third of the esophagus.
- Dilated, atonic esophagus from the aortic arch down.
- Esophagogastric junction is patulous.
- Gastroesophageal reflux
- In the upright position, barium flows rapidly into the stomach.

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Scleroderma

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Achalasia
Background:
- A primary esophageal motility disorder
- Functional obstruction of the distal esophagus with proximal
dilatation, caused by incomplete relaxation of the lower
esophageal sphincter.
Pathophysiology:
Paucity/absence of ganglion cells in the myenteric plexuses (Auerbachs) of
the distal esophageal wall.
Frequency:
- In the US

: The incidence = 1 per 100,000 people/year

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Sex: Male: female = 1 : 1

Age: Occurs in adults aged 25-60 years
History:
- Dysphagia
- Regurgitation
- Chest pain
- Heartburn
- Weight loss
Causes: Unknown

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Imaging Studies:
Chest radiograph
- Small/absent gastric air bubble.
- Dilatation & tortuousity of the esophagus causing
a widened mediastinum on the right side adjacent to
the cardiac shadow.
Barium meal
- Multiple uncoordinated tertiary contractions.
- Smooth tapered, conical narrowing of the distal esophagus
( a birds beak sign).
- Small spurts on barium entering the stomach on
erect films (jet effect).

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Achalasia

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Achalasia

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Lower Esophageal (Schatzki) Ring

Background:
- The most common structural abnormalities in the esophagus
Frequency:
- In the US
: The true prevalence of LER is unknown
- Internationally: Prevalence is unknown.
Mortality/Morbidity:
- Asymptomatic
- An esophageal lumen < 13 mm have dysphagia
- No reports on mortality exist

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Race: Predominantly affect white individuals

Sex :
- Dont demonstrate a sex prevalence
- LER are found mostly in female patients
Age:
- In all age
- Become symptomatic until after the age of 40 years
History:
- Dysphagia to solid food usually is greater than dysphagia to
liquid food.

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Causes:
- Congenital
- Acquired:
GERD, caustic ingestion, pill-induced inflammation,
mediastinal radiation
Imaging Studies:
Barium meal
- The diagnostic test of choice
- Relatively save
- Smooth concentric narrowing of the distal
esophagus
arising several centimeters above the diapragm.
- Reflux of barium

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Lower Esophageal (Schatzki) Ring

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Lower Esophageal (Schatzki) Ring

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Lower Esophageal (Schatzki) Ring

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Esophageal stricture
Background:
Disease processes that can produce esophageal strictures can be grouped
into 3 general categories:
- Intrinsic diseases (inflammation,fibrosis, or neoplasia)

- Extrinsic diseases (direct invasion/lymph node

enlargement)
- Diseases that disrupt esophageal peristalsis and/or
lower esophageal sphincter (LES)

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Pathophysiology:
Esophageal strictures are sequelae of GERD induced esophagitis.
Frequency:
- In the US:
Occur in 7-23% of untreated patients with reflux disease.
- GERD : 70-80% of all cases of esophageal strictures
- Postoperative strictures: 10%
- Corrosive strictures: < 5%

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Sex: More common in men.

Age:
Patients tend to be older, with a longer duration of reflux symptoms
History:
- Heartburn, dysphagia, odynophagia, food impaction,
weight loss, & chest pain.
- Progressive dysphagia for solids, this may progress to
include liquids

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Causes:
1. Proximal/mid esophageal strictures:
-Caustic ingestion (acid/alkali)
- Malignancy
- Radiation therapy
- Infectious esophagitis
- AIDS
- Medication-induced stricture (pill esophagitis)-Ascorbic
acid, ferrous sulfate, nonsteroidal anti inflammatory drugs
- Diseases of the skin Pemphigus vulgaris
- Extrinsic compression

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2. Distal esophageal strictures:

- Esophageal stricture-GERD, Zollinger-Ellison syndrome
- Adenocarcinoma
- Collagen vascular disease-scleroderma, SLE,
rheumatoid arthritis
- Extrinsic compression
- Sclerotherapy & prolonged nasogastric intubation
- Crohn disease

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Imaging Studies:
Barium esophagram
- 100% sensitivity with luminal diameter < 9 mm
- Disordered esophageal motility (dilated, atonic esophagus)
is often an early finding.
- Multiple ulcerations of various sizes that frequently involve
the entire thoracic esophagus.
- Irregular, nodular, plaque-like mucosal pattern with
marginal serrations (shaggy appearance)
- In radiation esophagitis, fibrotic healing produces
a smooth tapered stricture.

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 Chest radiograph
- Should be used as an adjunct if extrinsic compression is
considered a possible etiology of esophageal strictures.
CT
- To stage malignancies

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Peptic stricture

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Peptic stricture

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Esophageal cancer
Frequency:
- In the US:
*10,000-11,000 deaths/year
* Incidence of Esophageal cancer = 3-6 cases/100,000 persons
- Internationally:
* The 7th leading cause of cancer death worldwide
* Incidence : 30-800 cases per 100,000 persons
Sex: More common in men (Male : Female = 7 : 1)
Age:Occurs most commonly during the 6th & 7th decades of life

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History:
- Dysphagia is initially experienced for solids, but
eventually it progresses to include liquids.
- Weight loss (> 50%)
- Pain in the epigastric/retrosternal area
- Hoarseness
- Respiratory symptoms
Causes:
- It is thought to be related to exposure of the esophageal
mucosa to noxious/toxic stimuli.
- GERD is the most common predisposing factor.

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Imaging Studies:
Barium meal
- Flat plaque-like lesion on one wall of the esophagus.
- Encircling mass with irregular luminal narrowing &
overhanging margins.
- Polypoid (often fungating) filling defect.
- Large ulcer niche within a buldging mass.
CT
- Invasion of adjacent tissues (tracheobronchial tree, aorta,
pericardium).
- Mediastinal adenopathy.
- Metastases to the liver & abdominal lymph nodes.

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Esophageal cancer

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Esophageal cancer

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Treatment
- The patient is sent for a GI, pulmonary, ENT, or
oncology consult
- A consultation with a dietician

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