Approach to Dysphagia

• Dysphagia : difficulty swallowing, could be oropharyngeal or esophageal.

Hx :

1. oropharyngeal : difficulty in initiating swallowing , choking, coghing, nasal regurgitation.
2. esophageal : inability to move food down esophagus.
3. age?
4. mechanical(solids) or neuromscular-motility disorder (solids+liquids, progressive or nonprogressive)?
5. intermittent (rings or spasm) or progressive (strictures or malignancies)?
6. heartburn (stricture or esophagitis)?
7. chest pain, wheezing, chronic cough, hoarseness (GERD)?
8. chest pain (spasm)
9. neuromuscular symptoms such as dysarthria, diplopia, muscle weaknesses, vertigo, nausea, vomiting, tremor, and ataxia (neuromascular diseases)?
10. change in wt (CA & achlasia ;weight loss) & appetite?
11. any comorbidities : immunocompromized (infectious esophagitis) , neuromascular diseases?
12. drugs Hx (pill-induced esophagitis)

Examination:

1. head and neck : masses, lymph nodes, or enlarged thyroid, Signs of prior surgery and radiotherapy , oral cavity (inspection of dentition or dentures, tongue, and oropharynx) & eye signs of thyrotoxicosis.
2. chest : signs of pneumonia due to aspiration.
3. A neurologic examination for cranial nerve dysfunction, neuromuscular disease, cerebellar dysfunction, or movement disorder.
4. collagen-vascular diseases signs : joint abnormalities, calcinosis, sclerodactyly, telangiectasia, and other findings.

Investigations:

• oropharygeal dysphagia :

1. modified barium swallow (MBS)
2. fiberoptic endoscopic evaluation of swallowing (FEES)

• esophageal dysphagia :

1. Barium swallow mainly for stricture detection & upper endoscopy is the gold standard for obstructive lesion are usually used intially.
2. esophageal manometry for diagnosis of motility disorders after obstructive lesions been excluded.

Barrett’s esophagus

• metaplasia of normal squamous epithelium to abnormal columnar epithelium containing foci of intestinal metaplasia and resulting displacement of the squamocolumnar junction proximal to the gastroesophageal junction.
• thought to be acquired via long-standing GERD and consequent damage to squamous epithelium.
• a significant proportion of patients with Barrett's Esophagus (BE) do not report symptoms of GERD (up to 25%).
• up to 10% of GERD patients will have already developed BE by the time they seek medical attention.
• more common in males, >50 yrs, Caucasians and smokers.
• vigorous surveillance and endoscopic intervention is thought to reduce the risk of death from adenocarcinoma.
• most patients with BE are elderly and die of causes other than esophageal cancer.

• the rate of malignant transformation is 0.5-1.0% per year.

• risk of malignant transformation in high-grade dysplasia is significantly higher , it's 32-59% per 5-8 years of surveillance

Diagnosis:

• diagnosis relies on biopsy

1. endoscopy : erythematous epithelium in distal esophagus;
2. biopsy : the presence of specialized intestinal epithelium of any length within the esophagus , premalignant changes in abnormal columnar epithelium, characterized as low- or high-grade dysplasia.

Treatment:

1. acid suppressive therapy with high-dose proton pump inhibitor for symptoms relief.
2. anti-reflux surgery (fundoplication) , endoscopic ablation of dysplastic areas , endoscopic mucosal resection.
3. endoscopic surveillance every 2-3 years once diagnosis of BE established; frequency increased to annually once presence of low-grade dysplasia detected on biopsy.
4. surgical intervention recommended for most patients with high-grade dysplasia.

GERD

• It's the most common condition affecting the esophagus.

• Symptomatic retrograde flow of gastroduodenal contents into the esophagus or adjacent organs, with or without tissue damage.

• The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial.

• The clinical features of reflux occur when the antireflux mechanisms fail (see below) , allowing acidic gastric contents to make prolonged contact with the lower esophageal mucosa.

• Transient inappropriate relaxations of the lower esophageal sphincter (LES) (is the predominant pathophysiologic mechanism in the majority of GERD patients. they are the cause of almost all reflux in normals and about two-thirds in GERD patients.

• There is an association between BMI and reflux symptoms & Inappropriate relaxation of the LES . They can be exacerbated with increase in BMI.

• GERD found in 30–80% of adults patients with asthma. Any adult with new-onset asthma should be evaluated for GERD as a possible etiology.

