Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 446

An important cause of dysphagia or odynophagia in older individuals is mucosal injury caused by impaction of medications in the oesophagus, the incidence of which is likely to increase as the number of medications prescribed in this group escalates. Risk factors that are more prevalent in the elderly include less saliva, delayed oesophageal transit, and immobility (particularly recumbent position). Capsules – especially if gelatin‐coated – may present a greater risk than tablets due to slower oesophageal transit, and extended‐ or sustained‐release formulations are often implicated. The most frequent sites of hold‐up are the upper and mid‐oesophagus, corresponding to extrinsic compression from the left main bronchus, aortic arch, or enlarged left atrium, and also to a zone of low‐amplitude pressure waves between the proximal and distal oesophagus. Numerous medications are associated with oesophageal injury, including potassium chloride, tetracyclines, aspirin, non‐steroidal drugs, quinidine, theophylline, ferrous sulfate, and alendronate.³⁸ Dabigatran has also recently been associated with extensive sloughing of the oesophageal mucosa.³⁹

Figure 17.3 Oesophageal manometry in achalasia (type 2), displayed as a pressure topography plot. Note the simultaneous low‐amplitude pressure waves in the oesophageal body, i.e. pan‐oesophageal pressurization, and failure of LOS relaxation on swallowing.

Figure 17.4 Manometry recording in distal oesophageal spasm, displayed as a pressure topography plot. Note the excessively rapid propagation of contractions along the oesophagus (premature contractions) as well as a hypercontractile response in the distal oesophagus.

Symptoms usually resolve when the offending drug is withdrawn but may be persistent and related to stricture formation. Perforation and bleeding are other associated complications, particularly with potassium chloride, quinidine, and non‐steroidal drugs. The typical endoscopic or barium swallow appearance in pill esophagitis is of small superficial ulcers. There is anecdotal evidence that sucralfate is beneficial in severe or persistent disease. As a preventive measure, patients should be advised to take oral medications in the upright position, followed immediately by a full glass of water.

Figure 17.5 Barium swallow in a patient with distal oesophageal spasm, demonstrating segmentation of the barium column by contractions, producing a corkscrew appearance.