I just want to take a moment to formally introduce Dr. John Martin. He is with us right now, and together they're going to deliver the next talk on dysphagia. Dr. Martin is a full-time practicing gastroenterologist at the Mayo Clinic in Rochester, Minnesota. In addition to his clinical practice, his interests center on endoscopy unit operations and efficiency, technological innovations in endoscopy, and endoscopic training and simulation and hands-on training and education. He has served on the ASGE Governing Board and currently serves on ASGE practice operations. John and Sorrel, the audience is yours. Thank you very much, Sarah. It's wonderful to be back this morning. Good morning, everyone. It's a privilege to have you as our audience and participants, and we look forward to the rest of the day. So on behalf of Sorrel and myself, we work together closely. It's a privilege to be here. Here we go. I have nothing to disclose, and our objectives are as follows. To define dysphagia, to describe and categorize different types of dysphagia, to learn the etiologies of dysphagia, and to determine how to work up dysphagia, and then discuss some of the treatments available for various causes of dysphagia. I think it's always helpful to start with some questions. At least in the morning, it helps me to wake up. So let's do a couple of polling questions here. So dysphagia, and one of these is correct, does dysphagia describe painful swallowing? Does dysphagia, or is dysphagia usually caused by food getting stuck in the esophagus? Or does dysphagia describe difficulty swallowing? Does it describe swallowed food coming back up? Or is it always something that results in choking? Only one of these is correct in describing dysphagia. Fantastic, great job on the first dysphagia question. So painful swallowing is not described as dysphagia, but it's called odynophagia, kind of a funny word. Odynophagia is painful swallowing. Dysphagia is difficulty swallowing. Dysphagia, to say that it is usually caused by food getting stuck in the esophagus is not correct. It can be caused by a multitude of things, and in the majority of instances, isn't caused actually by an obstructing food bolus. However, an obstructing food bolus certainly can cause dysphagia, but it's not the most common scenario. And as the vast majority of you correctly identified, dysphagia does describe or define difficulty in swallowing. It doesn't describe swallowed food coming back up. As Cyril already explained to you, that that is regurgitation rather than dysphagia. And dysphagia, while it certainly can result in choking, it doesn't always result in choking. And because you're experts in testology, you know that if the question says always, it probably isn't the one to pick. So there you go. Great job. So polling question number two, this is again a single choice describing dysphagia. 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, or is a medical emergency when a patient cannot manage their own secretions? Which one is correct? All right, you cannot be fooled. I tried to be a little trickier on this one. We just got done saying that if it says always, that probably ain't the one. So if someone has mild difficulty swallowing but is able to eat, drink, and manage their secretions, that's obviously not the definition of a medical emergency. And questions or answers that say always, well, the ones that say never, ever are probably not the one to pick either. Obviously dysphagia where you can't manage your secretions is a medical emergency because you can have a bad aspiration event from that. So that type of dysphagia can be a medical emergency. So to say that dysphagia is never a medical emergency is not correct, and you nailed that one. To say that dysphagia is a medical emergency when the patient can't swallow solid food, that's not a medical emergency. That's not a great situation to be in, but they can certainly take nutrition in liquid form still. They can hydrate themselves orally, and they can manage their secretions. So that does not constitute a medical emergency. Is it a medical emergency when they can't swallow liquids for hydration? It might be a medical urgency, but not an emergency. An urgent situation can be taken care of by hydrating the patient, for instance, perennially, intravenously. What is a medical emergency is if they can't swallow their own secretions, the saliva that their salivary glands produce constantly, if they swallow that and that's coming back up and they have to constantly spit, they could actually drown in their secretions, and that would be aspiration, and that would be a medical emergency. So you are correct. You nailed it. It is a medical emergency when the patients can't manage their own secretions. Excellent. All right, moving on now. So it's time to define dysphagia. What is dysphagia? So in describing