Cadmore media player playing audio RTL- Ep 97- Approach to Dysphagia
Audio Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the audio. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Transcript
Result Count
of
Search
Segments
Result Count
of
Search
Name:
RTL- Ep 97- Approach to Dysphagia
Description:
RTL- Ep 97- Approach to Dysphagia
Thumbnail URL:
/images/podcast-microphone-banner.jpg
Duration:
T00H23M50S
Embed URL:
https://stream.cadmore.media/player/9953ce88-f67b-48b2-9dad-7c3d38d7fbc0
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9953ce88-f67b-48b2-9dad-7c3d38d7fbc0/RTL- Ep 97- Approach to Dysphagia.wav?sv=2019-02-02&sr=c&sig=r3%2FbNcqQSEUi4%2BY5eAoew%2BRAfnsjZ2XBrcSCBH4AMV8%3D&st=2025-01-15T08%3A44%3A46Z&se=2025-01-15T10%3A49%3A46Z&sp=r
Upload Date:
2023-08-11T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[Dr. Smith] Welcome to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou, and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only and should not be understood as medical advice under any circumstances.
[intro music] [Dr. Redd] Welcome back to Run the List. I'm here with Navin Kumar today, and we're coming back with a special episode that should be particularly high-yield for a symptom that we see both in the inpatient and outpatient settings, which is dysphagia. This is a common symptom that patients with esophageal disorders present with and so Navin and I are going to talk about the presentation, work-up, and management of that chief complaint but first, Navin's going to take a few moments to share an important message with our listeners.
[Dr. Kumar] Yeah, thanks, Walker. First off, really excited to be recording with you again, it's been a bit since we've been together on the podcast. I always love going through MedEd topics with you, so happy to be back, and then as Walker said, we wanted to mention the fact that we're going to do something a little new this time. For the past two seasons, we've had this great partnership with McGraw Hill that has really allowed our content to go to the next level in terms of both what we get to teach, but also the quality in which the recordings are done.
So for the next few episodes, we're going to do something new, where we launch our podcast on McGraw Hill's AccessMedicine website. The podcast will again be free and easily downloadable for any of our listeners and we'll post the link in our social media feed so that you all can go directly to the site and listen to our content.
And one great thing about the Access Medicine website is that you'll see when you click on the podcast link there, there're actually transcriptions of the episodes, I think it's a really helpful tool to look at when you're listening and trying to learn along with us 'cause I know sometimes we have to move through content fairly quickly and this is a good way to go back and review the key points. So something new this time, next couple of episodes we're going to launch exclusively on AccessMedicine and I hope you all will go there to listen.
[Dr. Redd] Yeah, as Navin said, we so appreciate your continued support and this would be a really helpful way to allow us to keep bringing you the most high-quality content that we can. And so with that, we're going to go ahead and take this chance to go through a couple of quick-hitting cases together to demonstrate the way that we think about how to manage a patient who presents with dysphagia. And so Navin's going to be the one presenting a couple of cases to me and I'll be going through how we think about this, as always, sort of taking that framework approach and then delineating based on our clinical reasoning, what we think is most likely going on and how to move forward.
[Dr. Kumar] Great and this is going to be a lot of fun for me 'cause I get to play the role of host and Walker's going to be the expert, as he is now a senior clinical fellow and research fellow in gastroenterology and so it's his turn to be the expert here. So as you all know, esophageal disorders are very common, we see them quite a bit both in the inpatient and outpatient setting.
And you know, oftentimes when we hear dysphagia, we immediately just jump to the need for an endoscopy without taking the time and to clinically reason through why this patient may be having dysphagia, developing a broad differential diagnosis prior to doing the first step in evaluation. So Walker's going to take us through two brief cases and provide that clinical reasoning so that you can take that back to your own settings when you're seeing patients with difficulty swallowing.
And so let's start with the first case and let's set the scene, this first patient you're seeing in outpatient clinic. So her name is Ms. A, she's a 52-year-old female with hypertension and hyperlipidemia and she's establishing care in your primary care clinic, and she, during your initial visit, reports difficulty swallowing. And so when you ask her to characterize that further, she says, "It feels like food is getting stuck in my chest." So Walker, with this initial chief complaint, what are the next questions you would ask to help clarify her symptoms?
[Dr. Redd] Sure, so this is to your point Navin, I mean, we do often end up getting upper endoscopy for these patients but we can really delineate a lot, and sometimes that's not the first step, if we ask a really careful history. So often patients will just say, "Food gets stuck when I try to swallow," or "I can't swallow," and that's where I explain to them, "Okay, I'm about to ask you in a lot of detail, about exactly from the time when you initiate your swallow, what happens after that?" And you know you can even get down to the seconds, "Is it that you have difficulty after one or two seconds, or is it 20 seconds after you start your swallow, are you able to initiate your swallow?" And even that part right there can sort of start to help us think through, "Is this more likely oropharyngeal dysphagia that's more proximal to the mouth?" And that can be caused by things like neuromuscular disorders we see a lot, in which case, actually like getting a modified barium swallow study and a speech-language pathologist consult may be the first step or that modified barium study may actually end up showing like a Zenker's diverticulum or a cricopharyngeal bar in which case it still may make sense to confirm that on an upper endoscopy and get GI involved but sometimes it's nice just to start and make sure, "Okay, if you're having difficulty with the actual initiation within a second or two of starting to swallow, it may be one of those etiologies versus more true esophageal dysphagia." Then, if you kind of clarify, "Okay, I'm able to initiate the swallow, but it feels like it gets stuck in my chest as I continue to swallow." It's hard for patients, based on the way our esophagus is innervated, to sort of delineate exactly where the problem is happening but that's why we use time, and if it's after the first four or five seconds of starting to swallow, you're going to start to think, "Okay, is this a problem in the esophagus?" In which case you can delineate, "Does this happen with primarily solid foods or both solids and liquids?" And if really the patient's like, "It never happens with liquids, I only have a problem swallowing solids, maybe like meats or breads," then you're going to start to think about, "Okay, this is maybe more likely a structural disorder or something with the mucosa that's really affecting the ability to get solid foods down." Whereas, if they're having trouble with solids and liquids, you want to think more about a motility disorder.
