Dysphagia

00:01 With dysphagia, we’ll be looking at an algorithm, and with the algorithm, as I told you earlier, the objective of this slide is to show you the behavior of the dysphagia.

00:14 If it’s solid food only that the patient is suffering or experiencing dysphagia to, what kind of differential… what kind of description would you then call it? Let’s talk about intermittent at first.

00:25 Intermittent to you would mean that there is a fixed obstruction in which the caliber of the esophagus is becoming a little bit more narrowed making it difficult for solid food to then transit through the esophagus.

00:41 And we will then describe in great detail esophageal rings.

00:46 Even show you esophageal rings.

00:47 There’ll be quite a number of images here that will do with endoscopy, upper endoscopy.

00:53 What if the patient says, “Hey Doc, I’m having a hard time eating”, “Oh, tell me about this difficulty that you’re having with eating.

01:00 Is it with solids? Liquids? Tell me about how that occurs. Is it solids?" “Yeah, I’m having a hard time with solids." “Okay." “But you know what Doc, I would say about a year ago I was having difficulty with solids but then I noticed that now that I think about it, I was having a hard time with drinking milkshakes couple months later." “Hmm." “And then it got to a point where I was having a hard time you know, just about getting anything through." That’s progressive.

01:31 Progressive.

01:33 See, initially the patient was having a hard time getting solids through because of the bulky nature of it.

01:39 And as this obstruction started growing within the esophagus, was making it more difficult for other substances to pass through as the substance got thinner and thinner and thinner referring to the fact that you’re moving from solids towards liquid, and as the obstruction is getting bigger.

01:55 Common sense.

01:58 Now, if it’s progressive and the patient is also feeling “heartburn”, then you should be thinking about peptic strictures which we’ll talk about upcoming.

02:09 Now peptic stricture, different from a ring because the stricture represents the fact that there was well, hardening that was taking place in the esophagus.

02:19 In the meantime, as far as the physiology is concerned with the esophagus, remember that the esophagus is in the upper portion.

02:27 Skeletal muscles are there for more or less under voluntary control but for the most part though, you really don’t think about getting food into the stomach.

02:35 So therefore, as you move down, distally through the esophagus, then your muscle now becomes smooth.

02:41 In other words, involuntary.

02:44 Also with the esophagus, physiologically you have peristalsis.

02:48 It’s nice and malleable.

02:50 It should not be hardened.

02:51 There shouldn’t be fibrosis.

02:53 It should be waves of peristalsis which then literally, if you were to squeeze toothpaste, you’re moving the paste forward.

03:01 That’s exactly what’s happening in your GI system.

03:04 So stricture, as we talk about this later, is a disruption with that.

03:10 If there is no heartburn, as a patient gets older, now this can be extremely concerning, maybe perhaps there’s esophageal cancer that’s involved.

03:22 And with esophageal cancer in esophagus, once again it’s a fact that you have to come back to the histology to pay attention to well, what was the nature and what was the trigger for this particular type of esophageal cancer? What do you mean type? Obviously there will be two major types that we will discuss in our discussion.

03:41 And which we will take a look at our squamous cell cancer and adenocarcinoma.

03:47 Point is, esophageal cancer even though technical as far as cancer is concerned, it does move rather quickly.

03:55 In description for dysphagia, it’ll be progressive.

03:59 Solids first then liquids as the tumor grows, grows, grows, grows, grows within the esophagus making it more difficult for substance to pass through.

04:10 What if the patient was having dysphagia to solids and liquids at the same time? At the same time.

04:17 “Hey Doc, I’m having a hard time eating." “Okay, well tell me about your eating pattern.

04:23 Is it solid foods that you’re having issues with?" “Yeah Doc, I’m having a hard time having my dinner.

04:31 Having a hard time swallowing my potatoes." “Okay, and what about the liquids?" “Yeah I’m having a hard time passing through my juices." “Hmm, well what occurred first?" “Well, to tell you the truth Doc, pretty much around the same time." “Mmm, same time." Dysphagia, intermittent with chest pain.

04:54 Now we have diffused esophageal spasms.

04:59 Comes back to your understanding once again of physiology.

05:02 What does peristalsis mean? Smooth coordinated movement so that you have proximal constriction and distal dilation.

05:11 So that as you squeeze the esophagus, involuntary, the propulsion movement of the food.

05:19 What… all of a sudden, you have diffuse esophageal spasms in which you don’t have coordinated contraction of esophagus. Then you would have issues with both solids and liquids as far as swallowing. Progressive, with this heartburn, you should be thinking about scleroderma. So here once again, let’s say that you’re having a hard time but the progress here mean for both solids and liquids is having a hard time getting through because scleroderma to you should mean fibrosis - excess deposition of collagen resulting in fibrosis of esophagus making it pretty much a lead pipe. And so therefore, a progressive nature for both solids and liquids. If there was no heartburn and there’s symptoms at night, you should be thinking about achalasia. Achalasia means lack of relaxation of your lower esophageal sphincter for whatever reason. I want to talk about both congenital and acquired.

06:19 If your lower esophageal sphincter doesn’t wish to open, then what kind of dysphagia are you going to have? Simultaneous solids and liquids.

06:28 A nice algorithm that you want to keep in mind as you walk through the differentials for dysphagia.

06:33 Make sure that you’re able to pay attention to the symptoms that the patient is clearly expressing based on the accurate or focused questions that you are then posing to the patient.

06:48 Dysphagia.

06:49 Mechanical causes : Strictures - It could be either benign or malignant.

06:53 We’ll get into that in a little bit.

06:55 Webs and rings - You need to keep those separate, and we will when the time is right.

07:00 Also, Diverticula and hernia.

07:04 Inflammatory conditions of the esophageal lining.

07:06 All of this are mechanical causes of dysphagia.

07:10 Each one of these are important differentials.

07:12 For example you’ve heard of Zenker’s diverticulum.

07:16 The hernia here might be of a hiatal hernia.

07:20 And inflammatory conditions, maybe your patient is immunocompromised and so therefore may be suffering from issues of cytomegalovirus infection of the esophagus.

07:31 Dysphagia.

07:32 Functional type : Achalasia - the lower esophageal sphincter doesn’t wish to open.

07:37 Failure of relaxation.

07:38 We’ll talk about a number of causes.

07:40 Scleroderma - increased fibrosis, thus there is going to be dysphagia to both solids and liquids, progressive type.

07:49 Or the smooth peristaltic activity of the esophagus has been lost, so therefore, there will be increased pressures within the esophagus resulting in lack of proper movement.

08:04 We call this, diffuse esophageal spasms.

08:08 That is not a good thing.

08:12 Causes Oropharyngeal : Swallowing disorders are usually neurological deficit.

08:16 So therefore, let’s say that your patient has lost his or her gag reflex.

08:20 Hmm.

08:22 This is a problem.

08:23 You should be thinking about neurologic issues such as Amyotrophic Lateral Sclerosis perhaps, maybe multiple sclerosis, maybe perhaps even diabetic neuropathy.

08:32 And so if there’s nerve damage that’s taking place, there’s the gag reflex that has obviously been lost, making it difficult for the patient to swallow.

08:41 Keep that in mind because they will then keep their food where? In the mouth, because they can’t swallow it properly.