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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.
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