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(Gastroenterology) swallowing & swallowing disorders in English by dr. kalimullah wardak

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(Gastroenterology) swallowing & swallowing disorders in English by dr. kalimullah wardak

  1. 1. UNIVERSITY OF KANDAHAR DEC/23/2013 DES BY: K. ALMAAS DES BY: K.W
  2. 2. Presenters: 2 1. Kaleemullah 10mins 2. Nisar Ahmad 10mins Defenders:
  3. 3. SWALLOWING / DEGLUTITION
  4. 4. 4 Anatomy
  5. 5. • Swallowing is a complicated mechanism, because the pharynx sub serves respiration as well as swallowing. • (1) a voluntary stage, which initiates the swallowing process; • (2) a pharyngeal stage, which is involuntary and constitutes passage of food through the pharynx into the esophagus; and • (3) an esophageal stage, another involuntary phase that transports food from the pharynx to the stomach. 5 Definition and
  6. 6. • When the food is ready for swallowing, it is "voluntarily" squeezed or rolled posteriorly into the pharynx by pressure of the tongue upward and backward against the palate. From here on, swallowing becomes entirely-or almost entirely-automatic and ordinarily cannot be stopped. 6 Stages of Swallowing
  7. 7. • As the bolus of food enters the posterior mouth and pharynx, it stimulates epithelial swallowing receptor areas all around the opening of the pharynx, especially on the tonsillar pillars, and impulses from these pass to the brain stem to initiate a series of automatic pharyngeal muscle contractions as follows: • The soft palate is pulled upward to close the posterior nares, to prevent reflux of food into the nasal cavities. • The palatopharyngeal folds are pulled medially, form a sagittal slit for a selective action, allowing only masticated food which lasts less than 1 second. 7 Stages of Swallowing
  8. 8. • The vocal cords of the larynx are strongly approximated, and the larynx is pulled upward and anteriorly by the neck muscles. These actions, combined with the presence of ligaments that prevent upward movement of the epiglottis, cause the epiglottis to swing backward over the opening of the larynx. • This process pulls up and enlarges the opening to the esophagus. Causing U.E.S/Pharyngoesophageal S. relaxation; leading food from the posterior pharynx into the upper esophagus. 8 Stages of Swallowing
  9. 9. • Following U.E.S relaxation, the entire muscular wall of the pharynx contracts, beginning in the superior part of the pharynx, then spreading downward over the middle and inferior pharyngeal areas, which propels the food by peristalsis into the esophagus. • The entire process occurring in less than 2 seconds. 9 Stages of Swallowing
  10. 10. • The motor impulses from the swallowing center to the pharynx and upper esophagus that cause swallowing are transmitted successively by the 5th, 9th, 10th, and 12th cranial nerves and even a few of the superior cervical nerves. • In summary, the pharyngeal stage of swallowing is principally a reflex act. It is almost always initiated by voluntary movement of food into the back of the mouth, which in turn excites involuntary pharyngeal sensory receptors to elicit the swallowing reflex. 10 Stages of Swallowing
  11. 11. • The entire pharyngeal stage of swallowing usually occurs in less than 6 seconds, thereby interrupting respiration for only a fraction of a usual respiratory cycle. The swallowing center specifically inhibits the respiratory center of the medulla during this time, halting respiration at any point in its cycle to allow swallowing to proceed. Yet, even while a person is talking, swallowing interrupts respiration for such a short time that it is hardly noticeable. 11 Stages of Swallowing
  12. 12. • With its organized movements, conducts food from pharynx to stomach. It exhibits two types of peristaltic movements: • • Primary peristalsis is the continuation of pharyngeal muscles’ contraction which takes 5-8 or 8-10 sec, depending on the position of the person. • Secondary peristalsis emerges when the first one is failed to move all of food to the stomach, originated by esophageal distention initiated partly by intrinsic neural circuits in the myenteric nervous system and partly by reflexes that begin in the pharynx and are then transmitted upward through vagal afferent fibers to the medulla and back again to the 12 Stages of Swallowing