And so then within either one of those categories, it's really important to delineate, you know, first, are there alarm symptoms? Of course, that would sort of- If this is progressive and there are alarm symptoms, that would really make something obstructive, like an esophageal cancer or external compression from another tumor more likely. Whereas, if there're no alarm symptoms and it still is kind of progressive with time, it may be something like a peptic stricture or really bad esophagitis.
Actually, I didn't learn this until fellowship, but if you have a lot of reflux and it causes some esophageal wall edema, that can actually contribute to dysphagia too. So maybe they just have really bad GERD which is super common. Or you know, if it's a little bit more intermittent, and it feels like things just get stuck sometimes, it may be something like a Schatzki's ring or eosinophilic esophagitis which can be complicated by a stricture as well.
And then over on the side of you know, them having both solids and liquid dysphagia, we really think a lot about the major motility disorders, particularly if it's progressive, something like achalasia we often think about or maybe a systemic disorder like scleroderma that causes a lot of sort of infiltration of the esophageal tissue and difficulty swallowing. And then if it's intermittent and it's just solids and liquids, we think more about some of the more minor motility disorders you know, maybe some of those spastic disorders you think about like distal esophageal spasm or a problem with like the actual outflow of the esophagus like esophagogastric junction outflow obstruction.
And so last thing I'm going to say about sort of the initial history is always just make sure to check the medication list. We now have delineated more and more that opioid medications in addition to causing lower GI dysmotility, like constipation, which we often think about and prophylactically treat, opioid medications can also cause a lot of difficulty swallowing and dysmotility of the upper GI tract.
So that's a really important pearl to maybe even first just look at the medication list to see if that may be contributing. [Dr. Kumar] That's great, Walker. In clinic, the other piece that I find is helpful in distinguishing oropharyngeal from esophageal dysphagia is just asking the patient to point to where they feel the trouble swallowing is. I completely agree that if it's esophageal, it's very hard to localize but often, if it's oropharyngeal, they'll point right to their throat.
And the other piece that I find is common for these patients is that they often have issues with swallowing their pills or medications, whereas, they're fine with drinking or having solid food. So in addition to the timing piece, it's also helpful to clarify with the patient where they think the problem is and how they do with their medications. [Dr. Redd] Absolutely, it's one of those things where often the patient will give you a lot of information about their diagnosis if you just give them time to give you a detailed history.
[Dr. Kumar] Excellent, and I remember another good pearl from this, I love how you distinguish the difficulty swallowing to solids or both, and then another presentation can be a patient who starts having difficulty with solids, but then it progresses to having difficulty with liquids as well, and that would again, favor a structural cause that is growing and narrowing the lumen, such that initially they could at least get liquids down past that potential stricture but once that stricture gets so tight, it can become an issue for swallowing both solids and liquids.
[Dr. Redd] Yeah, absolutely. [Dr. Kumar] All right, so let's get back to our patient, Ms. A, so she clarifies that she has had progressive dysphagia to both liquids and solids, so just what we were discussing, and positional regurgitation as well. So with this added information, Walker, what would your next steps be? [Redd] Yeah, so again, we want to go through all the really careful clinical thinking here, but just remember that dysphagia of sort of any kind, as long as it's not oropharyngeal, is an alarm symptom and an upper endoscopy should be performed.
So that's what I would start with, and in this situation, we wouldn't be surprised to see sort of a dilated esophagus and maybe puckering at the esophagogastric junction. And then our next step, assuming there was no other sort of obvious cause, would be a manometry study because that's actually how major motility disorders or minor motility disorders are diagnosed.
And so in this patient already, you may be sort of wondering if she has achalasia and that's exactly what would be found on manometry. There're three types of achalasia, we're not going to go into all of that detail right now, but just to say you would start with an upper endoscopy and then get a manometry study. And then sometimes there is a role for barium studies or even FLIP panometry, but those are a little bit more typically adjuncts and we're not going to discuss exactly what the role for those is, now just remember, a lot of these motility disorders are really manometric diagnoses.
And so assuming that the upper endoscopy showed like retained products in the esophagus and puckering at the GE junction, then we would sort of start to discuss treatment options and I can kind of discuss those as well, Navin. Anything else you would add about how you would think about the diagnostic evaluation of motility disorders? [Dr. Kumar] No, Walker, that's great. And so if I'm hearing you correctly, it was the fact that she was describing dysphagia to both liquids and solids that made you feel like this was likely going to be a motility issue, and then that's where you started building your differential from?
