Dysphagie Algorithmus der Abklärung. Andreas Eherer Abteilung f Gastroenterologie u Hepatologie Medizinische Klinik
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1 Dysphagie Algorithmus der Abklärung Andreas Eherer Abteilung f Gastroenterologie u Hepatologie Medizinische Klinik
2 Dysphagie Sodbrennen Dyspepsie Globus Odynophagie Rumination Aerophagie Non Cardiac Chestpain
3 Historical approach to diagnosis of dysphagia Castell DO. Evaluation of dysphagia: A careful history is crucial. Dysphagia 2:65, 1987
4 Rationale der Annahmen Motility Problem Mechanical Obstruction
5
6 Ursachen Oropharyngealer Dysphagie Iatrogen MedikamentenNebenwirkung Postoperativ Bestrahlung Infektiös Mucositis Diphtherie Botulismus Lyme Diseas Syphilis Metabolisch Amyloidose Cushing Syndrom Thyreotoxikose Mb. Wilson Myopathisch Connective tissue diesaese Dermatomyositis Myasthenia gravis Myotonic Dystrophy Oculopharyngeale Dystrophy Polymyositis Sarcoidose Paraneoplastisches Syndrom Neurologisch Hirnstammtumore Schädeltrauma Insult Zeebrale Lähmung Guillain-Barré Syndrom Multiple Sklerose Polio Postpolio Syndrom Tardive Dyskinesie Metabolische Encephalopathie Amyotrophe Lateralsklerose Parkinsonsche Erkrankung Demenz Strukurell Cricopharyngeal Bar Zenker s Divertikel Cervicale Webs Oropharyngeale Tumore Osteophyten Kongenital (Kieferspalten, Divertikel, Aus: Uptodate 2018
7 Werkzeuge oropharyngeale Dysphagie Videoflouroskopie Naso-Endoskopie Fiberoptische endosk. Evaluation des Schluckes (FEES) Pharyngoösophageale High-Resolution Manometrie Automated Impedance Manometry Wasserschlucktest
8
9 Ursachen Ösophagealer Dysphagie Mechanische Läsionen, intrinsisch Benigne Tumoren Verätzung / Strikturen Divertikel Maligne Tumoren Peptische Strikturen Eosinophile Ösophagitis Infektiöse Ösophagitis Pill induced Ösophagitis Postoperativ Strahlenösophagitis / Striktur Rings and Webs Lymphozytäre Ösophagitis Motilitätsstörungen Achalasie Chagas Erkrankung Primäre Motilitätsstörungen Sekundäre Motilitätsstörungen Funktionelle Dysphagie Mechanische Läsionen, extrinsisch Aberante Arteria subclavia Cervikale Osteophyten Aortenaneurysma Vergrößerter Linker Vorhof Mediastinale Kompression (Lnn, Lungentumore,...) Postoperativ (laryngeal, spinal) Aus:Uptodate 2018
10 Werkzeuge ösophageale Dysphagie Ösophago-Gastroskopie Schluckaktröntgen mit Barium Ösophagusmanometrie Ösophagus High-Resolution Manometrie (Radionuclid Ösophagus-Transit-Szintigraphie)
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12
13 Rationale der Annahmen Motility Problem Mechanical Obstruction
14 often a thorough history can lead the physician to a correct diagnosis in 80% to 85% of patients with dysphagia.. (1959!!) Schatzki R: Panel discussion on diseases of the esophagus. Am J Gastroenterol 1959, 31: INGELFINGER FJ, KRAMER P, SOUTTER L, SCHATZKI R.
15 The patient s localization of the site of bolus impaction is of limited help into a diagnostic algorithm, which can have a diagnostic accuracy as high as 80% when 39 questions are answered sequentially. Edwards, D.A.W. Clinics in Gastroenterology. Vol
16 Edwards, D.A.W. Discriminators Value of Symptoms in the Differential Diagnosis of Dysphagis
17 Flow charts of questions for the diagnosis of the common causes of dysphagia. The doctor should ask himself these questions; they are not designed to be addressed to the patient.
18 Rationale der Annahmen Motility Problem Mechanical Obstruction
19 Auch und viele andere denkbare Annahmen
20 Wie konnte eine solche anamnestisch-diagnostische Diskrepanz ein halbes Jahrhundert hingenommen werden?
21 Chicago Klassifikation 3.0 CDP Contractile deceleration point DCI Distal contractile integral IRP Integrated relaxation pressure DL Distal latency Kahrilas et al. Neurogastroenterol Motil 2015
22
23 Achalasia Type I Type II Type III Outflow Obstruction
24 Distal esophageal spasm Jackhammer esophagus Absent contractility
25 Versuch einer Alternative zu den bisherigen Algorithmen
26 Nie vergessen!! Dysphagia is an alarm symptom that warrants immediate evaluation to define the exact cause and initiate appropriate therapy. Dysphagia in older adult subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities, which are rarely symptomatic
27 Ösophagoskopie diagnostisch Mechanische Läsionen, intrinsisch Benigne Tumoren Verätzung / Strikturen Divertikel Maligne Tumoren Peptische Strikturen Eosinophile Ösophagitis Infektiöse Ösophagitis Pill induced Ösophagitis Postoperativ Strahlenösophagitis / Striktur Rings and Webs Lymphozytäre Ösophagitis Motilitätsstörungen Achalasie Chagas Erkrankung Primäre Motilitätsstörungen Sekundäre Motilitätsstörungen Funktionelle Dysphagie Mechanische Läsionen, extrinsisch Aberante Arteria subclavia Cervikale Osteophyten Aortenaneurysma Vergrößerter Linker Vorhof Mediastinale Kompression (Lnn, Lungentumore,...) Postoperativ (laryngeal, spinal) Aus: Uptodate 2018
28 Typische Konstellationen Das Häufige ist häufig
29 Vorgeschlagener Algorithmus Anamnese ÖGD Schluckaktröntgen Spezialuntersuchung
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