Chapter 24 Dysphagia in a 62-Year-Old Male (Case 13)
Cerebrovascular accident (CVA) | Peptic stricture | Achalasia |
Esophageal adenocarcinoma Squamous cell carcinoma | Spastic motor disorder, e.g., diffuse esophageal spasm (DES) | Zenker’s diverticulum |
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%.
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.
Physical Examination
• A general physical examination and focused oropharyngeal and external neck examination, including cervical and clavicular lymph nodes and the thyroid gland.
Tests for Consideration
$370 $515 (with dilatation) $670 (with biopsy) | |
$275 | |
$305 (24 hr) $675 (48 hr) | |
$750 |
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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