[Dr. Redd] Yeah, exactly, and the other really nice pearl that I was taught during fellowship, to really ask and oftentimes this is very true for patients with achalasia specifically, is if they have positional regurgitation, meaning a lot of times patients will say, "I have some acid that I feel like is coming up in my esophagus," but instead, this is like asking the patient "If you bend over, do you ever have kind of- You feel okay otherwise and you bend over positionally, and with gravity some liquid or even solid food comes back out of your mouth?" And so like if I got those type of symptoms, I would already have a high suspicion for something like achalasia.
[Dr. Kumar] Nice, and then I think like, the classic board's description of someone with achalasia would be that they find food, undigested food on their pillow upon waking up. Same idea with this positional regurgitation. [Dr. Redd] Exactly, and while we're on it, the other thing that's still tested a lot, even though we don't always use it, is on like a barium swallow study, you'll see the quote, "bird-beak appearance" at the end of the esophagus.
[Dr. Kumar] Excellent, and then, Walker, as we were discussing before this episode, I just came off a week of the inpatient consult service and I think one good point I want to just raise is that if you have a patient like Walker and I were just discussing, and there is a concern for the need to do an upper endoscopy to further evaluate, the barium swallow before, especially, if it's an acute presentation, can actually delay care.
We had a patient who we were consulted on, who had acute dysphagia to both solids and liquids very much like this patient but the primary team ordered a barium swallow and what happened was the barium just pooled in the upper esophagus and it was not draining whatsoever, and the barium is actually very caustic to endoscopes, and so we had to wait about 72 hours until the barium was able to pass through a very tight stricture before we could do an endoscopy.
So if you're worried, particularly for a complete obstruction, a barium swallow is not a good first test, it should certainly be upper endoscopy. [Dr. Redd] Yeah, that is such an important pearl, Navin. I think all of us have seen that, and it's with the best of intentions but yeah, for all the clinical reasoning you've just gone through, if you really think a patient has esophageal dysphasia in the inpatient or outpatient setting, you should always start with an upper endoscopy in almost all cases if they're a procedural candidate.
[Dr. Kumar] Excellent. [Dr. Redd] And so on that same note, let me just talk very briefly, 30,000-foot view of how we can help manage achalasia. So some patients who are older and may have multiple comorbidities and not be candidates for sort of a more invasive procedure that needs to be more durable, we will do an upper endoscopy and just inject Botox at the lower esophageal sphincter to help that relax.
That does have pretty good outcomes for patients, about 3/4 of them do respond, though it's not a very durable response. And so if you don't think someone's up for going to surgery or one of these bigger endoscopic procedures, you can give them Botox, almost all patients can tolerate getting that. Then if they are a procedural candidate, really we have three options that have relatively equivalent data.
We're not going to go into the subtleties of sort of what may direct you to choose one versus the other for a particular patient but just to say that the well-established laparoscopic Heller myotomy has really good outcomes, as does a newer procedure, which is called POEM or peroral endoscopic myotomy, as does pneumatic dilation, which is a really aggressive sort of balloon dilation that the GI endoscopist performs at the lower esophageal sphincter, so all that to say, we have some really nice options for these patients.
So the key is really diagnosing them appropriately with an EGD and then manometry study. [Dr. Kumar] Excellent, all right, so Walker, let's say for Ms. A, you decide to have her, after confirming that she has achalasia, undergo a POEM, and now you're back in clinic and it turns out you have a different patient with dysphasia. So now you're seeing Mr. E, he's a 28-year-old male with seasonal allergies and asthma, and he, just like Ms. A, is establishing care in your primary care clinic.
Now, he reports intermittent dysphagia with solid foods and his partner says that he notes him eating quite slowly whenever he's having a meal. His only medications are loratadine and albuterol as needed. Given that nice framework you provided earlier, Walker, you utilize that and obtain a more detailed history, where Mr. E states that his dysphagia primarily is occurring with solid foods, and over time he has noted that it feels like it's tougher foods like meats that are getting stuck if he eats too quickly.
The vast majority of foods go down okay, but it's these tougher, chewier items that seem to get stuck. So as we discussed, dysphagia is an alarm symptom and so the next step would be to get an endoscopy and you do that and you read the endoscopist's report and it notes that there was edema, there are rings in the esophagus, there are furrows and you look at the pathology report, the endoscopist obtained biopsies in the proximal and distal esophagus and in both jars, there are greater than 50 eosinophils per high-power field.
Walker, with that pathologic finding, do we have a diagnosis and if so, what treatment options would you discuss with this patient? [Dr. Redd] Yeah, thanks so much, Navin. So this is a clinicopathologic diagnosis of eosinophilic esophagitis or what we refer to as EOE. And so basically, what clinicopathologic diagnosis means is the patient has clinical symptoms which can be really subtle, it can be nausea or abdominal pain in younger patients and then more typically in adults dysphagia and/or sort of eating slowly, having food get stuck or in some cases, esophageal food impaction.
