أسئلة الأولى GIT الدلتا - Dysphagia

• Dysphagia refers to a delay in the movement of a swallowed bolus from mouth to stomach, or a sensation of food obstruction in the chest, oropharynx, or esophagus.
• Odynophagia is pain during swallowing and can coexist with Dysphagia in the same patient.
• Globus sensation is the feeling of a lump or fullness in the throat without swallowing difficulty.
• Aphagia is the inability to swallow, which happens when a food bolus gets stuck in the esophagus, blocking the passage of ingested substances.

Phases of Dysphagia

• The oral phase starts with the mechanical preparation of a food bolus by the muscles of the jaw, face, and tongue, which is then propelled posteriorly and superiorly by the tongue and palate.
• The pharyngeal phase begins as the bolus passes the anterior tonsillar pillars with the soft palate closing the nasopharynx.
• The tongue base and pharyngeal constrictors continue to propel the bolus posteriorly as the lips and jaw remain closed, to allow elevation of the larynx and closure of the laryngeal valves.
• Airway protection this opens the upper esophageal sphincter (UES) which takes less than 1 second.
• At rest, the UES protects against air entry into the esophagus and regurgitation into the pharynx.
• The pharyngeal phase is involuntary and happens at a rate of 3-4cm/second.
• The esophageal phase begins when a food bolus enters the esophagus with the UES closing and the bolus propelled to the stomach via coordinated muscular contractions.
• The oral and pharyngeal phases involve striated (voluntary) muscles of the mouth and pharynx
• Swallowing is controlled by medulla oblongata.
• The swallowing center can be activated by ①cerebral cortex (volitional swallowing) or ② Afferent impulses from oropharynx (reflexive swallowing).

Primary Peristalsis

• Primary Peristalsis is initiated by swallowing via a central program generator in the medulla.
• Coordinated contractions are propagated through the striated muscle and the more distal esophagus through multiple control mechanisms.

Secondary Peristalsis

• Secondary peristalsis is a response to esophageal distension due to retained or refluxed material.
• The lower esophageal sphincter (LES) contains esophageal smooth muscle and crural diaphragm and relaxes with swallowing and peristaltic contractions for passage of the food bolus into the stomach through the Vagus nerve.

Oropharyngeal Dysphagia (Transfer Dysphagia)

• Oropharyngeal Dysphagia is caused by defects in the oral and pharyngeal phases of swallowing.
• The discomfort is typically reported within 1 second of initial swallow.
• Difficulties include ①Preparing food for swallowing, ② Transferring a bolus of food from the oral cavity into the esophagus.
• Symptoms include, Difficulty initiating a swallow, sensation of food sticking in the back of the throat, couching/choking or nasal regurgitation of fluid or food.
• Neuromuscular disorders that can cause include, cerebrovascular accident, parkinsons disease, amyotrophic lateral sclerosis, poliomyelitis/polymyositis/myastenia gravis, brain tumors, hypothryoidism, abnormal upper esophageal sphincter relaxation.
• Structural lesions include oropharyngeal neoplasms, inflammation, plummer-vinson syndrome, cervical hyperostosis, thyromegaly, lymphadenopathy, prior, oropharyngeal surgery, zenker's diverticulum.

Plummer-Vinson Syndrome

• Occurs in people 40-50 and is rare, affecting less then 1% IDA with a classical triad of Dysphagia, Iron-deficiency anemia, Esophageal webs.
• The pathophysiology may involve Iron deficiency, malnutrition, genetic predisposition, or autoimmune processes.
• Treatment includes Iron Replacement, Dilatation
• Prognosis consist of increased risk of squamous cell carcinoma of the pharynx and esophagus.

Esophageal Dysphagia

• Caused by defects in the esophageal phase of swallowing.
• Symptoms include, Sensation of food sticking in the throat or chest, or chest pain of regurgitation soon after swallowing.
• Neuromuscular (motility) disorders cause dysphagia to both solids and liquids from onset of symptoms.
• These diseases include, Achalasia, Scleroderma, hypertensive lower esophageal sphincter, diffuse esophageal spasm, chagas' disease, nutcracker esophagus.
• Structural (anatomic, organic) lesions cause Dysphagia to solid foods but may later include liquids as well.
• These lesions include, Benign stricture, Esophageal cancer, Schatzki ring, esophageal webs, foreign bodies, extrinsic compressions.
• CREST refers to ①Calcinosis - Calcium deposits in the skin, ②Raynaud's phenomenon - spasms of blood vessels in response to cold or stress, ③ Esophageal dysfunction - acid reflux and decrease in motility of esophagus, ④Sclerodactyly - thickening and tighteting of the skin on the fingers and hands, ⑤ Telangiectasias - dilation of capillaries causing red marks on surface of the skin.

