SLP 558 - Exam 2

what happens in one stage of swallowing...

influences the others

esophageal dysphagia is diagnose and treated by the...

GI doctor (not SLP)

what is the role of SLPs in esophageal dysphagia?

- how esophageal deficits might impact oropharyngeal swallow functions/symptoms

- what signs and symptoms may indicate need for GI doc assessment

- esophageal treatments and their impact

- how the esophagus functions

- esophageal dysphagia symptoms and assessing

how to document esophageal disorders observed during a VFSS

- technically should be radiologist

- SLPs comment

esophagus

- distensible tube

- 21-27 cm (10 inches)

- collapsed at rest; distensible to ~ 3 cm

- from pharynx (C6) to stomach (T12); from PES to LES

proximal esophagus

- striated muscle

- voluntary

- innervated by RLN and sympathetic plexus

middle esophagus

- transition zone

- mixed muscles

distal esophagus

- smooth muscle

- innervated by autonomic input

two muscular layers of the esophagus

- inner circular fibers

- outer longitudinal fibers

tracheosophageal fistula

hole in the wall that the trachea and esophagus share

Killian's area

after inferior constrictor ends and before PES starts

esophageal stage of swallowing

sequentially timed medullary discharged results in the movement of the bolus through the esophagus

peristalsis

orderly ring-like muscular contractions that push material through the esophagus

primary peristalsis

initiated when bolus enters the esophagus

secondary peristalsis

- assists in propelling solid boluses

- initiated by bolus distension from the esophagus at specific locations

tertiary contractions ("co-contractions")

- not orderly or peristaltic

- occurs independently of swallowing

- may disrupt bolus transit

during the swallow, pharynx and esophagus interact...

significantly

secondary swallow attempts can interrupt...

the primary peristaltic wave

residue in the esophagus is often reported as being in the...

pharynx

fluoroscopy exam of swallowing should include...

a cursory inspection of the esophagus to check for any impact on or from the pharynx

classifications of esophageal dysphagia

- structural disorders

- motility disorders

- lower esophageal sphincter abnormalities

- disorders of the PES

types of structural disorders

- stenosis

- luminal deformity

- diverticulum

types of motility disorders

- disorders of peristalsis

- nonspecific disorders

types of LES abnormalities

- achalasia

- isolated LES abnormalities

types of PES disorders

- CP bar

- Zenker's diverticulum

structural disorders definition

a change in the esophageal structure limiting its ability to open

stenosis

abnormal narrowing

stenosis swallowing issues

- difficulty with tough, fibrous foods

- some liquid issues from bolus impaction

- symptoms are often inaccurately localized to the neck

esophagus distention

- normal: up to 33 mm

- non-symptomatic: 18-20 mm

- symptomatic: <10-12 mm

causes of stenosis

- mucosal rings

- benign strictures

- malignant tumors

assessment of stenosis

- esophagram

- radiopaque pill swallow

- marshmallow

treatment of stenosis

dilatation or bougie (tiered spacers)

stenosis: rings & webs

- bands of mucosal and sub-mucosal tissue

- webs: above the gastro-esophageal junction

- rings: at the gastro-esophageal junction or below

webs in the PES and cervical esophagus are...

usually asymptomatic

Schatzi's rings

- most common typ

- band-like

- always associated with hiatal hernia

- unknown etiology (maybe anemia)

hiatal hernia

part of stomach poking into the LES/diaphragm

impact of rings & webs

- intermittent solid food dysphagia

- symptoms can be lessened with patient compensations

- slowly progressive symptoms

treating rings & webs

dilatation

stenosis: benign strictures

- narrowed esophageal segment 1 cm or longer

- usually secondardy to esophagitis

causes of benign strictures

- GERD

- infections, traume

- pills dissolving in esophagus instead of stomach

impact of benign strictures

- progressive solid food complaints

- increased frequency and severity

- may progress to issues with thick liquids

treating benign strictures-

- targets both esophagitis and stricture

- meds and dilatation

stenosis: malignant strictures (cancer)

squamous cell carcinoma or adenocarcinoma

swallowing with malignant strictures

- dysphagia for solids and liquids

- liquid profile comes fast and is different from other stenoses

treating malignant strictures

- primarily esophagectomy

- palliative stenting

- dilatation

esophagectomy outcomes

- potential for oropharyngeal dysphagia

- 5 year survival at 5%

palliative stenting

- with hyperalimentation

- done when a tracheoesophageal fistula is present

stenosis: luminal deformity

- extrinsic compression

- aortic aneurysms, cardiomegaly, congenital abnormalities, lung cancer

- rarely symptomatic due to elasticity

- limited treatment options

diverticulum

- outpouching of tubular organ

- rare compared to hypopharyngeal diverticula

- small and usually asymptomatic

- commonly a consequence of esophageal bulging

esophageal bulging

obstruction distal to region of bolus collection

symptoms of diverticulum

- liquids and solids dysphagia

- regurgitation of swallowed food into the mouth

most mid-esophageal diverticula are caused by...

pulsion (acquired pouch in esophagus)

pulsion diverticula

forms as a result of high intraluminal pressures against weaknesses in the esophageal wall

treating luminal deformity

- treat only when symptomatic

- treat underlying abnormalities that are causing the high intraluminal pressures

- myotomy or dilatation

esophageal motility disorders definition

pathologic deviation from an orderly, progressive peristaltic wave

disorders of peristalsis

- amplitude (strength) is too high or too low

- duration is prolonged

- pattern is uncoordinated

causes of peristalsis disorders

- esophageal irritation (GERD)