it, the most precise term would be difficulty swallowing. We just said that it's not painful swallowing. Painful swallowing is odynophagia. Difficulty swallowing is dysphagia. Patients can certainly have both, right, Sorel? And the two do occur together, but some patients have painful swallowing, but no difficulty getting anything down. That would be odynophagia alone. And if they have dysphagia alone, that's just difficulty swallowing, but it's not painful. Now, a different sensation from both odynophagia and dysphagia is globus. Globus is commonly described as a sensation of a ball in your throat. Sometimes people say, I feel like I have a ping pong ball or a golf ball in my throat. And that's actually called globus because that doesn't mean they have any difficulty swallowing as a result of it, necessarily, if they did, they'd have globus and dysphagia. Nor does it imply that that feeling of a ball in the throat is actually painful. So they could actually have globus with or without odynophagia. But it's important because you'll hear the term globus batted around. Sorel, what would be an example of a disorder, a medical disorder that causes the globus sensation? Commonly we see it in upper respiratory infections or reflux can even sometimes cause that. It's important to really ask about dysphagia because if they have dysphagia and globus, that's usually not a good sign. I see. Thank you. Now we just said that dysphagia and odynophagia and globus can occur separately or in any combination or all together. And when it comes to dysphagia, it's important to know where the patient feels like their difficulty swallowing is. Where is the dysphagia located? Now the sensation is not always going to precisely or accurately predict where the location of the problem is. The concordance there is far from 100%, right? But it's always worthwhile to ask the patient because that can provide you with some clues as to how to work it up or in what order to perform testing. Questions to ask the patient are always important to help identify what you might want to do first to work the patient up because it may not be the best thing or the most economical thing or the most responsible thing as a clinician to throw the whole kitchen sink of work up at them from the get go. And we already talked about when dysphagia constitutes a medical emergency. So I won't belabor that. So how do we categorize dysphagia? Well, dysphagia can be the result of an obstruction. So the difficulty swallowing might be because the esophagus is obstructed mechanically. Or it might be due to esophageal dysmotility. Remember the esophagus is not just a copper pipe. You know, food isn't going down the esophagus because you swallow it and then gravity draws it down the pipe. It's actually a lot more akin, say, to the way that you carefully squeeze toothpaste up a toothpaste tube that's three quarters empty. You're going to start at the bottom and slowly work your way up to the top. The direction is the opposite. But with esophageal motility in its normal state, which is peristalsis, just like it is in the rest of the GI tract, there will be coordinated contraction from the proximal end of the esophagus down to the distal end of the esophagus. And that contraction above is accompanied by proper and coordinated relaxation below. And that happening repeatedly in a carefully coordinated fashion actually results in successful transit of that food bolus down the esophagus, or liquid bolus for that matter. So any disturbance in that coordinated pattern of contractile activity and relaxation leading to motility can lead to problems with swallowing or difficulty swallowing, which we call dysphagia. And of course, just because you have mechanical obstruction or dysmotility doesn't mean that you actually cannot have both. There might be a situation where someone has an obstructing cancer in the distal esophagus. And if that cancer is invading the nerves that are related to proper peristaltic motility, then the patient may have dysphagia both from the mechanical obstruction and from the dysmotility, correct? Correct. So then in further characterizing and categorizing dysphagia, we can categorize not just based on whether there's mechanical obstruction or dysmotility, we can categorize the dysphagia based on whether the problem swallowing has to do with delivering what's in the mouth into the esophagus or delivering what's in the proximal esophagus successfully down the esophagus into the stomach. The former would be called oropharyngeal dysphagia or transfer dysphagia. We call it oropharyngeal dysphagia because we're taking oral contents and delivering them or transferring them into the esophagus. And that's why we would call that transfer dysphagia. And it's basically, as we described, a dysfunction clinically of bolus transfer, transfer of the food or