Dysphagia is defined as discomfort during food intake.Habitually one distinguishes dysphagia oropharyngeal and esophageal dysphagia.
They can move gradually or acutely.
In chronic progressive dysphagia installation, diagnostics eliminate first is that of a tumor pathology, ENT or esophageal.
DIAGNOSIS:
Examination:
The first approach of dysphagia must be a careful examination that first defines the sharp, brutal or chronic or progressive although the symptom.
The patient’s medical context is defined: age, alcoolotabagique ground potential including ENT surgical history, recent medications, the existence or absence of gastroesophageal reflux.
The blocking level, oropharyngeal or oesophageal, must be specified, not always clearly expressed by the patient.
The signs associated with food blockage are to look for: reflux, hoarseness, hiccups, salivation, choking, aspiration pneumonia.
Clinical examination:
Clinical examination includes several stages:
– Oropharyngeal;
– Cervical;
– Respiratory;
– Neurological.
Following this review, a power test with a solid or liquid food can be proposed to properly assess the type and quality of dysphagia swallowing.
The research carefully oropharyngeal examination of movement disorders and lip sensitivity, tongue, jaw, oral hygiene, the existence of a salivary stasis, contraction of the soft palate.
The review of research neck lymphadenopathy, a possible goiter.
Respiratory examination search cough, bronchial congestion, pulmonary focus.
Neurological examination is interested in impaired alertness and understanding, the existence or absence of dysarthria, dysphonia, balance disorders or a challenge cit engine. In case of anomaly, recourse to a neurological specialist opinion should be considered.
Finally, in case of difficulty in the analysis of the disorder, often poorly described by the older patient, recourse to the ingestion of a glass of water can be used to assess the quality of swallowing, which can cause cough, aspiration, regurgitation.
The severity of dysphagia is assessed on several criteria: weight loss, dehydration, respiratory disorders with aspiration pneumonia.
Additional tests:
Dysphagia is well characterized, two major examinations should be considered.
If oropharyngeal dysphagia, a nasofibroscopy seems examining the most efficient looking particularly obstructive cause.
If normality, esophageal endoscopy is expected before considering more specialized investigations such as barium swallow pharyngoesophageal.
In case of swallowing disorders with myogenic component, dosage of CPK (myositis) and search for antibodies antirécepteurs acetylcholine (MG) are indicated.
Cervical CT scan or MRI can be programmed thereafter.
If lower dysphagia, review expected in the first place is a gastroesophageal endoscopy or if cons-indication, esophageal barium transit. Other more specialized investigations may be indicated in cases of normality this initial assessment, the first of which the esophageal manometry.
Diagnostic pitfalls:
Several pitfalls must be avoided: the globus pharyngeal which is a cervical tightness without true dysphagia who gives in principle during swallowing of the bolus and is an anxiety event.
Anorexia is often expressed, especially in the elderly, such as difficulty swallowing and must be well separated from a true dysphagia by careful examination.
Dysphagia may be underestimated or misunderstood, initially due to changes in eating behavior of the patient, the latter offsetting the inconvenience to solid foods by adopting semi-liquid foods or mixed. This technique of compensation can bring the patient to minimize a genuine progressive dysphagia appeared.
ETIOLOGY:
Oropharyngeal dysphagia and swallowing disorders:
This disorder involves several specialties as interested as well as ENT neurologist and a gastroenterologist.
Oropharyngeal dysphagia and swallowing disorders are dominated etiological elderly patients with neurological disorders and evolutionarily by the risk of respiratory complications with aspiration pneumonia.
Main causes of oropharyngeal dysphagia:
The list of etiologies of oropharyngeal dysphagia is shown in Box 1.
Box 1. Key etiologies of oropharyngeal dysphagia
Local causes
Foreign bodies
Cervical trauma
ENT malignancies, oesophageal
Adenomegaly
Xerostomia
Cricopharyngeal spasm
Zenker’s diverticulum
Osteomyelitis, abscess, cervical cellulite
Neuromuscular Causes
Cerebrovascular Accident
Head injury
Brain Tumors
Parkinson’s disease
Dementia
Amyotrophic lateral sclerosis
Multiple sclerosis
Local polyradiculoneuritis
Unilateral or bilateral cranial nerve
Myopathies
Myasthenia
Myositis
Iatrogenic causes
Antecedent cervical radiotherapy surgery: ENT, neurosurgery, carotid endarterectomy
Medications: Benzodiazepines, neuroleptics
Psychogenic causes
Etiologic diagnosis:
The diagnosis is most often mentioned as early as the interrogation and clinical examination: the presence of pain on swallowing, the beginning of the unrest mode, the existence of neurological signs associated with the concept of acquired or neuromuscular disease hereditary are important elements to guide the diagnosis.
