History

Fact Explanation
Difficulty in swallowing (dysphagia) This can be classified according to the area of origin, it can be oropharyngeal or oesophageal. In oropharyngeal dysphagia, patient complains accumulation of food in the mouth without entering it into the oesophagus. In oesophageal dysphagia, there is food stuck after passing through the mouth. It can get stuck behind the neck, middle of the chest or even lower down in the chest. Oesophageal carcinoma causes dysphagia when it is large enough to obstruct the oesophageal lumen. Therefore dysphagia in the oesophageal carcinoma is presentation of advanced disease. [5]
Progression of dysphagia If the symptoms started as dysphagia for fluids and gradually progressing towards the solids, that might be an indicator of malignancy of the oesophagus. In conditions like achalasia cardia, and neuromuscular problems dysphagia is more towards the liquids. Duration of the dysphagia is also helpful to get an idea about the underlying pathology. Acute onset may be due to foreign body ingestion [7] stricture or carcinoma. Long term history will suggests conditions like achalasia cardia, [5] diffuse oesophageal spasms and nut cracker oesophagus like neuromuscular problems.
Odynophagia This is painful swallowing which occurs due to the oral conditions like tonsilitis, candidiasis and thermal injuries etc, these can cause oropharyngeal dysphagia. [9]
Loss of weight, loss of appetite, hunger May be a feature of malignancy of the oesophagus. Compared to the oesophageal carcinoma, where hunger is prominent, gastric carcinoma will have marked loss of appetite. [10]
Nasal regurgitation of the ingested materials, choking and coughing Ingestion of food is followed by these symptoms in oropharyngeal dysphagia. [6]
History of stroke, guillen b'are syndrome, bulbar palsy or muscle weakness [1] poliomyelitis [3] Stroke can be a risk factor for the development of dysphagia. Most of the patients regain functional swallowing within the first month following stroke, but some will remain the dysphagia beyond that period. [1] Incidence of dysphagia ismore wiyth the brainstem lesionsthan hemispheric lesions.
Easy fatiguebility Myasthenia gravis [6] is a disease where the problem is in the neuromscular junction.
Heart burn and regurgitation These are symptoms of gastrooesophageal reflux disaese (GORD). GORD can produce strictures in the oesophagus. GORD and Barrett’s esophagus (migration of squamo- columnar junction) are risk factors for esophageal adenocarcinoma. [4]
Chest pain Can be a feature of achalasia or GORD. Achalasis is a neuromuscular disorder of the oesophagusdue to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing. [8]
History of corrosive, vinegar ingestion or exposure to radiation Can cause strictures. [11]
History of foreign body ingestion These can lodge in the oesophagus causing dysphagia. Most common ones are food boluses, batteries etc. [12]
Fever and productive cough As the ingested materials are unable to go through the obstruction, there is accumulation above the obstruction. These patients are vulnerable for the recurrent aspiration and entrance of swallowed materials into the airway results in aspiration pneumonia. [1]
History of traumatic brain injury [2] This is a neurological cause for dysphagia. Mostly due to the prolonged disturbance of consciousness. Impairment of the swallowing is mainly affects the voluntary component of swallowing such as oral dysphagia. [2]
History of parkinson’s disease Repeated tongue pumping movements, delayed triggering of the pharyngeal phase, delayed onset of laryngeal elevation, are some of the suggested factors contributing to the dysphagia. [2]
Betal chewing, smoking These are risk factors for the development of squamous cell carcinoma of the oesophagus which mainly affecs the upper two thirds of the oesophagus. [5]
References
  1. SURA L, MADHAVAN A, CARNABY G, CRARY MA. Dysphagia in the elderly: management and nutritional considerations Clin Interv Aging [online] 2012:287-298 [viewed 24 July 2014] Available from: doi:10.2147/CIA.S23404
  2. RUGIU M. Role of videofluoroscopy in evaluation of neurologic dysphagia Acta Otorhinolaryngol Ital [online] 2007 Dec, 27(6):306-316 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640050
  3. KRAMER P, ATKINSON M, WYMAN SM, INGELFINGER FJ. The Dynamics of Swallowing. II. Neuromuscular Dysphagia of Pharynx J Clin Invest [online] 1957 Apr, 36(4):589-595 [viewed 24 July 2014] Available from: doi:10.1172/JCI103458
  4. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  5. MEIJSSEN MA, TILANUS HW, VAN BLANKENSTEIN M, HOP WC, ONG GL. Achalasia complicated by oesophageal squamous cell carcinoma: a prospective study in 195 patients. Gut [online] 1992 Feb, 33(2):155-158 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1373921
  6. TSUNG K, SEGGEV JS. An unusual cause of dysphagia. West J Med [online] 1995 Aug, 163(2):159-160 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303018
  7. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297
  8. KENNEDY R, MENEZES C, AHMAD J, KENNEDY J. Laparoscopic Cardiomyotomy for Achalasia: A Single Unit study Ulster Med J [online] 2010 Jan, 79(1):16-19 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938994
  9. GO H, YANG HW, JUNG SH, PARK YA, LEE JY, KIM SH, LIM SH. Esophageal Thermal Injury by Hot Adlay Tea Korean J Intern Med [online] 2007 Mar, 22(1):59-62 [viewed 18 September 2014] Available from: doi:10.3904/kjim.2007.22.1.59
  10. RAJENDRA S, SHARMA P. Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development Therap Adv Gastroenterol [online] 2012 Sep, 5(5):285-299 [viewed 18 September 2014] Available from: doi:10.1177/1756283X12446668
  11. RANA SS, BHASIN DK, SINGH K. Role of endoscopic ultrasonography (EUS) in management of benign esophageal strictures Ann Gastroenterol [online] 2011, 24(4):280-284 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959337
  12. TE WILDT BT, TETTENBORN C, SCHNEIDER U, OHLMEIER MD, ZEDLER M, ZAKHALEV R, KRUEGER M. Swallowing Foreign Bodies as an Example of Impulse Control Disorder in a Patient With Intellectual Disabilities: A Case Report Psychiatry (Edgmont) [online] , 7(9):34-37 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952645

