General Medicine Lecture 6 Dysphagia Regurgitation Vomit

Front 1

Dysphagia and regurgitation are both manifestations of ________ disorders.

Back 1

Swallowing disorders

Front 2

What is the definition of dysphagia?

Back 2

Implies difficult or painful swallowing
-Typically a result of oral or pharyngeal disease

Front 3

Why is it so crucial to accurately determine if you're dealing with dysphagia or regurgitation?

Back 3

Can waste time and resources on work- up

Front 4

What are the 3 distinguishing characters that owners will often present with to describe vomit/ dysphagia or regurgitation?

Back 4

They can't keep anything down..
They bring food back up
They don't want to eat

Front 5

How does dysphagia usually manifest?

Back 5

As difficulty up to and around the act of swallowing

Front 6

When does regurgitation happen (with order of digestion)?

Back 6

Regurgitation occurs after swallowing and does not involve abdominal muscles

Front 7

How is vomiting different from regurgitation?

Back 7

Vomiting involves abdominal muscle contraction and "heaves" before the ejection of vomitus

Front 8

What are the 3 basic categories of dysphagia?

Back 8

1) Oral phase dysphagia
2) Pharyngeal phase dysphagia
3) Cricopharyngeal phase dysphagia

Front 9

How do you distinguish b/w pharyngeal phase dysphagia and cricopharyngeal phase dysphagia?

Back 9

Fluoroscopy

Front 10

In order to be able to swallow correctly, the patient requires what 2 things?

Back 10

1) Normal tongue and pharyngeal muscle motility
2) Normal innervation of tongue, pharynx, larynx, cricopharyngeal muscle and upper esophagus

Front 11

What initiates the act of swallowing?

Back 11

The voluntary passage of a bolus into the pharynx by the base of the tongue

Front 12

What happens during the act of swallowing when the bolus of food enters the pharynx?

Back 12

An involuntary pharyngeal phase is triggered by:
-Cranial nerves VII, IX, X and XII
-Swallowing center in the medulla

Front 13

What is the definition of regurgitation?

Back 13

The passive expulsion of esophageal content

Front 14

What is a common clinical sign b/w damage to nerve VII, IX, X, or XII?

Back 14

Results in difficulty swallowing

Front 15

What is the main muscle of the upper esophageal sphincter?

Back 15

Cricopharyngeal muscle

Front 16

What are the 4 steps of the pharyngeal phase of swallowing?

Back 16

1) Soft palate is pulled upwards
2) Vocal cords are approximated, epiglottis closes
3) Larynx is pulled cranially and ventrally
-begins the opening of upper esophageal sphincter
4) Cricopharyngeal muscle relaxes

Front 17

Why is vocal fold approximation more critical than epiglottis function during the pharyngeal phase of swallowing?

Back 17

Closure of vocal folds is far more important for stopping aspiration - why animals w/ laryngeal paralysis are at a higher risk of developing aspiration pneumonia

Front 18

What happens when the cricopharyngeus muscle relaxes during the pharyngeal phase of swallowing?

Back 18

Bolus enters the esophagus

Front 19

The laryngeal and cricopharyngeal activity must be coordinated during the pharyngeal phase of swallowing or _______ can occur.

Back 19

Aspiration

Front 20

During what phase of swallowing does the problem go from being dysphagia to regurgitation?

Back 20

After the bolus enters the esophagus during the pharyngeal phase of swallowing the issue is now regurgitation instead of dysphagia

Front 21

What type of dysphagia is more likely to be seen in isolation?

Back 21

Oral phase dysphagia

Front 22

Why are dysphagia and regurgitation commonly seen together?

Back 22

Pharyngeal and cricopharyngeal dysphagia often accompanies esophageal motility disorders

Front 23

To distinguish b/w the different times of dysphagia, it can be useful to watch them eat, when does oral, pharyngeal and cricopharyngeal dysphagia occur?

Back 23

-Oral dysphagia: difficulty before swallowing
-Pharyngeal dysphagia: chew normally, repeated attempts to swallow
-Cricopharyngeal dysphagia: start to swallow, then cough or gag

Front 24

What are the clinical signs of oral dysphagia?

Back 24

1) Difficulty prehending food, or painful on chewing/ eating (often inappetent)
2) Owners may report strange feeding behavior
-"Turkey poking", gobbling
-Dropping of food while eating
-Tilting the head back, chewing to one side

Front 25

What are 6 disease processes that can cause oral dysphagia?

Back 25

1) Inflammatory disease
-LP stomatitis
2) Foreign bodies
-Sticks, bones, toys
3) Neoplasms
4) Congenital defects
-Palate defects
5) Dental, periodontal disease
6) Trauma
-Mandibular fractures, TMJ dysfunction

Front 26

What are 3 diagnostic tools used for oral dysphagia?

Back 26

1) History: Acute vs chronic, toxin exposure, trauma
2) Exam: thorough & detailed oral exam
-may need deep anesthesia or sedation
3) Radiography: foreign bodies, fractures

Front 27

What cats usually develop feline lymphoplasmacytic stomatitis?

Back 27

~50% of cats w/ FIV
-+/- coinfection w/ calicivirus

Front 28

What pathology is associated with feline lymphoplasmacytic stomatitis?

Back 28

Severe lymphocytic/ plasmacytic inflammation of gingiva, periodontal structures & pharynx

Front 29

What will cats with feline lymphoplasmacytic stomatitis usually present for?

Back 29

Painful eating: dysphagia

Front 30

What causes feline lymphoplasmacytic stomatitis? How can it be treated?

Back 30

Immune mediated- reacts against primary membrane so can remove teeth fragments to remove the stimulation for inflammation
-sometimes have to put in feeding tube for support during initial therapy

Front 31

What are ranulae?

