Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Similar to dysphagia(Bsmmu-Hepatology)
Similar to dysphagia(Bsmmu-Hepatology) (20)
Recently uploaded
Recently uploaded (20)
dysphagia(Bsmmu-Hepatology)
- 1. Welcome to independent study Dr. Kazi Zakir Hossain Phase –B Student Department of Hepatology BSMMU
- 2. Dysphagia
- 3. Definition of Dysphagia The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). It specifically refers to the sensation of food being hindered in its normal passage from the mouth to the stomach.
- 4. Dysphagia(Definition)Cont • Dysphagia either refers to the difficulty someone may have with initiating a swallow (usually referred to as oropharyngeal dysphagia) or it refers to the sensation that foods and or liquids are somehow hindered in their passage from the mouth to the stomach (usually referred to as esophageal dysphagia).
- 5. Disease burden and epidemiology • Dysphagia is a common problem. • the incidence of dysphagia in acute care has been put as high as 33%, • studies in nursing homes have shown that 30–40% of patients have swallowing disturbances, resulting in a high incidence of aspiration complications.
- 6. • Cause of dysphagia tends to differ between western Europe and North America and south Asia, the Middle East, or Africa. • Childhood dysphagia is different from that of older age. • dysphagia occurs in all age groups but its prevalence increases with age.
- 7. • In younger patients, dysphagia often involves accident-related head and neck injuries • Corrosive strictures of the esophagus (individuals consuming corrosive agents with suicidal intent) and tuberculosis can also be important aspects in a non- Western setting.
- 8. key points • Swallowing is a process governed by the swallowing center in the medulla, and in the mid-esophagus and distal esophagus by a largely autonomous peristaltic reflex coordinated by the enteric nervous system.
- 11. CLASSIFICATION Two distinct syndromes Oropharyngeal dysphagiaOropharyngeal dysphagia Esophageal dysphagiaEsophageal dysphagia Produced by abnormalitiesProduced by abnormalities affecting the finely tunedaffecting the finely tuned neuromuscular mechanismneuromuscular mechanism of the striated muscle of theof the striated muscle of the mouth, pharynx, and UESmouth, pharynx, and UES Caused by the variety ofCaused by the variety of disorders affecting thedisorders affecting the smooth muscle of esophagussmooth muscle of esophagus
- 13. Oropharyngeal dysphagia • Inability to initiate the act of swallowing. • It is a transfer problem caused by – impaired ability to transfer food from mouth to upper esophagus – impaired oral preparatory phase
- 14. Oropharyngeal dysphagia Clinical presentation: – food sticking in the throat – difficulty initiating a swallow – nasal regurgitation – coughing during swallowing – They may also complain of • dysarthria • nasal speech because of associated muscle weaknesses – Other Neurological clinical findings
- 15. Abnormalities Causing Oropharyngeal Dysphagia • Neuromuscular Diseases Central nervous system (CNS) • Cerebral vascular accident (e.g., brain stem or pseudobulbar palsy) • Parkinson disease • Wilson disease • Multiple sclerosis • Amyotrophic lateral sclerosis • Brain stem tumors • Tabes dorsalis • Miscellaneous congenital and degenerative disorders of CNS
- 16. Abnormalities Causing Oropharyngeal Dysphagia • Neuromuscular Diseases – Peripheral nervous system • Bulbar poliomyelitis • Peripheral neuropathies (e.g., diphtheria, botulism, rabies, diabetes mellitus) – Motor end plate • Myasthenia gravis
- 17. Abnormalities Causing Oropharyngeal Dysphagia – Muscle disorders • Muscular dystrophies • Primary myositis • Metabolic myopathy (e.g., thyrotoxicosis, myxedema, steroid myopathy) • Amyloidosis • SLE
- 18. Abnormalities Causing Oropharyngeal Dysphagia • Local Structural Lesions Inflammatory • Pharyngitis • Abscess • Tuberculosis • Syphilis – Neoplastic – Congenital webs – Plummer-Vinson syndrome
- 19. Abnormalities Causing Oropharyngeal Dysphagia – Extrinsic compression • Thyromegaly • cervical spine hyperostosis • Lymphadenopathy – Surgical resection of the oropharynx
- 20. Clinical diagnosis • An accurate history covering the key diagnostic elements is important and can often establish a diagnosis with certainty. It is important to establish carefully the location of the perceived swallow problem (oropharyngeal vs. esophageal dysphagia).
