DYSPHAGIA

- a Greek word that means disordered

eating

OUTLINE
Anatomy of the Esophagus
Overview of Dysphagia
Investigation
- History
- Physical Examination
- Special Investigations
Categorization of Causes of Dysphagia
- Neuromuscular Causes

ANATOMY OF THE ESOPHAGUS

A muscular canal extending from the pharynx to the

stomach.
- about 23 25 cm in length

Begins in the neck at the lower border of the

cricoid cartilage (opposite C6) and ends at the
cardiacorifice of the stomach (opposite T11).

Pierces the diaphragm slightly to the left of the

midline.
- enters the stomach on its right side after a
short course of about 1.25cm

Deeply placed as it lies behind the left lobe of liver.

Is the narrowest part of the digestive tube.

Most contracted at its commencement, and at the point where
it passes through the diaphragm.
Has 3 constrictions in its vertical course:
(i) where the esophagus commences at the
cricopharyngeal sphincter
(ii) where it is crossed by the aortic arch and left
mainbronchus
(iii) where it pierces the diapraghm
(Lower esophageal sphincter, LES is located here as well)

Blood Supply

Cervical portion : Inferior thyroid artery

Thoracic portion : Bronchial & esophageal branches of

thoracic aorta

Abdominal portion : Ascending branches of the left phrenic

and left gastric arteries

Nerve Supply

Derived from the vagi and from the sympathetic trunks.

- Form a plexus which are groups of ganglion
cells.

DYSPHAGIA

Refers to difficulty in eating as a result of disruption in the

swallowing process.
- the feeling that food or liquid is stuck in the throat or at
any point before the food enters the stomach

May be experienced when swallowing solid foods, liquids, or

both.
Disorders leading to dysphagia may affect the oral, pharyngeal,
or esophageal phases of swallowing.

Can strike at any age, although the risk increases with age.

Divided into :
(i) Oropharyngeal dysphagia (Mouth

Upper esophagus)

(ii) Esophageal dysphagia (Through esophagus

Stomach)

Signs & Symptoms

Symptoms of oropharyngeal dysphagia:

- Difficulty trying to swallow
- Choking or breathing saliva into your lungs
while swallowing
- Coughing while swallowing
- Regurgitating liquid through your nose
- Breathing in food while swallowing
- Weak voice
- Weight loss

Symptoms of esophageal dysphagia:

- Pressure sensation in your mid-chest area
- Sensation of food stuck in your throat or
chest
- Chest pain
- Pain with swallowing
- Chronic heartburn
- Belching
- Sore throat

Can be a serious threat to ones health due to the risks of :

- Aspiration pneumonia
- Malnutrition
- Dehydration
- Weight loss
- Airway obstruction

Thorough history taking and careful physical examination are

important in the diagnosis and treatment of dysphagia.

INVESTIGATION
History

Subjective site of obstruction is not always exact.

- Patient often merely points vaguely to behind the sternum.
Diagnosis may be made based on :
(a) History of past swallowed caustic materials.
(b) History of reflux esophagitis
- Suggests peptic stricture
(c) Patient with achalasia (failure of LES to relax)
- Tends to be young
- Usually without loss of weight
(d) Malignant stricture
- Has a short history
- Usually occurs in the elderly
- Is associated with weight loss

Examination
Often negative.
However, search is made for :
(a) Plummer-Vinson syndrome
- Smooth tongue
Koilonychia
- Anaemia
- Koilonychia
(b) Secondary nodes from an esophageal carcinoma
- Can be felt in the neck and supraclavicular
fossae.
(c) Carcinoma of the cardia (stomach)
- Upper abdomen is palpated carefully.
- Common cause of dysphagia in the elderly.
- More common than esophageal CA.

SPECIAL INVESTIGATIONS

Barium swallow
- May demonstrate :
(i) the characteristic appearance of a cervical web
(ii) extrinsic compression and dilated esophagus of
achalasia

Fibreoptic esophagospy
- Enables biopsies to confirm malignancies
- Permits therapeutic dilatation or intubation (if
indicated).

* The investigations are complementary.