other bolus from the mouth into the top of the esophagus. So esophageal dysphagia, as opposed to oropharyngeal dysphagia, esophageal dysphagia is dysphagia that results from lack of successful transit of that food bolus down the entire esophagus so that it's deposited properly into the stomach. So oropharyngeal or transfer dysphagia is different from esophageal or transit dysphagia because oropharyngeal is food to esophagus, esophageal or transit is down the entire esophagus from top to bottom. So that's a dysfunction of bolus transit. I know that can be confusing, but it's important to understand. Once you understand it, it becomes clear and you don't need to memorize it, which is much better. So then moving on from describing dysphagia onto how to work it up, first, we always want to exclude mechanical obstruction because that can be serious. And so the reason why we exclude it first is it can be serious and patients with bad enough obstruction are at risk for aspirating food that they try to swallow or even their own secretions that they're attempting to swallow and manage. And aspiration into the airway can be a serious medical emergency, as we mentioned before. So if excluding mechanical obstruction is important, how do we do that? Well, first we ask the patient about their symptoms and their symptoms may well raise the suspicion of mechanical obstruction. In order to look for that mechanical obstruction, we will frequently perform an endoscopy first, but in certain situations, we may order an esophagram, which would be swallowing barium and obtaining usually live fluoroscopy or video images, x-ray, video x-ray images of that barium going down the esophagus to look not only for certain types of obstruction, mechanical obstruction that may not be seen with an endoscope as well, or to give you a clue as to motility disorders of the esophagus, which may be resulting in dysphagia. Any caveats to add to that, Cyril? Because I know you see a lot of these patients and always have to decide what test to undertake first. Do you get an esophagram with everybody or do you get an endoscopy with everybody or do you do one before the other all the time? How do you make that decision? It all depends on what you get on history. If you get enough information on history where you're comfortable enough where you think what it is, then you go straight to endoscopy. If the history is a little bit muddy and the patient is a little bit non-specific, then I get an esophagram. For oropharyngeal dysphagia, I will always get a video swallow study. Great. Thanks for clarifying that. So then moving on, what are some sources of mechanical obstruction of the esophagus? Well, we alluded to earlier in one of the polling questions that a foreign body impaction, whether that's food or something that was accidentally swallowed, like maybe a dental bridge or something like that, can cause mechanical obstruction of the esophagus. A cricopharyngeal bar is where the cricopharyngeus muscle, which some of you know as the upper esophageal sphincter. That muscle can fibrose and become hypertensive and basically create some degree of an obstruction, almost like a speed bump on the road. And that cricopharyngeal bar can not only cause esophageal obstruction, but can result in a Zenker's diverticulum, where the mucosa of the hypopharynx just above that cricopharyngeal bar, because you're trying to use your pharyngeal swallowing muscles to transfer bolus into the esophagus. But that cricopharyngeal bar is not letting the food pass easily. That mucosa of the esophagus above can posteriorly herniate and form a sac called the Zenker's diverticulum. And that Zenker's diverticulum can pack with food, right? And cause its own obstruction and dysphagia. An esophageal web might be present. We don't really know what caused those, but they're usually in the upper part of the esophagus, the proximal esophagus, and can sort of stick out like a baffle on one side or the other, and like a valve and cause obstruction. Or you can, in the distal esophagus, have a circumferential sort of a ring or speed bump called a Schottky's ring or a distal esophageal ring, which can act like a stricture or a stenosis and cause difficulty of passage of food bolus. Better yet, you can, or further yet, you can have an esophageal diverticulum. I described the Zenker's diverticulum. That sort of herniation of the esophageal mucosa layer between the muscle layer can cause an outpouching that can pack food and and cause an obstruction. And then you can have a frank esophageal stricture where the esophagus can narrow down at a point either due to acid reflux or many other causes that can be benign or as I described earlier it can be the result of a malignancy like an esophageal cancer. So all this isn't an exhaustive list but these are some of the more commonly occurring causes