A Patient with Dysphagia

Facilitating Learning Session
with

Participants (mostly surgical trainees with some certified general surgeons)
in the
Postgraduate Course of the Department of Surgery, Philippine General Hospital
Manila

September 7, 1999

9 Participants
Drs. Randy Abdulla, Janice Maddela, Marlo Rendon, Merceditha Althea Quinon,
Luis Serafin C. Dabao, Romulo Barrameda, Jr., Gemma Uy, Arlean, and others

(from Laguna, Polymedic Medical Center, Iloilo, Tondo Medical Center)

Facilitator: Reynaldo O. Joson, MD

Notes:

• This was the second day of the postgraduate course.
• A group of 9 participants was assigned to me in the preceptorial.
• My residents prepared cases for discussion. Dr. Gemma Uy prepared the case of dysphagia.
• I did not know the details of the problems of the patient nor did the participants.

How I Did It and What Transpired

• I used the framework of a "Management of a (Surgical) Patient."
• I focused on problem-solving and decision-making.
• I used inquiry approach and promoted interactions.

66-year-old female with dysphagia.

Q. What is your concept of dysphagia?

Answers: Difficulty of swallowing, which may be painful or not.

Q. What are the organs/systems involved in dysphagia?

Answers: oral cavity, oropharynx, hypopharynx, esophagus, and proximal stomach.

Q. What cues which you can use to determine the location of the cause of the dysphagia?

After some discussion, the group decided that if the difficulty occurs before or during swallowing, the problem is at the oral cavity, oropharynx, and hypopharynx. If the difficulty occurs after swallowing, the problem is at the esophagus and proximal stomach level.

Q. Gemma, can you provide us with data on this?

A: Difficulty occurs after swallowing.

Q: So, our consideration is that the problem is at the level of the esophagus or proximal stomach. If there is an esophageal disorder, what are considerations? What is/are most/more common and least common cause of dysphagia caused by an esophageal disorder?

A:

• Tumor - Cancer more than benign = most common
• Motility Disorder - Achalasia
• Reflux Esophagitis
• Stricture secondary to Corrosive Substances
• Foreign body = least common at this age

Q. Is there a characteristic pattern of dysphagia that is diagnostic of the different causes?

A. After some discussion, consensus is NONE.

Q. When do you suspect the different causes?

A.

• Ingestion of foreign body - foreign body as a cause
• Ingestion of corrosive substance - stricture secondary to corrosive substance
• Chronic history of heartburns - reflux esophagitis
• Tumor and Motility Problem - No history of the three above items, after which differentiation between the two is difficult. Prevalencewise, however, malignant tumor is more common than achalasia.

Q. Gemma, can you provide us with the data we need? When is the onset? What is the characteristic of the dysphagia?

A. Onset: 4 years - cannot tolerate solid; 3-years - cannot tolerate liquids. Weight loss. No ingestion of foreign body nor corrosive substances. No history of chronic heartburns.

Q. What are your considerations based on the data on hand?

A. Consensus: primary diagnosis: esophageal cancer; secondary diagnosis: achalasia.

Q. What physical findings will tell you that the diagnosis should be esophageal cancer or should be achalasia?

A. Presence of palpable mass on the neck and lymph nodes will point to esophageal cancer. There are no physical signs for achalasia.

Gemma: No mass observed and palpated in the patient. Wt: 42 kg.

A. Not sure of the diagnosis because we based it on prevalence. Also the treatment plan is different. Resection for cancer; esophagomyotomy for achalasia. Thus, we need a paraclinical diagnostic procedure.

Q. What is the most cost-effective paraclinical diagnostic procedure?

Answers:

Objective: To be more definite on the diagnosis of esophageal cancer

Options	Benefits	Risks	Cost	Availability
Endoscopy and biopsy	Direct and definite - 95% yield	discomfort of scope	Php 3000	Readily available
Barium swallow	Indirect - below 90%	radiation	Php 2000	Readily available
CT scan	Indirect - below 90%	radiation	Php 3000	Not readily available

Decision: Endoscopy with biopsy

Q. Gemma, was an endoscopy done?

A: Yes. There was a ulcerative lesion at 20 cm (about the middle 3rd of the thoracic esophagus). The biopsy showed squamous cell carcinoma.

Q. What is the next step?

A. Determine the extent of the disease.

Q. How?

A. History - inquire on pulmonary symptoms such as hemoptysis, since the lesion is on the middle 3rd near the tracheobroncial tree.

Gemma: No pulmonary complaints.

Q. What else?

A. Chest x-ray - to see the mediastinum as well as the pulmonary parenchyma.

Gemma showing the chest x-ray: There is a superior mediastinal mass. No evident parenchymal nodules to suggest pulmonary mets.

Q. Anything else you want to do?

A. Bronchoscopy or CT scan.

Q. Which is the most cost-effective? Which one will you choose in determining the extent of the tumor?

Options	Benefits	Risks	Cost	Availability
Bronchoscopy	Direct visualization but limited to tracheobronchial tree	discomfort of scope	Php 3000	Readily available
CT scan	Indirect (imaging) but may evaluate esophageal lesion and adjacent major vessels, pericardium, tracheobronchial tree, mediastinal nodes, and lung parenchyma	radiation	Php 3000	Not readily available

Decision: CT Scan

Gemma: CT Scan shows distortion of the tracheobronchial tree with mediastinal nodes.

Q. Is esophageal lesion resectable or worth resecting?

A: No

Q. So, what will be the goal in the treatment?

A: Palliative. To enable the patient to swallow and eat before she dies.

Q. How?

A. By-pass. Cervical esophagus to stomach through a mediastinal tunneling.

Q. How do you prepare the patient for the operation?

A.

• Informed consent
• Screen for medical conditions that may interfere with the success of the operation
• Build up the nutrition
• Prepare material needs for the operation
• Psychosocial support

Q. How do you build up the nutrition of the patient?

A. Choice between total parenteral nutrition and tube enterostomy

Gemma, we were able to insert an NGT. Through this the nutrition of the patient was improved. After 2-3 weeks, a bypass operation was done.

Q. What will be the long-term follow-up of this patient?

A. Palliative care - symptom-directed.

Questions and Comments from Readers

(You can use the text area below and then press the "submit" button or
you can email me your questions and comments.)

rjoson@pacific.net.ph

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