And so then the pathologic part of the criteria is that there are greater than 15 eosinophils per high-power field, and so this patient has 50 eosinophils per high-power field, and zero eosinophils are normal in the esophageal tissue. And so this patient has an ongoing, sort of allergic-type esophageal disorder with inflammation there that over time can actually progress from a more inflammatory sort of disease process to fibrostenotic disease.
And if there's fibrostenotic disease, they can actually get strictures there as well, and fibrosis of the esophagus, which can lead to those esophageal food impactions, which are actually sort of, an urgent emergent upper endoscopy that needs to be performed for those patients. And so, it's really important that we diagnose eosinophilic esophagitis early but as I said, the symptoms can be subtle, and for that reason and the fact that it's a relatively newly described disease over the last 15 or 20 years with an increasing incidence, and there is a lot more awareness about it now, it's still probably underdiagnosed.
It often takes patients about 10 years to be diagnosed with this disorder and so once we do diagnose it, and I feel confident you all will when you see these patients in clinic as you'll elucidate more details that it may be subtle about their presentation and get them an upper endoscopy if it's warranted, so once we have the diagnosis, there are a couple of sort of branches of treatment.
One thing I just want to mention before we talk about the medication or dietary options is that if patients do have fibrostenotic disease or strictures, they really will need dilations and they may need more of those over time. And so if patients do have that type of disease, you really want to make sure you're working closely with the GI endoscopist to take care of that aspect of treatment 'cause even if you're treating their inflammation, if they have strictures, they will need those to be dilated.
So in terms of how we treat the inflammation, there're two branches, one is actually dietary therapy. I'm not going to discuss it in detail now but there's evolving sort of recommendations for how patients can cut certain foods, eliminate certain foods from their diet and actually heal the inflammation that way. It can be relatively burdensome for patients, but for the right patient, it can be a really nice option and something they can sort of sustain over time.
Otherwise, as of right now, we do keep people on medications for this, as we do think maintenance therapy is necessary. And so oftentimes what we do is start with a proton pump inhibitor or steroids that are topical steroids that are swallowed, since we don't sort of have an FDA-approved steroid option yet in the US, we do in Europe but often patients have to kind of mix it together and it takes a little bit more work.
And so oftentimes, we'll start with a proton pump inhibitor and see if the patients respond, and if not, we'll sort of move to steroids. And then we're also at this exciting new era now, where we have the first FDA-approved medication for EOE, which is dupilumab and as a biologic agent that's probably going to be used more frequently going forward and so stay tuned for treatment options but remember right now, often you can discuss whether patients want to do medications or diet.
And typically we do start with a proton pump inhibitor to see if that helps improve their symptoms, 'cause it's easy enough to get. And then follow these patients up over the long term is the really important point. [Dr. Kumar] And Walker, when you mention assessing response to any of these therapeutic strategies, what does that entail in addition to checking on their symptoms?
[Dr. Redd] Yeah, so we definitely check on their symptoms and this may change with time, but based on what we know right now, kind of think about this like some of the content we've discussed for inflammatory bowel disease, Navin, we're looking for both symptomatic response or remission, and then also we're looking for endoscopic sort of improvement and more specifically in eosinophilic esophagitis, histologic response.
So we're looking for those eosinophils we found in the esophageal tissue to normalize back below 15. [Dr. Kumar] Excellent, so for some of these patients, especially when you first meet them, they may need a few endoscopies, as you're trying out different therapeutic strategies until you obtain an endoscopy where the mucosa has actually resolved itself of eosinophilia, is that right?
[Dr. Redd] That's exactly right and that's where you can just communicate really closely with whoever is the gastroenterologist following the patient about making sure you're both aware that sometimes these patients are younger, right? And they don't interact with the healthcare system as much. And so if you're on the same page with your gastroenterologist who's helping you follow this patient, you can make sure that the patient gets the care that they need at the intervals they need it, which includes yes, exactly, repeat endoscopies to check for sustained response to medication.
[Dr. Kumar] All right, Walker, this was great. Thank you so much. You did an awesome job walking us through these two cases on esophageal dysphagia. For our listeners, what are the takeaways you'd want them to remember from this excellent episode today? [Dr. Redd] Thanks, Navin. So really, the biggest thing I want you to remember is when a patient presents with dysphagia, sort of pause for a second, know you're going to have to take five minutes really delineating a careful history with the patient of exactly what they mean by difficulty swallowing.
Next, remember that if you are really concerned for esophageal dysphagia, absolutely the first step should be upper endoscopy. And lastly, I would just sort of reiterate that these patients, a lot of these disorders are chronic and sort of need care over time, absolutely the case for eosinophilic esophagitis, achalasia, it can be the the same way. And so make sure that these patients, you are seeing them at regular intervals in clinic until they're doing really well and that you're sort of there for them if they have recurrence of symptoms, which is really common since these are chronic disorders.
[Dr. Kumar] Excellent, I'd just like to highlight your excellent teaching point about dysphagia/solids, think that is most likely due to structural causes versus dysphagia to both solids and liquids, then think more motility issues. So Walker, thank you so much, loved this topic, loved being the host, and hearing you as the expert. And then for our listeners, we really hope you enjoyed listening as well.
And remember, we're going to post this episode on our partner's, McGraw Hill's AccessMedicine website, where you'll be able to access the full episode as well as a transcript, and we'll send out the link so you all can tune in there. And thanks again for joining us, we'll look forward to talking with you all again. [Dr. Redd] Thanks, Navin for being a great host. Talk soon.