Examination

Fact Explanation
Pallor May be due to malnutrition, malignancy of the oesophagus or Plummer winson syndrome/ Paterson-Brown-Kelly syndrome [7] where there is a combination of upper esophageal webs, postcricoid dysphagia, and iron deficiency anemia. Long-term, iron deficiency anemia is the cause for the disease.
Icterus Disseminated malignancy into the liver can produce jaundice. [8]
Wasting Due to malnutrition [1] and loss of weight in malignancy.
Koilonoychia, glossitis There are associated nutritional deficiencies [1] due to the poor intake result in iron, vitamin B 12 deficiency. Plummer-Vinson syndrome is also associated with iron deficiency.
Fatiguebility Seen in myasthenia gravis, ocular muscles can be used to demonstrate the fatiguebility. [3]
Focal neurological signs, facial nerve palsy Stroke is a risk factor for the dysphagia. [1] They will have limb weakness, abnormalities in the muscle tone, power, abnormal gait(hemiplegic gait) and cranial nerve palsies.
shuffling gate, involuntary tremor, dyskinesia (slowing of the moments) These are seen in parkinson disease. [2]
Lymphadenopathy In conditions like lymphoma, there can be large intra thoracic lymphoid masses compressing the oesophagus. [6]
Sunken eyes, reduced skin turgor, reduced tearing These are features of dehydration due to the poor intake. [2]
Palmar and plantar thickening These are found in tylosis A, which is associated with oesophageal carcinoma. [5]
Enlarged tonsils, bad breath [4] Due to the tonsillitis causing oropharyngeal dysphagia. [4]
References
  1. SURA L, MADHAVAN A, CARNABY G, CRARY MA. Dysphagia in the elderly: management and nutritional considerations Clin Interv Aging [online] 2012:287-298 [viewed 24 July 2014] Available from: doi:10.2147/CIA.S23404
  2. RUGIU M. Role of videofluoroscopy in evaluation of neurologic dysphagia Acta Otorhinolaryngol Ital [online] 2007 Dec, 27(6):306-316 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640050
  3. TSUNG K, SEGGEV JS. An unusual cause of dysphagia. West J Med [online] 1995 Aug, 163(2):159-160 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303018
  4. IQBAL Y. Gonococcal tonsillitis. Br J Vener Dis [online] 1971 Apr, 47(2):144-145 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1048171
  5. O'MAHONY MY, ELLIS JP, HELLIER M, MANN R, HUDDY P. Familial tylosis and carcinoma of the oesophagus. J R Soc Med [online] 1984 Jun, 77(6):514-517 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1439827
  6. FRIZZELL JD, PERKINS BJ, MOREHEAD RS. Thyroid Lymphoma as a Cause of Dysphagia and Dyspnea in a Patient without Palpable Nodules or Goiter Case Rep Med [online] 2009:385461 [viewed 18 September 2014] Available from: doi:10.1155/2009/385461
  7. NOVACEK G. Plummer-Vinson syndrome Orphanet J Rare Dis [online] :36 [viewed 18 September 2014] Available from: doi:10.1186/1750-1172-1-36
  8. MUDAN SS, GIAKOUSTIDIS A, GIAKOUSTIDIS D, SLEVIN M. Synchronous oesophagectomy and hepatic resection for metastatic oesophageal cancer: report of a case Hippokratia [online] 2010, 14(4):291-293 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031329