of esophageal mechanical obstruction. We talked about strictures being benign versus malignant in etiology. If it's caused by acid reflux we usually call that a peptic ulcer with benign strictures. Other common causes are eosinophilic esophagitis which is an autoimmune condition where an excess population of white blood cells called eosinophils can accumulate in the esophagus, release their evil humors in that area and cause inflammation and fibrosis resulting in bad esophageal strictures which have to be dilated. Lichen planus is another autoimmune condition that can cause disease in squamous mucosa or skin and that can cause esophageal strictures that are benign. And of course things that providers do like radiation or surgery can result in their own types of strictures and since they're caused by providers they're called iatrogenic. Causes of malignant esophageal strictures include esophageal cancer including adenocarcinoma or squamous cell carcinoma, metastatic cancer that's traveled to the esophagus causing masses that can constrict the esophagus, or local regional cancers like lung cancers or pleural cancers that can invade or otherwise extrinsically compress the esophagus causing an esophageal obstruction. So in going on with working up dysphagia if it's not mechanical obstruction then it must be due to a disturbance in esophageal motility. So what are some causes of that? Well some causes of esophageal dysmotility can include conditions like gastroesophageal reflux like Sorel talked to you about. We talked about eosinophilic esophagitis. Scleroderma is another autoimmune condition that can cause dysmotility of the esophagus and even strictures. Diffuse esophageal spasm is a condition where you can get incoordinated contraction rather than peristalsis and that can cause bad dysmotility and dysphagia and even odynophagia. Nutcracker esophagus is a controversial condition that can cause really high pressure contractions, hyper contractility of the esophagus causing terrible odynophagia and also dysphagia. That's a dysmotility. Achalasia is a condition that results from denervation or a problem with the nerves that normally cause proper relaxation of esophageal muscle and when that's disturbed you have contraction of esophageal muscle without proper downstream relaxation and that can result in serious problems of swallowing leading to terrible weight loss. Also pseudo achalasia is a situation where the esophagus can look like there is achalasia but actually there's a condition like a cancer at the esophagogastric junction that can result in a similar clinical presentation and situation to real achalasia. So in working up esophageal dysmotility if it's oropharyngeal dysphagia you may want to consult a speech pathologist who will be able to perform a formal swallowing study with a modified barium swallow to determine if there is a true problematic transfer of bolus into the esophagus and sometimes even penetration into the airway with aspiration. EGD with biopsy is helpful as is a barium esophagogram as we described earlier and also esophageal manometry as we described earlier and impedance planimetry where we can test the proper compliance of the esophagus. So this is what a standard solid state esophageal manometry study and the catheter that's used to perform that study looks like. It's placed through the nose and this is what a barium esophagogram looks like where the patient has swallowed barium and it is now transferred down into the esophagus and is transiting the esophagus. And next Sorel is going to take over and describe some treatments for dysphagia. So moving on to treatment options it really depends on the etiology. Important body impaction usually happens with meat, chicken, or steak. It's never really vegetables. Oftentimes people can have these secretions or can have these secretions and I tell them that's really an emergency. If it's stuck for 15 minutes you need to go to the emergency room and you still get some patients that will you know wait it out overnight. The risk of doing that is esophageal perforation with them regurgitation and the bowl is moving back up. Cricopharyngeal bars John explained earlier these can respond to dilation. I usually have patients undergo one dilation. If they don't have response then I prefer to send them to ENT but you also can have them undergo a myotomy with a flexible endoscope. Zinker's diverticulum depending on how big the pouch is and how bad the patient's symptoms are. If they have pneumonia or if they get lots of food bowls impactions some of these patients will have halitosis. Even describing a fullness in one side of their neck when they eat. This can be done in a scopic group here or surgical diverticulectomy again depends on the size. Webs are easily dilated. On rare occasions they can be associated with iron deficiency anemia. I