Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Rohan Mudkavi DysphagiaCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2How to split the differential High dysphagia – difficulty initiating swallow/ immediately after Low dysphagia – feels food getting stuck a few seconds after swallowingHigh dysphagia ‘PS MMM’ and ‘consultants prioritize cancer’ differential STRUCTURAL FUNCTIONAL LUMINAL MURAL EXTRINSIC • Parkinson’s disease • None • Cancer • None • Stroke • Pharyngeal pouch • Multiple Sclerosis • Cricopharyngeal bar • Myotonic dystrophy ‘Consultants prioritize cancer’ • Motor neuron disease • Myasthenia gravis ‘PS MMMM’ Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. Low dysphagia ‘No ACDC’, ‘PSC PSC’ and ‘PROB MDT’ differential STRUCTURAL FUNCTIONAL LUMINAL MURAL EXTRINSIC • Nutcracker oesophagus • Foreign body • Plummer-Vinson syndrome • Pericarditial • Achalasia • Schatzki ring effusion • Chagas disease • Congenital atresia • Retrosternal • Diffuse oesophageal spasm • Post-fundoplication surgery goitre • CREST syndrome • Strictures • Ortner’s ‘No ACDC’ • Cancer syndrome ‘PSC PSC’ • Bronchial carcinoma • Mediastinal mass • Dysphagia lusoria • Thoracic aortic aneurysm ‘PROB MDT’ Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2HISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.HPC Dysphagia itself: Associated symptoms: 1. What are you feeling exactly? 1. Coughing/ choking (neurological) 1. High vs low 2. Gurgling (pharyngeal pouch) 2. How long? 3. Heartburn (GORD, achalasia) 1. Short – cancer 4. Weight loss, fever, night sweats, loss of 2. Long – motility appetite (cancer) 3. Intermittent or progressive? 5. Nocturnal cough/ Wheeze (GORD, 1. Intermittent – motility achalasia) 2. Progressive – stricture 6. Rheumatological symptoms (CREST) 4. Liquid, solids or both? 7. Neurological symptoms (PS MMMM) 1. Solids – stricture 2. Liquids – motility ie achalasiaPMH 1. GORD – strictures, Barrett’s oesophagus, fundoplication surgery 2. Peptic ulcers – scarring and strictures 3. Cardiovascular disease – TAA, Ortner’s syndrome 4. Neuromuscular disease – PS MMMM 5. Rheumatological disease – CREST syndromeDHX Drugs which loosen oseophageal Drugs causing peptic ulcers sphincter • Nitrates • NSAIDs • CCBs • Steroids • BisphosphonatesFHX 1. Cancer 2. rheumatological)n PMH – (GORD, peptic ulcers, CVD, neurological,SHx 1. Alcohol and smoking– risk factors for SCC of oesophagus 2. Diet– IDA leads to Plummer-Vinson syndromeCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2Investigations Endoscopy Barium Manometry swallow Adv – sensitive+specific, allows Adv – non-invasive, allows high Adv – definitive diagnosis of biopsy lesion detection motility disorders Disadv – can lead to injury if Disadv – not as sensitive and Disadv – invasive high lesion specific for low lesionsCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 21. Which of the following is not a functional cause of dysphagia? 1. Parkinson’s disease 2. Cancer 3. Achalasia 4. Myotonic dystrophy 5. Oesophageal spasm2. Which of the following is a muralstructural cause of a high dysphagia? 1. Cricopharyngeal bar 2. Schatzki ring 3. Plummer-Vinson syndrome 4. Post-fundoplication surgery 5. Myasthenia gravis3. Which of the following is the cause of Plummer-Vinson syndrome? 1. B12 deficiency 2. Folate deficiency 3. Trypanosoma Cruzi infection 4. Iron deficiency 5. Cancer4. Which of the following is true of CRESTsyndrome? 1. It is a structural cause of dysphagia 2. Patients also can have Raynaud’s 3. All patients have lung involvement 4. It tends to cause a high dysphagia 5. Associated with erythematous butterfly rash across face5. What does gurgling most likely indicate? 