Barium swallow
test
showing dilated
esophagus in
achalasia

Fibreoptic
esophagoscopy

CAUSES OF DYSPHAGIA
Neuromuscular

Stroke
Myasthenia gravis
Poliomyelitis
Guillain-Barre
Neuropathy
Multiple sclerosis
Bulbar palsy

Extraluminal
Presence of enlarged
lymph nodes
Thoracic aortic
aneurysm
Bronchial carcinoma
Retrosternal goitre

Mural
Congenital atresia
Inflammatory stricture
Caustic stricture
Achalasia
Plummer-Vinson
syndrome
Shattzki Ring
Tumour of esophagus or
cardia

Intraluminal
Foreign body
Food bolus

NEUROMUSCULAR
CAUSES

Stroke

- Characterized by the sudden loss of blood circulation to an area

of the brain
~ results in corresponding loss of neurologic function
- Previously called cerebrovascular accident (CVA) or stroke
syndrome
- Classified as either haemorrhagic or ischaemic.
(i) Acute ischaemic stroke (80-87%):
- Stroke is caused by thrombosis or embolism.
- Results from events that limit or stop blood flow.
- More common than haemorrhagic stroke.
(ii) Haemorrhagic stroke (13-20%):
- Patients present with similar neurologic deficits
BUT tend to be more ill than ischaemic stroke
patients.
- Can be intracerebral (more common) or subarachnoid.

* Middle cerebral artery (MCA) is the most commonly

affected vessel in CVA.

* Transient ischaemic attack (TIA)

- Like a temporary ischaemic attack.
- An artery is temporarily blocked; prevents blood flow to part of the
brain
~ causes that part of brain to stop functining
- Symptoms are similar to ischaemic stroke.
~ most last less than 30 minutes
- TIA patients are at HIGH risk of developing stroke soon
thereafter.
~ immediate medical evaluation is needed.

Clinical Features:
- Symptoms depend on part of brain that is damaged.
~ Develop suddenly and without warning/ On and off for
first day or two.
~ Most severe when stroke first happens/ Can slowly get worse.

- Symptoms:
(i) Headache (if stroke caused by bleeding in brain)
(ii) Change in alertness, hearing and taste
(iii) Confusion or loss of memory
(iv) Dysphagia
(v) Dizziness or abnormal feeling of movement (vertigo)
(vi) Loss of balance and coordination
(vii) Muscle weakness in the face, arm, or leg (usually
just on one side)
(viii) Numbness or tinglingon one side of the body
(ix) Trouble speaking or understanding others who are
speaking
(x) Trouble walking
(xi) Lack of control over the bladder or bowels

Myasthenia gravis

- A type of autoimmune disorder of the neuromuscular

junction (NMJ) characterised by muscle weakness.
- Can present at any age; has a predilection for women.
- Exact cause is unknown.

Pathophysiology:

- Due to presence of autoantibodies against acetylcholine

receptors (AchR)
~ leads to loss of functional AchRs at NMJ either by:
(i) increasing the internalization and degradation of
the receptors
(ii) blocking the binding of Ach to its receptors

- Results in a characteristic pattern of progressively reduced

muscle strength with repeated use
~ recovery of muscle strength only after a period of rest
Clinical Features:
- Weakness typically first noticed in extraocular muscles:

(i) Drooping eyelids (Ptosis)

(ii) Double vision (Diplopia)

- Generalised muscle weakness can fluctuate dramatically

~ alterations over course of days, hours or even minutes
~ affected muscles include those which control
breathing (SOB), swallowing (dysphagia), facial
expressions and limb movements.

Poliomyelitis
- A viral disease that can affect nerves and can lead to
partial or fullparalysis
~ caused by small RNA viruses of the
enterovirus group of the Picornavirus family.

Pathphysiology:
- Poliovirus is spread by the fecal-oral route and by aerosol
droplets.
~ shed in oral secretions (for several weeks)
~ shed in faeces (for several months)
- Poliovirus destroys the anterior horn cells in
the spinal cord.

Clinical Features:
- 3 basic patterns of polio infection:
(i) Subclinical infections
~ Includes malaise, headache, vomiting, slight fever
and sore throat.
(ii) Non-paralytic
~ Includes back pain, diarrhea, fatigue etc.
(iii) Paralytic
~ Includes dysphagia, difficulty in breathing,
muscle contractions (calf, neck or back), abnormal
sensations etc.

Guillain-Barr syndrome (GBS)

- One of the most life-threatening diseases of peripheral
nervous system.
- A collection of clinical syndromes that manifests as an
acute inflammatory polyradiculoneuropathy with
resultant weakness and diminished reflexes.
- May develop spontaneously or after a systemic infection
(usually viral) or other stress.

Pathophysiology:
- Is a postinfectious, immune-mediated disease.
- Cellular and humoral immune response play a role in its
development.

Lymphocytic infiltration of spinal roots and peripheral

nerves
Macrophage-mediated, multifocal stripping of myelin
Defects in the propagation of electrical nerve impulses
Eventual absence or profound delay in conduction
Flaccid paralysis

* Recovery is usually associated with remyelination.

