9/18/2015. Disclosures. Objectives. Dysphagia Sherri Ekobena PA-C. I have no relevant financial interests to disclose I have no conflicts of interest

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1 Dysphagia Sherri Ekobena PA-C Disclosures I have no relevant financial interests to disclose I have no conflicts of interest Objectives Define what dysphagia is Define types of dysphagia Define studies to show a possible cause Define common causes and treatment of dysphagia 1

2 Dysphagia What is it? Subjective feeling of difficulty or abnormality of swallowing Other terms Odynophagia Pain with swallowing Globus Nonpainful sensation of lump in throat Without dysphagia, odynophagia, GERD or motility disorder For at least 3 of 6 months Types of dysphagia Oropharyngeal Also called transfer dysphagia Difficulty initiating a swallow May be accompanied by choking, coughing, regurgitation, aspiration Esophageal Usually several seconds after swallowing Feeling of food sticking in esophagus 2

3 Evaluation History taking to help determine oropharyngeal vs esophgeal Even in elderly should not just be attributed to age Oropharyngeal dysphagia Difficulty initiating a swallow Drooling, piecemeal swallows Coughing or choking during food consumption Dysphonia Evaluation through Speech Pathology 3

4 Esophageal dysphagia Sensation of food sticking several seconds after initiating a swallow From sternal notch down Sensation may be referred, especially if sensation suprasternal History taking Solids? Liquids? Differential for esophageal dysphagia Intraluminal Intrinsic Extrinsic Motility Functional Diagnostic Testing Upper endoscopy Barium Swallow Motility Testing 4

5 Upper endoscopy Web or ring Linear furrows consistent with EOE Esophagitis from reflux Laryngeal or esophageal cancer Zenkers diverticulum (+/-) Radiation stricture or changes Upper endoscopy If no significant pathology, esophageal biopsies looking for eosinophils Barium Esophagram Swallowing barium in prone-oblique position Swallow barium rapidly Also swallow 13 mm pill Can be used before or after endoscopy depending on risk factors 5

6 Barium Esophagram Better to do initially if: If high suspicion for Zenkers Diverticulum If history of radiation especially for head/neck cancers If suspicion for laryngeal cancer If high risk patient (anticoagulated, on plavix, etc) Esophageal Manometry New technology uses high resolution Checks squeezing and relaxing pressures in esophagus 6

7 Esophageal Manometry Can be helpful in diagnosing motility disorders Achalasia Spasm Nutcracker esophagus Scleroderma esophagus- but can also get stricture Sjogrens syndrome Other motility disorders Reflux esophagitis Inflammation inside the esophagus from acid Can cause dysphagia alone Can lead to strictures Reflux Esophagitis 7

8 Treatment of Reflux Esophagitis Medication PPIs or H2 blockers depending on severity surgery Nissen Fundiplication Linx Esophageal Stricture Most commonly from acid reflux Can happen in up to 10% of people with GERD Other conditions that lead to increased acid exposure Zollinger Ellison or s/p Heller Myotomy for Achlalsia Anastomotic stricture Damage from previous ingestion or causes such as graft vs host Esophageal Stricture 8

9 Treatment of Esophageal Stricture Depends on the cause Anastomotic Periodic dilation depending on symptoms Peptic-acid Acid blocker to prevent recurrence Esophageal Web/Ring Web most commonly happens in the cervical esophagus Thin mucosal fold protrudes into lumen Esophageal Web/Ring Esophageal Ring typically mucosa May be muscular Typically at GE junction 9

10 Eosinophilic Esophagitis Up to 15% of patients with dysphagia will have EoE Can be in younger patients as well May have linear furrows, stacked circular rings or white papules Diagnosed by biopsy Mid esophageal Greater than 15 eosinophils per high power field Eosinophilic Esophagitis Treamtent of Eosinophilic Esophagitis Acid suppression to help GERD Topical steroids such as fluticasone inhaler, swallowed vs budesonide Allergy testing and elimination of allergen Food and environmental Elemental diet Esophageal dilation 10

11 Esophageal Cancer Typically presents with rapidly progressive dysphagia Starts with solids then also with liquids May also have weight loss, anemia, odynophagia Other symptoms include chest pain, anorexia Esophageal Cancer Evaluation of Esophageal Cancer EUS can be helpful in staging CT versus PET scan Sometimes bronchoscopy is necessary in upper esophageal cancers to rule out invasion or fixation to the trachea 11

12 Treatment of Esophageal Cancer Depends on extent of disease Esophagectomy Radiation and/or chemotherapy Palliative stenting for dysphagia Radiation Injury Acutely can cause esophagitis Due to effects on basal epithelial layer Usually within 2-3 weeks of starting therapy Can complain of dysphagia, odynophagia, or chest pain May see mucositis or ulcerations on endoscopy Radiation Injury Late effects due to inflammation and scarring within the muscle layer Usually 6 months after treatment Dysphagia can be from stricture, motility disorder or nerve injury Can have chronic ulcerations which tend to be dose dependent 12

13 Radiation Injury Extrinsic causes of dysphagia Typically cardiovascular abnormalities Rare Older adults Severe atherosclerosis or aneurysm of the aortic arch Enlargement of the left atrium due to valvular disease Dysphagia Lusoria Aberrant right subclavian artery Dysphagia Lusoria 13

14 Diagnosis of extrinsic causes Mainly through esophagram Can also be diagnosed via CT scan of the chest EUS can diagnose Motility Disorders Achalasia Spastic motility Systemic sclerosis (scleroderma) Sjogrens Achalasia Loss of peristalsis in lower esophagus Failure of LES to relax Uncommon but can occur at any age Equal in men and women Progressive dysphagia Dysphagia to solids and liquids Can also regurgitate undigested food Unknown etiology 14

15 Achalasia Typical findings on esophagram include dilated esophagus and birds beak Will also find delayed emptying of barium Achalasia Need manometry for diagnosis Pseudoachalasia Chagas disease most common reason Malignancy Amyloid Sarcoid 15

16 Spastic Motility Disorders Diffuse Esophageal Spasm Nutcracker Esophagus Hypertensive Lower Esophageal Sphincter Ineffective esophageal motility disorder Diffuse Esophageal Spasm Rosary bead or corkskrew esophagus on esophagram May also be normal Can also be detected on manometry 16

17 Diagnosis of Motility Disorders Nutcracker esophagus, hypertensive LES and ineffective esophageal motility disorder all diagnosed via manometry Systemic Sclerosis 90% of patients with scleroderma have esophageal involvement Sclerosis or hardening of the smooth muscle layer of the gut Most commonly in distal 2/3 of esophagus Diagnosis via manometry Aperistalsis or low amplitude Sjogrens Defective peristalsis Xerostomia Exacerbates but not sole cause of dysphagia 17

18 Functional Dysphagia Rome III criteria Sense of solid or liquid lodging in esophagus Absence of GERD causing symptoms Absence of motility disorder Symptoms may be present intermittently or with every meal Treatment with calcium channel blocker, smooth muscle relaxant, antidepressant, anxiolytic or anticholinergic 18