We distinguish between local cause of dysphagia and dysphagia related to neuromuscular disease.
Several clinical situations may be encountered:
– High painful dysphagia;
– High dysphagia acute or subacute onset;
– High chronic dysphagia.
Painful dysphagia:
The painful dysphagia is usually related to a locoregional lesion easily diagnosed on clinical examination: oropharyngeal mucosal inflammation (angina), lymphadenopathy, goiter or thyroid tumor or salivary glands.
Acute dysphagia installation:
The acute onset dysphagia are due to the presence of a foreign body, sometimes submucosal (while requiring soft tissue radiography and / or CT). This is sometimes an isolated acute food blockage is often idiopathic without cause found despite a thorough review. Muscle diseases: myasthenia, poly and dermatomyositis may start on an acute mode.
Chronic dysphagia:
Chronic oropharyngeal dysphagia may be due to oropharyngeal tumor or functional sequelae of their treatment (surgery or cervical radiotherapy). Another common anatomical abnormality, Zenker’s diverticulum can make it difficult to introduce the endoscope or even dangerous: they are better objectified by a barium swallow.
Drug iatrogenic causes are frequent, the first of which psychotropic and narcotic. In particular, neuroleptics alter the oral phase of swallowing disrupting the coordination of movements of the tongue, the initiation of swallowing and chewing, all aggravated by psychotropic induced xerostomia.
Most neurological diseases may present with dysphagia in their clinical picture, the main causes are stroke, head trauma, Parkinson’s syndrome, amyotrophic lateral sclerosis (the swallowing disorders may be indicative) and Alzheimer ‘ Alzheimer.
Treatment:
Treatment falls course of etiology, infectious, tumor. The neurological etiologies, inaccessible to effective etiological treatment may justify a feeding gastrostomy which can be achieved endoscopically.
Esophageal dysphagia:
Main causes of esophageal dysphagia:
The main causes of esophageal dysphagia are listed in Box 2.
Box 2. Main causes of esophageal dysphagia
Cancers of the esophagus
Progressive dysphagia prevailing on the solid and liquid with impaired general condition and context of alcohol and tobacco intoxication
Benign tumors
Rare. Late dysphagia and moderate
Caustic esophagitis and strictures
Severe dysphagia, occurring several weeks after ingestion in case of stenosis
Esophagitis and peptic strictures
Long history of gastroesophageal refl ux. Progressive dysphagia that can be brutally by a food blockage episode
Infectious esophagitis
Most often mycotic (Candida albicans) with white beaches. Search for a fungus associated oropharyngeal.Viral esophagitis (CMV, herpes, VZV) especially during immunosuppression
Drug esophagitis
Toxicity of a tablet enclosed in the esophagus. Esophageal ulcer suspended
Esophageal diverticula
Zenker’s diverticulum: elderly, foul breath, high cervical dysphagia with regurgitation spontaneous, sometimes responsible for nocturnal cough and pneumonia. The TOGD diagnostic aid
Foreign bodies
Brutal painful dysphagia, drooling, aphagia
Dysphagia postfundoplicature
Early Dysphagia (6 to 12 weeks after surgery): abnormal ux antirefl assembly or pre-existing disorders engines surgery
Late Dysphagia: impaired ux antirefl assembly or recurrence of GERD
Ring Schatzky
Thin annular narrowing sitting at the junction glandular mucosa and squamous above a hiatal hernia
Kelly-Paterson syndrome
High dysphagia with cervical stenotic membrane of the esophagus and iron deficiency anemia
Extrinsic compression
Cancers neighborhoods of organs: thyroid, trachea, mediastinum
Vascular compression: aortic aneurysm, dysphagia lusoria (ectopic right subclavian artery)
Motor disorders of the esophagus
Often poorly explored in daily practice. To investigate whether gastroscopy is normal
Chronic esophagitis dissecans
Layered diaphragm stenosis of the esophageal mucosa, with significant weakness in the mucosa biopsies.
