dysphagia achalasia

1. A Case Of Dysphagia-
Stricture Esophagus

2.  ESOPHAGEAL STRICTURE AND DIVERTICULUM

3. HISTORY OF PRESENTING ILLNESS:
 My patient normotensive, normoglycaemic was in usual state of health 3 months
back when he ingested half cup of acid ( sulphuric acid) used for cleaning toilet.
 After acid intake he developed persistent vomitting. There were 7 to 8 episodes of
vomiting in which 2 episodes contained blood.

4.  Since two and a half month he is not able to swallow anything as he experiences
pain. He was admitted in medical ward and was treated there.
 Esophageal stricture was diagnosed on endoscopy and endoscopic dilatation was
done on 27 june 2015.
 After endoscopy patient was able to swallow water but not any solid food.

5.  Second endoscopy done on 11 july 2015 and diagnosis of esophageal
diverticulum was made. Patient was then referred to surgical unit 1 by medical
department.
 history of heart burn, bitter taste in mouth and cough is also present.

6.  PAST MEDICAL HISTORY:
 No history of diabetes mellitus, hypertension, ischemic heart disease, hepatitis,
tuberculosis and epilepsy.
 PAST SURGICAL HISTORY:
 there is no history of any previous surgeries.
 FAMILY HISTORY:
 no history of hypertension, diabetes mellitis, tuberculosis, hepatitis and
ischemic heart disease in the family.

7.  PERSONAL HISTORY:
 he is married, non-smoker, sleep and bowel habits are normal.
 SOCIOECONOMIC HISTORY:
 he belongs to low socioeconomic class.

8. SYSTEMIC REVIEW
 CARDIOVASCULAR SYSTEM:
 there is no history of chest pain, edema feet and palpitations.
 GASTROINTESTINAL SYSTEM:
 history of decreased appetite, vomitting and heart burn are present.
 RESPIRATORY SYSTEM:
 history of productive cough on and off. Sputum was white in colour.
 no history of dyspnea

9.  GENITOURINARY SYSTEM:
 no history of polyurea, polydipsia, urgency, frequency, hematuria and flank pain.
 CENTRAL NERVOUS SYSTEM:
 no history of headache, vertigo, diplopia and visual acquity is normal.

10. GENERAL PHYSICAL EXAMINATION
 A young man, wasted in appearance lying on the bed. He is well oriented in time,
person and place. On examination his vital signs are
 pulse = 80/min
 blood pressure= 100/60 mmhg
 temperature = 98 F
 respiratory rate = 16/min

11.  On examination of hands there is no cyanosis, clubbing, leuconychia, koilonychia,
splinter hemorrhages, sweating, tremors, muscle wasting and palmer erythma.
 On examination of head and neck pallour was present, jaundice was absent,
lymph nodes were impalpable, no neck swelling. Thyroid status was normal.
 Sacral and pedal edema was absent.

12.  On examination of gastrointestinal system
 Abdomen soft, non tender
 Viscera impalpable
 Shifting dullness and fluid thrill absent
 Bowel sounds sluggish

13.  on examination of cardiovascular system
 S1 + S2 + 0

 on examination of respiratory system
 Bilateral normal vesicular breathing with no added sounds

14.  on examination of central nervous system
 GCS 15/15
 Sensory and motor system intact

15. INVESTIGATIONS
 BLOOD COMPLETE EXAMINATION:
 HB % = 10.9 g/dl
 TLC = 7800 cumm
 Neutrophils = 59 %
 Eosinophils = 2 %
 Lymphocytes = 38 %
 Monocytes = 1%
 ESR = 58 mm

16. URINE COMPLETE EXAMINATION
 Appearance = light yellow
 pH = 5.0
 Sp gravity = 1.020
 Protein = nil
 Sugar = nil
 Blood = nil
 Ketone =nil
 WBCs = 03/ HPF
 RBCs = 02/ HPF

17.  Sodium = 131.1 mmol/l (135-145)
 Potassium = 2.81 mmol/l (3.5- 5.0)
 Chloride = 95.8 mmol/l (98-108)

18.  ULTRASONOGRAPHY : Normal abdominopelvic scan
 ENDOSCOPIC FINDINGS:
 Esophagus : normal upper and middle third. Stricture at 35 cm from lower incisor.
Dilation done with 10 f balloon. Normal LES.
 Stomach : gastric anatomy distorted
 Duodenum : could not be visualised
 Followed up after 2 weeks for repeat dilatation

19.  SECOND ENDOSCOPY FINDINGS
 Esophagus : scope passed with some difficulty from piriform fossa to esophagus.
Diverticulum with ulcer noted at 35cm from the lower incisor which end blindly.

20.  BARIUM SWALLOW AND MEAL STUDY:
 Noted spillage oF contents into trachea.
 Study of stomach showed corrosive tight stricture involving pyloric canal and
duodenal bulb.

