CAUSES :
MECHANICAL DYSPHAGIA
1. LUMINAL
- LARGE BOLUS
- FOREIGN BODY
2. INTRINSIC NARROWING
A. INFLAMMATORY CONDITIONS CAUSING EDEMA & SWELLING
- STOMATITIS
- PHARYNGITIS
- EPIGLOTTITIS
- ESOPHAGITIS DUE TO VIRAL , BACTERIAL, FUNGAL INFECTIONS, MUCOCUTANEOUS BULLOUS DISEASES & CAUSTIC, CHEMICAL OR THERMAL INJURY
B. WEBS & RINGS
- PHARYNGEAL ( PLUMMER-VINSON SYNDROME)
- ESOPHAGEAL ( CONGENITAL, INFLAMMATORY)
- LOWER ESOPHAGEAL MUCOSAL RING ( SCHATZKI RING)
C. BENIGN STRICTURES
- PEPTIC
- CAUSTIC & PILL INDUCED
- INFLAMMATORY ( CROHNS DISEASE, CANDIDAL, MUCOCUTANEOUS LESIONS)
- ISCHAEMIC
- POSTOPERATIVE, POSTRADIATION
- CONGENITAL
D. MALIGNANT TUMORS
* PRIMARY CARCINOMA
- SQUAMOUS CELL CARCINOMA
- ADENOCARCINOMA
- CARCINOSARCOMA
- PSEUDOSARCOMA
- LYMPHOMA
- MELANOMA
- KAPOSIS SARCOMA
* METASTATIC CARCINOMA
E. BENIGN TUMORS
- LEIOMYOMA
- LIPOMA
- ANGIOMA
- INFLAMMATORY FIBROID POLYP
- EPITHELIAL PAPILLOMA
3. EXTRINSIC COMPRESSION
- CERVICAL SPONDYLITIS
- VERTEBRAL OSTEOPHYTES
- RETROPHARYNGEAL ABSCESS & MASS
- ENLARGED THYROID GLAND
- ZENKERS DIVERTICULUM
- VASCULAR COMPRESSION
* ABERRANT RT SUBCLAVIAN ARTRY
* RT SIDED AORTA
* LT. ATRIAL ENLARGEMENT
* AORTIC ANEURYSM
- POST MEDIASTINAL MASSES
- PANCREATIC TUMOR, PANCREATITIS
- POSTVAGOTOMY HEMATOMA & FIBROSIS
MOTOR ( NEUROMUSCULAR) DYSPHAGIA
1. DIFFICULTY IN INITIATING SWALLOWING REFLEX
- PARALYSIS OF TONGUE
- OROPHARYNGEAL ANESTHESIA
- LACK OF SALIVA ( SJOGREN SYNDROME)
- LESIONS OF SENSORY COMPONENTS OF VAGUS & GLOSSOPHARYNGEAL NERVES
- LESIONS OF SWALLOWING CENTER
2. DISORDERS OF PHARYNGEAL & ESOPHAGEAL STRIATED MUSCLE
A. MUSCLE WEAKNESS
* LOWER MOTOR NEURONE LESION ( BULBAR PARALYSIS )
- CEREBROVASCULAR ACCIDENTS
- MOTOR NEURONE DISEASE
- POLIOMYELITIS, POSTPOLIO SYNDROME
- POLYNEURITIS
- AMYOTROPHIC LATERAL SCLEROSIS
- FAMILIAL DYSAUTONOMIA
* NEUROMUSCULAR
- MYASTHENIA GRAVIS
* MUSCLE DISORDERS
- POLYMYOSITIS
- DERMATOMYOSITIS
MYOPATHIES ( MYOTONIC DYSTROPHY, OCULOPHARYNGEAL MYOPATHY)
B. NONPERISTALTIC CONTRACTIONS OR IMPAIRED DEGLUTITIVE INHIBITION
* PHARYNGEAL OR UPPER ESOPHAGEAL
- RABIES
- TETANUS
- EXTRAPYRAMIDAL TRACT DISEASE
- UPPER MOTOR NEURONE LESIONS ( PSEUDOBULBAR PARALYSIS )
* UPPER ESOPHAGEAL SPHINCTER
- PARALYSIS OF SUPRAHYOID MUSCLES ( CAUSES SAME AS PARALYSIS OF PHARYNGEAL MUSCULATURE)
- CRICOPHARYNGEAL ACHALASIA
3. DISORDERS OF ESOPHAGEAL SMOOTH MUSCLE
A. PARALYSIS OF ESOPHAGEAL BODY CAUSING WEAK CONTRACTIONS
- SCLERODERMA 7 RELATED COLLAGEN-VASCULAR DISEASES
- HOLLOW VISCERAL MYOPATHY
- MYOTONIC DYSTROPHY
- METABOLIC NEUROMYOPATHY( AMYLOID, ALCOHOL, DIABETES)
- ACHALASIA ( CLASSICAL )
B. NONPERISTALTIC CONTRACTIONS OR IMPAIRED DEGLUTITIVE INHIBITION
1. ESOPHAGEAL BODY
- DIFFUSE ESOPHAGEAL SPASM
- ACHALASIA ( VIGOROUS )
- VARIANTS OF DIFFUSE ESOPHAGEAL SPASM
2. LOWER ESOPHAGEAL SPHINCTER
A. ACHALASIA
1. PRIMARY
2. SECONDARY
- CHAGAS DISEASE
- CARCINOMA
- LYMPHOMA
- NEUROPATHIC INTESTINAL PSEUDOOBSTRUCTION SYNDROME
- TOXINS & DRUGS
B. LOWER ESOPHAGEAL MUSCULAR ( CONTRACTILE ) RING
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DIFFERENTIAL DIAGNOSIS :
β’ Cardiac chest pain
β’ Globus hystericus
SPECIAL TESTS :
. IN INFANTS/CHILDREN :
. Observe sucking/eating
. Attempt to pass nasogastric tube to assess esophageal patency
. X-ray neck and chest
. Contrast x-ray
. Endoscopy
. IN ADULTS :
. X-ray of neck and chest
. Endoscopy
. Barium cine/video esophagogram
. Ambulatory, 24 hour pH testing
. Esophageal manometry
IMAGING :
. X-ray: chest, neck, abdomen
. Contrast x-ray: esophagram, cine-esophagram, modified cine-esophagram (cookie swallow)
. CT scan of chest
DIAGNOSTIC PROCEDURES :
. Endoscopy with biopsy
. Esophageal manometry (altered by anticholinergics [propantheline], calcium channel blockers [nifedipine], nitrates [nitroglycerin], prokinetic [metoclopramide], sedatives [diazepam])
. Esophageal pH monitoring (altered by anticholinergics [propantheline], H2 receptor antagonists [cimetidine], proton pump inhibitors [omeprazole], prokinetic [metoclopramide])