Evaluation of Oropharyngeal Dysphagia

• History and physical examination should begin with examination to identify underlying illness.
• Careful neurologic examination included direct observation of the patient while swallowing water.
• A modified barium swallow (MBS) is the best initial study for suspected oropharyngeal Dysphagia.
• During an MBS the oral and pharyngeal phases are observed in real time by testing the patient with thin liquids/thick liquids, and barium cookies/crackers.
• MBS helps identify abnormalities of oropharyngeal phases and diet
• A fiberoptic endoscopic evaluation of swallowing (FEES) requires passing an endoscope via the nares to observe the nasopharynx/oropharynx/larynx to analyze swallow structures and their function during intake of food with various constistencies.
• Evaluation of High resolution manometry (HRM) identifies upper esophageal sphincter pathology.
• CT scans are needed to evaluate patients with signs of malignancy such as bleeding and weight loss.
• Esophagogram (barium swallow) is needed for the diagnosis of Zenker's diverticulum.

Evaluation of Esophageal Dysphagia

• An upper GI endoscopy allows for direct visualization of the esophagus, tissue biopsy and dilating/stenting the stricture.
• Barium Swallows or esophagograms are most useful when when subtle stricture or narrowing can be visualized before endoscopic evaluation while it also reveals esophageal abnormalities.
• Motility disorders, achalasia, diffuse esophageal spasm, and scleroderma can be diognised.
• Indications are used when structural or obstructive processes not identified or when a motility disorder is suspected.
• Pass a thin catheter by the nose down the esophagus and over the LES.
• Pressure measurements are taken over length of esophaguses during swallow.
• Modern modification of traditional esophageal manometry
• It is the gold standard for diagnosis of achalasia, primary, and seconday motor disorderes..

Advantages of High Resolution Impedance Manometry (HRIM)

• Better Visualization and accuracy with the Pan-Esophageal Pressure (PEP) with the colorimetric graphic presentation (Clouse plot).
• An Impedance measurement is conducted adding electrodes to measure conductivity.
• Swallow generated a low impedance with peristalsis.
• Direction of reflux can be measured easy.

Clouse Plot for Esophageal Dysphagia

• Type 1 Achalasia - LES-IRP is increased and LES fails to relax.
• There's a total lack of peristalsis with intermediate repose.
• Type 2 Achalasia - LES-IRP is increased and LES fails to relax.
• Theres no peristalsis.
• Increase in pressure with medication, best prognosis
• Type 3 Achalasia - LES-IRP is increased and LES fails to relax.
• Theres no peristalsis with worst prognosis

Primary Motility Disorders of the Esophaguses

• Nutcrakcer Esophagus
• LE Pressure > 180 mmhg and duration is >7 sec, peristaltic wave progression is normal and normal relaxation of the LES, and additional info includes multipeak contractions.
• Diffuse Esophageal Spasm
• High amplitude of >120 mm Hg in duration of >2.5sec, peristaltic wave progression is least 20% simultaneous, normal relaxation of the LES, and additional info includes simultaneous, contractions of high amplitude.
• Hypertensive lower Esophageal Sphincter-
• LEs pressure is >26 w/ hyperperistaltic and normal relaxation of the LEs
• Achalasia Cardia
• LEs pressure is ≥26 mmH and has loss of peristalsis

Chicago Classification of Esophageal 1ry Motility Disorders

• Type 1 had an elevated IRP and failed to relax which means 100% failure of the swallow to reach that valve
• Type 2 has an elevated IRP and and Paneosophagus Pressure in 20% swallows
• Type 3 has an elevated IRP and spasm in 20% swallows

Dysphagia-Associated Complications

• Aspiration
• Aspiration-induced pneumonia
• Malnutrition, Morbidity, and Mortality.
• Inpatient hospital stays are lengthened.
• This diminishes life quality

Management of Dysphagia

• Treatment of the cause is critical
• Consultation a speech therapist provides consistency
• Endoscopic treatment for Zenker
• Alternative Nutritional Support is a nasogastric/jejunosotomy Tube inserted by a gastronenterologist/surgeon.
• Endoscopic therapies; including dilation of structures and rings
• Obstructing tumors/tumors can be treated with tumor dilation
• Motility disorders treatment by botulinum toxin
• Surgical myotomy for achalasia is crititcal
• Gastronomy placement

Functional Dysphagia

• Sense of dysphagia results in normal radiographic or manometric but normal transit and normal esophageal biopsy
• Augmented afferent esophageal sensation as they "feel"
• Stili have food/liquid longer Symptoms:
• dyspepsia/satiety
• therapies are behavioral/cognitive/pharmocologic

Sarcopenic Dysphagia

• Limb and swallowing muscles are weakened in muscle mass related to elderly w/ diminished swallowing.
• Evaluate swallowing to assess questionnaires with modified water tests and studies
• Apply electromyography and manometry to assess
• Strengthen muscles with exercises or nutrition