  13. 13. • Both upper third striated muscle portion and the lower two thirds smooth muscles of esophagus are innervated by vagus, When the vagus nerves to the esophagus are cut, the myenteric nerve plexus of the esophagus becomes excitable enough after several days to cause strong secondary peristaltic waves even without support from the vagal reflexes. Therefore, even after paralysis of the brain stem swallowing reflex, food fed by tube or in some other way into the esophagus still passes readily into the stomach. 13 Stages of Swallowing
  14. 14. • When the esophageal peristaltic wave approaches toward the stomach, a wave of relaxation, transmitted through myenteric inhibitory neurons, precedes the peristalsis. Furthermore, the entire stomach and, to a lesser extent, even the duodenum become relaxed as this wave reaches the lower end of the esophagus and thus are prepared ahead of time to receive the food propelled into the esophagus during the swallowing act. 14 Stages of Swallowing
  15. 15. Position and composition: • This sphincter normally remains tonically constricted with an intraluminal pressure at this point in the esophagus of about 30 mm Hg, in contrast to the midportion of the esophagus, which normally remains relaxed. • When a peristaltic swallowing wave passes down the esophagus, there is "receptive relaxation" of the lower esophageal sphincter ahead of the peristaltic wave, which allows easy propulsion of the swallowed food into the stomach. Rarely, the sphincter does not relax satisfactorily, resulting in a condition called achalasia. 15 Stages of Swallowing
  16. 16. • Lower esophageal Sphincter/Pharyngioesophageal S./Physiologic S. • Oblique insertion of esophagus into stomach. • Right crus of diaphragm grasps the lower portion of esophagus. • Gastric sling fibers. • Mucosal rosette of esophageal epithelium. • Crico-pharyngeal sphincter is the last resort. 16 Reflux Prevention
  17. 17. • Lower one eight portion of the esophagus has a similar epithelial layer as that of stomach and is quite resistant to reflux, but the rest of esophagus tends to be susceptible to gastric juices. • Otherwise, every time we walked, coughed, or breathed hard, we might expel stomach acid into the esophagus. 17 Reflux Prevention
  18. 18. • General: body habitus, mental status, drooling, wheezing, dyspnea, voice quality • Cranial nerves • Inspection of the tongue and palate for strength/symmetry • Laryngeal Examination: pooled secretions, vocal fold movement, interaretynoid area 18 Evaluation
  19. 19. • Plain radiography • Fiberoptic Endoscopic Evaluation of Swallowing (FEES) • Modified Barium Swallowing Study (MBSS) o Video-fluoroscopic Swallowing Examination • Air Contrast Barium Esophagram • Manometric Investigations • Bolus Scintigraphy 19 Reflux Prevention
  20. 20. DISORDERS OF SWALLOWING / DYSPHAGIA
  21. 21. • Mandibular immobility: Trismus, Ankylosis of Temporomandibular joint • Lingual immobility: Cancer; XII/soft palatal Paralysis, cleft lip/palate • Hyposalivation: Diabetes, Diuretics • Tonsillar Hypertrophy • Lingual Cancer • Nasopharyngeal Isthmus failure • XII paralysis • Pharyngeal muscles’ paralysis or Diverticulae 22 Etiology
  22. 22. A. Congenital: Short esophagus, Stricture, T.E fistula, Thymus hypertrophy B. Acquired: 1. Inflammatory: Acute/Chronic (Erosive) Esophagitis, Hiatal hernia… 2. Traumatic: Foreign body, Corrosive stricture/poisoning, Instrumentation 3. Neoplasms 4. Neurological: Myasthenia gravis, Tetanus, Crico- pharyngeal spasm 5. Mass lesions: Thyroid tumors, Lymphadenopathy, Cervical spondylitis, Aortic aneurism, Mediastinal Tumor 6. Miscellaneous: Achalasia, Diverticulum, Hysterical, 23 Etiology Foreign Body Tracheostomy; the ITT balloon causes esophageal obstruction Cervical Spondylitis
