Dysphagia 吞咽障碍课件

DYSPHAGIAWendyFunk,M.D.UniversityofConnecticutHealthCenterJanuary7,2005Definition?InabilitytoswallowRegurgitationPainfulswallowingCoughing/chokingFood“sticks”GlobusFeels“tight”ImportanceApproximately50%ofnursinghomeresidentssufferfromsomeformdysphagiaPatientsareoftenconcernedaboutthepossibilityofcancerItisessentialthatthephysiciandemonstratesseriousinterestinthepatient’scomplaintstoruleoutamalignantorCNSprocessEsophagealAnatomyUpperone-thirdiscomposedofskeletalmuscleDistaltwo-thirdsissmoothmuscleNOSEROSAOuterlongitudinal,innercircularmusclelayerMyentericplexusofAuerbach,parasympatheticganglioncells,interspersedamongthemusclelayersSubmucosa–bloodvessels/lymphatics,myentericplexusofMeissner(parasympatheticganglioncells)Mucosa–stratifiedsquamousepitheliumReviewTheoutermostcollection,lyingbetweentheinnercircularandouterlongitudinalsmooth-musclelayersofthegut,iscalledthemyenteric(orAuerbach's)plexus.Neuronsofthisplexusregulatetheperistalticwaves,consistingofpolarizedmuscularactivity,thatmovedigestiveproductsfromoraltoanalopenings.Inaddition,myentericneuronscontrollocalmuscularcontractionsthatareresponsibleforstationarymixingandchurning.Theinnermostgroupofneuronsiscalledthesubmucosal(orMeissner's)plexus.Thisgroupregulatestheconfigurationoftheluminalsurface,controlsglandularsecretions,alterselectrolyteandwatertransport,andregulateslocalbloodflowSwallowingStage1OralFoodingested,prepared(mastication)andmodified(lubrication)VoluntarycontrolFrequentlyresultsfromweakness–lips,tongue,cheeksUnabletoorganizefoodintowellformedbolusandmoveposteriorlyXerostomia–difficultybreakingdownsolidsSwallowingStage2PharyngealPreventedfromenteringnasopharynx,larynxrises,retroflexionofepiglottisandvocalfoldclosure,synchronizedcontractionofmiddleandinferiorconstrictors,andsynchronizedrelaxationofthecricopharyngealmuscleInvoluntaryTiming–neurologic–epiglottisdoesn’tprotectlarynx-leadstocough/aspirationWeakness–neurologicinjury/cancer–residualfoodafterswallow–canleadtoaspirationPhysiologyDetailedaccount–Gatesp.478-485DifferentialDiagnosis

(continued)ExtrinsiclesionsThyroidmassDysphagialusoriaAorticaneurysmIntrinsiclesionsZenker’sdiverticulumBenigntumors(leiomyoma)Carcinoma(SCCA,Adeno)StricturesAchalasiaEsophagealwebsSchatzki’sringHistoryWhileeatingorbetweenmeals?Difficultywithsolids/liquidsisaseriouscomplaintusuallycausedbyanobstructiveorneuromusculardisorderObstructiveLesionsNeuromuscularDisordersEffectbetween-mealswallowingLateincourseearlyNasalregurgitationnoyesAffectedfirstsolidsliquidsAffectedbytemperaturenoYes;roomtemp>extremetempsHistoryTemporalpattern<4secondsafterinitiationusuallycanbelocalizedtotheOC,pharynxorCPregions>4secondsmostareduetopathologyintheesophagusWeightlossincreasesthelikelihoodofasignificantorganicprocessStricturesmayoccurfromchemicalingestionortraumaticinjuriesHistoryVoicechangesConsiderreflux,vocalcordparalysis(s/pCVAorfromtumorinvolvement)orpresbylaryngeusGlobushystericusPressure,fullness,oralumpinthethroat,notrelatedtomealsOldmythofoverweight,depressed,obsessive,menopausalfemalesActuallyoftenassociatedwithrealGERD/LPRHistoryMedsDrug-induceddysphagiaAffectssmoothmusclefunctionorproductionofxerostomiaROSPMHPSHOropharynxUlcerativecanceroftherighttonsilThesourcemightbeVERYOBVIOUSduringtheH&NexamPEAbsenceofanupwardmovementoflarynxwithdeglutitionindicatesfixationduetoinflammation,tumor,orparalysisNeurologicexamEvaluateforotherdeficitsorCNpalsiesFlexiblefiberopticlaryngoscopyidentifydefectsinthelarynx/pharynx,poolingofsecretionsinthehypopharynx,ormasslesionsthatmayproduceobstructionFluoroscopyStandardbariumswallowusesthinbarium,isaquickview,andisnotsatisfactoryformostswallowingdisordersMBSisthedefinitivestudyforevaluationoftheswallowingmechanismUsesboththickandthinbariumconsistenciesandsimulatedfoodsMBSDynamicrecordingsusingair-contrastexamsbothintheuprightandrecumbentpositionsAssesspharyngealanatomyandmotilityMosthaveaspeechpathologistpresentSuperiortoFEESforevaluatingtheoralphaseandaspirationFEESST

