Topic : Dysphagia ( Achalasia, Hiatus hernia, Oesophageal Ca )

Ddx
A. Anatomical
- Luminal - Foreign body (causing bolus obstruction)
- Intrinsic inflammatory stricture 2* to reflux, achalasia,
oesophageal cancer, oesophageal web (plummer-vinson
syndrome), pharyngeal pouch.
- Extrinsic lymphadenopathy, retrosternal goiter, bronchial
carcinoma, left atrial enlargement in mitral stenosis.
B. Functional
- Neurological causes ( MND, post stroke, globus hystericus)
- Oesophageal dysmotility (scleroderma, diffuse oesophageal
spasm)

HPC
- When did it start?
- Did it occur gradually or suddenly?
- Was it constant or comes and go?
- What cant you swallow from the start? Is it liquid or solid? Or both? Any
changes?
- Do you have difficulty to initiate swallowing or food stuck in your throat?
(if food stuck in throat ask them to show you where) (bulbar palsy)
- Was it painful when swallowing? (malignancy, ulcer, infection, spasm)
- Was there any bulging in the neck when you swallowed water?
(pharyngeal pouch)
- Was there anything that triggered this or makes it worse?
- Anything that relieve it?
- Associated symptoms:
n/v? haemetemesis? (bleeding oesophageal lesion, PUD)
bitter taste in the mouth? Heartburn? Worse after eating or relieved by
food? (PUD, GORD)
loss of appetite (anorexia)
weight loss? (malignancy/poor feeding)
dysphonia (malignancy causing RLN palsy)
fatigue (Fe def anaemia in Plummer-Vinson syndrome, upper GI bleeding)
SOB? (bronchogenic ca, anemia)
Nocturnal cough, haemoptysis? (malignancy,pharyngeal pouch,achalasia)
Neck swelling (malignancy causing SVC obstruction)
Horners Syndrome
Chest pain? (Achalasia)
Muscle weakness? Numbness? Pins and needles? (oesophageal motility
disorder, polio, bulbar palsy, myasthenia gravis, syringomyelia)

Risk Factors:
History of GORD
Barrets oesophagus
 History of PUD
Hx of Coeliac
Known history of cancer
Smoking
Alcohol
High fat intake
Steroids, NSAIDs

Physical Exam
Signs of anaemia koilonycia,
Clubbing bronchial ca
Waxy and tight fingers scleroderma
Raynauds phenomenon scleroderma
Virchows node
Retrosternal goiter
Respiratory exam

Investigations
1. CXR primary lung ca, mediastinal mass, large retrosternal goiter, aspiration
pneumonia, achalasia (air-fluid level in mediastinal shadow indicates dilated
oesophagus ass/w achalasia, hiatus hernia (lateral view shows air-fluid level in
post mediastinum, 1st line)
2. Upper GI endoscopy + biopsy diagnose Oesophageal Ca
3. CT neck/thorax (abnormal endoscopy)
4. Barium swallow (normal endoscopy)
5. Manometry and pH studies for DeMeester score (normal barium swallow)
6. Repeat endoscopy/CT neck/thorax (abnormal barium swallow)
7. Staging oesophageal CA
Endoluminal US (local)
CT TAP, laparascopy (regional)
PET scan (disseminated disease)

**Oesophageal Ca marked in red

Management
1. Achalasia balloon dilatation, Hellers cardiomyotomy, injection of
botullinum toxin in LOS
2. Diffuse oesophageal spasm Nifedipine and reassurance
3. Scleroderma partial fundoplication
4. Hiatus hernia
Medical:
- Reduce acid production : stop smoking, alcohol, lose weight
- Counteract acid production : PPI, symptomatic relief with
antacid
- Promote oesophageal and gastric emptying metoclopramide
Surgical:
 - Laparascopic or open reduction of hernia and fixation
(gastropexy)
- Nissens Fundoplication if GORD symptoms predominate

5. Oesophageal Ca

a. Neo-adjuvant chemo and rx

b. Surgery Ivor Lewis, McKeown three phase oesophagectomy,
transchiatal resection
c. Chemotherapy metastatic, good for adenocarcinoma
d. Radiotherapy good for SCC, may cause stricture or fistula
e. Palliative - intubation
- Treat dysphagia with endoluminal self-expanding
metal stenting (SEMS)
- Laser treatment for short, intrinsic tumour to
restore swallowing, repeat tx,
risk of perforation

Oesophageal Ca:

Dysphagia
Hematemesis
Dysphonia
Cough, haemoptysis
Neck swelling
Horners syndrome

Adenocarcinoma SCC

- Barrets - Alcohol
- GORD - Smoking
- Obese - Vi A, C def
- High fat intake - Coeliac
- Smoking - Stricture, webs
- Alcohol - Achalasia
- Sensitive to chemo, not rx - PUD
- Lower 1/3rd oespphagus - Sensitive to rx
- Western - Anywhere in oesophagus
- Surgery! - Japan, north china, south Africa