[Dr. Kumar chuckles] Bye, Walker. [outro music]
Segment:0 .
[Dr. Smith] Welcome to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou, and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only and should not be understood as medical advice under any circumstances.
[intro music] [Dr. Redd] Welcome back to Run the List. I'm here with Navin Kumar today, and we're coming back with a special episode that should be particularly high-yield for a symptom that we see both in the inpatient and outpatient settings, which is dysphagia. This is a common symptom that patients with esophageal disorders present with and so Navin and I are going to talk about the presentation, work-up, and management of that chief complaint but first, Navin's going to take a few moments to share an important message with our listeners.
[Dr. Kumar] Yeah, thanks, Walker. First off, really excited to be recording with you again, it's been a bit since we've been together on the podcast. I always love going through MedEd topics with you, so happy to be back, and then as Walker said, we wanted to mention the fact that we're going to do something a little new this time. For the past two seasons, we've had this great partnership with McGraw Hill that has really allowed our content to go to the next level in terms of both what we get to teach, but also the quality in which the recordings are done.
So for the next few episodes, we're going to do something new, where we launch our podcast on McGraw Hill's AccessMedicine website. The podcast will again be free and easily downloadable for any of our listeners and we'll post the link in our social media feed so that you all can go directly to the site and listen to our content.
And one great thing about the Access Medicine website is that you'll see when you click on the podcast link there, there're actually transcriptions of the episodes, I think it's a really helpful tool to look at when you're listening and trying to learn along with us 'cause I know sometimes we have to move through content fairly quickly and this is a good way to go back and review the key points. So something new this time, next couple of episodes we're going to launch exclusively on AccessMedicine and I hope you all will go there to listen.
[Dr. Redd] Yeah, as Navin said, we so appreciate your continued support and this would be a really helpful way to allow us to keep bringing you the most high-quality content that we can. And so with that, we're going to go ahead and take this chance to go through a couple of quick-hitting cases together to demonstrate the way that we think about how to manage a patient who presents with dysphagia. And so Navin's going to be the one presenting a couple of cases to me and I'll be going through how we think about this, as always, sort of taking that framework approach and then delineating based on our clinical reasoning, what we think is most likely going on and how to move forward.
[Dr. Kumar] Great and this is going to be a lot of fun for me 'cause I get to play the role of host and Walker's going to be the expert, as he is now a senior clinical fellow and research fellow in gastroenterology and so it's his turn to be the expert here. So as you all know, esophageal disorders are very common, we see them quite a bit both in the inpatient and outpatient setting.
And you know, oftentimes when we hear dysphagia, we immediately just jump to the need for an endoscopy without taking the time and to clinically reason through why this patient may be having dysphagia, developing a broad differential diagnosis prior to doing the first step in evaluation. So Walker's going to take us through two brief cases and provide that clinical reasoning so that you can take that back to your own settings when you're seeing patients with difficulty swallowing.
And so let's start with the first case and let's set the scene, this first patient you're seeing in outpatient clinic. So her name is Ms. A, she's a 52-year-old female with hypertension and hyperlipidemia and she's establishing care in your primary care clinic, and she, during your initial visit, reports difficulty swallowing. And so when you ask her to characterize that further, she says, "It feels like food is getting stuck in my chest." So Walker, with this initial chief complaint, what are the next questions you would ask to help clarify her symptoms?
[Dr. Redd] Sure, so this is to your point Navin, I mean, we do often end up getting upper endoscopy for these patients but we can really delineate a lot, and sometimes that's not the first step, if we ask a really careful history. So often patients will just say, "Food gets stuck when I try to swallow," or "I can't swallow," and that's where I explain to them, "Okay, I'm about to ask you in a lot of detail, about exactly from the time when you initiate your swallow, what happens after that?" And you know you can even get down to the seconds, "Is it that you have difficulty after one or two seconds, or is it 20 seconds after you start your swallow, are you able to initiate your swallow?" And even that part right there can sort of start to help us think through, "Is this more likely oropharyngeal dysphagia that's more proximal to the mouth?" And that can be caused by things like neuromuscular disorders we see a lot, in which case, actually like getting a modified barium swallow study and a speech-language pathologist consult may be the first step or that modified barium study may actually end up showing like a Zenker's diverticulum or a cricopharyngeal bar in which case it still may make sense to confirm that on an upper endoscopy and get GI involved but sometimes it's nice just to start and make sure, "Okay, if you're having difficulty with the actual initiation within a second or two of starting to swallow, it may be one of those etiologies versus more true esophageal dysphagia." Then, if you kind of clarify, "Okay, I'm able to initiate the swallow, but it feels like it gets stuck in my chest as I continue to swallow." It's hard for patients, based on the way our esophagus is innervated, to sort of delineate exactly where the problem is happening but that's why we use time, and if it's after the first four or five seconds of starting to swallow, you're going to start to think, "Okay, is this a problem in the esophagus?" In which case you can delineate, "Does this happen with primarily solid foods or both solids and liquids?" And if really the patient's like, "It never happens with liquids, I only have a problem swallowing solids, maybe like meats or breads," then you're going to start to think about, "Okay, this is maybe more likely a structural disorder or something with the mucosa that's really affecting the ability to get solid foods down." Whereas, if they're having trouble with solids and liquids, you want to think more about a motility disorder.