Eosinophilic esophagitis
Especially described in children, but also observed
in adults. Diagnosis esophageal biopsies
Etiologic diagnosis:
The existence of esophageal dysphagia well described by the patient, whether for liquids (paradoxical dysphagia) or solid, should prompt investigations grow even if the upper gastrointestinal broscopie fi is normal before concluding that a functional dysphagia banal.
Esophageal cancer:
In a man of over 45 years, especially alcoolotabagique is esophageal cancer that should be feared in the first place.
Oesophageal dyskinesia:
We must especially think of esophageal dyskinesia first and foremost the mega-esophagus and disease staggered spasms, during normal endoscopy.
The mega-esophagus, which often affects young subjects, in early development can not be expanded and fi broscopie upper gastrointestinal perfectly normal. Only at this stage manometry allows the diagnosis. Other dyskinesia have been described, the source of dysphagia, especially the painful peristalsis Syndrome (esophagus “Nutcracker”) which is also with the disease staggered spasms, one of the common causes of chest pain pseudoangineuses original esophageal. Finally, peristalsis disturbances are common in very elderly patients, sometimes a source of difficult treatment dysphagia (presbyoesophage).
Gastroesophageal reflux:
The gastroesophageal refl ux may also cause dysphagia due to intense esophagitis and in this case dysphagia disorders regress quickly under medical treatment. It can also determine a peptic stricture. Curiously, peptic strictures, which are rare (less than 2% of patients), are often inaugural, peptic stricture is observed during the first consultation, suggesting a severe but not symptomatic reflux.
Ring Schatzky:
In the case of hiatal hernia, it frequently appears an annulus at the level of the Z line, the ring Schatzky, which may sometimes be sufficient for determining a stenosing dysphagia.
Its expansion treatment is very simple.
Plummer-Vinson syndrome and esophagitis dissecans:
Plummer-Vinson syndrome (or Patterson-Kelly said syndrome) is commonly called dysphagia sideropenic: it is observed in patients with iron deficiency during the course and results of endoscopically by membranes at the cervical esophagus. One can approximate the esophagitis dissecans, with diaphragms stenoses stepped over the entire height of the esophagus, sometimes associated with stenosis, easily expandable balloon.
This recently described entity, especially independent of iron deficiency and occurs in people over 60 years.
Eosinophilic esophagitis:
Eosinophilic Esophagitis (biopsies) once described in children can also occur in adults and cause dysphagia (whitish deposits pseudocandidosiques endoscopy).
Other causes:
Esophageal dysphagia can finally be related to extrinsic compression: cancer of adjacent organs, vascular abnormality (dysphagia lusoria), aortic aneurysm. These causes are easily recognized by a chest CT examination.
Treatment:
The treatment of aphasia is of course dependent on its etiology:
– Esophageal cancer at an early stage may benefit from surgical treatment. At a later stage, only the radio-chemotherapy may be considered;
– The mega-esophagus can be treated either by endoscopic dilation or surgically, ideally laparoscopic (Heller intervention);
– Disease storied spasms can benefit from treatment with calcium channel blocker (Adalate®) or nitrates;
– Gastroesophageal reflux is treated in another chapter;
– The annular stenosis (ring Schatzky, esophagitis dissecans) are easy to endoscopically dilate when troublesome dysphagia.
Ingestion of foreign body:
Ingestion of foreign bodies is a therapeutic emergency that occurs mostly at the two extreme ages. The population of patients ingesting foreign objects is 80% pediatric with a peak incidence between 6 months and 3 years. Prisoners, psychotic patients or having a psychological delay, alcoholics also are subject to risk and those with a history of malformation or gastrointestinal surgery, as well as edentulous older adults.
Diagnosis:
In general, the diagnosis is obvious interrogation or, if this is not possible, by an entourage of investigation or witnesses.
Site Blocking occurs most often at the glottis, the valécules of cricopharyngeus muscle in the esophagus at the level of the aortic arch or at the lower esophageal sphincter.
In the stomach, foreign bodies are locked instead in the pylorus and the intestine in the ileocecal valve.
Eighty-ten percent of ingested foreign bodies pass spontaneously require 10 to 20% of non-surgical maneuvers extraction and only less than 1% require surgical remedies.
Real foreign bodies are usually radio-opaque. This is usually metal objects or glass: parts, batteries, needles, pins.Foreign bodies foodborne (cartilage, bone, bones) or plastic items are not always radiopaque.
