Overview of Dysphagia

1.Esophageal Dysphagia OVERVIEW OF DYSPHAGIA Dysphagia = Difficulty in swallowing Two major types: • Oropharyngeal dysphagia • Esophageal dysphagia Esophageal dysphagia is classified into: 1. Progressive → suggests structural/mechanical obstruction 2. Intermittent → suggests motility disorder PROGRESSIVE vs INTERMITTENT DYSPHAGIA Progressive Dysphagia: • Achalasia – solids + liquids • Peptic stricture – solids → liquids • Carcinoma – progressive solids → liquids • Progressive systemic sclerosis Intermittent Dysphagia: • Schatzki ring • Diffuse esophageal spasm • Zenker’s diverticulum (SOLIDS vs SOLIDS+LIQUIDS) • Dysphagia to solids only → Mechanical obstruction - Peptic stricture - Esophageal carcinoma - Schatzki ring - Webs • Dysphagia to solids AND liquids → Motility disorder - Achalasia - Diffuse esophageal spasm - Scleroderma INVESTIGATIONS FOR DYSPHAGIA 1. Initial investigation: **Barium swallow** - Bird-beak → Achalasia - Corkscrew → DES - Rat-tail → Carcinoma 2. Investigation of choice (gold standard): for motility disorder **Esophageal Manometry** - Achalasia → High LES pressure, no relaxation - DES → High amplitude uncoordinated contractions 3. Endoscopy: - Investigation of choice for suspected **mechanical obstruction** - Useful for strictures, carcinoma, webs, rings 4. 24-hour pH monitoring: - Done in suspected GERD TYPES OF ESOPHAGEAL CONTRACTIONS Primary Peristalsis: • Triggered by swallowing • Propels bolus Secondary Peristalsis: • Triggered by esophageal irritation • Clears food residue 2. DYSPHAGIA LUSORIA • Dysphagia caused by **external compression** of esophagus • Most common cause → Aberrant right subclavian artery Tertiary Contractions (Nonperistaltic): • Non-propulsive • Seen in diffuse esophageal spasm • Radiology: Corkscrew appearance 3.ACHALASIA CARDIA Definition: • Primary esophageal motility disorder with: - Absence of esophageal peristalsis - Failure of LES to relax - Increased LES resting pressure Pathogenesis: • Degeneration of Auerbach’s (myenteric) plexus • Loss of inhibitory neurons (NO & VIP producing) • Incomplete LES relaxation → functional obstruction Clinical Features: • Progressive dysphagia (solids AND liquids) • Regurgitation of undigested food • Chest pain • Weight loss • Aspiration risk Investigations: Esophageal manometry = **gold standard** • High LES pressure (>45 mm Hg) • Incomplete LES relaxation • Aperistalsis of distal esophagus Barium swallow: • “Bird beak” appearance • Dilated sigmoid esophagus Complications: • Increased risk of **Squamous cell carcinoma** Treatment: • Laparoscopic Heller’s myotomy + partial fundoplication = procedure of choice • Balloon dilation • Botulinum toxin injection 4.DIFFUSE ESOPHAGEAL SPASM (DES) Definition: • Hypercontractile, uncoordinated esophageal contractions • Causes intermittent chest pain + dysphagia Barium Swallow: • “Corkscrew esophagus” • Tertiary contractions Manometry: • Key diagnostic test • Intermittent normal peristalsis + simultaneous high-amplitude contractions 5.ZENKER’S DIVERTICULUM (HYPOPHARYNGEAL DIVERTICULUM) • Pulsion diverticulum (false diverticulum) • Herniation through Killian’s dehiscence • Occurs in posterior pharyngeal wall above cricopharyngeal Epidemiology: • Age > 60 years • More common in elderly males Symptoms: • Dysphagia • Regurgitation of old food • Gurgling sound • Halitosis • Aspiration pneumonia • Chronic cough Investigation: • Barium swallow (diagnostic test of choice) Treatment: • Excision + cricopharyngeal myotomy • Endoscopic stapling/division (Dohlman procedure) 6.SCHATZKI RING Definition: • Mucosal/submucosal ring at squamocolumnar junction • Causes intermittent dysphagia ONLY to solids Features: • Located in lower esophagus • Narrower lumen → episodic obstruction • Often associated with Hiatus Hernia Treatment: • Esophageal dilation • Endoscopic diathermy/laser 7.PLUMMER–VINSON SYNDROME (PATTERSON-KELLY SYNDROME) Components: • Upper esophageal webs • Iron deficiency anemia • Glossitis + angular stomatitis Epidemiology: • Middle-aged women Risk: • Premalignant → increased risk of **SCC of esophagus** Management: • Iron supplementation • Web dilation 8.MALLORY–WEISS SYNDROME Definition: • Longitudinal mucosal tear near gastroesophageal junction Etiology: • Forceful vomiting, retching, coughing • Seen with alcoholism, hiatus hernia Clinical Features: • Hematemesis (fresh blood) • Tear is linear • Bleeding usually stops spontaneously Management: 9.BARRETT’S ESOPHAGUS • Barrett’s esophagus = **metaplasia of squamous epithelium → columnar epithelium** (PYQ). • Most important: **Specialized intestinal metaplasia with goblet cells**. • Occurs due to **chronic GERD**. • Affects **distal esophagus**. TYPES OF COLUMNAR EPITHELIUM IN BARRETT’S 1. **Gastric type** – resembles gastric epithelium 2. **Junctional type** – resembles cardia 3. **Intestinal type** – distinct; contains goblet cells → **Most commonly associated with dysplasia → adenocarcinoma (highest risk) ** (PYQ) EPIDEMIOLOGY • More common in **males** • More common in **whites** • Risk increases with age COMPLICATIONS 1. **Peptic ulcer in Barrett mucosa** 2. Strictures (long segment) 3. **Adenocarcinoma – most important complication** (dysplasia-cancer sequence) DIAGNOSIS Suggested by Endoscopy: • Salmon-pink mucosa above GE junction replacing white squamous mucosa Confirmed by Biopsy: • Presence of **intestinal-type columnar epithelium with goblet cells** (PYQ)