Clinical Features:
- Patients usually present with rapidly progressive,
ascending motor weakness.
~ may lead to death from failure of respiratory muscles.
- Sensory involvement usually much less striking as
compared to motor dysfunction.

* With supportive care, most affected individuals recover over

time.

Neuropathy

- Damage to a single nerve or nerve group, which results

inloss of movement, sensation, or other function of that
nerve.
- A type of damage to nerves outside the brain and spinal
cord (peripheral neuropathy).
- Most commonly caused by injury.
~ Systemic disorders can also cause isolated nerve
damage.

Pathophysiology:
- Can be caused by long-term pressure on a nerve due to
swelling or injury
~ myelin sheath or axon of nerve may be damaged
~ slows or prevents signals from travelling through
the damaged nerves

Clinical features:
- Symptoms depend on the specific nerve affected and
may include:
(i) Loss of sensation
(ii) Paralysis
(iii) Tingling, burning, pain,abnormal sensations
(iv) Weakness

Multiple Sclerosis
- An autoimmune demyelinating disorder.
- Characterised by distinct episodes of neurologic deficits,
separated in time, attributable to white matter lesions
that are separated in space.
- Becomes clinically apparent at any age; onset in
childhood or after the age of 50 is relatively rare.
- Twice more common in women compared to men.

Pathophysiology:
- Caused by a combination of environmental and genetic
factors:
~ results in a loss of tolerance to self-proteins (myelin
antigens)

- Due to T cell-mediated delayed type hypersensitivity

reaction towards myelin proteins.
- Toxic effects of lymphocytes, macrophages and their
secreted molecules may be involved in initiating axonal
injury:
~ sometimes leading to neuronal death.

Clinical Features:
- Multiple episodes of new symptoms (relapses) followed by
episodes of recovery (remission).
~ typically, recovery is not complete
~ leads to gradual accumulation of neurologic deficits
- Frequent initial manifestation:
~ Unilateral vision impairment occurring over course of
a few days

- Classic MS symptoms include sensory loss, spinal cord

symptoms, cerebellar symptoms etc.
- May present with many other manifestations, including
the following:
(i) Aphasia or dysphasia
(ii) Seizures (5% of patients with MS)
(iii) Other paroxysmal symptoms (eg, ataxia, akinesia,
paresthesias, pruritus)
(iv) Significant motor complaints without sensory deficits
or dysautonomia

MULTIPLE SCLEROSIS

Bulbar Palsy
-Refers to impairment of function of thecranial nervesIX,
X, XI and XII:
~ which occurs due to alower motor neuronlesion
either at nuclear or fascicular level in themedulla
oblongataor from lesions of the lower cranial
nerves outside thebrainstem.
- Is an assortment of signs and symptoms.

Causes:
(a) Genetic

(e) Malignancy

(b) Vascular

(f) Toxic

(c) Degenerative diseases

(g) Autoimmune

(d) Inflammatory/Infective

Clinical Features:
- Among some of the symptoms include:
(i) dysphagia(difficulty in swallowing)
(ii) difficulty in chewing
(iii) nasal regurgitation
(iv) slurring of speech
* Ocular muscles are spared and this differentiates it from
myasthenia gravis.

-PERFORATION OF ESOPHAGUS
-INTRALUMINAL CAUSES
-EXTRALUMINAL CAUSES

PERFORATION OF THE
ESOPHAGUS
Causes:
-

Swallow foreign bodies

Rupture at esophagoscopy
Rupture during esophageal echocardiography
Boerhaave syndrom (spontaneous rupture)

Boerhaave syndrom

- sudden rise in intraluminal esophageal pressure produced during

vomiting, as a result of neuromuscular incoordination causing
failure of the cricopharyngeus muscle to relax.
Hx - a middle-aged man
- repeated episodes of retching and
- recent excessive dietary and alcohol intake.
p/w - pain in the neck, chest, upper abdomen
- dysphagia

Investigation :
- chest X ray (gas in the neck and mediastinum)
- Gastrograffin swallow (confirm position)

Boerhaave syndrome.
Chest radiographs show pneumomediastinum (arrows).
Esophagram with extravasated water soluble contrast material in
left hemithorax (asterisk)

Spontaneous oesophageal
perforation. Sudden onset of
pain during a meal.
(a) Water soluble contrast
swallow shows an ovoid filling
defect (upper border shown by
large arrow) due to intramural
haematoma, and linear
collection of submucosal
contrast (small arrow).