- 21. Timed water-Swallow test • It is an inexpensive, potentially useful basic screening test to complement the evidence obtained by clinical history and physical examination. • The test consists of the patient drinking 150 mL water from a glass as quickly as possible, with the examiner recording time taken and number of swallows.
- 22. • From these data, the speed of swallowing and the average volume per swallow can be calculated. This test is reported to have a predictive sensitivity of > 95% for identifying the presence of dysphagia.
- 23. Special investigations • 1. video-fluoroscopic swallowing study (also known as the “modified barium swallow”)- is the gold standard for diagnosing oropharyngeal dysphagia . • 2. Endoscopy is the gold standard for the evaluation of structural causes of dysphagia
- 25. Treatment options • Nutrition and diet. • Diet change, with softer foods, and postural measures are helpful. • Oral feeding is best whenever possible. • Modifying the food consistency to thicken fluids and the soft foods can make an important difference .
- 26. • Care must be taken to monitor fluid and nutritional needs (dehydration risk). • Addition of citric acid to feedings improves swallowing reflexes, possibly on account of increased gustatory and trigeminal stimulation of acid . • Adjuvant treatment with an angiotensin-converting enzyme inhibitor to facilitate cough reflex may also be helpful
- 27. Tube feeding • Jejunal tube feeding should be used in the acute setting, and percutaneous gastrostomy or jejunostomy tube feeding in the chronic setting. • Gastrostomy feeding post-stroke reduces the mortality and improves nutritional status in comparison with nasogastric feeding. • Percutaneous endoscopic gastrostomy is usually preferable to surgical gastrostomy.
- 28. Surgery • Surgical treatments aimed at relieving the spastic causes of dysphagia, such as cricopharyngeal myotomy, have been successful in up to 60% of cases, but their use remains controversial
- 29. Swallowing Re-education. • Various swallowing therapy techniques have been developed to help facilitate impaired swallowing. • These include strengthening exercises, bio feedback, and thermal and gustatory stimulation.
- 30. Esophageal Dysphagia • Three important questions are particularly crucial. – What kind of food (i.e., liquid or solid) produces the symptom? – Is the dysphagia intermittent or progressive? – Is there associated heartburn? • Physical examination is usually not revealing in patients with esophageal dysphagia, with the exception of scleroderma.
- 33. Diagnosis • History • Examination • CBC • CxR • Barium studies • Endoscopy • Computed tomography scanning • Endoscopic ultrasound • Endoscopy • Esophageal Manometry • Esophageal pH studies
- 35. Esophageal manometry. • It is based on recording the esophageal lumen pressure using either solid-state or perfusion techniques. The three main causes of dysphagia that can be diagnosed using esophageal manometry are achalasia, scleroderma (ineffective esophageal peristalsis), and esophageal spasm • . Special Investigations
- 36. Radionuclide esophageal transit scintigraphy. The patient swallows a radiolabeled liquid (for example, water mixed with 99m technetium sulfur colloid), and the radioactivity within the esophagus is measured. Patients with esophageal motility disorders typically have a delayed disappearance of the radiolabel from the esophagus.
- 38. Peptic esophageal strictures • Peptic strictures are usually the result of gastroesophageal reflux disease (GERD)– but The differential diagnosis has to be excluded: • Caustic strictures after ingestion of corrosive chemicals • Drug-induced strictures • Postoperative strictures • Fungal strictures • After confirmation by endoscopy, dilation is the treatment of choice.
- 39. Procedure Esophageal strictures should be dilated in a progressive manner with flexible Savary bougies or balloons. The choice among dilator types should be based on the availability of the dilators in a given institution and on the operator’s experience and comfort in using them. • If dilation is performed with bougies, the first bougie passed should have a diameter approximately equal to that estimated for the stricture. • Bougies of progressively increasing diameter are introduced until resistance is first encountered, after which no more than two additional bougies are passed during one session
- 40. • If balloon dilators are used, the initial dilation usually should be limited to a diameter of no more than 45 Fr. • Most patients experience good relief of dysphagia with dilation to a diameter between 40 Fr and 54 Fr. Strictures generally should not be dilated to a diameter beyond 60 Fr. • Aggressive antireflux therapy with proton-pump inhibitors or fundoplication improves dysphagia and decreases the need for subsequent esophageal dilations in patients with peptic esophageal strictures.
- 41. Management of Achalasia • The management of achalasia depends largely on surgical risk. • A low-risk endoscopic procedure such as botulinum toxin injection, often effective but with only temporary effects (usually 6 months or less), is reserved for patients totally excluded from surgery
- 43. THANK YOU