The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical an Medical Pedagogical Faculty

2. Motivation

Patients with complaints of dysphagia seek medical help. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of these complaints caused by various diseases, to provide medical care in the FCP (SP), or referral to specialized hospitals. These circumstances are the basis for the inclusion of this subject in the training of GPs.

3. Interdisciplinary communication and Intra

The teaching of this subject is based on the knowledge of students osnovAnatomiya, histology and cytology with embryology, biology, normal physiology, biochemistry,. Pathological Anatomy, Pathological Physiology, Topographic anatomy and operative surgery, internal medicine Propedeutics, Tuberculosis. Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy, Hospital Therapy, Orthopedics.

4.Teoreticheskaya part

When parsing the theme focuses on the following points.

The main symptom of functional and organic diseases of the esophagus is dysphagia, which develops as a result of violations of one of the three phases of swallowing - oral, which is a free act, pharyngeal, depending on the swallowing reflex involving the muscles of the pharynx, larynx, esophageal (low), ie related to cross the esophagus in its middle and lower thirds.

By their nature, dysphagia can have a functional and organic origin. The functional dysphagia include: psychogenic, hysterical, dysphagia with stem stroke, in botulism and cardiospasm. The basis of the functional forms of swallowing disorders is dyskinesia of the esophagus.

Dyskinesia of the esophagus - the functional disorder, manifested a violation of its motility. There are primary esophageal spasm, which is a consequence of the regulation of cortical disorders of the esophagus, and esophageal spasm secondary - emerging diseases such as esophagitis, peptic ulcer, etc. or in cases involving the general convulsions. Clinical evidence of dysphagia and esophageal spasm are chest pain, in some cases resembling coronary. Dysphagia is intermittent, sometimes a paradoxical form: occurs when fluid intake and not if swallowed thick and pasty food. The diagnosis is confirmed by X-ray examination of the esophagus, detecting various strains spastic esophagus if swallowed barium suspension: in the form of a corkscrew, rosaries, false diverticula, etc. Treatment involves administering a sedative, antispasmodic and anticholinergic agents. When vtorichnomezofagospazme untreated underlying disease. Psychogenic, hysterical dysphagia observed in the neuroses, is more common in women aged 20-40 years. Dysphagia may be a manifestation of anxiety neurosis (anxiety syndrome). The objective manifestations of the disease, along with dysphagia include increased tone of skeletal muscles, psychogenic headache, tremor, muscle twitching, tremors, anxiety, fatigue.

Dysphagia can be observed in stem stroke, which, along with paresis of limbs, often observed swallowing disturbances, cerebellar symptoms (severe dizziness), nystagmus, hypotonia or atonia, chanted or dizartrichnaya speech. All of these symptoms are manifestations of the syndrome of the lateral medulla oblongata at the stem stroke.

In botulism, dysphagia occurs in connection with the use of poor-quality canned products. Therefore, constant vigilance of the physician in infectious hue appears on the background of choking, the presence of paresis and other symptoms of the disease, in which the prognosis depends on prompt diagnosis.

When cardiospasm (synonyms: ahalaziyakardii, hiatospazm, megaezofagus, idiopathic enlargement of the esophagus) of swallow is the leading symptom of the clinical course of the disease. The disease equally affects both men and women, most often occurs between the ages of 20 and 40. The main symptoms are dysphagia, regurgitation, and chest pain. Dysphagia first episodic, in severe cases, it is observed at every meal and is especially apparent if swallowed dry or poorly chewed food. Chest pain is manifested in the form of painful crises, occurring more frequently at night. Achalasia of the esophagus when there is a lot of spit up stuck in the esophagus of the masses (saliva, mucus, food residues) that occurs when the torso, the overflow of the esophagus. Regurgitatsiyavozmozhna night (a sign of "wet air"). Complications of the disease include: recurrent pneumonia and chronic bronchitis, due to aspiration regurgitate the masses, as well as chronic esophagitis, esophageal diverticula. The diagnosis is confirmed by radiographic and endoscopic studies of the esophagus.

We must dwell on hiatal hernia, not infrequently accompanied by esophagitis. Distinguish the gastroesophageal axial hernia (sliding) and paraezofagalnogo type. By their appearance can cause Barrett's esophagus - a congenital or acquired pathology with shortening of the esophagus. The diagnosis is confirmed by radiographic studies of the esophagus, in both the vertical and horizontal position of the patient. Generally, a conservative symptomatic treatment of reflux esophagitis. In the absence of an effect or accession complications surgical treatment of hiatal hernia.

Oesophagitis - inflammation of the esophagus. Esophagitis distinguish acute, subacute and chronic. Acute esophagitis occur due to irritation of the mucous membrane of the esophagus hot food and liquid chemicals can be observed in acute infectious diseases (scarlet fever, diphtheria, sepsis, etc.). The most frequent cause of subacute and chronic reflux esophagitis is an active gastric and intestinal juices into the esophagus due to cardiac failure esophageal sphincter - the so-called reflux esophagitis, which is usually observed in the axial hiatal hernia. For reflux esophagitis are the main symptom of heartburn and regurgitation, worse torso in a horizontal position. The most reliable method of diagnosis is esophagoscopy, which allows you to identify esophagitis and to determine its extent and character.