• fewer than 50% of patients who present for medical attention for reflux symptoms have esophagitis.

Clinical features:

• The most common symptom is "heartburn" (pyrosis) : Retrosternal burning discomfort located in the epigastric area , May radiate up toward the neck & Typically occurs after eating or when lying down or bending over especially after a high fat or a large-volume meal.

• Regurgitation of acid is the most specific symptom GERD.

• Typical (esophageal) symptoms : heartburn, regurgitation & dysphagia.
• Atypical (extraesophageal) symptoms: Otitis media in children, Frequent throat clearing , Asthma , Globus, Chronic sinusitis, Tracheobronchitis, Dental erosions, Chronic cough/wheezing, Aphthous ulcers, Aspiration pneumonia, Halitosis, Pulmonary fibrosis, Pharyngitis & sore throat, Chronic bronchitis, Laryngitis, Bronchiectasis, Laryngospasm , Noncardiac chest pain, Postnasal drip, Sleep apnea.
• Alarm features :Dysphagia (stricture , ulcer , AdenoCA), Odynophagia(esophagitis), Weight loss (CA), GI bleeding (ulcer), Family history of upper GI tract cancer, Anemia (chronic bleeding), Advanced age (CA).

Differential Diagnosis:

1. Achalasia : dysphagia for both liquids and solids; also may be associated with chest pain. Heartburn/chest pain in achalasia is not

   due to reflux but to fermentation of retained esophageal contents or esophageal muscle spasm.
2. Coronary artery disease : chest pain that may be clinically indistinguishable from chest pain associated with GERD. Coronary artery disease

   should be ruled out before evaluating GERD as a cause.
3. Diffuse esophageal spasm : dysphagia for both liquids and solids; also may be associated with chest pain. May be coincident with GERD.
4. Esophageal cancer : dysphagia for solids and later liquids and weight loss, often in patients with longstanding GERD.
5. Infectious esophagitis : dysphagia/odynophagia, often in immunocompromised patients with candidal, CMV, or HSV

   esophagitis.
6. Pill esophagitis : dysphagia/odynophagia & Hx of offending pill ingestion (e.g., potassium chloride, quinidine,

   tetracycline, NSAIDs, alendronate).
7. Peptic ulcer disease : Pain or distress centered in the upper abdomen, relieved by food or antacids.
8. Biliary disease : Epigastric or right upper quadrant pain, jaundice, acholic stools, dark urine, abnormal liver tests.

Complications:

1. Esophagitis (50% of patients) , esophageal peptic ulcer & GI bleeding: The vast majority heal completely with PPIs.
2. Stricture formation (scarring): present with progressive dysphagia to solids for an average of 4–6 years, require endoscopic dilation to relieve the obstruction, followed by intensive antisecretory therapy to prevent recurrence.
3. Barrett’s esophagus and esophageal adenoCA : especially in pt with frequent, severe GERD.
4. Respiratory complications.
5. Anemia

Diagnosis:

• Is often clinical : typical symptoms & +ve PPI test (symptom resolution after PPI).
• No Investigations , but if indicated :

1. Gastroscopy (esophagogastroduodenoscopy) (EGD)
2. Barium swallow
3. 24-hour pH monitoring
4. Esophageal manometry

EGD:

• highly specific but has limited sensitivity for GERD
• used for:

1. Ruling out GERD like syptoms diseases (diffrential diagnosis).
2. Grading the severity of GERD-induced esophagitis.
3. Presence of GERD complications or alarm features.

Barium swallow:

• Its major usefulness in GERD is in identifying strictures, hiatal hernias but can be used also for evaluating tumors & PUD with limitted sensitivity.

24-hour pH monitoring:

• the most sensitive & accurate test.
• pH ≤ 4 for >4% of the time is considered to be +ve.

Esophageal manometry:

• Cannot detect presence of reflux.
• Essential for positioning the probe for the 24-hour pH monitoring.

When to use 24-hour pH monitoring or/and Esophageal manometry:

1. Atypical symptoms without esophagitis.
2. Comorbid illnesses.
3. Persistence of the typical symptoms with therapy.
4. Recurrence of the symptoms after medications discontinuation.
5. Preparation for antireflux surgery.
6. Post-op evaluation after antireflux surgery, in order to determine whether GERD is still present.

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