Dysphagia

Dysphagia
NAusea vomiting may be there
Squamous-cell carcinoma
• The two major risk factors for esophageal squamous-cell
carcinoma are tobacco (smoking or chewing) and alcohol
• the combination of tobacco and alcohol has a strong
synergistic effect
• Physical trauma may increase the risk This include the drinking
of very hot drinks
• Underlying esophageal diseases like Achalasia, Stricture→food
accumulates proximal to the obstruction chronic exposure to
carcinogens in the food
Adenocarcinoma
• Arises from glandular cells present in the lower third of the esophagus
• They have already transformed to intestinal cell type ( Barrett's esophagus)
• Barrett's esophagus
• Characterized by the replacement of the normal stratified squamous
epithelium lining of the esophagus by simple columnar epithelium with
goblet cells
• Because of chronic GERD
• Risk of Barrett's esophagus is increased by central obesity(males)
• There fore know risks for adenocarcinoma is Barret esophagus(long
standing GERD and central obesity )
• Smoking is also known risk factor
Risk factors
• Smoking
• Alcohol
• Long standing GERD—Barret esophagus
• Central obesity
• Drinking hot liquids
• Achalasia
• Stricture –secondary to GERD, caustic ingestion
• Caustic ingestion
• History of radiation therapy for other conditions in the chest
• Previous or current history of carcinoma of head and neck
• Human papillomavirus (HPV)
• Tylosis(thickening of palms ) with esophageal cancer –a rare
• Chewing betel nut (areca) is an important risk factor in Asia
• Typically esophageal cancer patients won’t have findings unless it has
metastasized

•General appearance
• Chronically sick looking (cachexic)

•HEENT
• Look for signs of anemia and liver involvement/ metastasis
• Signs of dehydration→sunken eyball
• LGs
• Lymphadenopathy in the lateral cervical or supraclavicular areas
(especially look for Virchow’s node)
• Chest
• Malignant pleural effusion in case of metastasis
• dullness to percussion
• diminished breath sounds on affected side
• decreased fremitus
• CVS
• Try to appreciate ejection systolic murmur & gallop in case of high output
heart failure due to severe anemia
• Abdominal examination
• Try to appreciate hepatomegaly (in case liver metastasis). If any characterize
the mass
• o Elicit signs of ascites /dullness, fluid shift & fluid thrill
INVESTIGATIONS
• UGI endoscopy
• To visualize growth and take biopsy *
• Cant tell extension to submucosal or muscle

• Endoscopic ultrasound
• is the most sensitive for determining Depth of penetration (for T staging/TNM)
• Presence of enlarged peri-esophageal lymphnodes (for N staging/TNM)

• Barium swallow
• Very sensitive for detecting strictures and intraluminal mass
• Detect mucosal irregularities and filling defects
• Helps to study the distal anatomy in obstructing tumors that are not accessible for endoscopy
• Draw backs
• Does not allow staging or biopsy
• Bronchoscopy
• To exclude invasion of trachea or bronchus (for cancer of the upper &
middle 1/3 of esophagus)
• Chest x-ray
• To look for mediastinal widening or posterior tracheal indentation
• To rule out aspiration pneumonia
• Metastatic workup –CT can of abdomen
• Laboratory studies
• CBC, Serum electrolyte, OFT
• Esophagectomy— difficult operation with a relatively high risk of mortality or post-
operative difficulties.
• Transhiatal and a transthoracic procedure.
• Chemotherapy
• Radiotherapy
• Combination of the above
• Palliative therapy
• Laser phototherapy
• Stent the person cannot swallow at all, an esophageal stent may be inserted to
keep the esophagus open; stents
• surgeon enters the body through
an incision in the lower abdomen
and another in the neck→lower
part of the esophagus is freed
from the surrounding tissues and
cut away as necessary→The
stomach is then pushed through
the esophageal hiatus →nd is
joined to the remaining upper
part of the esophagus at the neck
• transthoracic approach opens
the abdominal and thoracic
cavities together, the two-stage
Ivor Lewis approach involves
• an initial laparotomy and
construction of a gastric tube,
• followed by a right thoracotomy
to excise the tumor and create
an esophagogastric anastomosis
• Chemotherapy
• Radiotherapy
• Combination of the above
• Palliative therapy
• Laser phototherapy
• Stent the person cannot swallow at all, an esophageal
stent may be inserted to keep the esophagus open; stents
Achalasia
• Men and women are affected with equal frequency.
• Is common between the ages of 25 and 60 years, but can occur at
any age.
• It is also known to be a premalignant condition of the esophagus.
• Primarily idiopathic motility disorder characterized by
• Failure of lower esophageal sphincter (les) relaxation
• Loss of peristalsis in the distal esophagus &
• Increased resting tone of les
• A small proportion occurs secondary to other conditions, such as chagas disease ((an
infectious disease common in south america).
Clinical presentation –achalasia
Diagnosis
• Specific tests for achalasia are
• BARIUM SWALLOW AND ESOPHAGEAL MANOMETRY.
• In addition, endoscopy of the esophagus, stomach, and
duodenum→ to rule out the possibility of cancer
Treatment
→drugs that reduce LES pressure are useful.
• Calcium channel blockers such as nifedipine
• Botulinum toxin (botox)
→pneumatic dilatation or balloon dilatation
→Heller myotomy
• Either through the chest (thoracotomy) or through the
abdomen (laparotomy)
• Usually a complication of chronic GASTROESOPHAGEAL REFLUX
(GERD).
• Peptic stricture is a progressive mechanical dysphagia,
• Initial intolerance to solids followed by inability to tolerate liquids
• Classic triads of symptoms of GERD are
• Heart burn ,
• Acidic taste in mouth
• Regurgitation
• Treatment usually involves ballon dilation combined with acid-
suppressive therapy
•Can also be due to other causes

• Trauma from a Nasogastric tube placement, and

• Chronic acid exposure in patients with poor esophageal motility
and lower esophageal sphincter tone from scleroderma.
• Infectious esophagitis,
• Caustic ingestion
• Previous esophageal surgery
• Benign esophageal tumors
• Esophageal leiomyoma (accounts for > 50%)
• Proximal gastric CA
• Esophageal rings
• Diffuse esophageal spasm