Differential Diagnoses

Fact Explanation
Oesophageal carcinoma Oesophageal cancer is the sixth most common cause of cancer-related deaths in the world. [4] There are 2 types of oesophageal carcinoma. Squamous cell carcinoma affects the upper two thirds of the oesophagus. Adenocarcinoma of the oesophagus affects the lower third of the oesophagus. Predisposing factors for the adenocarcinoma will be gastrooesophageal reflux disease and Barrett's oesophagus. [5] Barrett's oesophagus is where squamous cell lining is replaced by columnar cells with extension of the squamo-columnar junction proximally. Betel chewing and smoking predispose to is squamous cell carcinoma. New onset progressive dysphagia in elderly person may be due to oesophageal malignancy. Incidence of adenocarcinoma is rising over the last two decades in developed countries. [1]
Achalasia cardia Symptoms may be progressive dysphagia with long term history, odynophagia, and chest pain. Barium swallow gives the bird's beak appearance. Achalasia is a neuromuscular disorder of the oesophagus due to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing. [2]
Gastrooesophageal reflux disease Gastroesophageal reflux disease (GORD) is due to the mucosal damage caused by the abnormal reflux of gastric contents into the esophagus. Heartburn, regurgitation are the common symptoms. [3]
Stricture Can be due to malignancy or benign conditions. Ingestion of vinegar, corrosives, gastroesophageal reflux disease (GORD) are some of the causes causing strictures. Reflux causes oesophagitis [3] that heals with scaring leaving a stricture.
References
  1. CHENG KK, SHARP L, MCKINNEY PA, LOGAN RF, CHILVERS CE, COOK-MOZAFFARI P, AHMED A, DAY NE. A case-control study of oesophageal adenocarcinoma in women: a preventable disease Br J Cancer [online] 2000 Jul, 83(1):127-132 [viewed 25 July 2014] Available from: doi:10.1054/bjoc.2000.1121
  2. KENNEDY R, MENEZES C, AHMAD J, KENNEDY J. Laparoscopic Cardiomyotomy for Achalasia: A Single Unit study Ulster Med J [online] 2010 Jan, 79(1):16-19 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938994
  3. VAN PINXTEREN B, NUMANS ME, LAU J, DE WIT NJ, HUNGIN AP, BONIS PA. Short-term Treatment of Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis of the Effect of Acid-suppressant Drugs in Empirical Treatment and in Endoscopy-negative Patients J Gen Intern Med [online] 2003 Sep, 18(9):755-763 [viewed 25 July 2014] Available from: doi:10.1046/j.1525-1497.2003.20833.x
  4. BABA Y, WATANABE M, YOSHIDA N, BABA H. Neoadjuvant treatment for esophageal squamous cell carcinoma World J Gastrointest Oncol [online] 2014 May 15, 6(5):121-128 [viewed 25 July 2014] Available from: doi:10.4251/wjgo.v6.i5.121
  5. RAJENDRA S, SHARMA P. Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development Therap Adv Gastroenterol [online] 2012 Sep, 5(5):285-299 [viewed 18 September 2014] Available from: doi:10.1177/1756283X12446668

