dysphagia - vanderbilt university medical center · barium swallow is first test in the work -up of...

Dysphagia

Rebeccah Baucom, PGY 3 August 3, 2011

Case Presentation

55-year-old female – Difficulty swallowing for 1 month

PMHx: HTN, HLD PSHx: lap chole, appendectomy Social: 1 PPD x 30 years, occ EtOH Meds: Lisinopril, HCTZ, Lipitor, Vitamin

Differential Diagnosis • OROPHARYNGEAL

– Stroke – Myasthenia gravis – Zenker diverticulum – Oropharyngeal cancer

• ESOPHAGEAL – Scleroderma – GERD – Achalasia – Esophageal spasm – Webs – Neoplasm – Extrinsic compression – Eosinophilic esophagitis – HMV/CMV/Candida – Caustic ingestion

Work-Up

Suspect caustic ingestion?

Yes No

Flexible endoscopy Barium swallow

BARIUM SWALLOW is first test in the work-up of dysphagia in almost all cases

Achalasia

Manometry findings?

- Failure of LES to relax

Treatment?

- Laparoscopic Heller esophagomyotomy with partial anterior fundoplication

Diffuse esophageal spasm

Manometry findings: - Periodic contractions - High-amplitude - Multipeaked - During wet swallow - Normal peristalsis during

intervening periods

Treatment: - CCB or nitrates

Zenker diverticulum

Risk of endoscopy as first step?

- PERFORATION

Treatment?

- Surgery - Divide

cricopharyngeus muscle (myotomy)

- If >2cm should be excised

Schatzki ring

Treatment?

- dilation

Mid-esophageal SCC

Ulcerative esophagitis

Work-up after barium swallow

• Guided by history

Possible mass upper endoscopy

Staging EUS

Possible reflux pH monitoring

Motility disorder manometry

Extrinsic compression CT scan

Manometry

Normal LES

Normal Relaxation

Achalasia = “failure to relax”

Hiatal Hernia

Sources

• Villeneuve, James P. MDCM, PhD, FRCSC, and R. Sudhir Sundaresan, MD, FRCSC, FACS. “Dysphagia.” ACS Surgery. April 2010.

• Bremner, Cedric G. “Section I – Esophagus.” Ed. John L. Cameron. Current Surgical Therapy, 9th Ed. Mosby, Inc. 2008.