DR. Akanis Srisukwattana

1. DR. Akanis Srisukwattana

2. SCOPE PREVALENCE CHANGES IN ESOPHAGEAL PHYSIOLOGY WITH AGING CAUSES OF DYSPHAGIA DIAGNOSTIC AND THERAPEUTIC APPROACHES

3. Introduction Dysphagia is a very common problem in older individuals. In a survey from the Netherlands, 16% of a cohort of residents older than 87 years described symptoms of swallowing dysfunction Some esophageal diseases are much more common in older patients, including Zenker�s diverticulum, cervical osteophytes, and dysphagia aortica.

4. Introduction Other disorders may have special diagnostic considerations, in older patient with achalasia, the possibility of secondary achalasia due to a distal esophageal malignancy is more likely than in a young They are also more likely to be on multiple medications, which may have unwanted side effects and drug-drug interactions.

5. Introduction Eating problem are relate with gastrointestinal tract, including cognitive or psychiatric problems, physical disability of the upper limbs, deterioration of the muscles of mastication, dental disease, and osteoporosis affecting the mandible.

6. PREVALENCE  In studies from Europe, dysphagia occurs in 8% to 10% of persons over age 50 years, Studies of patients in general medical wards have noted prevalence rates of 10% to 30% One study reported that, even in older patients without dysphagia, video fluoroscopy shows abnormalities in up to 63%.

7. PHYSIOLOGY OF SWALLOWING Oral preparatory phase Under voluntary control and involves use of cranial nerves V , VII , and XII. Pharyngeal phase Esophageal phase

8. Pharyngeal phase Pharyngeal peristalsis. occurs by advance of soft palate to posterior nasopharyngeal wall, which narrows upper pharynx, and contraction of the superior constrictor muscles. Simultaneously, larynx and hyoid are pulled upward and forward, causing relaxation of the cricopharyngeus muscle, which makes up much of the upper esophageal sphincter Controlled reflexively and involves CN V , X , XI and XII. During swallowing, respiration is inhibited centrally

9. Esophageal phase Peristaltic contractions in body of esophagus combined with simultaneous relaxation of the lower esophageal sphincter propel the bolus into the stomach.

10. CHANGES IN ESOPHAGEAL PHYSIOLOGY WITH AGING Motility of the Upper Esophageal Sphincter (UES)/Pharynx Motility of the Esophageal Body Motility of the Lower Esophageal Sphincter Changes in Sensory Function

11. Motility of the Upper Esophageal sphincter(UES)/Pharynx Dysfunction of the proximal aspects of swallowing (UES and pharynx) Pharyngeal muscle weakness and abnormal cricopharyngeal relaxation Abnormal of the coordination of muscle Lower resting UES pressure and delayed UES relaxation after swallowing.

12. Motility of the Upper Esophageal sphincter(UES)/Pharynx longer in duration of oropharyngeal swallowing, Increase the sensory threshold for initiating a swallow result in a increased risk of pharyngeal stasis and potential for aspiration

13. Motility of the Esophageal Body Decrease in myenteric neurons, which result in dysmotility Impaired secondary peristalsis Increased frequency of failed primary peristalsis (possibly reflux related) More patients with ineffective esophageal motility (IEM)

14. Motility of the Lower Esophageal Sphincter Abnormal LES responses to deglutition, including a reduced amplitude after contraction, Hiatal hernias seem to increase in aging

15. Changes in Sensory Function Secondary peristalsis decrease with aging Impaired sensation with balloon distention Impaired sensation with acid perfusion (Berstein test) Impaired pharyngeal sensation (decreases swallow initiation)

17. CAUSES OF DYSPHAGIA Devided into two categories: Oropharyngeal dysphagia (OPD) Abnormalities affecting the neuromuscular mechanisms controlling movements of the tongue, pharynx, and UES Esophageal dysphagia (ED) Abnormal affecting the esophagus itself

18. Oropharyngeal Dysphagia (OPD)

19. Stroke Affects the swallowing center in the brainstem or the nerves that modulate the swallowing process, including the fifth, seventh, ninth, tenth, and twelfth cranial nerves Evidence of a swallowing disorder was noted in 51% in patient with acute stroke Increased rate of complications such as aspiration pneumonia, dehydration, malnutrition, and depression.