Back 31

Rupture of sublingual salivary ducts, causing accumulation of saliva and mucus at the base of the frenulum and sets off dramatic inflammatory response bc of mucous proteins so rapidly develop saliva, mucus, inflammatory cells, scar tissue

Front 32

How can you treat a ranula?

Back 32

Marsupialization: make an incision in the ranula, flip it over and suture it down so hole is there to drain -works sometimes, sometimes have to remove salivary gland that lead to problem

Front 33

What causes a ranulae?

Back 33

Mechanical obstruction

Front 34

What are 5 disease processes that can cause pharyngeal and cricopharyngeal dysphagia?

Back 34

1) Congenital
-Cricopharyngeal achalasia: cricopharyngeal m. that isn't innervated and unable to relax
2) Foreign bodies
-Usually dramatic onset of retching and gagging
3) Neoplasia
4) Rabies
-uncommon
5) Neurologic disease

Front 35

What are 5 examples of neurologic disease that can cause pharyngeal and cricopharyngeal dysphagia?

Back 35

1) CN VII, IX, X or XII
2) Brainstem
3) Polyradiculopathies
-coonhound paralysis, idiopathic diseases
4) Tick paralysis
-Usually start w/ progressive paralysis from forelimbs to hindlimbs-if get tick in mouth or on neck then toxin is close to ends of cranial nerves so can get swallowing disorders
5) Myasthenia gravis
-diffuse muscular disease- see dysphagia and esophageal dysfunction prior to classic myasthenic signs

Front 36

You have a dog that appears to be chewing okay, facial mm are normal in appearance, makes an attempt to swallow and then bolus comes out and can see its nicely formed bolus, what type of dysphagia is this?

Back 36

bolus formation occurs in pharyngeal phase, so tells us that pharynx is working ok, and attempts to swallow and it is excreted- this was cricopharyngeal dysphagia

Front 37

What is the time frame of regurgitation, related to eating?

Back 37

May be immediately after eating, or up to several hours after eating

Front 38

Regurgitation is the most common clinical sign of _______ disease.

Back 38

Esophageal

Front 39

What are the common clinical presentation for an animal that is regurgitating?

Back 39

Appetite is increased but weight loss or poor growth is noted

Front 40

Why are regurgitating animals at higher risk for aspiration pneumonia than vomiting animals?

Back 40

Bc the vomiting reflex involves motor reflexes of larynx that closes the vocal folds and epiglottis, regurgitation is intrinsic to esophagus= no central involvement so reflex closure of larynx doesn't happen when animals is doing pure regurgitation--> greater chance of materials going down through open vocal folds
-Upper airway protective reflexes are not as stimulated w/ regurgitation

Front 41

What are 6 disease processes that can cause regurgitation?

Back 41

1) Megaesophagus
2) Esophagitis
3) Mechanical obstructions
-strictures, foreign bodies, vascular ring anomaly
4) Endocrine
-HypoT4, hypoAdr
5) Neuropathies
-Polyradiculopathies
-Lead poisoning
-Distemper
-Brainstem lesion
6) Immune mediated
-SLE, myositis

Front 42

Is premonitory nausea present with regurgitation and/or vomiting?

Back 42

Regurgitation: absent
Vomiting: present

Front 43

Are the "heaves" present with regurgitation and/or vomiting?

Back 43

Regurgitation: absent
Vomiting: present

Front 44

Are tubular "casts" present with regurgitation and/or vomiting?

Back 44

Regurgitation: common
vomiting: rare (Except cats)

Front 45

What is the pH with regurgitation? Vomiting?

Back 45

Regurgitation: neutral
Vomiting: acid, neutral or alkaline!

Front 46

Is white stable foam present with regurgitation and/or vomiting?

Back 46

Regurgitation: common
Vomiting: rare

Front 47

Does re-consumption of food usually happen with animals that are regurgitating or vomiting?

Back 47

Regurgitating

Front 48

What causes heaving?

Back 48

Generation of negative pressure in thorax and positive pressure in abdomen so it pumps stuff into esophagus and then that stops and esophagus takes over and delivers material to outside world

Front 49

What is the central mediation of vomiting?

Back 49

Centrally mediated- the chemoreceptor trigger zone integrates inputs from the vestibular centre, abdominal organs and sensors with the CRTZ itself
-Discharge of the CRTZ stimulates the vomition center

Front 50

Why is there debate on whether or not vomiting is the "hallmark" of gastric disease?

Back 50

Vomiting is a hallmark sign of gastric disease - means stomach did something, but its a clinical sign of a lot of diseases, including those that are outside the stomach

Front 51

Is vomiting a clinical sign or a disease?

Back 51

Clinical sign of many diseases
-gastritis, pancreatitis, hepatitis, enteritis, nephritis, acute renal failure, chronic renal failure

Front 52

What are the 3 phases of vomiting?

Back 52

1) Nausea
2) Retching
3) Vomiting

Front 53

What are the signs that an animals feels nauseous?

Back 53

Animal may appear uneasy, licking of lips, repeated swallowing, pacing, obtunded, hiding, whining to get outside

Front 54

What is retching?

Back 54

Contraction of abdominal muscles and diaphragm, negative pressure in thorax
-Gastric and duodenal contents move into esophagus

Front 55

What is vomiting?

Back 55

Forceful ejection of gastric contents, positive pressure in thorax

Front 56

What should you consider when there's acute onset of frequent vomiting?

Back 56

-Dietary indiscretion*
-Gastritis*
-Obstruction of GIT
-Viral disease
* often mild and self limiting

Front 57

Why is it important to consider the age of an animal with vomiting?

Back 57

-Younger animals: dietary indiscretion, infections and intestinal accidents more common
-Older animals: metabolic disease, neoplasia, inflammatory disease