have not seen that. Schatzky's ring responds well to endoscopic dilation. In my practice if these rings come back within that first year then I tend to place patients on the PPI. Esophageal diverticulum and the metesophagus they are a pulse gene or traction diverticulum and the lower esophagus they're epiphrenic. Also depends on really what the size is, how the patient's symptoms are, how you treat these. Workup for the metesophageal diverticuli could include a CT of the chest just to look for any other metastinal etiologies of that diverticulum. Sorel you were saying halitosis can be seen in Zanker's diverticulum. What causes that? That's interesting. As the food sits in that little pocket it tends to ferment and I get that interesting clue. Benign stricture depends on the location, responds well to endoscopy and anti-reflux treatment. Malignant really if it's early stage adenocarcinoma or squamous these can be resected endoscopically either by endoscopic sub-mucosal dissection or endoscopic mucosal resection. Ablation is used oftentimes. If it's more local regional disease, patients with T1B cancer can be sent directly to surgery. And with the more advanced cancers and palliative care we sometimes will stent. If the lesion is at the GA junction it can be difficult to keep the stent in place as it falls through into the stomach. Higher up lesions can cause, stenting can cause a lot of pain. Most people don't really tolerate those stents but just having that discussion and trying to keep them to swallow. Cryoablation is oftentimes used to help with palliative treatment of advanced esophageal cancers. This is a picture of a peptic stricture at the distal esophagus. This is a closer up picture as John explained to me. If you put the endoscopy probe in the bottom of the esophagus and you can get these little areas here where we can get an estimation of how big the stricture is. You want to be careful not to dilate too aggressively. For example, this standard endoscopy probe is about 9.8 millimeters. You can estimate this stricture to be about seven and eight and that can give you an idea of how far you should dilate. Usually we try to follow the rules of three, not dilate more than three at one setting. It also depends on where the stricture is, if there's ulceration present. There's a picture of the through the scope balloon going through with the balloon inflated and dilating the stricture. This is an expected mucosal tearing after dilation. You want to see some tearing to know that you were successful in dilating the stricture. And this is just a stricture after you increase the diameters of the balloons and dilate it more. Moving on to some other treatments for dysmotility. As I said earlier in my talk, treatment of GERD options are their lifestyle modification and selected patients you can do anti-reflux surgery. Eosinophilic esophagitis is diagnosed by getting biopsies from the esophagus. The criteria is 15 eosinophils per hypoart field or higher. First treatment for us is a high dose PPI for two months. About 30% of people respond, meaning they have 15 or less eosinophils on hypoart field on the biopsies. If they don't respond, we move on to topical budesonide. There are really three or four different forms depending on what insurance covers. We frequently use the budesonide capsule. I prefer that patients mix it in honey and they take it twice a day or this budesonide gel or even the swallowed inhaler. About up to 90% of people, patients respond histologically after a course of steroid. Then I usually titrate them down to a bedtime dose indefinitely. If they stop the therapy, the eosinophils will come back. Diet therapy is used in a select few patients if they live close to your facility because we have them take out the six most allergy-causing foods in their diet, biopsy the esophagus, make sure there's no eosinophils, and then we introduce one food at a time about every two to four weeks to see if you see a flare-up in the eosinophil count. Usually about 70% response rate. Sometimes you just get too many foods that flares up the eosinophils and it's not feasible to keep them on a diet. Scleroderma. These patients can have a lot of reflux symptoms and get strictures. I have some patients with scleroderma even on TID, PPI, and some even have to sleep in a recliner, but strictures are easily managed with dilation. Exam to look for is sclerodectomy, and oftentimes patients get a kind of a tighter mouth area, just some exam things to look at. Diffuse esophageal spasm and nutcracker, herniated glasia is in that spectrum. For the spasm patients, depending on what their symptoms are, there are some options for nitrates or dephosphate inhibitors, or even calcium channel blockers. Nothing really works great as a trial and error, depending on what their symptoms are. Lepsin is sometimes used to treat