(Functionalendoscopicevaluation

ofswallowingwithsensorytesting)FEESTobjectiveevaluationoflaryngealsensoryfunctionusesanairpulsestimulustodeterminelaryngopharyngealsensorydiscriminationthresholdsonmucosaofSLNdistributionSensorydecreaseandconsequentdecreasedreflexesmayleadtoaspirationEsophagoscopyFlexible(inoffice)vs.rigidForeignbody,biopsyoflesions,evaluationofstenosisPatientswithpersistentneckpain,odynophagiaorthosewithtumorsfoundinthepreliminaryworkuprequirearigidexamination(DL/E)Esophagusshouldbebiopsiedinallpatientssuspectedofhavingesophagitis,aneuromusculardisorder,oracollagenvasculardiseaseSpecialTestspHprobe-monitorsovera24hourperiodAcidinfusiontestsinfusesadiluteHCLsolutionintotheesophaguschecksreproducibilityofsymptomsManometry–essentialifdysfunctionofthecricopharyngeus,esophagusorLESidentifiedonswallowstudyQualitylaboratoryInterpretedbyanexperiencedgastroenterologistManometrySensestheactivityofthemusclesIdentifiessubtlefailuresofpressuregenerationorhyperfunctioningofthesphinctersHelpsaccuratelydiagnosethesiteofdysfunctionManometryCP=UEShasanormalrestingtone,whichisincreasedduringinspirationandrelaxedduringboluspassageLEShasanormalrestingtonewithrelaxationcoincidentwithbolusarrivalEsophagealantegradeperistalsismaybedisruptedduetospasm,aperistalsisorotherdyskineticcontractionsMaybeasymptomatic,althoughinflammationandmuscularspasmareoftenrecognizedbysensationsofsubsternalpressureordiscomfortDifferentialDiagnosisInflammatorylesionsThrush(Candida)Tonsillitis(PTAvs.lingualtonsillitis)Abscesses(retro-,para-)SystemiccausesSclerodermaPlummer-VinsonsyndromeNeuromusculardisorderEsophagealspasmPseudobulbarpalsyCVAMultipleSclerosisMyastheniaGravisDermatomyositisMuscularDystrophyCandidiasisMultipleulcerationsandnodularityoveralongsegmentMostcommoninimmuno-compromisedpatientsDifferentialDiagnosisInflammatorylesionsThrush(Candida)Tonsillitis(PTAvs.lingualtonsillitis)Abscesses(retro-,para-)SystemiccausesSclerodermaPlummer-VinsonsyndromeNeuromusculardisorderEsophagealspasmPseudobulbarpalsyCVAMultipleSclerosisMyastheniaGravisDermatomyositisMuscularDystrophySclerodermaChronic,degenerative,autoimmunedisorderthatleadstotheover-productionofcollageninthebody'sconnectivetissueDecreasedmotilityChronicrefluxduetoincompetentLESStrictureofthedistalesophagusPlummer-VinsonSyndromeIron-deficiencyanemiaUpperesophagealwebHypothyroidismGlossitis&/orcheilitisGastritisDysphagia(evenwithoutpresenceofaweb)Plummer-VinsonSyndrome90%womenPredominantlyinnorthernhemisphere/ScandinaviandescentRx:ironreplacementalonemayreversesomeofthepathologicchanges;dilationofwebIncreasedincidenceofpostcricoidSCCA

(15%inoneprospectivestudy)