21.  DIAGNOSIS:
 Esophageal stricture with diverticulum

23. REVIEW of LITERATURE
 ESOPHAGUS - gullet
 Muscular tubular structure 25 cm long in adults,
 10-11 cm in newborns; develops from cranial portion of the foregut; connects
pharynx and stomach;
 has cervical, thoracic and abdominal segments
 Carries food from pharynx to stomach via peristalsis;
 secretes mucin for lubrication
 minimize reflux of gastric contents - LES

24.  Extends from cricopharyngeus muscle in pharynx (level of C6) to lower esophageal
sphinchter at gastroesophageal junction (T11/T12

25.  Cervical (lower border of cricoid cartilage to suprasternal notch / thoracic inlet, 5
cm long, begins 15 cm from incisors); contains striated muscle
 Upper thoracic (suprasternal notch to tracheal bifurcation, 5 cm long, begins 20
cm from incisors); has striated and smooth muscle

26.  Mid-thoracic (tracheal bifurcation to diaphragmatic hiatus, 5 cm long, begins 24
cm from incisors); has striated and smooth muscle
 Lower thoracic and abdominal (10 cm long, begins 30 cm from incisors); extends
past diaphragm to its junction with stomach; has smooth muscle only

27.  Usual points of narrowing (possible sites of food / pill lodging):
 cricoid cartilage (due to cricopharyngeus muscle),
 aortic arch,
 anterior crossing of left main bronchus and left atrium, where it passes through
diaphragm.
 Gastroesophageal junction proximal limit of gastric rugal folds;
 endoscopic definition is Z ("zigzag") line at irregular boundary of squamous and
columnar mucosa in distal esophagus

29.  Esophageal sphincters
 upper esophageal sphincter is at cricopharyngeus and inferior pharyngeal
constrictor muscles;
 lower esophageal sphincter is 2-4 cm proximal to esophagogastric junction at
level of diaphragm (composed of intrinsic esophageal muscles, sling fibers of
proximal stomach and crural diaphragm)
 Vagotomy does NOT affect tone of lower esophageal sphincter; tone is affected by
gastrin, acetylcholine and serotonin

30.  Arterial blood supply:
 cervical region-inferior thyroid artery
 upper thoracic-bronchial and intercostal arteries
 lower thoracic-aortic branches;
 abdominal-left gastric and inferior phrenic arteries
 Venous drainage:
 extensive submucosal venous plexus
 flows into inferior thyroid (upper 1/3),
 azygous (middle 1/3) and gastric veins (lower 1/3);
 azygous vein empties into superior vena cava and gastric veins into portal system; this connection between caval
and portal venous systems explains esophageal varices due to portal hypertension

31.  Nerves: left and right vagus nerves run lateral to esophagus, form plexi along
anterior and posterior surfaces, then reunite to form anterior and posterior vagal
trunks .
 Lymphatic drainage:
 upper third drains into paratracheal and internal jugular nodes
 middle third to mediastinal nodes
 lower third to nodes around aorta and celiac axis

32. ESOPHAGEAL STRICTURE
 A benign esophageal stricture is a narrowing or tightening of the esophagus that
causes swallowing difficulties.
 gastroesophageal reflux disease - esophagitis
 a dysfunctional lower esophageal sphincter ---disordered motility
 acid ingestion or a hiatal hernia
 esophageal surgery laser therapy or photodynamic therapy

33. DIAGNOSIS
 X-ray while the patient swallows barium (called a barium study of the esophagus),
 by a computerized tomography scan,
 by an endoscopy / biopsy.

34. SYMPTOMS
 Symptoms of esophageal strictures include heartburn, bitter or acid taste in your
mouth,
 choking, coughing, shortness of breath, frequent burping or hiccups,
 pain or trouble swallowing, throwing up blood, or weight loss.

35. TREATMENT
 Balloon dilatation
 Medical treatment---- H2 antagonist (e.g. ranitidine)
proton-pump inhibitor (e.g. omeprazole)

36. SURGICAL TREATMENT
 The role of surgical treatment in peptic stricture remains in dispute. Indications
include failed aggressive medical therapy or an unsuitable candidate for
aggressive medical therapy. This is usually a rare occurrence in the era of PPI
therapy. Various procedures advocated include the following:
 Esophageal-sparing procedures - Standard antireflux surgery (Nissen total or
Belsey partial fundoplication), esophageal lengthening with antireflux surgery
(Collis-Nissen or Belsey gastroplasty)

37.  Esophageal resection and reconstruction - Gastric or colon interposition or jejunal
segment
 If the benign peptic stricture is dilatable, an esophageal-sparing operation is
performed.
 If the length of the esophagus is normal, standard antireflux surgery and
postoperative dilation as necessary is recommended.

38.  If the esophagus is short, performing Collis gastroplasty and postoperative
dilation as necessary is recommended.
 If the stricture is undilatable, esophageal resection and interposition is
recommended.

39.  THANK YOU