Article: Dysphagia

Dysphagia (/dɪsˈfe(ɪ)ʒjə/, not to be confused with dysphasia) is a medical term defined as "difficulty swallowing". It derives from the Greek root dys meaning difficulty or disordered, and phagia meaning "to eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach ^[1]. Dysphagia is distinguised from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. It is also worthwhile to refer to the physiology of swallowing in understanding dysphagia.

Epidemiology and diagnostic approach

Dysphagia is a common complaint, and the incidence of dysphagia is higher in the elderly ^[2], in patients who have had strokes ^[3], and in patients who are admitted to acute care hospitals or chronic care facilities. It is a symptom whose cause can usually be elicited by a careful history by the treating physician ^[4].

Dysphagia is classified into two major types: oropharyngeal dysphagia (or transfer dysphagia) and esophageal dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having functional dysphagia.

Oropharyngeal dysphagia

Arises from abnormalities of the upper esophagus and the pharynx.

Symptoms, Signs, and Evaluation

Patients usually experience food getting stuck immediately after swallowing, nasal regurgitation, or even difficulty initating a swallow, and will point to the cervical (neck) region as the site of the obstruction.

Differential diagnosis (causes)

Neurologic disorders such as stroke, Parkinson's disease, amyotrophic lateral sclerosis, Bell's palsy, or myasthenia gravis can cause weakness of facial and lip muscles that are involved in coordinated mastication.

• Oculopharyngeal muscular dystrophy is a genetic disease with palpebral ptosis, orophryngeal dysphagia, and proximal limb weakness.

Decrease in salivary flow can be due to Sjogren's syndrome, anticholinergics, antihistamines, or certain antihypertensives and can lead to incomplete processing of food bolus.

Poor dentition can lead to inadequate mastication.

Abnormality in oral mucosa such as from mucositis, aphthous ulcers, or herpetic lesions can interfere with bolus processing.

Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, or cervical osteophytes.

Increased upper esophageal sphincter tone can be due to Parkinson's disease which leads to incomplete opening of the UES. This may lead to formation of a Zenker's diverticulum.

Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents.

Infection may cause pharyngitis which can prevent swallowing due to pain.

Esophageal dysphagia

Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems.

Symptoms, Signs, and Evaluation

Patients usually experince food getting stuck several seconds after swallowing, and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once motility vs mechanical causes have been distinguished, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia most likely can be diffuse esophageal spasm (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia include scleroderma or achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss. An intermittent mechanical dysphagia is likely to be an esophageal ring. Progressive mechanical dysphagia is most likely due to peptic stricture or esophageal cancer.

Differential diagnosis (causes)

Peptic stricture, or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to gastroesophageal reflux (GERD). These patients are usually older and has had GERD for a long time. Acid reflux can also be due to other causes, such as Zollinger-Ellison syndrome, NG tube placement, and scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present.

Main article: peptic stricture

Esophageal cancer also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or adenocarcinoma. Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed Barrett's esophagus (intestinal metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use.

Main article: esophageal cancer

Esophageal rings and webs, are actual rings and webs of tissue that may occlude the esophageal lumen.

• Rings --- Also known as Schatzki rings from the discoverer, these rings are usually mucosal rings rather than muscular rings, and are located near the gastroesophageal junction at the squamo-columnar junction. Presence of multiple rings may suggest eosinophilic esophagitis. Rings are intermittent mechanical dysphagia, meaning patients will usually present with transient discomfort and regurgitation while swallowing solids and then liquids, depending on the constriction of the ring.

• Webs --- Usually squamous mucosal protrusion into the esophageal lumen, especially anterior cervical esophagus behind the cricoid area. Patients are usually asymptomatic or have intermittent dysphagia. An important association of esophageal webs is to the Plummer-Vinson syndrome in iron deficiency, in which case patients will also have anemia, koilonychia, fatigue, and other symptoms of anemia.

Main article: esophageal web

Achalasia is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of peristalsis in the distal esophagus (which is mostly smooth muscle). Both of these features impairs the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids is most characteristic of achalasia. Other symptoms of achalasia include weight loss, regurgitation, chest pain, hiccups, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. Achalasia can also be due to Chaga's disease from infection by Trypanosoma cruzi.

Main article: achalasia

Scleroderma is a disease characterized by atrophy and sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux.

Main article: scleroderma

Spastic motility disorders include diffuse esophageal spasm (DES), nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific spastic esophageal motility disorders (NEMD).

• DES can be caused by many factors that affect muscular or neural functions, including acid reflux, stress, hot or cold food, or carbonated drinks. Patients present with intermittent dysphagia, chest pain, or heartburn.

Rare causes of esophageal dysphagia not mentioned above

• Diverticulum
• Aberrant subclavian artery, or (dysphagia lusoria)
• Cervical osteophytes
• Enlarged aorta
• Enlarged left atrium
• Anterior mediastinal mass

Diagnostic tools

Once esophageal dysphagia has been implicated in a patient, next step is to determine whether to directly proceed to a barium swallow or an upper endoscopy. Any suspicion for a proximal lesion such as:

• history of surgery for laryngeal or esophageal cancer
• history of radiation or irritating injury
• achalasia
• Zenker's diverticulum

should be proceeded to a barium swallow first instead of endoscopy to prevent any perforation. If achalasia suspected on barium swallow, proceed to manometry to confirm. If a stricture is suspected, proceed to endoscopy. Any other lesions found should be treated as such.

If there's no suspicion for any of the above lesions, endoscopy can be proceeded directly. Any structural or mucosal abnormality should be treated. A normal endoscopy should be followed by manometry. If manometry is normal, patients are diagnosed with functional dysphagia.

Treatment

Treatment is directed at the underlying causes. (see above)

Vitalstim Therapy ([1]) is targeted for oropharyngeal dysphagia and uses electrical stimulation to retrain the muscles used in swallowing.

GI, pulmonary, ENT, or oncology consult is usually sent depending on suspicion of underlying cause. A consultation is usually sent for a dietician because many patients cannot have a proper diet due to inability to ingest solids or liquids. Speech therapist may be needed for those with oropharyngeal dysphagia.

Diets of people with swallowing problems would include soft foods but liquids must be thickened in order to ease retrieval in case of choking.

See also

• stroke
• Neurodegenerative diseases
  • Parkinson's disease
  • Alzheimer's disease
• Gastroesophageal reflux disease
• achalasia