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy Upper gastrointestinal endoscopy is the key investigation for the diagnosis of dysphagia. It can visualize the growths like malignancy in the walls of the oesophagus, ulcers and strictures. Ulcer, typical of friable hyperemic mucosa with necrotic debris with a tendency for easy to touch bleeding can be found in injuries to the mucosa due to hot beverages. [5] Endoscopy has diagnostic advantages such as biopsy and therapeutic advantages such as insertion of synthetic tubes and dilatation. [3]
Barium swallow This will show a core of an apple appearance in malignancy of the oesophagus due to the malignant growth, bird's beak appearance is seen in achalasia cardia, corkscrew appearance in diffuse oesophageal spasm and stasis of barium in the pyriform sinuses is in globus pharyngeus. [2] This can not do the biopsy.
Oesophageal manometry Used for the diagnosis of gastro oesophageal reflux disease. [6]
Edrophonium test [4] Acetylcholine esterase inhibitor is given and the amount of acetylcholine is increased at the neuromuscular junction, that produces short term improvement of the fatigability. [4]
Serum iron and ferritin studies Plummer Vinson syndrome is due to the long term iron deficiency anemia, that need evaluation of iron levels in the body. [1]
References
  1. GUDE D, BANSAL D, MALU A. Revisiting Plummer Vinson Syndrome Ann Med Health Sci Res [online] 2013, 3(1):119-121 [viewed 24 July 2014] Available from: doi:10.4103/2141-9248.109476
  2. RUGIU M. Role of videofluoroscopy in evaluation of neurologic dysphagia Acta Otorhinolaryngol Ital [online] 2007 Dec, 27(6):306-316 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640050
  3. WILKINS WE, WALKER J, MCNULTY MR, BRITTON DC, GOUGH KR. The organisation and evaluation of an open-access dysphagia clinic. Ann R Coll Surg Engl [online] 1984 Mar, 66(2):115-116 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492444
  4. TSUNG K, SEGGEV JS. An unusual cause of dysphagia. West J Med [online] 1995 Aug, 163(2):159-160 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303018
  5. CHUNG WC, PAIK CN, JUNG JH, KIM JD, LEE KM, YANG JM. Acute Thermal Injury of the Esophagus from Solid Food: Clinical Course and Endoscopic Findings J Korean Med Sci [online] 2010 Mar, 25(3):489-491 [viewed 25 July 2014] Available from: doi:10.3346/jkms.2010.25.3.489
  6. TACK J, SIFRIM D. Anti-relaxation therapy in GORD Gut [online] 2002 Jan, 50(1):6-7 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1773085

Investigations - Fitness for Management

Fact Explanation
Full blood count Anaemia with low haemoglobin is found in malignancy, achalasia like chronic diseases and Plummer Vinson syndrome due to iron deficiency. [2]
Lung function tests, chest x-ray and echocardiogram Oesophagectomy is a major surgery involving the thorax. On the other hand most of the elderly patients are having severe cardio respiratory co morbidities. [1] So pulmonary functions need to be assessed before the surgery.
References
  1. BABA Y, WATANABE M, YOSHIDA N, BABA H. Neoadjuvant treatment for esophageal squamous cell carcinoma World J Gastrointest Oncol [online] 2014 May 15, 6(5):121-128 [viewed 25 July 2014] Available from: doi:10.4251/wjgo.v6.i5.121
  2. NOVACEK G. Plummer-Vinson syndrome Orphanet J Rare Dis [online] :36 [viewed 18 September 2014] Available from: doi:10.1186/1750-1172-1-36

Investigations - Followup

Fact Explanation
Upper gastrointestinal endoscopy Periodic testing with endoscopy is indicated as this is a premalignant condition. [1] Aim is to detect the carcinoma at an curable early stage.
References
  1. MEIJSSEN MA, TILANUS HW, VAN BLANKENSTEIN M, HOP WC, ONG GL. Achalasia complicated by oesophageal squamous cell carcinoma: a prospective study in 195 patients. Gut [online] 1992 Feb, 33(2):155-158 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1373921

Investigations - Screening/Staging

Fact Explanation
Echocardiography Left atrial dilatation may be a cause for the dysphagia. [1]
Endoluminal ultrasound scan This is used to stage the tumours of the oesophagus and gastro-oesophageal junction. [2,3]
Computer tomography Is used for the preoperative assessment of oesophageal carcinoma. [2] CT is used for the staging, assessment of the lymph nodes, liver involvement, and peritoneal deposits.
Laparoscopy Combined thoracoscopy/laparoscopy has >90% accuracy rate in staging. [2]
Bone scan Done if there are symptoms of bone involvement of bone due to metastasis. [2]
References
  1. WILKINS WE, WALKER J, MCNULTY MR, BRITTON DC, GOUGH KR. The organisation and evaluation of an open-access dysphagia clinic. Ann R Coll Surg Engl [online] 1984 Mar, 66(2):115-116 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492444
  2. RICHARDS DG, BROWN TH, MANSON JM. Endoscopic ultrasound in the staging of tumours of the oesophagus and gastro-oesophageal junction. Ann R Coll Surg Engl [online] 2000 Sep, 82(5):311-317 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503633
  3. RANA SS, BHASIN DK, SINGH K. Role of endoscopic ultrasonography (EUS) in management of benign esophageal strictures Ann Gastroenterol [online] 2011, 24(4):280-284 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959337