TREATMENT
- Medical or Surgical
Decision depend on :
- Time delay in presentation and diagnosis
- Extent of perforation
- Overall medical condition of the patient

Medical Therapy

Standard therapy includes the following:

Admission to medical/surgical ICU
Nothing by mouth
Parenteral nutritional support
Nasogastric suction
Broad-spectrum antibiotics
Narcotic analgesics

Features that support conservative therapy include the

following:
- no signs of infection
- Contained perforation in the mediastinum and the visceral pleura
without penetration to another body cavity
- Perforation draining back into the esophagus

Surgical treatment
Tube thoracostomy (Drainage with a chest tube
or operative drainage alone)
Primary repair with reinforcement with pleura,
intercostal muscle, diaphragm, pericardial fat,
pleural flap
Diversion
Diversion and exclusion
Esophageal resection
Thoracoscopic repair
Esophageal stent

Intraluminal causes

Foreign Bodies
- Previous history of swallowing of foreign object
- Children (esp sharp and irregular item)
- p/w - dyspahgia
- coughing
- dysphagia even to saliva
- chocking
- vomiting
- retching
- neck and/or throat pain
- Foreign body at the level of
upper oesophageal sphincter - children
lower oesophageal sphincter - adult

Investigation
- X-ray

- Barium Swallow

Treatment

- Oesphagoscopic removal
- oesophagotomy

Anteroposterior chest radiograph depicts

a penny at the thoracic inlet of a 13month-old infant who refused to eat.

EXTRALUMINAL
Enlargement of the structure surrounding esophagus that
produces a mass effect compressing on the esophagus
EX :

Mediastinal lymphadenopathy
Bronchial carcinoma
Retrosternal goitre
Aortic aneurysm

Cross section of the neck

Transverse section : T4 - 5

MEDIASTINAL
LYMPHADENOPATHY
Mediastinum
- .Superiorly to thracic oulet
- Inferiorly to diaphragm
- Anteriorly to sternum
- Posterirly to vertebral column
Lymphadenopathy enlargement of lymph node
- Mediastinal nodes drain lungs,
heart, thymus, and thoracic esophagus.

p/w - cough, wheezing, dysphagia,

hemoptysis, atelectasis, and the

obstruction of the great vessels

Causes - 95% by tumors or cysts.

- Lymphomas and acute lymphoblastic leukemia are the most
common etiologies and usually involve the
anterior mediastinum
- rarely infection

Investigation
Lab studies - peripheral blood smear
- full blood count
- hepatic and renal function, urine analysis
Imaging studies - Chest X-ray
- chest CT

Treatment

- underlying etiology
- antibiotic - infection
- surgical removal of affected node

BRONCHIAL CARCINOMA
p/w - cough, haemoptysis, breathlessness, wheeze and stidor
- persistent respiratory infection
- dysphagia
Investigation
- X- ray
- CT
Treatment
- Surgery, chemotherapy, radiotherapy

RETROSTERNAL GOITRE
- Enlargement of the thyroid gland
- Physiological
- Pathological

p/w swelling in the neck, dyspnea, dysphagia, stridor, plethora

or hoarseness of voice

Signs and symptoms of hyper/hypothyroidism

Investigation

Thyroid function test

Ultrasound (size, nodularity, consistency)

CT (size, effect of the thyroid gland on nearby structures)

MRI

Barium (esophageal obstruction)

(black arrows) large mass

of low attenuation in
right lobe of thyroid with
(white arrow)focal
bulging in mucosal
portion of trachea.

AORTIC ANEURYSM
Aneurysm localized or diffuse dilation of an artery with a
diameter at least 50% greater than the normal size of the artery
AA - TA
- AAA (most common)
- TAA

media layer consist collagen and elastin.

Elastic fiber fragmentation and loss with degeneration of the
media result in weakening of the aortic wall, loss of elasticity, and
consequent dilation.
Elastin content of the ascending aorta is high and diminishes
down to the abdominal.

Thoracic aneurysm
p/w - asymptomatic
- local compression
- descending aorta, back pain localized
between the scapulae
- dyspnea, stridor, wheezing, or cough
- dysphagia
- erosion into surrounding structures
hemoptysis, hematemesis
- spinal cord compression or thrombosis of spinal
arteries may result in neurologic symptoms of paraparesis or
paraplegia.
Investigation - X ray
- CT
- MRI

Treatment
- Surgical repair of DTA
- Endovascular stent grafts

MURAL CAUSES

CAUSTIC STRICTURE

Follows accidental or suicidal ingestion of

strong acids or alkalis.
(e.g. caustic soda, ammonia).
Often occurs in children.