DifferentialDiagnosisInflammatorylesionsThrush(Candida)Tonsillitis(PTAvs.lingualtonsillitis)Abscesses(retro-,para-)SystemiccausesSclerodermaPlummer-VinsonsyndromeNeuromusculardisorderEsophagealspasmPseudobulbarpalsyCVAMultipleSclerosisMyastheniaGravisDermatomyositisMuscularDystrophyFunctional/MotorDisordersSpasmCorkscrewesophagusNeuromusculardisordersDiabetes,alcoholism,ALSPresbyesophagusAssociatedwithageIncoordinationofsphincterfunctionReducedperistalsisFrequenttertiarycontractionsDiffuseEsophagealSpasmNumerousnonpropulsivecontractions“corkscrew/rosarybead”esophagusDESrequiresnormalperistalsisinterspersedwith30%+periodsofnonpropulsivemotoractivityTertiarycontractionsTransientmotorphenomenonNonpropulsiveDifferentialDiagnosis

(continued)ExtrinsiclesionsThyroidmassDysphagialusoriaAorticaneurysmIntrinsiclesionsZenker’sdiverticulumBenigntumors(leiomyoma)Carcinoma(SCCA,Adeno)StricturesAchalasiaEsophagealwebsSchatzki’sringAnatomiccompressionlocationsCricoidThyroidAortaLeftmainstembronchusDiaphragmCervicalspinemayimpinge,heelderlyChestcompressiondueto…LargenodesMediastinaltumorsEnlargementoftheheartAneurysmsMassiveenlargementoftheliverDysphagialusoriaVeryrarecauseDuetoanaberrantrightsubclavianarterycoursingposteriortoesophagusCausesaspiralfillingdefectDifferentialDiagnosis

(continued)ExtrinsiclesionsThyroidmassDysphagialusoriaAorticaneurysmIntrinsiclesionsZenker’sdiverticulumBenigntumors(leiomyoma)Carcinoma(SCCA,Adeno)StricturesAchalasiaEsophagealwebsSchatzki’sringDiverticulumSmallpouchRetainscontrastduringbariumswallowLeiomyomaSubmucosalmassArisefromcircularorlongitudinalsmoothmuscleSolitarylesions,multipleseen3-4%ofthetimeRoundfillingdefectSplittingofbariumaroundtumorEsophagusappearswidenedonAPviewCarcinoma(SCCA,Adeno)AssociatedwithEtOH/TobaccoPredisposingfactorsLyestricturePlummer-VinsonsyndromeEsophagitis/Barrett’sEsophagusCancerofthemid-esophagusShelfattheupperandlowerextentExtensiveirregularitiesinthetumormassCancerofthemid-esophagus“apple-core”fillingdefectStrictureLowerthirdofesophagusDuetolong-standingrefluxStrictureStrictureatGEjunctionSecondarytorefluxesophagitisStrictureHigh-gradePartialobstructionofdistalesophagusDilatedproximallyRetainedbariumabovestrictureRefluxHypertrophyofthecricopharyngealmuscleiscommonlyseeninpatientswithlong-standingrefluxNarrowsthelumenandcausessolid-fooddysphagiaZenker'sdiverticulummayformfromtheareaofmusclethinningjustsuperiortotheCPmuscleTypicallyretainsfluid/foodparticles(oftenmedications/pills)AchalasiaFailureoftheLEStorelaxnormallyEsophagealdilationAperistalsisPrimaryidiopathicdegenerationoftheganglioncellsofAuerbach’splexusSecondary-causedbyotherconditionsi.e.Distalesophagealcarcinoma,Chagas’disease,postvagotomysyndrome,CVA,DMAchalasiaGrosslydilatedesophagusContainsfoodandliquiddebrisDistalpartoftheesophagusisextremelynarrowAchalasiaLESisnarrowedEsophagusisdilatedto6-7cmwideAir-fluidlevelEsophagealwebDeepwebinanteriorwallDifferentialDiagnosisOTHERSequelaeofIrradiationAcute/subacuteeffectsofmucositissuchaspain,sorenessOropharyngealmotilitydisordersRadiationdamagetotheCPmuscularportionofthesphincterParesisofthepharyngealconstrictormusclesSequelaeofIrradiationFailureoftheepiglottistotiltcompletelydownoverthelaryngealinletduringswallowingAlteredlaryngeal/hyoidelevationcontributetoreducedlaryngealvestibuleclosureduringtheswallow,resultinginaspirationPost-laryngectomyPharyngealdysmotilityCricopharyngealdysmotilityRecurrenttumorBenignstricturePseudodiverticulumPost-laryngectomyHealthyneopharynxAppearsasarelativelystraight,featurelesstubetotheleveloftheCPimpressionPost-laryngectomyTaperednarrowinganteriortoC-5Post-laryngectomyHPsteno