- may be secondary to LES disorders (high pressure and incomplete relaxation

- corkscrew or nutcracker esophagus

swallowing in peristalsis disorders

- dysphagia for solids and liquids

- associated chest pain and regurgitation

- diffuse esophageal spasm

diffuse esophageal spasm

- nonspecific dysmotility

- abnormal contractions

treatment for peristalsis disorders

- medications or food modifications for idiopathic

- few "trusted" drugs

- most important to treat the underlying cause (e.g. GERD)

LES abnormalities: achalasia

failure of LES to relax

swallowing with achalasia

- dysphagia for solids and/or liquids

- late (hours after) food regurgitation

- secondary loss of motility

vigorous achalasia

- variant of achalasia

- prolonged, high amplitude contractions of the esophagus

treating achalasia

- calcium channel blockers to reduce smooth muscle contractions

- dilatation

- surgery (myotomy)

- botox

severe esophageal weakness is...

rare

motor weakness is most commonly found in patients with...

collagen vascular disease

scleroderma

- hardening of the collagen tissue

- common esophageal involvement

- loss of contraction

- low LES pressure

- poor clearance, severe reflux

- esophageal inflammation and strictures

other disorders of esophageal motor weakness

- diabetes (autonomic neuropathy, gastroparesis)

- alcohol abuse

- medication side effects (narcotics, calcium channel blockers)

antireflux barrier

what's keeping food in the stomach (LES, diaphragm)

physiologic reflux (GER)

- normal movement of gastric contents into esophagus

- common and normal physiologic event due to constant changes in pressure relations

- relaxation of LES is normally brief and refluxate is immediately cleared

gastroesophageal reflux disease (GERD)

- when gastric contents entering the esophagus are not immediately cleared, or transient relaxations are frequent, leading to symptom development

- heart burn

- many negative effects on QOL

transient LES relaxations (tLESrs)

- part of normal reflux, but becomes pathological if occurring too often

- not clear on what triggers these events

- GERD patients have more

- catheter for reflux texting in pharynx can trigger more

what contributes to GERD?

- impaired esophageal clearance

- impaired salivary function

- hiatal hernia

- transient, inappropriate relaxations of LES

- gastric acid, pepsin secretion normal/raises

- pyloric incompetence; duodenogastric reflux

- impaired esophageal mucosal defense

- reduced resting pressure of LES

- delayed gastric emptying

pyloris

keeps contents in stomach, brings to intestines, and keeps in intestines

negative sequelae of GERD

- may or may not cause esophagitis

- may cause esophageal dysmotility secondary to edema

- may cause cervical symptoms secondary to esophageal dysmotility

- abnormal LES pressures are only observed with severe esophagitis

esophagitis

inflammation of esophagus

esophageal dysmotility

uncoordinated, weak, slow

GERD assessment

- pH probe (gold standard)

- esophagram

- esophagogastroduodenoscopy (EGD)

- transnasal esophagoscopy (TNE)

- high resolution manometry (HRM)

pH probe

- GERD assessment gold standard

- solid state reusable GI manometry transducer with pH probe

- acid level < 4.0 is abnormal

esophagram

- radiologic study of esophageal motility

- cursory text of pharynx, in-depth test of esophagus

- primarily liquids, may include solids

- both upright and supine positions

- done prior to pH probe (if "failed")

esophagogastroduodenoscopy (EGD)

- performed by GI physicians

- light sedation & laying down

- scope thru esophagus -> stomach -> small intestine

transnasal esophagoscopy (TNE)

- newer technique

- used by ENTs

- topical anesthesia alone & sitting upright

high resolution manometry (HRM)

- spatiotemporal and line plots from high resolution manometry

- insertion of manometry-pH catheter assisted by drinking

GERD treatment aims

- enhance the antireflux barrier

- improve esophageal clearance and emptying

- decrease noxiousness of gastric contents

biggest risk factor for GERD

obesity

3 prolonged approach to antireflux therapy

- lifestyle changes

- medication

- surgery

GERD treatment: lifestyle changes

- diet

- smoking/alcohol

- sleeping (wedge pillow)

GERD treatment: medication

- proton pump inhibitors (taken 30 min before first meal, lasts 12 hours)

- H2 blockers (pepcid, zantac)

- prokinetics (motility enhancers make esophagus squeeze better)

acid (H+)

- pumped via islet cells into stomach

- too much can lead to reflux

GERD treatment: surgery

- hiatal hernia repair and fundoplication

- creates a 1 sided LES, can't reflux or vomit

laryngopharyngeal reflux (LPR)

- reflux contents reach the laryngeal level (or pharynx)

- requires higher medication doses for symptom control

- differs from GERD because most events are during the day

signs and symptoms of LPR

- globus

- hoarseness, soreness

- chronic cough, croup

- halitosis (bad breath)

- laryngitis, pharyngitis, sinusitis

- laryngeal stenosis

- strior

- dysphonia

- cancer of the larynx

- taste disorders

globus

feeling of lump in throat after every swallow due to laryngeal tension

nasopharyngeal pH probe

?

reflux symptom index (RSI)

- QOL index

- self-administered

- > 7 indicate LPR

PES abnormalities

- webs

- CP bar (failure of CP muscle to fully relax/distent)

- pharyngeal diverticula

- Zenker's diverticulum (up by CP muscle)

- weakness

most patients reporting solid dysphagia at the level of the lower neck have...

esophageal disorders

pharyngoesophageal relations

- stages of swallowing are all related

- dysphagia localized to the neck may have primary esophageal disorder

- PES abnormalities may be causes by achalasia

- patients with GERD may also report PES level dysphagia which may or may not be clinical

achalasia

term used to LES or UES not opening

esophagus summary

- 10 inch distensible tube

- sphincters at either end (PES and LES)