Tumors of the esophagus. Benign tumors of the esophagus are rare. Of the malignant tumors of the esophagus is most common cancer, which affects mostly men (women get 3 times less) over the age of 40 years. The main symptom is dysphagia is most often the first manifestation of the disease. Sometimes the appearance of dysphagia preceded by chest pain when swallowing (especially solid food), pain during the passage of food to the level of destruction, "scratching" in the chest, feeling of a foreign body in the esophagus. Intermittent nature of dysphagia does not exclude the diagnosis of cancer. With further growth of tumors appear dull pain in the chest, back, chest pain, simulating angina, cough, hoarseness, shortness of breath, and general symptoms of cancer illness - fatigue, malaise, loss of appetite, etc. Diagnosis is based on these clinical symptoms, X-ray data and esophagoscopy with biopsy. In cancer of the esophagus is recommended surgical and combined treatment. When unresectable tumors receiving radiation therapy and palliative.

The defeat of the esophagus in systemic sclerosis is accompanied by a number of patients against the passage of food through the esophagus and pain, the need to wash down the dry food with water. When X-ray observed dysmotility of the distal esophagus and cardia insufficiency, regurgitation of food into the esophagus, particularly in the patient lying down, reflux esophagitis. Especially dangerous is the development of chronic esophagitis, which can lead to a narrowing of the lower esophagus and severe dysphagia, esophageal radiographic changes are also observed in those patients who are not clinically observed no clinical signs of lesions of the esophagus.

Half of the patients with dermatomyositis digestive organs are involved in the pathological process. Violation of swallowing in patients with dermatomyositis associated with hypotension upper third of the esophagus. This is associated with damage to the muscles of the esophagus. In the following may develop mucosal lesions of the mouth and esophagus to produce necrosis, edema and hemorrhages. Structures and stenosis of the esophagus, are also accompanied by a symptom of dysphagia. Dysphagia symptom severity depends on the degree of stenosis of uncertain discomfort behind the breastbone to the complete inability to take food and water. In patients with high stenosis of the esophagus when you try to eat, the water and the food hits the esophagus and into the airway, causing laryngospasm, agonizing bouts of coughing and breathlessness. When long-existing narrowing of the distal esophagus often develops his suprastenoticheskoe extension. The diagnosis of esophageal stenosis confirmed by X-rays and esophagoscopy. The main method of treatment of benign esophageal stenosis is its probing. In cases where the lack of success of bougienage resorting to surgery. In cases of severe malnutrition and contraindications for surgical intervention is recommended overlaying gastrostomy.

The causes of dysphagia can be diverticulum of the esophagus. With larger diverticulum it can accumulate a significant amount of food, whereby the pouch compresses the esophagus and makes it difficult to pass through it first solid food, and then the liquid. Some time after the meal can be spontaneous regurgitation of undigested food and mucous fluid from the sac diverticulum. Diagnosis of esophageal diverticula is possible only if the contrast X-ray examination and esophagoscopy. The exception is faringoezofagalnye (neck) diverticula, which sometimes can be detected during the inspection and palpation of the neck. In the absence of indications for surgery treatment should be aimed at preventing delays in the diverticula of food masses.

Dysphagia sideropenic-observed with a deficiency of iron in the body, usually associated with gastric Akhil and iron deficiency anemia. Manifested dysphagia, over time becoming permanent and is accompanied by unpleasant sensations in the course of the esophagus. At survey trophic changes in the skin, hair, nails, pale skin and mucous membranes, atrophic glossitis, sore throat and other symptoms of anemia. Determined by endoscopy esophagitis, and atrophic gastritis. In a number of cases in the initial segment of the esophagus revealed thin connective tissue membrane. When X-ray changes are usually not detected. Treatment: prescribers iron, in addition - B vitamins

Dysphagia may occur with compression of the esophagus or displacement due to hyperplasia of the thyroid gland, tumors or mediastinal abscesses, pericarditis, aortic aneurysm, and pleural effusion. Violation of swallowing can be observed in the presence of foreign bodies in the esophagus.

Checking the initial level of preparedness of students using the 'pen in the middle of the table. "

The purpose of the method: simultaneous involvement in the process of discussing topics of all students with an objective assessment of their knowledge.

Action: The proposed mission to the whole group, each student writes down on a piece of your answer and sends it to a neighbor, and my pen moves to the middle of the table so as not to further supplement its response heard informatsiey.preimuschestvom method is. That is controlled by employment in the educational process of all members of the group with simultaneous evaluation of knowledge. The disadvantage of the method is that the student can see the corresponding previous answers.

Example: List the causes of dysphagia.

Each student must write one of the following responses:

Functional and organic, psychogenic, hysterical, after stem stroke in botulism, cardiospasm, hiatal hernia, Barrett's esophagus, tumors of the esophagus, esophagitis, esophageal stricture, esophageal diverticulum.

The teacher monitors the work of the group and the involvement of everyone, read and summarize the results of the answers. Students record the final answer in their workbooks

The evaluation criteria

The maximum score 20-19	18-17 point	16-15 point	14-13 point	12 point
perfect	good	satisfactorily	unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less