And so then within either one of those categories, it's really important to delineate, you know, first, are there alarm symptoms? Of course, that would sort of- If this is progressive and there are alarm symptoms, that would really make something obstructive, like an esophageal cancer or external compression from another tumor more likely. Whereas, if there're no alarm symptoms and it still is kind of progressive with time, it may be something like a peptic stricture or really bad esophagitis.
Actually, I didn't learn this until fellowship, but if you have a lot of reflux and it causes some esophageal wall edema, that can actually contribute to dysphagia too. So maybe they just have really bad GERD which is super common. Or you know, if it's a little bit more intermittent, and it feels like things just get stuck sometimes, it may be something like a Schatzki's ring or eosinophilic esophagitis which can be complicated by a stricture as well.
And then over on the side of you know, them having both solids and liquid dysphagia, we really think a lot about the major motility disorders, particularly if it's progressive, something like achalasia we often think about or maybe a systemic disorder like scleroderma that causes a lot of sort of infiltration of the esophageal tissue and difficulty swallowing. And then if it's intermittent and it's just solids and liquids, we think more about some of the more minor motility disorders you know, maybe some of those spastic disorders you think about like distal esophageal spasm or a problem with like the actual outflow of the esophagus like esophagogastric junction outflow obstruction.
And so last thing I'm going to say about sort of the initial history is always just make sure to check the medication list. We now have delineated more and more that opioid medications in addition to causing lower GI dysmotility, like constipation, which we often think about and prophylactically treat, opioid medications can also cause a lot of difficulty swallowing and dysmotility of the upper GI tract.
So that's a really important pearl to maybe even first just look at the medication list to see if that may be contributing. [Dr. Kumar] That's great, Walker. In clinic, the other piece that I find is helpful in distinguishing oropharyngeal from esophageal dysphagia is just asking the patient to point to where they feel the trouble swallowing is. I completely agree that if it's esophageal, it's very hard to localize but often, if it's oropharyngeal, they'll point right to their throat.
And the other piece that I find is common for these patients is that they often have issues with swallowing their pills or medications, whereas, they're fine with drinking or having solid food. So in addition to the timing piece, it's also helpful to clarify with the patient where they think the problem is and how they do with their medications. [Dr. Redd] Absolutely, it's one of those things where often the patient will give you a lot of information about their diagnosis if you just give them time to give you a detailed history.
[Dr. Kumar] Excellent, and I remember another good pearl from this, I love how you distinguish the difficulty swallowing to solids or both, and then another presentation can be a patient who starts having difficulty with solids, but then it progresses to having difficulty with liquids as well, and that would again, favor a structural cause that is growing and narrowing the lumen, such that initially they could at least get liquids down past that potential stricture but once that stricture gets so tight, it can become an issue for swallowing both solids and liquids.
[Dr. Redd] Yeah, absolutely. [Dr. Kumar] All right, so let's get back to our patient, Ms. A, so she clarifies that she has had progressive dysphagia to both liquids and solids, so just what we were discussing, and positional regurgitation as well. So with this added information, Walker, what would your next steps be? [Redd] Yeah, so again, we want to go through all the really careful clinical thinking here, but just remember that dysphagia of sort of any kind, as long as it's not oropharyngeal, is an alarm symptom and an upper endoscopy should be performed.
So that's what I would start with, and in this situation, we wouldn't be surprised to see sort of a dilated esophagus and maybe puckering at the esophagogastric junction. And then our next step, assuming there was no other sort of obvious cause, would be a manometry study because that's actually how major motility disorders or minor motility disorders are diagnosed.
And so in this patient already, you may be sort of wondering if she has achalasia and that's exactly what would be found on manometry. There're three types of achalasia, we're not going to go into all of that detail right now, but just to say you would start with an upper endoscopy and then get a manometry study. And then sometimes there is a role for barium studies or even FLIP panometry, but those are a little bit more typically adjuncts and we're not going to discuss exactly what the role for those is, now just remember, a lot of these motility disorders are really manometric diagnoses.
And so assuming that the upper endoscopy showed like retained products in the esophagus and puckering at the GE junction, then we would sort of start to discuss treatment options and I can kind of discuss those as well, Navin. Anything else you would add about how you would think about the diagnostic evaluation of motility disorders? [Dr. Kumar] No, Walker, that's great. And so if I'm hearing you correctly, it was the fact that she was describing dysphagia to both liquids and solids that made you feel like this was likely going to be a motility issue, and then that's where you started building your differential from?
[Dr. Redd] Yeah, exactly, and the other really nice pearl that I was taught during fellowship, to really ask and oftentimes this is very true for patients with achalasia specifically, is if they have positional regurgitation, meaning a lot of times patients will say, "I have some acid that I feel like is coming up in my esophagus," but instead, this is like asking the patient "If you bend over, do you ever have kind of- You feel okay otherwise and you bend over positionally, and with gravity some liquid or even solid food comes back out of your mouth?" And so like if I got those type of symptoms, I would already have a high suspicion for something like achalasia.