Acute phase: associated burns of the mouth

and pharynx.
Middle and lower eosophagus usually affected
as these are sites of temporary hold-up of
caustic material where oesophagus is crossed
by aortic arch and cardiac sphincter.

INVESTIGATION

Eosophageal endoscopy

Barium swallow

ACHALASIA OF THE CARDIA

Failure of relaxation at lower end of oesophagus with progressive

dilatation, tortuosity, incoordination of peristalsis and often
hypertrophy of the oesophagus above.

A muscle ring at the lower oesophageal sphincter normally relaxes

during swallowing. In Achalasia, this muscle ring does not relax as
well.
Most common in middle-aged and older adults.
Causes progressive dysphagia over months to years, sometimes with
chest-pain.
Complications: Acid reflux, pneumonia, perforation of oesophagus,
malignant change in the dilated oesophagus.

INVESTIGATION

Chest X-Ray- shows the dilated oesophagus

Oesophageal manometry

Barium swallow

Oesophagoscopy

REFLUX OESOPHAGITIS

Produced by reflux of peptic juice through the incompetent cardiac sphincter

into the lower oesophagus.

Symptoms: Heartburn, nausea after eating.

Complications: Ulceration
Inflammation
Stricture formation
Barretts oesophagus

Special Investigation: Barium swallow

Eosophagogastroduodenoscopy
Eosophageal manometry
Fibreoptic oesophagoscopy
Continuous oesophageal pH monitoring
Acid infusion test

OESOPHAGEAL CARCINOMA

Upper two thirds Squamous carcinomas

Lower one third Adenocarcinoma

Clinical Features: Dysphagia, enlarged nodes, hoarseness and bovine

cough(if present, suggests invasion of left laryngeal nerve by an upper
oesophageal tumour)
Risk factors: Squamous carcinoma linked to achalasia and celiac disease.
Adenocarcinoma linked to Barretts oesophagus
Smoking, alcohol.

Investigation: Barium swallow, Biopsy,

Eosophagoscopy,
CT scan, Endoscopic ultrasound.

BARRETTS OESOPHAGUS

A pre-malignant condition

Long-standing reflux of duodenogastric contents

cause metaplasia of the lower oesophageal epithelium
to a gastric-type columnar epithelium.
Continued inflammation leads to dysplasia and
subsequently to malignancy (Adenocarcinoma)

PLUMMER-VINSON SYNDROME

A syndrome comprising of dysphagia and iron-deficiency anaemia

usually in middle-aged or elderly women.
The dysphagia is associated with hyperkeratinization of the
oesophagus and often with the formation of a web in the upper
part of the oesophagus.
Premalignant condition, associated with development of
carcinoma in the cricopharyngeal region.
Investigation- Oesophagoscopy

PLUMMER-VINSON SYNDROME

PHARYNGEAL POUCH

Mucosal protrusion between thyropharyngeus and

cricopharyngeus muscle (Both forms the inferior constrictor of the
pharynx) through Killians dehiscence.
An example of pulsion diverticulum, forming as a result of
increased intraluminal pressure.
Often occurs in men and the elderly.

Symptoms: Dysphagia, regurgitation of food collected in pouch, foetor.

Complications: Aspiration pneumonia & lung abscess.

Investigation: Barium swallow- show residual pool of contrast within the

pouch.

CONGENITAL ATRESIA

A congenital disorder in which the oesophagus does not develop

properly.
In most cases, the oesophagus does not connect with the lower
oesophagus and stomach.

Presence of tracheosophageal fistula (TEF)

A surgical emergency

Symptoms: Cyanosis/coughing/choking- with attempted feeding.

Drooling, Poor Feeding.

Complications: Feeding problems, Reflux after surgery,

Stricture after surgery due to scarring.

SCHATZKI RING

Narrowing of the lower part of the oesophagus caused by a ring of

mucosal tissue or muscular tissue.
Subdivided into: A Ring Above oesophagus/stomach junction

oesophagus)

B Ring At the squamocolumnar junction (lower

Complication: Complete obstruction of the eosophagus by a bolus of food

which can cause crushing chest pain.

Investigation: Barium swallow, oesophagogastroduodenoscopy

OTHER CAUSES

Scleroderma

Diffuse oesophageal spasm

Chagas Disease

COMPLICATIONS OF DYSPHAGIA

Coughing and choking

Aspiration pneumonia

Malnutrition and dehydration