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home - Oesophagus - Dysphagia - Oropharyngeal Dysphagia Written by Dr Sebastian Zeki
Knowledge


Knows the various causes of dysphagia and their clinical
presentations

Understands the methods of assessment and investigation including
the use of manometric assessment where appropriate

Knows the range of therapeutic options including the potential for
endoscopic treatment, and how to select appropriate treatment

Non-Cardiac Chest Pain:
Understands the potential role of the oesophagus in patients
presenting with chest pain in whom a cardiac cause has been
excluded and its role in the genesis of functional symptoms.

Knows the range of appropriate investigation of such patients and the
various avenues of management

Carcinoma of the Oesophagus:
Knows the predisposing factors, presentation, diagnostic work-up and
staging

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Skills
Can make a thorough clinical assessment, select investigations
appropriately and plan therapy.

Behaviours
Manages patients with oesophageal disease with care and
compassion.

Also....

Oropharyngeal Dysphagia

Balloon dilatation complications:Severe postprocedural chest pain- 15%.Oesophageal perforation in 4%- especially if had vigorous achalasia.Reflux in 2% (saggy LOS).Intramural hematomas, esophageal mucosal tears, and diverticula at the gastric cardia. Botulinum toxin injectionIt inhibits excitatory cholinergic neurons.It can be used if other techniques contraindicated.The technique involves 1 mL aliquots injected into each of four quadrants approximately 1 cm above the Z line.An improvement can be seen after 24hrs.Complications include post-procedural transient chest pain (25%) and heartburn (5%).Oesophageal wall injury and paraesophageal tissue inflamm-tion are rare.Botulism is not a risk. Surgical MyotomyThe Modified Heller approach gives 80% relief.Most failures occurred within 12 months and the majority were treated successfully with PD.The complication rate is 6%.Reflux esophagitis occurs in 20%- antireflux procedure may be done at same time. Overview of the treatment of achalasia Good short-term results in 60 to 85% in one sessionNo effect on chest pain 40% will require at least one additional dilation If 2-3 repeats needed consider alternative PD after myotomy —Symptomatic response seen in only about 50% Doesn’t make subsequent myotomy harder Doesn’t make subsequent myotomy harder PD after botulinum toxin injection — Safe if previously received botulinum toxin injection.Combination therapy offers no additional benefit 70 to 85% remission at 10 years, and 65 % at 20 years Short-term response (<5 years) — 80 % efficacy after one injection, lasting 3-12monthsDo equally well after further injectionsPredictors of outcome — Older age and the presence of vigorous achalasia. Good operative risk Pneumatic dilatation or myotomy (if dilatation fails can repeat or do myotomy) Poor operative risk Medical treatment (nitrate/ ca channel blockers) Consider bougie dilatation Botulinum injection Consider feeding gastrostomy/ pneumatic dilatation/ myotomy Comparitive StudiesPD and BoNT/A injection have similar efficacy for short term symptoms (1-2 yrs), although most patients treated with BoNT/A will further sessions. Surgery most effective long term, but more get GERD after surgery than PD (36 versus 4 %)Surgery is superior to pneumatic dilation for both the short-term and long-term relief of dysphagia.Less complications for surgery. Written by Dr Sebastian Zeki

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