[Dr. Kumar] Nice, and then I think like, the classic board's description of someone with achalasia would be that they find food, undigested food on their pillow upon waking up. Same idea with this positional regurgitation. [Dr. Redd] Exactly, and while we're on it, the other thing that's still tested a lot, even though we don't always use it, is on like a barium swallow study, you'll see the quote, "bird-beak appearance" at the end of the esophagus.
[Dr. Kumar] Excellent, and then, Walker, as we were discussing before this episode, I just came off a week of the inpatient consult service and I think one good point I want to just raise is that if you have a patient like Walker and I were just discussing, and there is a concern for the need to do an upper endoscopy to further evaluate, the barium swallow before, especially, if it's an acute presentation, can actually delay care.
We had a patient who we were consulted on, who had acute dysphagia to both solids and liquids very much like this patient but the primary team ordered a barium swallow and what happened was the barium just pooled in the upper esophagus and it was not draining whatsoever, and the barium is actually very caustic to endoscopes, and so we had to wait about 72 hours until the barium was able to pass through a very tight stricture before we could do an endoscopy.
So if you're worried, particularly for a complete obstruction, a barium swallow is not a good first test, it should certainly be upper endoscopy. [Dr. Redd] Yeah, that is such an important pearl, Navin. I think all of us have seen that, and it's with the best of intentions but yeah, for all the clinical reasoning you've just gone through, if you really think a patient has esophageal dysphasia in the inpatient or outpatient setting, you should always start with an upper endoscopy in almost all cases if they're a procedural candidate.
[Dr. Kumar] Excellent. [Dr. Redd] And so on that same note, let me just talk very briefly, 30,000-foot view of how we can help manage achalasia. So some patients who are older and may have multiple comorbidities and not be candidates for sort of a more invasive procedure that needs to be more durable, we will do an upper endoscopy and just inject Botox at the lower esophageal sphincter to help that relax.
That does have pretty good outcomes for patients, about 3/4 of them do respond, though it's not a very durable response. And so if you don't think someone's up for going to surgery or one of these bigger endoscopic procedures, you can give them Botox, almost all patients can tolerate getting that. Then if they are a procedural candidate, really we have three options that have relatively equivalent data.
We're not going to go into the subtleties of sort of what may direct you to choose one versus the other for a particular patient but just to say that the well-established laparoscopic Heller myotomy has really good outcomes, as does a newer procedure, which is called POEM or peroral endoscopic myotomy, as does pneumatic dilation, which is a really aggressive sort of balloon dilation that the GI endoscopist performs at the lower esophageal sphincter, so all that to say, we have some really nice options for these patients.
So the key is really diagnosing them appropriately with an EGD and then manometry study. [Dr. Kumar] Excellent, all right, so Walker, let's say for Ms. A, you decide to have her, after confirming that she has achalasia, undergo a POEM, and now you're back in clinic and it turns out you have a different patient with dysphasia. So now you're seeing Mr. E, he's a 28-year-old male with seasonal allergies and asthma, and he, just like Ms. A, is establishing care in your primary care clinic.
Now, he reports intermittent dysphagia with solid foods and his partner says that he notes him eating quite slowly whenever he's having a meal. His only medications are loratadine and albuterol as needed. Given that nice framework you provided earlier, Walker, you utilize that and obtain a more detailed history, where Mr. E states that his dysphagia primarily is occurring with solid foods, and over time he has noted that it feels like it's tougher foods like meats that are getting stuck if he eats too quickly.
The vast majority of foods go down okay, but it's these tougher, chewier items that seem to get stuck. So as we discussed, dysphagia is an alarm symptom and so the next step would be to get an endoscopy and you do that and you read the endoscopist's report and it notes that there was edema, there are rings in the esophagus, there are furrows and you look at the pathology report, the endoscopist obtained biopsies in the proximal and distal esophagus and in both jars, there are greater than 50 eosinophils per high-power field.
Walker, with that pathologic finding, do we have a diagnosis and if so, what treatment options would you discuss with this patient? [Dr. Redd] Yeah, thanks so much, Navin. So this is a clinicopathologic diagnosis of eosinophilic esophagitis or what we refer to as EOE. And so basically, what clinicopathologic diagnosis means is the patient has clinical symptoms which can be really subtle, it can be nausea or abdominal pain in younger patients and then more typically in adults dysphagia and/or sort of eating slowly, having food get stuck or in some cases, esophageal food impaction.
And so then the pathologic part of the criteria is that there are greater than 15 eosinophils per high-power field, and so this patient has 50 eosinophils per high-power field, and zero eosinophils are normal in the esophageal tissue. And so this patient has an ongoing, sort of allergic-type esophageal disorder with inflammation there that over time can actually progress from a more inflammatory sort of disease process to fibrostenotic disease.
And if there's fibrostenotic disease, they can actually get strictures there as well, and fibrosis of the esophagus, which can lead to those esophageal food impactions, which are actually sort of, an urgent emergent upper endoscopy that needs to be performed for those patients. And so, it's really important that we diagnose eosinophilic esophagitis early but as I said, the symptoms can be subtle, and for that reason and the fact that it's a relatively newly described disease over the last 15 or 20 years with an increasing incidence, and there is a lot more awareness about it now, it's still probably underdiagnosed.