  23. 23. • Damage to the 5th, 9th, or 10th cerebral nerve can cause paralysis of significant portions of the swallowing mechanism. poliomyelitis or encephalitis, can damage the swallowing center in the brain stem. Paralysis of the swallowing muscles, as occurs in muscle dystrophy or in failure of neuromuscular transmission in myasthenia gravis or botulism, can also prevent normal swallowing. • When the swallowing mechanism is partially or totally paralyzed, the abnormalities that can occur include 24 Paralysis
  24. 24. • One of the most serious instances of paralysis of the swallowing mechanism occurs when patients are under deep anesthesia. Often, while on the operating table, they vomit large quantities of materials from the stomach into the pharynx; then, instead of swallowing the materials again, they simply suck them into the trachea because the anesthetic has blocked the reflex mechanism of swallowing. As a result, such patients occasionally choke to death on their own vomitus. 25 Paralysis
  25. 25. • Achalasia is a condition in which the lower esophageal sphincter fails to relax during swallowing. As a result, food swallowed into the esophagus then fails to pass from the esophagus into the stomach. Pathological studies have shown damage in the neural network of the myenteric plexus in the lower two thirds of the esophagus. As a result, the musculature of the lower esophagus remains spastically contracted, and the myenteric plexus has lost its ability to transmit a signal to cause "receptive relaxation" of the gastroesophageal sphincter as food approaches this sphincter during swallowing. 26 Achalasia
  26. 26. • When achalasia becomes severe, the esophagus often cannot empty the swallowed food into the stomach for many hours, instead of the few seconds that is the normal time. Over months and years, the esophagus becomes tremendously enlarged until it often can hold as much as 1 liter of food, which often becomes putridly infected during the long periods of esophageal stasis. The infection may also cause ulceration of the esophageal mucosa, sometimes leading to severe sub-sternal pain or even rupture and death. Considerable benefit can be achieved by stretching the lower end of the esophagus by means of a balloon inflated on the end of a swallowed esophageal tube. Antispasmodic drugs (drugs that relax smooth muscle) can also be helpful. 27 Achalasia
  27. 27. • For crico-pharyngeal achalasia, crico-pharyngeal myotomy is the last solution: 28 Achalasia
  28. 28. • Numerous nonpropulsive contractions • “corkscrew/ rosary bead” esophagus 29 Diff. Esophageal Spasm
  29. 29. 30 Eso. Webs and rings
  30. 30. 1. Pneumonia • Risk increases as dysphagia worsens 2. Choking 3. Longer Meal Times 4. Malnutrition 5. Dehydration 6. Weight Loss 7. Quality of Life • Loss of social interaction associated with eating 31 Complications
  31. 31. TREATMENT
  32. 32. 1. If coughing/choking, never inhibit cough 2. Heimlich Maneuver 3. Stack breathing 4. Portable suction 5. CoughAssist device 33 What to do? CoughAssist™ Mechanical In- Exsufflator
  33. 33. 1. Don’t talk with mouth full 2. Repeat swallows 3. Alternate solids and liquids • One sip at a time 4. Sip straws 5. Smaller bites 6. Slowed rate 7. Supervision and cueing 8. Smaller, more frequent meals per day 34 Safe Swallowing
  34. 34. 1. Avoid problem textures and consistencies 2. Gel/powder liquid thickener 1. Steak consistency diet 2. Pot roast consistency diet 3. Meat loaf consistency diet 4. Pudding consistency diet 5. Cream consistency diet (tube feedings) 35 Safe Swallowing
  35. 35. 1. Chin tuck 1. Reduce distractions 2. Eat more calories early in the day or when there is less fatigue 1. Take with applesauce, yogurt, pudding, ice cream, or any other slippery medium • Long-necked bottles • Carbonated beverages 2. Crush with pharmacist’s consent 36 Safe Swallowing
  36. 36. • Provides nutrition via an alternate route • Allows one to receive required nutrition and hydration when no diet texture can be swallowed safely or when oral feeding is not meeting nutritional / hydration needs • Allows for the combination of oral eating for pleasure and tube feeding for fluids and calories 37 Alternative Methods
  37. 37. 38 References
  38. 38. Arranged and Designed By: Dr. Kaleemullah (Wardak)

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