The esophagus
Objactives1. what are the symptoms of the esophagueal diseases?
2. what are the types of dysphagia?
3. patient had a history of CVA present with inability to swallow the bolus of food, what is the type of dysphagia?
Evaluation of oesophageal diseases
Symptoms:-
The clinical history is extremely important in the diagnosis of oesophageal dis. Heart burn ,dysphagia,and odynophagia virtually always indicate a primary disorder.
heart burn (pyrosis):- is the feeling of substernal burning ,often radiating to the neck, caused by reflex of acidic (or rarely alkaline) material into the oesophagus , it is highly specific for gastro esophageal reflux disease. produce retrosternal chest pain radiating to the neck, back or to the side of the chest, exaggerated by bending down and relieved by drinking soda, antacid and diagnosed by (Bernstein test), introduction of hyperosmotic solution or diluted hydrochloric acid (0.1N) into the esophagus.
Dysphagia:- difficulties in swallowing may arise from problem in transferring the food bolus from the oropharynx to the upper oesophagus or from impaired transport of the bolus through the body of the esophagus.(esophageal dysphagia),it may occur by obstruction of passage of food bolus from the mouth also.
Aphagia complete obstruction which is medical emergency.
Non cardiac chest pain: it is a must to exclude cardiac cause before consideration of esophageal disease as a cause of non cardiac chest pain.it may be caused by GERD which relieved by PPI ingestion , diffuse esophageal spasm(DES) which relieved by smooth muscle relaxant , esophageal hypersensitivity syndrome which is relieved by antidepressant drugs many patients may have psychiatric abnormalities, and peri esophageal content may be a cause also.
Odynophagia: painful swelling.
Regurgitation effortless appearance of esophageal or gastric contents in the mouth.it may result in chronic cough, laryngitis, and laryngeal aspiration. Water brash is reflux salivary hyper secretion that occur in response to peptic esophagitis must be differentiated from GERD.
Upper GIT bleeding
Weight loss
Causes of dysphagia in general
Oesophagitis:-
Reflux oesophagitis
Infective oesophagitis
Peptic oesophagitis
Erosive oesophagitis
Causes of oropharyngeal dysphagia:
Oropharyngeal mechanical dysphagia:
Wall defect-
Congenital as cleft palate and lipsOr post surgery.
2.intrinsic causes :
a. inflammatory-infectious, bullous diseases ,caustic, chemical or thermal.
b. webs
c. stricture.
tumours.
3. extrinsic compression:
Thyroid, vertebral osteophytes, Zenker's diverticulum, abscess or mass.
Oropharyngeal motor dysphagia
It may occur in conscious or un conscious patientsNeurological disorders: - brain stem lesion, mass lesion, pseudo bulbar pulsy, amyotrophic lateral sclerosis, multiple sclerosis, poliomyelitis .
Neuromuscular junction diseases as myasthenia gravis ,eaton-lambert syndrome, aminoglycoside drugs and others or botulism .
Muscular disorder:- myopathies, polymyositis or hypothyroidism
Motility disorders: - upper esophageal sphincter dysfunctions.
Cranial nerve diseases.
Causes of esophageal dysphagia
1.Congenital as tracheoesophageal fistula
2.Intrinsic narrowing
a. Inflammatory- infection.
b. webs, ring,
c. benign strictures
d. tumours
3.extrinsic compression
a. vascular compression(aberrant right subclavian artery, right sided aorta, left atrial enlargement or aortic aneurysm)
b. post mediastinal mass.
c. post vagotomy hematoma or fibrosis
Causes clues
Mechanical obstruction solid foods worse than liquids--Schatizki ring intermittent dysphagia; not progressive
--peptic stricture chronic heart burn; progressive dysphagia
--oesophageal CA progressive dysphagia; age more than 50 years
Motility disorders
--achalasia progressive dysphagia--diffuse oesophageal spasm intermittent not progressive may have chest pain
--scleroderma chronic heart burn; rhaynaud phenomenon.
Other causes:-
Chronic alcoholism
DM
Extrinsic compression (mediastinal tumor).
Psychiatric ex:-globus hystericus
Referances:Gyuton's text book of physiology
Harrison textbook
Davidson text book