Ingestion of foreign bodies can cause retrosternal pain, pain on swallowing or drooling. In case of obstructive syndrome, emergency extraction is necessary.
Most of the time, it is in adults a food obstruction that is easily solved with the evacuation of the stomach insufficiently chewed food or swallowed too quickly, using an endoscopic operation .
Treatment:
Emergency therapy:
Must be removed urgently foreign bodies from the hypopharynx and esophagus that are obstructive, foreign substances or cutting edge given their ability to punch in 15-35% of cases.
Extraction strategy:
The extraction strategy is decided according to the size of the foreign body and its contours, its anatomical position during blocking and the operator’s experience. The removal of the foreign body is done by laryngoscopy if it is blocked above the cricopharyngeal muscle (upper esophageal sphincter) and endoscopically below. She is the most possible time with many amenities available to endoscopists: basket with handle, snare polypectomy, “crocodile” clamp.
The risk of traumatizing again esophagus to lift a sharp object can be overcome by the use of an over-tube which is easily positioned during endoscopy.
Main causes:
Inhalation:
We must quickly perform standard radiographs if there is a doubt inhalation.
Plain radiography can also search the control satellite air presence of a perforation in some cases chest CT may be useful. Avoid the barium opacification if there is a suspected perforation.
An inhalation syndrome occurs when switching airways sometimes shock, dyspnea, asthma, stridor. The inhalation syndromes cause wheezing when the object is stuck in the pharynx or at the cervical trachea, and if blocked expiratory wheezing in the intrathoracic trachea. When the foreign body crosses the trachea, it blocks most of the time in the right bronchus is verticalized compared to the left bronchus. There is in this case an asymmetry on auscultation.
Complications of inhaled foreign body may go unnoticed and cause the appearance of hemoptysis, pneumonia, pneumothorax, or pneumomediastinum abscess.
The extraction should be done under general anesthesia or using a laryngoscope or using a bronchoscope.
Sharp object:
It is especially feared bleeding or esophageal perforation if swallowed a sharp object.
This is most often tooth picks, bone, bones, razors, plastics drug packaging (blister ), denture, needles or nails of imprudently put into the mouth when tinkering.
Sharps are an emergency especially if they are impacted in the esophagus or stomach. When they passed the pylorus, radiographic monitoring must be daily: Surgery is indicated when the object remains more than three days in one place.
Batteries:
The batteries stuck in the esophagus are also an emergency: these small round cells when they remain stuck in the esophagus determine a risk of perforation.
They pass through the stomach, they are more dangerous and can evacuate spontaneously from below. These round cells create a standard x-ray image with a peripheral halo.
Soft objects:
Soft objects, if the size is less than 6 cm long and 2.5 cm in diameter, and if they do not determine obstructive syndrome, should not automatically indicate an extraction operation. Regular monitoring allows ASP to monitor the transit of the foreign body. Surgery is indicated only if the foreign body is still more than a week in one place.
Coin:
The prototype of the object “foam” is the coin. The blockage is most often at the cricopharyngeal muscle, sometimes at the aortic arch in the esophagus or the lower third of the esophagus.
The endoscopic extraction is necessary only in case of blockage in the esophagus.
Long objects:
Large objects (greater than 6 cm) constitutes an emergency in the esophagus and stomach since there is often a risk of perforation.
This is usually pens, toothbrushes, spoons (voluntary ingestion of prisoners who wish to be hospitalized).
Extraction of the stomach requires the use of the over-tube.
Bezoars:
Bezoars are foreign bodies which are mainly encountered in edentulous adults or in case of stenosis or diverticulum.We distinguish trichobezoars that are related to hair amalgam (trichophilie) the phytobezoars which consist of vegetables and dehydrated lactobézoards in preterm with low birth weight. In these extreme cases, an endoscopic fragmentation bezoar may be necessary to achieve an evacuation.
Body-packing:
The body-packing are filled condoms drugs, trick well known for crossing borders from the traffi quants. The major risk of this type of technique is the failure of the packaging with a risk in the event of death by overdose. So do not try to extract them but simply monitored daily by the patient radiography and propose an intervention in cases of suspected perforation.
Opioid antagonist (naloxone) to be used in case of rupture with overdose.
Iatrogenic foreign bodies:
Finally, we can cite foreign bodies from the digestive tract iatrogenic: these gastrostomy buttons, intragastric balloon inserted into the treatment of obesity, esophageal and biliary stents migrated. The strategy for extraction is decided case by case.