20. Parkinson�s Disease Dysphagia develops in approximately 50% of patients Due to damage to both the central and enteric nervous system Tremor of the tongue or hesitancy in swallowing Dysfunction of the pharyngeal phase of swallowing

21. Myasthenia Gravis (MG) Nasal regurgitation ,jaw claudication Bulbar muscle weakness causes dysphagia and dysarthria labeled Atrophy of the tongue with paresis and atrophy of other muscle of the palate and uvula

22. Multiple Sclerosis (MS) 34% reported dysphagia. Dysphagia in MS from bulbar involvement and severity of the illness.

23. Idiopathic Upper Esophageal Sphincter Dysfunction Cricopharyngeal dysfunction Inability of muscle to function in synchrony with other components of swallowing mechanism

24. Local Structural Lesions Head and neck tumors. Abscess, congenital web, prior surgical resection Enlarged thyroid gland Cervical hypertrophic osteoarthropathy and cervical osteoarthritis

25. Zenker�s Diverticulum Outpouching in the posterior pharyngeal wall above the UES More common in males than females Present with classic symptoms of cough, fullness and gurgling in the neck, postprandial regurgitation, and aspiration. If become large will produce visible mass, which may gurgle on palpation (Boyce�s sign) or obstruct esophagus thereby contributing to esophageal dysphagia

26. DIAGNOSTIC AND THERAPEUTIC APPROACHES Oropharyngeal Dysphagia (OPD)

27.  Careful history and physical examination may provide clues to the diagnosis. Evidence of a systemic neurologic disorder should be sought. Careful examination of the head and neck for a neoplasm.

28.  The major diagnostic study in the evaluation of OPD is a barium x-ray of the pharynx and UES with videofluoroscopy a) dysfunction or inability to initiate the pharyngeal swallow, b) aspiration c) nasal regurgitation d) obstruction to the normal barium flow e) residual bolus in the pharynx after swallowing.

30. Treatment depends on the underlying cause. Parkinsonism, myasthenia gravis, polymyositis, and thyroid dysfunction Neoplasms require resection and chemotherapy or radiotherapy Rehabilitation ,trained in swallowing therapy Type of food -thickened liquids (honey-like consistency). In permanent dysphagia gastrostomy or jejunostomy may be the only option and should not be delayed

31. Esophageal Dysphagia

32. Three most important questions 1) Is the dysphagia with solids alone or also with liquids? 2) Is the dysphagia intermittent or progressive? 3) Is there any symptom associated?

34. Achalasia Slowly progressive dysphagia for solids and liquids and gradual weight loss. Associated with a significant increase risk for pulmonary complications, malnutrition, and gastroesophageal cancer Secondary achalasia should suspected in a patient with clinical triad of age greater than 50 years, dysphagia of less than 1 year�s duration, and weight loss of greater than 15 lb.

35. Achalasia The principal treatment options are pneumatic dilatation, surgical myotomy, and injection of botulinum toxin. Pneumatic dilation is a safe procedure in the elderly. Injection of botulinum toxin into the LES provides effective short-term symptomatic relief in patient that have serious medical illness.

37. Diffuse Esophageal Spasm and Related Disorders Present by intermittent dysphagia for both solids and liquids, association with chest pain Esophageal manometry shows normal peristalsis interrupted by simultaneous (nonperistaltic) contractions

38. Scleroderma Esophageal involvement occurs more than 80% of patients. Slowly progressive dysphagia for both solids and liquids, as in achalasia. Heartburn is prominent symptom of severe gastroesophageal reflux, >40% develop a peptic esophageal stricture that increased risk for Barrett�s esophagus and esophageal adenocarcinoma.

39. Esophageal Cancer Progressive dysphagia associated with weight loss. History of tobacco and alcohol use. Gastroesophageal reflux may risk for Barrett�s esophagus to adenocarcinoma Investigation- Barium X ray study and Endscope with biopsy.

40. Peptic Stricture Occur in 7-23% of patients with untreated reflux disease, especially older men. Present with progressive dysphagia for solids food with history of heartburn and other symptoms of gastroesophageal reflux.

41. Rings or Webs Present with nonprogressive intermittent dysphagia for solids food Most symptomatic rings present after 50 years Has been called Steakhouse syndrome. Diagnosis by Barium swallow with a solid bolus and endoscopy is indicated if question about the diagnosis and to facilitate dilation.

43. Vascular Compression Dysphagia aortica is a disorder of hypertensive elderly, more often female. Caused by external compression from an ecstatic, tortuous, or aneurysmal aorta Radiographic findings include a prominent indentation of aortic arch on plain chest radiograph. On barium swallow show partial esophageal obstruction at aortic arch area, pulsatile movement of barium synchronous with aortic pulsation Endoscopic findings include stenosis, band-like pulsatile extrinsic compression, or kinking of the esophagus.

44. Medication-Induced Esophageal Injury Occur when caustic medicinal preparations dissolve in the esophagus termed pill esophagitis or pill-induced esophageal injury. Elderly are risk for several reasons; Take more medications Have anatomic or motility disorders Spend more time in a recumbent position Reduced salivary production and/or impaired esophageal motility.

45. Medication-Induced Esophageal Injury Factor that relate injury Sustained-release preparations Large pills or those with sticky surfaces Patient�s position at the time of ingested Volume of fluid ingested with the drug.

46. DIAGNOSTIC AND THERAPEUTIC APPROACHES Esophageal Dysphagia (ED)

48. Esophageal Dysphagia (ED) Characterized according to Predominant type of material involved (solids only or liquids and solids) Intermittent, stable, or progressive. Associated symptoms including heartburn, regurgitation and weight loss. Diagnostic procedure are barium studies, manometry, and endoscopy.