Management - General Measures

Fact Explanation
Postural adjustments to prevent aspiration Changes in body and head posture may be recommended reduce aspiration as this may the affects the speed and flow direction of a food or liquid bolus. [2,4]
Swallow maneuvers These are are changes in the the normal swallowing to produce safe or efficient swallowing. Eg:- supraglottic and super supraglottic swallow techniques- voluntary breath holding, related to laryngeal closure to protect the airway during swallowing. Mendelsohn maneuver to extend opening or relaxation of the upper esophageal sphincter. [2]
Diet modifications If the person is unable to swallow the solids, it has to be replaced with liquids. Thickened liquids are a important compensatory intervention in long term caring to supply adequate nutrition. [2]
Nutrition Poor nutrition causes problems such as poor wound healing, deterioration of cognitive status and immune system. Therefore provision of adequate nutrition by oral or non oral routes is mandatory. [2]
Swallow rehabilitation This focuses on improving physiology of the swallowing. Eg:- Expiratory muscle strength training (EMST), Shaker head lift exercise. [2]
Transcranial magnetic stimulation This is a new technique for the post stroke dysphagia. The treatment is applied for 20 minutes daily for 5 days and it improves swallow reaction time and decreases aspiration scores. [3]
Iron replacement This is recommended for patients with Plummer Vinson syndrome which is due to iron deficiency anemia. [1]
References
  1. GUDE D, BANSAL D, MALU A. Revisiting Plummer Vinson Syndrome Ann Med Health Sci Res [online] 2013, 3(1):119-121 [viewed 24 July 2014] Available from: doi:10.4103/2141-9248.109476
  2. SURA L, MADHAVAN A, CARNABY G, CRARY MA. Dysphagia in the elderly: management and nutritional considerations Clin Interv Aging [online] 2012:287-298 [viewed 24 July 2014] Available from: doi:10.2147/CIA.S23404
  3. SHAKER R, GEENEN JE. Management of Dysphagia in Stroke Patients Gastroenterol Hepatol (N Y) [online] 2011 May, 7(5):308-332 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127036
  4. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297