spasm. Echolasia I will cover in the coming slides. Pseudoecholasia, the three that I have seen is infiltrating a submucosal gastric mass at the G-junction, a perineoplastic phenomenon with a patient with metastatic lung cancer that's excreting these hormones, causing an echolasia pattern, and a patient with a really tight gastric lab band over several years creating a pseudoecholasia pattern. Treatment really depends on what the cause is here. If a cancer is suspected, what makes it different from echolasia, if you suspect weight loss that's unusual, or especially in patients with that smoke, do CT imaging and look for a lung cancer, and you can draw a perineoplastic antibody panel, and if that is positive, those patients can be referred to neuroimmunology and usually treated with steroids and IVIG. Moving on to echolasia, there are about three types. Type one is where the esophagus, with the absence of peristalsis, type two is where it squeezes at the same time, and type three is really an aggressive peristalsis at the lower esophagus. One and two can be treated the same. Three could be more treated with a poem. There's some controversy over that, but I'll kind of go over the treatment options here. This is an esophagum. As you can see, there's some dilation. Usually the esophagus diameter normal is about 15 to 25 centimeters. This is a standing column of barium, and you can see the typical bird's beak appearance of the esophagus, so these are kind of three classic findings of echolasia. Moving on to treatment options, if you do a workup, so the workup for echolasia includes manometry, esophagum, and endoscopy, and we have added endoflip in the last year. If you have clear evidence of echolasia, or if you don't have clear evidence of echolasia, you can certainly try Botox as a diagnostic trial to see if you inject Botox at the gastroesophageal junction, are the patients going to get better? Botox is generally reserved for patients that are not a surgical candidate. They have lots of comorbidities. It's injected in the four quadrants, usually a total of 100 units. The more you do it, the less effective it gets. As a caution, if you have a patient that you think about having surgery down the road for echolasia, you would want to minimize the amount of Botox you do at the G-junction as you can get some fibrosis. One Botox injection will not make a difference. The standard dilations we have in endoscopy is the fluid-filled balloons. They go up to about 20 millimeters. This is a pneumatic dilation balloon with actually air-filled. It starts at about 30 millimeter balloon, and the next one is 35, and then 40 millimeter balloon. It's usually used to rupture that muscle in the bottom of the esophagus. A very good option in the hands of a trained endoscopist. I quote my patients at about 1% to 2% risk of perforation. Half of these patients can be repaired endoscopically. The other half really will need a major surgery to repair the perforation. Most patients, if they choose pneumatic dilation for the echolasia, will require a second pneumatic dilation, either with a higher balloon diameter. Do you get a lot of reflux after this, or is it manageable? You can, but we can manage it with PPI. This is a gold standard for echolasia surgery. As you can see, these patients will have four to five laparoscopic incisions. The esophagus is dissected, and the myotomy incision is done. It's usually taken, or it should be taken, about two to three centimeters onto the stomach, and this is accompanied with a partial wrap to help prevent reflux. Lastly, the poem, an incision is made in the wall of the esophagus into the submucosal space, and then the muscle is cut all the way down onto the stomach and the submucosal tunnel. The endoscope is brought out, and usually this is clipped with three little clips to when the scope is out. A good procedure, similar to the heller myotomy, we do see quite a bit of reflux in patients, up to 60%. I think the latest evidence come out of these patients after a poem will have reflux. If you have a patient that's really against taking any PPI for their reflux, the poem is likely not a good procedure to treat their echolasia. Practice pearls. Dysphasia describes difficulty swallowing. It could be oropharyngeal or esophageal in nature. Workups really differs for each, maybe mechanical or dysmotility, or a combination of both. Workup dysphagia often includes esophagram and endoscopy. It all depends on how much you get on history. If you suspect motility, a manometry is indicated. Treatment of obstruction involves disinfection, strict dilation, or even surgery, and oftentimes medications or myotomy is used for dysmotility. And that's all I have. Thank you. Thank you.

dysphagia

difficulty swallowing

odynophagia

regurgitation

globus sensation

mechanical obstruction

esophageal dysmotility