A Multidisciplinary Approach to Esophageal Dysphagia: Role of the SLP Darlene Graner, M.A., CCC-SLP, BRS-S Sharon Burton, M.D.
What is the role of the SLP? Historically SLPs the preferred providers for evaluation and treatment of oral and pharyngeal stage dysphagia Assessment of the esophagus was not always included in the evaluation
ASHA Guidelines Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004) Issue: Pharyngoesophageal considerations While it is the responsibility of appropriately trained physicians to evaluate and diagnosis esophageal stage dysphagia. Clinicians should be aware that oropharyngeal swallowing function is often altered in patients with esophageal motility disorders and dysphagia. SLP have knowledge and skills to recognize patient signs and symptoms..associated with esophageal phase dysphagia.
ASHA Policy Statement Knowledge and Skills Needed by Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies (2004) B. Skills required 7. If esophageal screening is completed, describe any suspected anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow, deferring to radiology for diagnostic statements
ASHA Position Statement Instrumental Diagnostic Procedures for Swallowing (1991) The results of the VFSS may suggest that referral to a radiologist/gastroenterologist for an upper GI series or air contrast esophagram may be needed to view the esophagus. SLPs should have sufficient knowledge to make an appropriate referral and plan cooperative management.
ACR Appropriateness Criteria Abnormalities of the mid or distal esophagus or gastric cardia can cause referred dysphagia to the upper chest or pharynx Therefore, a combined radiographic evaluation of the pharynx, esophagus and gastric cardia is recommended in patients with unexplained pharyngeal dysphagia
Goals Review normal esophageal anatomy and physiology and how we evaluate them Demonstrate anatomic and/or physiologic abnormalities of the esophagus which might impact the pharyngeal swallow and produce dysphagia symptoms Present unknown case examples
Normal Esophagram Double Contrast High density barium thick Fizzies Goal: Mucosal detail Esophagitis Neoplasm
Single Contrast Phase Low density barium thin Single swallows for peristalsis Multiple swallows for detection of Rings Strictures Hernia
Esophageal Dysphagia Structural Causes Motility Disorders Diverticula Web Ring Stricture Hernia Neoplasm Achalasia Scleroderma Diffuse spasm Non-specific esophageal dysmotility (NEMD)
Cervical Web 1-2 mm, anterior wall Hemispheric and circumferential webs (rings) cause solid food dysphagia Associations: GE reflux, Plummer- Vinson syndrome
GE Reflux Fluoroscopic evaluation is limited for detection of GER 24-hour ambulatory ph testing is the most accurate way to document reflux Evaluate patient for complications of GERD
Peptic Esophagitis Abnormal Motility Granular mucosa Thickened folds > 3mm Nodularity Ulceration Better detected with endoscopy
Peptic Strictures Distal esophagus Hiatal hernia in > 90% Fluoroscopy better than EGD for ring and stricture detection 95% sensitivity EGD for biopsy and dilatation
Barrett Esophagus Columnar metaplasia Occurs in 10-15% of patients with reflux esophagitis Premalignant High stricture or ulcer, reticular pattern
Eosinophilic Esophagitis Esophageal biopsies: Many intraepithelial eosinophils (80/high power field) Associated with food allergies Treatment: Oral steroid (Fluticasone) therapy 220 mcg two puffs a day
Hiatal Hernias Sliding Paraesophageal Mixed Intrathoracic stomach
Esophageal Cancer Chronic GERD Barrett esophagus Adenocarcinoma Risk factors for squamous cell carcinoma: Smoking ETOH Achalasia
Achalasia Primary Idiopathic Progressive dysphagia Dilated esophagus Birdbeak Secondary Neoplasm of distal esophagus or gastric cardia Chagas disease
Achalasia Aperistaltic esophagus Failure of relaxation of lower esophageal sphincter Treatment options Dilatation Heller myotomy and fundoplication Botox injection
Scleroderma Motility pattern Proximal 1/3 striated muscle normal peristalsis Distal 2/3 smooth muscle impaired motility Patulous GE junction GE reflux can cause distal stricture
Diffuse Esophageal Spasm (DES) Chest pain Intermittent dysphagia Segmental nonperistaltic contractions Corkscrew esophagus Muscular hypertrophy
References Adler, D. G., Romero, Y., Primary esophageal motility disorders. Mayo Clin Proc. 2001;76:195-200. Crescenzo, D. G., Trastek, V. F., Allen, M. S., Deschamps, C., Pairolero, P. C. Ann Thorac Surg. 1998; 66:347-350. Martin, R. E., Letsos, P., Taves, D. H., Inculet, R. I., Johnston, H., Preikasaitis, H. G., Oropharygeal dysphagia in esophageal cancer before and after transhiatal esophagectomy, Dysphagia. 2001; 16:23-31. Philippsen, L. P., Weisberger, E. C., Whiteman, T. S., Schmidt, J. L., Endoscopic stapled diverticulotomy: Treatment of choice in Zenker s diverticulum. The Laryngoscope. 2000; 110:1283-1286. Sofer, E., Murray, J. A., Schulze-Delrieu, K., Esophagoscopy and tests of esophageal function. In Perlman, A. L. and Schulze-Delrieu, K. (eds) Deglutition and its Disorders. Singular Publishing Group: San Diego. 1998.
Reference Links Levine M.S., Rubesin S.E. Diseases of the Esophagus: Diagnosis with Esophagography. Radiology 2005; 237:414-427. http://radiology.rsnajnls.org/cgi/content/full/237/2/414?maxtoshow=& HITS=10&hits=10&RESULTFORMAT=&author1=levine&fulltext=esop hagus&searchid=1&firstindex=0&sortspec=relevance&resourcety pe=hwcit ACR Appropriateness Criteria: Dysphagia http://www.acr.org/s_acr/bin.asp?cid=1207&did=11772&doc=file. PDF