It often takes patients about 10 years to be diagnosed with this disorder and so once we do diagnose it, and I feel confident you all will when you see these patients in clinic as you'll elucidate more details that it may be subtle about their presentation and get them an upper endoscopy if it's warranted, so once we have the diagnosis, there are a couple of sort of branches of treatment.
One thing I just want to mention before we talk about the medication or dietary options is that if patients do have fibrostenotic disease or strictures, they really will need dilations and they may need more of those over time. And so if patients do have that type of disease, you really want to make sure you're working closely with the GI endoscopist to take care of that aspect of treatment 'cause even if you're treating their inflammation, if they have strictures, they will need those to be dilated.
So in terms of how we treat the inflammation, there're two branches, one is actually dietary therapy. I'm not going to discuss it in detail now but there's evolving sort of recommendations for how patients can cut certain foods, eliminate certain foods from their diet and actually heal the inflammation that way. It can be relatively burdensome for patients, but for the right patient, it can be a really nice option and something they can sort of sustain over time.
Otherwise, as of right now, we do keep people on medications for this, as we do think maintenance therapy is necessary. And so oftentimes what we do is start with a proton pump inhibitor or steroids that are topical steroids that are swallowed, since we don't sort of have an FDA-approved steroid option yet in the US, we do in Europe but often patients have to kind of mix it together and it takes a little bit more work.
And so oftentimes, we'll start with a proton pump inhibitor and see if the patients respond, and if not, we'll sort of move to steroids. And then we're also at this exciting new era now, where we have the first FDA-approved medication for EOE, which is dupilumab and as a biologic agent that's probably going to be used more frequently going forward and so stay tuned for treatment options but remember right now, often you can discuss whether patients want to do medications or diet.
And typically we do start with a proton pump inhibitor to see if that helps improve their symptoms, 'cause it's easy enough to get. And then follow these patients up over the long term is the really important point. [Dr. Kumar] And Walker, when you mention assessing response to any of these therapeutic strategies, what does that entail in addition to checking on their symptoms?
[Dr. Redd] Yeah, so we definitely check on their symptoms and this may change with time, but based on what we know right now, kind of think about this like some of the content we've discussed for inflammatory bowel disease, Navin, we're looking for both symptomatic response or remission, and then also we're looking for endoscopic sort of improvement and more specifically in eosinophilic esophagitis, histologic response.
So we're looking for those eosinophils we found in the esophageal tissue to normalize back below 15. [Dr. Kumar] Excellent, so for some of these patients, especially when you first meet them, they may need a few endoscopies, as you're trying out different therapeutic strategies until you obtain an endoscopy where the mucosa has actually resolved itself of eosinophilia, is that right?
[Dr. Redd] That's exactly right and that's where you can just communicate really closely with whoever is the gastroenterologist following the patient about making sure you're both aware that sometimes these patients are younger, right? And they don't interact with the healthcare system as much. And so if you're on the same page with your gastroenterologist who's helping you follow this patient, you can make sure that the patient gets the care that they need at the intervals they need it, which includes yes, exactly, repeat endoscopies to check for sustained response to medication.
[Dr. Kumar] All right, Walker, this was great. Thank you so much. You did an awesome job walking us through these two cases on esophageal dysphagia. For our listeners, what are the takeaways you'd want them to remember from this excellent episode today? [Dr. Redd] Thanks, Navin. So really, the biggest thing I want you to remember is when a patient presents with dysphagia, sort of pause for a second, know you're going to have to take five minutes really delineating a careful history with the patient of exactly what they mean by difficulty swallowing.
Next, remember that if you are really concerned for esophageal dysphagia, absolutely the first step should be upper endoscopy. And lastly, I would just sort of reiterate that these patients, a lot of these disorders are chronic and sort of need care over time, absolutely the case for eosinophilic esophagitis, achalasia, it can be the the same way. And so make sure that these patients, you are seeing them at regular intervals in clinic until they're doing really well and that you're sort of there for them if they have recurrence of symptoms, which is really common since these are chronic disorders.
[Dr. Kumar] Excellent, I'd just like to highlight your excellent teaching point about dysphagia/solids, think that is most likely due to structural causes versus dysphagia to both solids and liquids, then think more motility issues. So Walker, thank you so much, loved this topic, loved being the host, and hearing you as the expert. And then for our listeners, we really hope you enjoyed listening as well.
And remember, we're going to post this episode on our partner's, McGraw Hill's AccessMedicine website, where you'll be able to access the full episode as well as a transcript, and we'll send out the link so you all can tune in there. And thanks again for joining us, we'll look forward to talking with you all again. [Dr. Redd] Thanks, Navin for being a great host. Talk soon.
[Dr. Kumar chuckles] Bye, Walker. [outro music]
Form Title Download
Media
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html audio player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the audio player are generally tabs, one of which shows a scrolling transcript of the audio and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the audio player is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the audio by opening up an explore dialog which contains an about tab which contains rich metadata about the media, a segments tab which contains further information about the audio, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
E: Explore Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Form Title Embed Media
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the media.
You can press A to open the Accessibility Dialog.
This describes many other keyboard shortcuts for media controls.
Exit Clip Mode
The video is currently set-up to show just a clip from 0:00 to video end. You have requested to see a portion of the media outside of the clip.
Click OK to switch to the full media or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode