This is evaluation of the patient with dysphagia. Sorel, maybe we should start with the objectives and maybe some polling questions. So neither of us have anything to disclose. The objectives of this session are to describe common esophageal symptoms, to describe and categorize different types of dysphagia, to learn the etiologies of dysphagia, to determine how to work up dysphagia, and then also to discuss some of the treatments that are available for various causes of dysphagia. So let's start with the first polling question. Dysphagia, is it A, describes painful swallowing, B, is usually caused by food getting stuck in the esophagus, C, describes difficulty swallowing, D, describes swallowed food coming back up, or is it E, always results in choking? Only one is correct. Go for it. What do you think? That's great. Yeah, looks good. I agree, Sorel. Alrighty, then I think we're ready to move on to the next one. Okay, so this is polling question number two, fire away. So dysphagia is always a medical emergency, is never a medical emergency, is a medical emergency when a patient cannot swallow solid food successfully, is a medical emergency when a patient cannot swallow liquids for hydration, is a medical emergency when a patient cannot manage their own secretions. This is a really important concept, isn't it, Sorel? Yeah. Awesome. Fantastic. So Sorel, before you move on, what if they can't swallow liquids for hydration? Is that urgent? I would say if they can't swallow saliva, obviously that's urgent. You know, you see some patients that would sit on a food bowl's inflection overnight and I counsel them to say, if it's 15 minutes, that becomes an emergency, you have to go in. Yeah, I think we're worried really about them aspirating, right? And saliva has a lot of bacteria in a situation with a food bowl, so it can contain solid particles of food that can break off and lodge in the airway. So that's what really makes that a medical emergency, isn't that right? Correct. Yeah, alrighty, next one. Well, I think it's time for you to take it away, actually. Here are some common symptoms that I see in the esophagus clinic, you know, reflux, as we alluded to earlier, the dysphagia we talked about a little bit earlier, you know, it can be anywhere. Patients can describe it sticking in the sternal notch, mid chest, or lower chest, and then a dynaphagia. Globus, usually this is better when they swallow, but it's usually in the mid to lower neck, and then water brush. Can I ask you a question really quickly? I think sometimes the term water brush is used, but not everybody knows what that means. What does it mean to you, clinically? Yeah, it's just, you know, you see patients with this excessive salivation they get, and then it's just really hard to control. You don't see a lot of them, but I've seen some with water brush. They used to say it can taste somewhat salty. Right, because of the sodium bicarbonate that's secreted by the salivary glands in an effort to try to get the acid back down, right, or get the food back down. So yeah, water brush. So when I see a patient in the clinic, I try to determine, is this a structure issue? Is it a motility issue, combination of both, or is it a sensory issue? And unfortunately, we cannot test for sensory dyslipidation. What does that mean, sensory issue? Meaning they are feeling things more than they should. Perhaps they had a food bowls impaction, now their esophagus is hypersensitive, so they feel every bite or every sip of liquid. So they think something's still there, but it isn't necessarily there anymore, but they still feel like it, I see. History is quite important. You know, ask the patient where the food gets stuck. Is it in the upper esophagus, mid-esophagus, lower esophagus? Do they have some associated with dynaphagia? Those are good questions to ask. If I think about a structural abnormality, these are some good history that can come from the patient. It's usually with solid foods and pills. The size of the bite does matter. It usually happens in the first few bites. As we take larger bites, we're more hungry. We take bigger bites and don't chew as well. Patients can usually wash it down with liquids, the last anything, you know, less than five minutes. And when you ask them, can they continue to eat? They're generally able to do that. Commonly happening at a restaurant, at a party, especially when they standing up eating. The alternative of dysmotility can be liquids and solids. May start with solids and progress to liquids. It's consistent swallowing issues. They do regurgitate more often. Dysphagia is more likely to happen mid to end of meal. They sometimes describe a stacking up sensation in their chest and they will regurgitate and really stop eating. They give up. Here are the tools we have to evaluate dysphagia. Barium studies. If you suspect oropharyngeal dysphagia, you can add a video swallow study to the barium esophagram. And then you can also have an option to ask the radiologist to do a timed barium esophagram. That's where they measure the flow of barium through the esophagus at one minute, two minutes and five minutes. And obviously endoscopy, esophageal manometry and then the endoflip. So how do we work up dysphagia? I think it's important to exclude an obstruction. How do we do that? And you undertake endoscopy. Certainly an esophagram is an option, but perhaps that can be done if the endoscopy does not show obvious stricture as the esophagram can pick up some subtle strictures and give you a minor sense of the motility. It's not a gold standard. But in terms of what did you do first, it really depends on availability. But if it's obstructed, I would say endoscopy first. Is that because you're worried that you send them for the esophagogram, they swallow the contrast and they aspirate the contrast? Yeah. So here's some common etiologies for obstruction, foreign body impaction, the cricopharyngeal bar, that's the upper esophageal sphincter that just tends to be tight when they swallow, it's supposed to relax. Is that a fibrosis thing or is it a hypertension thing? It's a hypertension thing, I see. And then in some patients, they can develop a Zanker's diverticulum. A less commonly seen are Webbs, Chomsky's rings, diverticulum, anywhere really in the esophagus, and then benign or malignant strictures. And the Zanker's, which I guess goes posteriorly, right? That can be related to the cricopharyngeal bar because it's like squeezing against a closed door sort of thing. Correct. And then the esophagus will balloon out. Benign strictures commonly seen are peptic strictures, EOE, lichen planus, we commonly see here. And then folks that have had hidden axial or radiation. And then malignant strictures. So if not mechanical, then it must be dysmotility. So what are some sources of esophageal dysmotility? Abnormal reflux can certainly affect the esophagus squeeze as can EOE if it's fibrotic. Scleroderma is a condition where the lower esophageal sphincter is really wide open and the esophagus doesn't squeeze anymore. So those folks can have a bad reflux. And then you're moving into the esophageal motility disorders, some spastic disorders, which we don't really have great treatment options for, except for achelation. Can I ask you a question? I've always found the term pseudo achalasia to be a little confusing. So you can get a motility disorder of the lower esophageal sphincter secondary to malignancy, right? Correct. Now, if you actually have a malignant tumor causing mechanical obstruction at the esophagogastric junction, is that still called pseudo achalasia or pseudo achalasia is strictly a motility thing that's secondary to cancer? Yeah, so in my mind, I see that as an obstruction of the G-junction anywhere from a G-junction tumor or perhaps lung cancer secreting these peroneoplastic antibodies causing a type of pseudo achalasia. So either one? Either one. I also see this in post-gastric bypass, banding perhaps. Thanks for clearing that up. Image of the esophageal manometry. It has 36 pressure sensors that's spaced a centimeter apart. It gives us good information on the esophageal motility as well as the pressure at the lower esophageal sphincter. It kind of throws it on this topographic map. This is an image of the esophogram. Generally you can see the aortic arch coming out and hugging the esophagus. So that's not a stricture there, right? That's just an indentation from extrinsic compression due to where the aorta crosses over. So I'll move over to a case here. This is a 50-year-old female who has dysphagia that's progressive over the last four years. She reports this pressure in her chest after solids and liquids and oftentimes regurgitate undigested solid food that she consumed several hours earlier. Doesn't have any weight loss, no prior medical illness, and she's been prescribed Omeprazole twice daily for her symptoms. Physical exam is the overall honor mark. So undigested suggests what? Perhaps food that's not going into the stomach that's sitting in the esophagus. So different from vomiting, which is from the stomach, right? Gotcha. So we're looking at what are the possible causes of dysphagia? Malignancy, certainly could be. Less likely because it's been going on for four years. Peptic stricture, I would keep that on the differential. But less likely because it's with liquids and solids. EOE, same, mostly solids, not as much liquids unless they have a very tight esophagus stricture. Schatzky's ring, infectious esophagitis, medication-induced, doesn't have any high-risk medications. And motility disorder, I'm leaning towards this as there's liquid and solid dysphagia. And no evidence of oropharyngeal dysphagia on exam or history. Anything you want to add here, the thought process, John? Yeah, I mean, I think that's a great list. There are also things that are similar to some of the things that you've listed, right? There are mucosal diseases that are less common than EOE, like lichen planus. We manage a lot of those patients. Another inflammatory condition that affects the skin as well as the esophagus. And I guess that's because the esophagus is lined by squamous mucosa, right? So it's a lot like the skin. And there's a lot of skin diseases that manifest also in the esophagus. And much as you can have rings which are circumferential in the esophagus. You can also have webs, right, which are not circumferential, but might be less than circumferential. Are there particular medications that tend to cause esophagitis that you see more commonly? Yeah, so I would say any medication can really cause esophagitis. Mostly we can see it in potassium, antibiotics. You can see it even in vitamin C. Those are probably the ones we see it in more commonly. And any particular spots where they tend to hang up? It tends to hang up in the upper metastatic is kind of where the aortic arch. Yeah, I just was thinking back to the picture that you just showed of the barium swallow. And so just to connect that with it. And then with infections, they can not only be common things like candida, which is a yeast or a fungus, but also and particularly in patients who are immunosuppressed viral etiologies, right? So what is the best next thing to do? You know, barium esophagum is an okay option. pH impedance, I'm not sure I would go to this right away. Upper endoscopy will be a good one to do. And or a change in the omeprazole to esomeprazole. Not right or wrong, I think barium esophagum is probably the best next step. Do you wanna say something about that? Yeah, I think, you know, it really depends on what you think the likelihood is in your differential diagnosis. I think I always wanna make sure in my mind, at least that you're not gonna be in a situation where the patient swallows that barium. And they're not doing that in your presence, they're doing that in the presence of a technologist. And they aspirate that, right? And so as long as you think that it's safe to do that first, I think there's great value in a contrast study like that, because it not only gives you anatomical information, but it also gives you some functional information as well. So it's a little bit of looking at the used car on the car lot, but also taking it for at least a short, quick test drive, you get both. It's not a formal motility study, but it gives you many times at least some basic information as to whether there may be some dysmotility involved. And overall, it's a pretty low risk study. It's inexpensive and it's widely available, right? Easy to schedule and easy to get. For sure. I think if we're worried about aspiration, we tend to go for an upper GI endoscopy first. I think it's even possible that this patient who's on high dose PPIs probably have that done at some point along the way. So you have an esophagram here and the radiologist gave you a nice measurements here at one, two and five minutes. You see the standing column barium with a tight lower esophageal sphincter with food and fluid debris in the esophagus. Notice the aortic arch is even more up there, right? So given these findings, your next step, you go for, you pursue an upper endoscopy. Then you receive a call from the endoscopist and they're like, what should we do? Should we take biopsies? Or what is the next step? He's describing, or they're describing is dilated esophagus with pain secretions. Do you do esophageal biopsies? Do you perform dilation? Perform a resolution manometry or a CT scan? So I think in my mind, yes, certainly biopsies can be done, but if this is likely a esophageal motility disorders, it's not gonna be helpful. You can consider through the scope balloon dilation to 20 millimeters. If it is like a laser, it's likely not gonna be helpful. What are your thoughts on doing a CAT scan on this patient? Well, I guess it depends on what we think we're looking for, right? Yeah. Sorry, the right answer is here, next step would be a manometry. Yeah, and I think it's pretty clear from that barium study that you just showed that we have a good direction for our differential diagnosis and what this is likely to be. And I'm guessing that's what would drive you to get the manometric study. If this patient was a smoker, was significant weight loss, I would consider a chest CT. Yeah. So here's a manometry results. This is commonly how you would see them in the chart showing abnormal relaxation. IRP is 19.1, normal is less than 14.7. And this patient had some pan-esophageal pressurization. And it's type II echolasia for the Chicago classification, 4.0. So what is echolasia? It's basically loss of these neurons in the myenteric plexus. It causes the esophagus not to squeeze or have no motility. And the lower esophageal sphincter doesn't relax. I often tell patients, we don't really have any treatments to get the motility back, but we only have options to make the sphincter relax. I feel like the failed relaxation of the LES gets a lot more play than the failed peristalsis part of this diagnosis. But I'm glad you brought that up because it's important to remember that it's both. It's a closed door and reduced coordinated strength of squeeze. It's both. So this is no wonder it's so debility. And it's really, now I tell them, it's that your esophagus is not open, but it's really not swallowing. It's really kind of flat and it becomes this tube that you need gravity. Here's clinical presentation, liquid and solid food dysphagia to have regurgitation. Some will induce vomiting as they feel too much chest pressure. Majority have difficulty in the belt. This is likely because the sphincter is so tight, they can't move anything from the stomach up. And some can have some substantial chest pain. Unclear if this is coming some part in the undigested food or part of the achalasia spectrum where the esophagus tends to cause squeeze. Hiccups likely related to the distention of the esophagus causing some irritation to the diaphragm. This image of a normal manometry, the top line is the upper esophageal sphincter. There's a gap in it. That's where the sphincter relaxes. And as the swallow progresses down to the bottom line, there's a break in between the left and the right. That's where the lower esophageal sphincter relaxes. So this is a normal esophageal manometry. So with this type of high resolution manometry, the X-axis is time, right? And then your pressure is denoted by the colors? Correct. So the higher the pressure, the brighter the color, the higher the pressure. So here are the subtypes of achalasia. Type one on top is really the sphincter is tight and there's no squeeze in the esophagus. Type two, you do have about 20 to 30% of some panesophageal pressure in the esophagus. And type three is really the spastic achalasia. All of these have failure of the lower esophageal sphincter to relax. Just depends on what the squeeze of the esophagus is. Can patients go from over time from one type of achalasia to another? Or do you generally not see that? I generally don't see that. So endoscopy is important to really look for at a good retroflex view to make sure there's no tumor in there. Some can be normal. And this is some pseudo-achalasia that we talked about earlier. And think about peroneoplastic coming from a lung cancer. Treatment options listed here. Briefly, Botox, that's generally reserved for folks that have significant comorbidities. And it's not a candidate for a more durable therapy. Then there's pneumatic dilation. I generally reserve that as a rescue therapy after lap-halotomy or a POM. Can I ask you a couple questions? How long does that Botox tend on the average patient? Or is there an average patient? How long does that last? Like, what's the longest duration you've seen that be really helpful? Probably a year, but anywhere from three months to a year. And then they have to come back and be injected again? They have to come back, and it tends to, the more you do it, the less it works. I see. So looking at the efficacy of the treatment options and the subtypes, if you have a patient with type 2 and type 1 achalasia, there is not a lot of difference between a lap-halotomy and POM. It really becomes a patient preferred what they really prefer. Surgical incisions in the abdomen with the lap-halo versus no incisions with the POM. If you think about type 3 achalasia, POM is preferred because it's more of a spastic type of achalasia, and they can make the POM incision higher up in the esophagus in type 3 achalasia. Boy, it really shines. POM really shines for the type 3s, doesn't it? Wow. Uses an esophagram before the POM, and then same day after the POM, or sorry, post-POM day one. See how the barium empties the esophagus. So you really see that bird beak, so to speak, appearance with that pre-POM image. That's a really nice contrast study. You can see the indentation of the aortic arch. It's fantastic. And so that's post-POM one day. Might still be a little edema in the area, right? Yeah. And we do it mostly to rule out if there's any leak or perforation. A follow-up in my practice, everybody comes back with an endoscopy and a flip with the Bravo capsule to really see if they have reflux. As most patients with achalasia would not feel the heartburn. POM has a risk of about 40 to 50% of reflux afterwards, depends on which study you look at. And then follow-up after that, there's a lot of gray areas that don't have clear guidance, but I bring them back yearly, at least to have a chat with them and see how their symptoms are and do an esophagraph. Now your practice is highly consultative and a lot of these patients come in from distances. So I'm guessing that they also have other providers locally that are seeing them in between, right? Right. And I'll just leave these slides here as kind of other options or other things to think about for dysmotility, spastic conditions, EOE, that can be a talk on itself, and esophageal obstructions and some brief treatment options. Those are excellent lists to keep in our back pocket. Practice trials, dysphasia describes difficulty swallowing. It could be oropharyngeal, like I said earlier, a structural or a motility issue. It evolves usually endoscopy with an esophagram or even an esophageal manometry with an endoflip. Treatment depends on what the cause is, dysinfection, dilation, or surgery. If it's a motility issue, it usually involves myotomy. I don't have a lot of options for medications to treat dysmotility. That's all we have. Fantastic. Always a privilege and a pleasure to work with you, Cyril. Thanks for having me along for the ride. Of course.

dysphagia

esophageal symptoms

diagnostic strategies

treatment strategies

achalasia

esophageal manometry