My Clinical Notes

• Difficulty swallowing - always investigate
• Causes;
  • Mechanical block;
    • Malignant strictures - oesophageal cancer, gastric cancer, pharyngeal cancer
    • Benign strictures - oesophageal web or ring, peptic stricture
    • Extrinsic pressure - lung cancer, mediatinal LN, retrosternal goitre, aortic aneurysm
    • Pharyngeal pouch
  • Motility disorders;
    • Achalasia
    • Diffuse oesophageal spasm
    • Systemic sclerosis
    • MG
    • Bulbar or pseudobulbar palsy
  • Other causes - oesophagitis (infection or reflux), globus hystericus

Things to ask;

• Is it difficult to swallow liquids and solids? If yes think pharyngeal causes or motility disorder. If solids were harder to swallow before liquids then think stricture (benign or malignant)
• Is it difficult to make the swallowing movement? If yes think bulbar palsy
• Is swallowing painful? - Yes then think cancer, oesophagitis, achalasia, oesophageal spasm
• Is this dysphagia intermittent, constant or getting worse? If intermittent suspect oesophageal spasm. If constant or worsening then think malignant stricture
• Does the neck bulge or gurgle on drinking? If yes suspect a pharyngeal pouch

Investigations

• FBC, U&Es
• CXR - mediastinal fluid level, absent gastric bubble, aspiration
• Barium swallow
• Video fluoroscopy
• Upper GI endoscopy, biopsy

Achalasia

• Failure of relaxation of the LOS due to degeneration of the myenteric plexus
• On barium swallow shows a dilated, tapering oesophagus
• Treatment - endoscopic balloon dilation, Heller’s cardiomyotomy, PPIs, botulinum injection

Benign oesophageal stricture

• Causes;
  • GORD
  • Corrosives
  • Surgery
  • Radiotherapy

Oesophageal cancer

• Associated with;
  • Being male
  • GORD
  • Smoking and alcohol
  • Barrett’s oesophagus
  • Achalasia
  • Paterson - Brown - Kelly syndrome

Patterson-Brown-Kelly (Plummer-Vinson) syndrome

• Post cricoid web and iron deficiency

Nausea and vomiting

Tests

• Bloods - FBC, U&Es, LFTs, calcium, glucose, amylase
• ABG - hypocholaemic metabolic alkalosis

Treatment - antiemetics

Histamine antagonists

• Cyclizine - GI causes
• Cinnarizine - vestibular causes

Dopamine antagonist

• Metachlopromide - GI causes, prokinetic
• Domperidone - prokinetic
• Prochlorperazine - vestibular and GI causes
• Haloperidol - chemical causes e.g. opioids
• Can cause dystonia and oculogyric crisis

5HT3 antagonists

• Ondansetron - used in chemotherapy

Others;

• Hyosine butylbromide - antimuscarinic (don’t prescribe with a prokinetic)
• Dexamethasone
• Midazolam - unknown action, antiemetic lasts longer than sedative effect

This entry was posted on Monday, February 9th, 2009 at 3:47 pm and is filed under Gastrointestinal. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.