Dysphagia in a 62-Year-Old Male (Case 13)

Chapter 24 Dysphagia in a 62-Year-Old Male (Case 13)



Paul Vesco, MD




Differential Diagnosis













Cerebrovascular accident (CVA) Peptic stricture Achalasia
Esophageal adenocarcinoma Squamous cell carcinoma Spastic motor disorder, e.g., diffuse esophageal spasm (DES) Zenker’s diverticulum



Speaking Intelligently


When I am asked to see a 62-year-old male with dysphagia, I try to determine right away if it is oropharyngeal (upper) or esophageal (mid to lower) dysphagia. I want to know if the patient has obstructive-type symptoms or difficulty swallowing. I ask about the duration of the symptoms, change in eating habits, and weight loss. I want to know if the dysphagia began with solids and has progressed to liquids, and whether it is intermittent. I ask whether there is a hx of tobacco or alcohol use, or gastroesophageal reflux disease (GERD). Questions regarding past hx should also include recent medication changes, strokes, strokelike symptoms, neuromuscular disorders, as well as prior head or neck cancers or previous radiation therapy.



PATIENT CARE



Clinical Thinking



• Dysphagia is frequently seen in people as they age, and a careful hx should elucidate a narrow differential in 80% to 85%.

• Esophageal cancer rises with age and should always be considered in the differential dx.

• A careful hx will enable you to initiate the workup with the correct order of tests.


History



• The patient has come to you because of difficulty swallowing. Ask about any other new cognitive or motor deficits that might suggest a CVA.

• A patient with obstructive type symptoms and weight loss needs an evaluation for esophageal carcinoma.

• Progressive dysphagia might be due to a peptic stricture or carcinoma especially when there is a long hx of GERD.

• Intermittent dysphagia may suggest esophageal rings or webs or a spastic motility disorder such as DES.


Physical Examination



• A general physical examination and focused oropharyngeal and external neck examination, including cervical and clavicular lymph nodes and the thyroid gland.

• It may be of value to observe the patient swallowing different consistencies of food.


Tests for Consideration


















• Gastroesophageal endoscopy: Test of choice for obstructive type symptoms or GERD; provides avenue for visualization of mucosa, biopsy, or therapeutic maneuvers.
 $370
$515 (with dilatation)
$670 (with biopsy)

• Esophageal manometry: Measures pressure of upper and lower esophageal sphincters (UES, LES), amplitude, duration, and velocity of esophageal contractions.
 $275

• pH probe study: Good if patient has GERD symptoms; measures distal esophageal pH level.
 $305 (24 hr)
$675 (48 hr)

• Endoscopic ultrasonography: After a cancer dx is made, used to determine depth of invasion, possible lymph node status.
 $750



IMAGING CONSIDERATIONS












→ Barium esophagram (barium swallow): Initial examination. Requires minimal patient fasting. Swallowing barium liquid under fluoroscopic review. Spot x-ray images and possible cine review of surgical anatomy, mucosal lesions, and function of the esophagus. Barium swallow is cost effective and should be the first test ordered for nonobstructive dysphagia.
 $370

→ Video fluoroscopy or cinematographic (cine) esophagram: An examination of swallowing function rather than anatomy. Different solid and semi-solid foods are followed from oral to pharyngeal stages of swallowing. Generally used for neurologic problems and airway protection from aspiration.
 $500























Clinical Entities Medical Knowledge
Cerebrovascular Accident
PΦ Dysphagia is documented in up to 47% of stroke patients, and up to 68% of causes of dysphagia may be related to a CVA. CVA can directly affect the cranial nerves and muscles, or lead to discoordinated action of the very complex oropharyngeal swallowing process.
TP The typical patient has other signs and symptoms of a CVA or a past hx of a CVA. In general, CVAs occur more commonly in males with hypertension, heart disease, and cigarette smoking.
Dx Barium swallow can be performed as an initial screening test. After a CVA, video fluoroscopy is the most sensitive test to document dysphagia.
Tx First, treat the CVA. A dedicated speech therapy regimen has been shown to help recover function. Dietary modifications altering consistency of foods can be helpful. Behavioral changes, e.g., chin tucking and turning the head to the side, may help prevent aspiration. See Sabiston 72, Becker 39.




















Peptic Stricture
PΦ Peptic stricture usually occurs as the result of chronic GERD-induced esophagitis. Peptic strictures are most commonly seen at the gastroesophageal junction (GEjx) and are usually 1 to 4 cm in length. The chronic reflux causes fibrosis and scarring of the area, narrowing the lumen and leading to a progressive dysphagia.
TP The typical patient has a long-standing hx of GERD. Up to 85% of patients with peptic stricture also have a hiatal hernia. Patients with reflux and stricture are more likely to have a decreased LES pressure and decreased motility of the esophagus.
Dx Barium swallow can document the presence of a constricting lesion near the GEjx. Upper endoscopy can directly visualize the area and confirm the presence of a benign peptic stricture by endoscopic biopsy.
Tx Pneumatic dilation followed with proton pump inhibitor therapy has decreased the recurrence rate of peptic strictures. See Sabiston 42, Becker 27.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Dysphagia in a 62-Year-Old Male (Case 13)

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