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Feb 22 2008, 5:14 PM EST (current) dr.rufusrajadurai 417 words added, 1 photo added
Feb 22 2008, 5:13 PM EST dr.rufusrajadurai

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Causes of dysphagia

  • Extrinsic mechanical
    • Carcinoma of the bronchus
    • Thoracic aortic aneurysm
    • Goitre
  • Intrinsic mechanical
    • Benign stricture
    • Oesophageal carcinoma
    • Bolus obstruction
  • Primary neuromuscular
    • Achalasia
    • Diffuse oesophageal spasm
    • Nutcracker oesophagus
  • Secondary neuromuscular
    • Multiple sclerosis
    • Systemic sclerosis
    • Chagas' disease
    • Autonomic neuropathy

Investigation of dysphagia

  • History and examination may suggest underlying pathology
  • Consider the following investigation
    • Upper GI endoscopy
    • Barium swallow
    • Endoscopic ultrasound
    • Oesophageal manometry
    • CT or MRI scan

Achalasia

  • Due to reduced number of ganglion cells in myenteric plexus
  • Vagi show axonal degeneration of the dorsal motor nucleus and nucleus ambiguous
  • Aetiology is unknown but a neurotropic virus may be important
  • Similar to Chagas' disease due to Trypanosoma Cruzi

Clinical features
  • Commonest in patients between 40 - 70 years
  • Male : female ratio is approximately equal
  • Symptoms include dysphagia, weight loss, regurgitation, chest pain
  • 5% of patients develop squamous carci
  • noma

Investigations
  • CXR - widening of mediastinum, air / fluid level and absence of gastric fundus gas bubble
  • Barium Swallow - dilatation & residue, small tertiary contractions and 'rat tail' of distal oesophagus
Barium swallow showing achalasia
  • Manometry - absent primary peristaltic wave and non-propulsive tertiary contractions
  • Endoscopy - essential to exclude 'pseudoachalasia' due to submucosal carcinoma
  • Tight lower oesophageal sphincter which relaxes with gentle pressure usually seen
  • Isotope transit studies

Differential diagnosis

  • Diffuse oesophageal spasm
  • Infiltrating carcinoma
  • Hypertrophic lower oesophageal sphincter
  • Scleroderma
  • Chagas' disease

Treatment options

  • Two treatment options are commonly available
  • Treatment selected should be based in individual patient needs

Balloon Dilatation
  • Rider Moeller Balloon
  • Inflated to 300 mmHg for 3 minutes
  • 3% perforation rate
  • 60% dysphagia free at 5 years
  • May be repeated if necessary

Cardiomyotomy
  • Described by Heller (1914) & Grenveldt (1918)
  • May be performed laparoscopically
  • 85% will have an improvement in symptoms
  • 10% develop oesophageal reflux
  • 3% will develop and oesophageal stricture
  • Some combine cardiomyotomy with an antireflux operation

Bibliography

Banerjee S. Achalasia of the cardia. Hospital Update Sep 1993. 480 - 488.
Hunt D R, Wills V L. Laparoscopic Heller Myotomy for achalasia. Aust NZ J Surg 2000; 70: 582-586.
Hunter J G, Richardson W S. Surgical management of achalasia. Surg Clin N Am 1997; 77: 993-1115.
Lamb P J, Griffin S M, Beckingham I J. Controversial topics in surgery. Achalasia of the cardia - dilatation or division? Ann R Coll Surg Engl 2006; 88: 9-12
Leslie P, Carding P N, Wilson J A. Investigation and management of chronic dysphagia. Br Med J 2003; 326: 433-436.
Navaratnam R M, Clayman C, Winslet M C. Clinical advances in the evaluation of oesophageal disease. Hosp Med 2000; 64: 194-199