1. Pharyngeal pouch 2. Myasthenia gravis 3. Cancer 4. Stricture 5. Thoracic aortic aneurysm.CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2Oesophageal cancerWhat are the types of Oesophageal cancer? Split into: 1. Squamous Cell Carcinoma (upper2/3, >90% of cases) 2. Adenocarcinoma (lower 1/3, rarer) IMPORTANT DISTINCTIONCAUSES/ RISK FACTORS Squamous cell carcinoma Adenocarcinoma Coeliac disease. 1. GORD (Barrett’s oesophagus) Hereditary tylosis Alcohol Achalasia Aflatoxins Plummer-Vinson syndrome Smoking ‘CHAAAPS’‘Barrett’s oesophagus’ • aka Columnar lined Oesophagus (CLO) • 1% of population • Only 5% diagnosedSYMPTOMS AND SIGNS Common symptoms Less common symptoms 1. Dysphagia (75%). 1. GI bleeding 2. Weight loss (60%) 2. Fatigue (anemia) 3. GI reflux (20%) 3. Hoarseness (recurrent laryngeal nerve) 4. Odynophagia (20%) 4. Cough 5. Dyspnoea (10%) 5. Facial flushing (SVC obstruction),DIAGNOSIS Definitive Diagnosis Staging investigations 1. CT – thorax, abdomen, pelvis (CT-TAP) 1. Upper GI endoscopy (gastroscopy) 2. Biopsy with histology 2. Abdominal US for liver metastases 3. PET 4. Endoscopic ultrasound 5. LaparoscopyStaging (part of diagnosis) – TNM • TX – can’t be assessed • NX – can’t be assessed • TO – no evidence of primary • N0 – no nodes • MX – can’t be assessed • Tis – carcinoma in situ • M0 – no distant metastasis • T1 – invades into lamina propria, muscularis mucosa-2 nodes • M1 – Distant metastasis or submucosa • N2 – 3-6 nodes o T1a –lamina propria or muscularis muco•a N3 – 7 or more o T1b – submucosa • T2 – invades into muscularis propria • T3 – invades adventitia • T4 – invades adjacent structures o T4a – pleura, pericardium, peritoneum, o T4b – others TREA TMENT 1. Limited disease (T1-2, N0, M0) 1. EMD, ESD, oesophagectomy 2. Locally advanced (T3-4, N1-2, M0) 1. SCC – neoadjuvant chemo/ radio then oesophagectomy or radical chemo/radio with 3 monthly follow up 2. AC – preoperative chemo then oesophagectomy, chemo and radio then oesophagectomy 3. Not an operation candidate/ advanced disease 1. Radiotherapy 2. Chemotherapy 3. Endoscopic stenting 4. Targeted therapy – trastuzumab for HER2 5. Psychological and social supportCOMPLICA TIONS • Death • Stage 3 – 16% 5 year survival • Oesophagectomy complications • Breakdown of anastomosis • Pneumonia • Cardiac arrythmiasCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2AchalasiaWhat is Achalasia? • Motility disorder • Failure to relax lower oesophageal sphincterCAUSES/ RISK FACTORS Primary achalasia Secondary achalasia • Loss of inhibitory ganglion cells • Loss of LOS relaxation due in myenteric plexus to secondary cause: • No secondary cause • Infiltrating cancer • Chagas disease • Sarcoidosis • Amyloidosis • Eosinophilic oesophagitisSYMPTOMS • Dysphagia • Regurgitation • Vomiting • Weight loss • Chest pain • HeartburnDIAGNOSIS • Endoscopy – exclude structural cause • Barium swallow – ‘bird’s beak appearance’ • Manometry – definitive diagnosisTREA TMENT Conservative: 1. Lifestyle advice Medical: 1. CCBs or Nitrates 2. Botulinum toxin injection Surgical (first line): 1. Pneumatic balloon dilatation 2. POEM 3. Surgical/ Heller’s myotomy 4. Oesophagectomy (rare)COMPLICA TIONS 1.Aspiration 2.Squamous cell carcinomaCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 2What is a pharyngeal pouch? • Also called Zenker’s diverticulum • Hcreate a pouchharynx through Killian’s dehiscence toRISK FACTORS • Male (2x as likely) • AgeSYMPTOMS AND SIGNS 1. Dysphagia ‘DR Geriatrics 2. Regurgitation 4. Neck lump Notices Halitosis’ 5. HalitosisDIAGNOSIS 1. Endoscopy 2. Barium swallow – definitive diagnosis 3. Ultrasound - if barium swallow not suitableTREA TMENT Conservative: 1. Lifestyle advice 2. Asymptomatic pouches <1cm in size Medical: 1. Antibiotics for pneumonia (a complication) Surgical: 1. Trans-oral (endoscopic) 2. Open percutaneous surgery – large pouch or specific patient factorsCOMPLICA TIONS • Ulceration • Squamous cell carcinoma of pouch • Aspiration pneumonia • Fistulation to trachea • Vocal cord paralysis • ‘2 things can happen to the pouch, 2 to the airways and 1 to the voice’CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. High dysphagia 3. Low dysphagia 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. INVESTIGATIONS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING DYSPHAGIA 1. Oesophageal cancer 2. Achalasia 3. Pharyngeal Pouch 6. QUIZ NUMBER 21. Which of the following is true regarding the different types of oesophageal cancers? 1. AC is more common than SCC 2. SCC tends to be located higher up than AC 3. Smoking and alcohol are more of a risk factor of AC 4. Barrett’s oesophagus is a risk factor for SCC 5. SCC represents around half of cases2. Which of the following is true of oesophageal cancer staging? 1. T2 means the adventitia has been invaded 2. N1 means 3-6 nodes have been invaded 3. Invasion of just the lamina propria only would be T1a 4. Staging has no impact on treatment 5. M1 means only 1 metastasis has been found3. Which of the following is true regarding oesophagectomy? 1. It is the first line treatment for advanced disease 2. It is done for all locally advanced disease 3. Postoperative chemotherapy is commonly used 4. Anastomotic leakage can be encouraged by infection 5. It has a low mortality rate4. Which of the following is not a cause of secondary achalasia? 1. Amyloidosis 2. Trypanosoma Cruzi 3. Infiltrating cancer 4. Enterobius vermicularis 5. Sarcoidosis5. Which of the following is found on barium swallowin achalasia? 1. Corkscrew oesophagus 2. Pouch 3. Perforation 4. Blockage half way along the oesophagus 5. Bird’s beak appearance6. Which of the following is not a treatment option for achalasia? 1. POEM 2. Laparoscopic fundoplication 3. Heller’s myotomy 4. Botulinum toxin injections 5. Nitrates7. Which of the following is the area which pharyngeal pouchesarise from? 1. Taeniae coli 2. Cricothyroid membrane 3. Stylopharyngeus 4. Killian’s dehiscence 5. Thyrohyoid membrane8. Which of the following is the first line treatment option for pharyngealpouch? 1. Surgical management with Heller’s myotomy 2. Conservative management with avoiding hot or cold foods 3. Medical management with CCBs or nitrates 4. Botulinum toxin injections 5. Surgery (endoscopic or open) @prescribing_the_essentials THANK YOU!REFERENCES 1. Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. 2. Anon, (n.d.). Zero To Finals – Tools for Medical School. [online] Available at: https://zerotofinals.com. 3. Pulsenotes. (n.d.). Oesophageal cancer notes. [online] Available at: https://app.pulsenotes.com/medicine/gastroenterology/notes/oesophageal-cancer 4. Pulsenotes. (n.d.). Achalasia. [online] Available at: 5. updated, D.M.A.S. (2023). Pharyngeal Pouch (Zenker’s Diverticulum) | Geeky Medics. [online] geekymedics.com. Available at: https://geekymedics.com/pharyngeal-pouch- zenkers-diverticulum/ 6. Chilukuri, P., Odufalu, F. and Hachem, C. (2018). Dysphagia. Missouri Medicine, [online] 115(3), pp.206–210. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140149/.