Chapter 038. Dysphagia (Part 5) docx

Dysphagia Part 5 Diseases of the striated muscle often also involve the cervical part of the esophagus, in addition to affecting the oropharyngeal muscles.. Clinical manifestations of t

Chapter 038 Dysphagia

(Part 5)

Diseases of the striated muscle often also involve the cervical part of the esophagus, in addition to affecting the oropharyngeal muscles Clinical manifestations of the cervical esophageal involvement are usually overshadowed

by those of the oropharyngeal dysphagia

Diseases of the smooth-muscle segment involve the thoracic part of the esophagus and the LES Dysphagia occurs when the peristaltic contractions are weak or absent or when the contractions are nonperistaltic Loss of peristalsis may

be associated with failure of LES relaxation Weakness of contractile power occurs due to muscle weakness, as in scleroderma or impaired cholinergic effect Nonperistaltic contractions and failure of LES relaxation occur due to impaired inhibitory innervation In diffuse esophageal spasm (DES), inhibitory innervation only to the esophageal body is impaired, whereas in achalasia inhibitory

innervation to both the esophageal body and LES is impaired Dysphagia due to esophageal muscle weakness is often associated with symptoms of gastroesophageal reflux disease (GERD) Dysphagia due to loss of the inhibitory innervation is typically not associated with GERD but may be associated with chest pain

The causes of esophageal motor dysphagia are also listed in Table 38-2; they include scleroderma of the esophagus, achalasia, DES, and other motor disorders

Approach to the Patient: Dysphagia

Figure 38-1 shows an algorithm of approach to a patient with dysphagia

Approach to the patient with dysphagia ENT, ear, nose, and throat;

VFSS, videofluoroscopic swallowing study

HISTORY

The history can provide a presumptive diagnosis in >80% of patients The site of dysphagia described by the patient helps to determine the site of esophageal obstruction; the lesion is at or below the perceived location of dysphagia

Associated symptoms provide important diagnostic clues Nasal regurgitation and tracheobronchial aspiration with swallowing are hallmarks of pharyngeal paralysis or a tracheoesophageal fistula Tracheobronchial aspiration

unrelated to swallowing may be due to achalasia, Zenker's diverticulum, or gastroesophageal reflux

Association of laryngeal symptoms and dysphagia occurs in various neuromuscular disorders The presence of hoarseness may be an important diagnostic clue When hoarseness precedes dysphagia, the primary lesion is usually in the larynx; hoarseness following dysphagia may suggest involvement of the recurrent laryngeal nerve by extension of esophageal carcinoma Sometimes hoarseness may be due to laryngitis secondary to gastroesophageal reflux Hiccups may rarely occur with a lesion in the distal portion of the esophagus Unilateral wheezing with dysphagia may indicate a mediastinal mass involving the esophagus and a large bronchus

The type of food causing dysphagia provides useful information Difficulty only with solids implies mechanical dysphagia with a lumen that is not severely narrowed In advanced obstruction, dysphagia occurs with liquids as well as solids In contrast, motor dysphagia due to achalasia and DES is equally affected

by solids and liquids from the very onset Patients with scleroderma have dysphagia to solids that is unrelated to posture and to liquids while recumbent but not upright When peptic stricture develops in patients with scleroderma, dysphagia becomes more persistent

The duration and course of dysphagia are helpful in diagnosis Transient dysphagia may be due to an inflammatory process Progressive dysphagia lasting a few weeks to a few months is suggestive of carcinoma of the esophagus Episodic dysphagia to solids lasting several years indicates a benign disease characteristic

of a lower esophageal ring

Severe weight loss that is out of proportion to the degree of dysphagia is highly suggestive of carcinoma