Management - Specific Treatments

Fact Explanation
Surgery Radical esophagectomy with radical lymph node dissection is the gold standard surgery for oesophageal squamous cell carcinoma. [7] Patients with advanced, inoperable tumor stages and severe comorbidities may not be suitable for surgery. Stage 0 or I disease is usually treated with surgery alone. Stage II and III disease is treated with surgery, with or without neoadjuvant therapy. Techniques of resection will be Ivor-Lewis, a thoracoabdominal approach, transhiatal that involves the abdomen and neck without thoracotomy the transabdominal, that is mainly for the lower gastroesophageal junction and thoracoscopic/laparoscopic, which is a minimally invasive approach. [8]
Ivor-Lewis oesophagectomy Ivor-Lewis, involves a thoracoabdominal approach, where abdominal incision is made to mobilize stomach with preserving the gastroepiploic vessels and then thoracotomy to approach the oesophagus. This provides a better access to the oesophagus, lymph node dissection is possible, but there is a risk of mediastinitis as the thoracotomy is involved. This approach is advantageous in decreasing the recurrent nerve lesion and other complications associated with a cervical dissection. [10]
Mc Keown oesophagectomy [12] This is an extension of Ivor Lewis method, where there are abdominal incision, thoracotomy and third neck incision. This is three stage approach with a cervical anastomosis that reduces the risk of mediastinitis. But this also has the thoracotomy associated morbidity. [12]
Transhiatal/Oringers oesophagectomy Transhiatal/Oringers that involves the abdomen and neck without thoracotomy. Oesophagus is then connected to the stomach via cervical esophagogastric anastomosis. As there is no thoracotomy involved, this is a blind dissection and is suitable for middle and lower oesophageal malignancies. Complications will be thoracic or pulmonary complications such as pneumothorax, pleural effusions, pneumonias, empyemas, and respiratory failure and anastomotic leak. [9]
Video assisted thoracoscopic surgery Laparoscopic and thoracoscopic techniques has been used as the the treatment of esophageal disorders such as oesophageal malignancy, achalasia and gastroesophageal reflux disease (GERD). Shorter hospital stay, less postoperative complications [13] , and early recovery are the advantages of this laparoscopic and thoracoscopic techniques.
Endoscopic dialatation Can be used for the peptic strictures [1]
Insertion of stent Stents are inserted in non operable patients with malignancy . [1] This can relieve dysphagia in 90% of patients. Stent can give rise to complications such as stent migration, blocking of the tube, perforation and infection. Self expanding metal stents are beneficial as it is associated with less complications and easy insertion. [3]
Neoadjuvant or definitive chemoradiotherapy Chemotherapy, radiotherapy , and chemoradiotherapy can be combined with the surgery for the better outcome. [7] Preoperative neoadjuvant radiotherapy is used to down stage the tumour. Chemotherapy is with bleomycin, vindesine, 5-flurouracil or combination of these. These are used specially for the treatment of squamous cell carcinoma. This has shown to improve the survival compared with surgery alone.
Laser ablation therapy Good as a palliative method. [11] This procedure is expensive, [3] Repeated treatments are needed for the success, it also as serious adverse effects.
Brachytherapy, photodynamic therapy or immunotherapy Used to downstage the tumor in some patients. [8]
Management of gastroesophageal reflux disease The main agents available for patients with GORD are antacids, H2-receptor antagonists, and proton pump inhibitors such as pantoprazole, omeprazole etc. [2] Chronic relapsing GORD requires long-term maintenance treatment.
Surgical resection of pharngeal pouch Surgical resection of pharyngeal pouch will relieve the symptoms. [4]
Management of food bolus/foreign body Ingested foreign body if stays at one place for a longer time needs extraction or moving it into the stomach via endoscopy. [5]
Management of achalasia cardia Medical therapies for the achalasia are calcium antagonists or sildenafil with the aim of relaxing the smooth muscle of the lower oesophageal sphincter (LOS). Pneumatic dilatation using endoscope and injection of botulinum toxin provide short term improvement. Surgical management is cardiomyotomy that is to divide the muscle of the LOS longitudinally via transabdominal, transthoracic or thoracoscopic routes.[6]
References
  1. WILKINS WE, WALKER J, MCNULTY MR, BRITTON DC, GOUGH KR. The organisation and evaluation of an open-access dysphagia clinic. Ann R Coll Surg Engl [online] 1984 Mar, 66(2):115-116 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492444
  2. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  3. CLEMENTS WD, JOHNSTON LR, MCILWRATH E, SPENCE RA, MCGUIGAN J. Self-expanding stents for malignant dysphagia. J R Soc Med [online] 1996 Aug, 89(8):454-456 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295887
  4. GLADMAN JR, KUPFER RM, BRADLEY PJ. Pharyngeal pouch presenting as dysphagia after a stroke. Postgrad Med J [online] 1993 Mar, 69(809):243-244 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399729
  5. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297
  6. KENNEDY R, MENEZES C, AHMAD J, KENNEDY J. Laparoscopic Cardiomyotomy for Achalasia: A Single Unit study Ulster Med J [online] 2010 Jan, 79(1):16-19 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938994
  7. BABA Y, WATANABE M, YOSHIDA N, BABA H. Neoadjuvant treatment for esophageal squamous cell carcinoma World J Gastrointest Oncol [online] 2014 May 15, 6(5):121-128 [viewed 25 July 2014] Available from: doi:10.4251/wjgo.v6.i5.121
  8. PATEL AN, PRESKITT JT, KUHN JA, HEBELER RF, WOOD RE, URSCHEL HC JR. Surgical management of esophageal carcinoma Proc (Bayl Univ Med Cent) [online] 2003 Jul, 16(3):280-284 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200781
  9. ORRINGER MB, MARSHALL B, IANNETTONI MD. Transhiatal Esophagectomy: Clinical Experience and Refinements Ann Surg [online] 1999 Sep, 230(3):392 [viewed 26 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420884
  10. MAAS K. W., BIERE S. S. A. Y., SCHEEPERS J. J. G., GISBERTZ S. S., TURRADO RODRIGUEZ V., PEET D. L., CUESTA M. A.. Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers. Surg Endosc [online] December, 26(7):1795-1802 [viewed 26 July 2014] Available from: doi:10.1007/s00464-012-2149-z
  11. RAJENDRA S, SHARMA P. Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development Therap Adv Gastroenterol [online] 2012 Sep, 5(5):285-299 [viewed 18 September 2014] Available from: doi:10.1177/1756283X12446668
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