Dysphagia

1. Suliman Al-Sharfan Abdulrahman Al-Khalifah Dysphagia

2. Definition • Approach • Etiology • Achalasia • Esophageal strictures • Esophageal rings and webs • Tumors

3. DysphagiaDefinition • Difficulty swallowing ,means it takes more time and effort to move food or liquid from your mouth to your stomach. • A normal swallow takes place in four stages, and involves 25 different muscles and five different nerves.

4. History • Key features to consider in the medical history are: • Location ( oropharyngealdysphagia vs. esophageal dysphagia ) • Types of foods . • Progressive or intermittent • Duration of symptoms

5. Etiology Structural disorders: Inflammatory and/or fibrotic strictures Mucosal rings and webs Anatomical abnormalities • Motility disorders: • Idiopathic (classic) achalasia • Atypical disorders of lower esophageal sphincter relaxation • Pseudoachalasia

6. Achalasia Functional disorder characterized by: Weak peristalsis wave in the body of esophagus Failure of cardiac sphincter to relax during swallowing that lead to functional obstruction with progressive dilatation of esophagus defect cholinergic receptors of Auerbach’s plexus.

7. Symptoms : • Dysphagia • Regurgitation • Weight loss • Retrosternal chest pain • Recurrent pulmonary infections

8. Investigations CXR Barium swallow Manometry esophagoscopy

9. Treatment • Medical : • Drugs that reduce LES pressure like CCB ( nifidipine) • Botulinum toxin injection. Pneumatic dilatation Surgery • myotomy

10. Benign Esophageal Stricture Local, stenotic regions within the lumen of esophagus that result from scarring of esophageal lining; usually from inflammation or neoplastic process. Risk factor and causes: Long standing GERD infection esophagitis Corrosive esophagitis Sclerotherapy for bleeding varices Prolonged use of a nasogastric tube

11. Treatment: Dilation ( either performed by passing a dilator or air-filled balloon ) Proton pump inhibitors (omeprazole) Surgery (is rarely necessary, it is performed if a stricture can't be dilated enough to allow solid food to pass)

12. Lower Esophageal Ring(Schatzki's Ring) • Is a 2- to 4‑mm mucosal stricture, probably congenital, causing a ring-like narrowing of the distal esophagus at squamocolumnar junction. • -Dx:By barium swallow . • -Rx:Instructing the patient to chew food thoroughly is usually the only treatment required in wider rings, but narrow-lumen rings require dilation by endoscopy. • -Surgical resection is rarely required.

13. Upper Esophageal WebPlummer-Vinson Syndrome An esophageal web is a thin mucosal membrane that grows across the lumen. webs develop in patients with untreated severe iron-deficiency anemia and rarely in patient without anemia. Dx: By barium swallow. They can be easily ruptured during esophagoscopy. Webs resolve with treatment of the anemia.

14. Benign tumors of the esophagus

15. Benign Tumors • They are rare. (< 1%) • May arise from any layer at any level • classification: • Mucosal tumors:fibrovascularpolyps, papillomas • Submucosa: adenoma • Muscularispropria: rhabdomyoma • Adventitia: fibroma • Intramural :leiomyomas(the most common), cysts.

16. Leiomyoma • Nearly two thirds of benign esophageal tumors are leiomyomas • They usually arise as intramural growths, most commonly along the distal two thirds of the esophagus • Typically occur in individuals aged 20-50 years

17. Symptoms • Mostly are asymptomatic when they are smaller than 5 cm in diameter. • Large tumors can cause dysphagia, vague retrosternal discomfort, chest pain, and regurgitation.

18. Diagnosis • Barium swallow • Endoscopy • Biopsy ( to exclude malignant lesions) • CT scan • Endoscopic Ultrasound is the gold standard

20. Treatment • Surgical excision is recommended for symptomatic leiomyomas and those greater than 5 cm. • Asymptomatic or smaller lesions should be followed periodically with barium swallow. • Enucleation is the treatment of choice. It can be done by a thoracotomy or thoracoscope. • Segmental esophageal resection may be indicated for giant leiomyomas of the cardia.

22. Malignant tumorsof the esophagus

23. Malignant tumors • More common than benign tumors of the esophagus! • Two types: (comprise 95% of cases) • SCC, associated with smoking and alcohol. • Adenocarcinomas(GERD and Barrett's) • The most common malignant tumor in the proximal two thirds of the esophagus is SCC. • Adenocarcinoma is the most common in the distal one third.

24. Signs & Symptoms • Dysphagia ( most common) • Weight loss • Pain may be severe and worsened by swallowing • Nausea, vomiting and regurgitation of food. • Hematemesis. • Fistula may develop between the esophagus and the trachea. • Metastatic symptoms: • Liver metastasis: jaundice and ascites • Lung metastasis: SOB and pleural effusion.

25. Risk Factors Smoking Alcohol Plummer-Vinson syndrome GERD and Barrett's esophagus Corrosive injury Celiac disease (SCC) Obesity (adenocarcinoma 4 folds!): ￪ regurgitaion Radiation therapy Achalasia

26. Diagnosis • 1-Barium swallow:

27. l 2-Esophagoscopy: ( with multiple biopsies)

28. CT chest, abdomen and pelvis Endoscopic ultrasound (EUS) the best Bronchoscopy ( fistula)

31. TNM Classification Used in Staging SquamousCell Carcinoma and Adenocarcinoma of the Esophagus T1, T2, T3, T4: Different depths of invasion No: No nodes N1: Positive nodes Mo: No metastasis M1: Metastasis 

32. Treatment • Radiation • Primary treatment for poor-risk patients and palliation for unresectable lesions with obstructive symptoms • Chemotherapy • May decrease tumor mass pre-op • Increase survival when given pre and post op. • Multimodal • Preop chemo, surgery, and postop chemo for responding tumors and radiation to residual mediastinal disease is the current treatment of choice

33. Palliation • Esophageal dilatation • Esophageal stent • Laser and photodynamic therapy • Surgical resection or bypass is best long-term palliation • Prognosis • Mortality 1 year – 80% • Overall 5-year survival - <10%

35. Thank you