Running diagnostics

Running diagnostics

Tuesday, June 26, 2018

Dysphagia

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Onto this week's topic:

Have you ever had to swallow something big and had it stuck in your throat? It’s a really uncomfortable sensation, right? Can you imagine what it would feel like having difficulty swallowing everything you eat all the time? Today’s topic—dysphagia—literally means difficulty swallowing. It can be due to a range of conditions/diseases, so let’s start with a broad overview:
Esophageal diverticula are defined as outpouchings of one or more layers of the esophageal tract. They are commonly associated with motility disorders, and clinical features include dysphagia, regurgitation, retrosternal pain, and intermittent vomiting; however, they can also be asymptomatic in some people.



Esophageal diverticula are classified according to their location:
·      Pharyngoesophageal (Zenker’s) diverticulum
o   Most frequent form of esophageal diverticulum
o   Posterior pharyngeal outpouching found most often on the left side, above cricopharyngeal muscle and below the inferior pharyngeal constrictor muscle
o   Symptoms: dysphagia, regurgitation of undigested food, halitosis
o   Treatment: endoscopic or surgical myotomy of cricopharyngeal muscle +/- surgical excision of sac
·      Mid-esophageal diverticulum
o   Secondary to mediastinal inflammation (“traction” diverticula) or motor disorders
o   Usually asymptomatic and no treatment is required
·      Diverticulum just proximal to lower esophageal sphincter (pulsatile type)
o   Usually associated with motor disorders
o   Usually asymptomatic and no treatment required
Peptic strictures caused by esophagitis usually presents as dysphagia with a long history of reflux symptoms, but reflux symptoms may disappear as stricture develops. The diagnosis is made through endoscopy or barium study (if endoscopy contraindicated or unavailable). Treatment includes endoscopic dilatation and indefinite PPI therapy; if these two are unsuccessful, consider anti-reflux surgery.

Sometimes esophagitis does not have to cause strictures to cause dysphagia. Infectious esophagitis—severe mucosal inflammation and ulceration can result from viral or fungal infections. Risk factors include diabetes, chemotherapy, and immune-compromised states. Patients characteristically present with odynophagia, less often with dysphagia. The diagnosis is made via endoscopic visualization (whitish-yellow plaques—Candida (most common); focal ulcers—Herpes (second most common) or CMV) and biopsy. Treatment is based on investigation findings. For candida, Nystatin swish and swallow, ketoconazole, and fluconazole are prescribed. Herpes is often self-limiting and is treated with anti-viral agents like acyclovir, valacyclovir, or famcyclovir. CMV is treated with IV anti-viral agents gancyclovir or famcyclovir.

Esophageal webs refer to partial occlusions of the upper esophagus. Esophageal rings refer to circumferential narrowing of the lower esophagus. These can be asymptomatic with the lumen diameter is >12mm, provided peristalsis is normal. Dysphagia occurs with large food boluses. A special case is the occurrence of a Schatzki’s ring, which is a mucosal ring at the squamous-columnar junction above a hiatus hernia; it causes intermittent dysphagia with solids. Treatment involves disrupting ring with endoscopic bougie.

The significance of esophageal webs comes with exam questions about Plummer-Vinson Syndrome Triad!
·      Iron deficiency anemia
·      Dysphagia
·      Esophageal webs
This is a very rare condition (prevalence < 1/1,000,000) but the prognosis is good when treated with iron supplementation and esophageal dilatation.

Esophageal motor disorder falls under neuromuscular category. Patients present with dysphagia of both solids and liquids; some may also present with chest pain. It may be idiopathic or due to achalasia (no pain), scleroderma (no pain), diabetes mellitus, and diffuse esophageal spasm (DES—may have chest pain; rare and hard to diagnose due to intermittent presentation). Tests such as esophageal manometry (motility study) will help confirm diagnosis; barium swallow can sometimes be helpful too.





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