Dysphagia

Description:

Dysphagia is the medical term for the symptom of difficulty in swallowing. or it takes more time and effort to move food or liquid from your mouth to your stomach. Dysphagia may also be associated with pain. In some cases, swallowing may be impossible . It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A psychogenic dysphagia is known as phagophobia.

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Occasional difficulty swallowing, which may occur when you eat too fast or don’t chew your food well enough, usually isn’t cause for concern. But persistent dysphagia may indicate a serious medical condition requiring treatment. Dysphagia can occur at any age, but it’s more common in older adults. The causes of swallowing problems vary, and treatment depends on the cause.

Sign & Symptoms:
Signs and symptoms associated with dysphagia may include:
* Having pain while swallowing (odynophagia)
* Being unable to swallow
* Having the sensation of food getting stuck in the throat or chest or behind breastbone (sternum)
* Drooling
* Being hoarse
* Bringing food back up (regurgitation)
* Having frequent heartburn
* Having food or stomach acid back up into the throat
* Unexpectedly losing weight
* Coughing or gagging when swallowing
* Having to cut food into smaller pieces or avoiding certain foods because of trouble swallowing

Causes:
Swallowing is complex, and a number of conditions can interfere with this process. Sometimes the cause of dysphagia can’t be identified. However, the causes of dysphagia generally falls into one of the following categories.
1.Esophageal dysphagia
Esophageal dysphagia refers to the sensation of food sticking or getting hung up in the base of our throat or in our chest after we started to swallow. Some of the causes of esophageal dysphagia include:
* Achalasia. When our lower esophageal muscle (sphincter) doesn’t relax properly to let food enter our stomach, it may cause us to bring food back up into our throat. Muscles in the wall of our esophagus may be weak as well, a condition that tends to worsen over time.
* Diffuse spasm. This condition produces multiple high-pressure, poorly coordinated contractions of our esophagus, usually after we swallow. Diffuse spasm affects the involuntary muscles in the walls of our lower esophagus.
* Esophageal stricture. A narrowed esophagus (stricture) can trap large pieces of food. Tumors or scar tissue, often caused by gastroesophageal reflux disease (GERD), can cause narrowing.
* Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.
* Foreign bodies. Sometimes food or another object can partially block our throat or esophagus. Older adults with dentures and people who have difficulty chewing their food may be more likely to have a piece of food become lodged in the throat or esophagus.
* Esophageal ring. A thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods.
* GERD. Damage to esophageal tissues from stomach acid backing up into our esophagus can lead to spasm or scarring and narrowing of our lower esophagus.
* Eosinophilic esophagitis. This condition, which may be related to a food allergy, is caused by an overpopulation of cells called eosinophils in the esophagus.
* Scleroderma. Development of scar-like tissue, causing stiffening and hardening of tissues, can weaken our lower esophageal sphincter, allowing acid to back up into our esophagus and cause frequent heartburn.
* Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus.

2. Oropharyngeal dysphagia
* Certain conditions can weaken our throat muscles, making it difficult to move food from our mouth into our throat and esophagus when  we  start to swallow.  we may choke, gag or cough when  we  try to swallow or have the sensation of food or fluids going down  our windpipe (trachea) or up  our nose. This may lead to pneumonia.

Causes of oropharyngeal dysphagia include:
*Neurological disorders. Certain disorders — such as multiple sclerosis, muscular dystrophy and Parkinson’s disease — can cause dysphagia.
* Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can affect  our ability to swallow.
* Pharyngoesophageal diverticulum (Zenker’s diverticulum). A small pouch that forms and collects food particles in our throat, often just above  our esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.
* Cancer. Certain cancers and some cancer treatments, such as radiation, can cause difficulty swallowing.

Risk Factors &  complications

* The following are risk factors for dysphagia

* Aging. Due to natural aging and normal wear and tear on the esophagus and a greater risk of certain conditions, such as stroke or Parkinson’s disease, older adults are at higher risk of swallowing difficulties. But, dysphagia isn’t considered a normal sign of aging.

* Certain health conditions. People with certain neurological or nervous system disorders are more likely to experience difficulty swallowing.

The Complecations can be as follows:

• Malnutrition, weight loss and dehydration. Dysphagia can make it difficult to take in adequate nourishment and fluids.
• Aspiration pneumonia. Food or liquid entering your airway when you try to swallow can cause aspiration pneumonia, because the food can introduce bacteria to the lungs.
• Choking. When food becomes impacted, choking can occur. If food completely blocks the airway, and no one intervenes with a successful Heimlich maneuver, death can occur.

Diagnosis:

The gold-standard of diagnosing dysphagia is to perform an instrumental evaluation, as the area of interest is not visible to the eye, and the person may not accurately sense the dysphagia or localize where the problem is.

One of the gold-standards for diagnosing oropharyngeal dysphagia is the modified barium swallow study (MBSS), also known as the videofluoroscopic swallow study (VFSS/fluoroscopy). This is a lateral and anterior-posterior (AP) view of a motion x-ray that provides objective information on the structure and physiology of the swallow. The oral, pharyngeal and esophageal phases of the swallow are analyzed. Oral phase components that are evaluated are: lip closure, bolus control, initiation of lingual movement, mastication, bolus transport, and oral residue after the swallow. Pharyngeal phase issues that are examined are: velopharyngeal closure, initiation of the pharyngeal swallow, laryngeal elevation, anterior hyoid movement, epiglottic inversion, laryngeal vestibule closure and reaction times, tongue base retraction, pharyngeal constriction or stripping wave, and pharyngeal residue after the swallow. The esophagus is analyzed for clearance versus retention of food, liquids and a barium pill. Any retention is monitored to see if it returns to the upper esophagus or back to the pharynx and airway. The clinician tests a variety of foods, liquids, and potentially a barium tablet. It is important to test a variety of viscosities and volumes. Typically the test involves a thin/regular liquid, a mildly thick/nectar thick liquid, a moderately thick/honey thick liquid, a pudding/puree, a cracker or cookie, a mixed consistency, and a barium pill taken with liquid or with a puree (depending on the person’s baseline method). The clinician determines if the swallow is safe (lack of aspiration) and efficient (lack of residue). The goal is to figure out why the person is having difficulty swallowing and to figure out what can be done to improve safety and efficiency. Sometimes regular liquids can easily cause aspiration, and the clinician can test various maneuvers, postures, and safe swallow strategies to prevent aspiration depending on that person’s specific anatomy and physiology. One method to potential improve the safety of the liquid bolus is to alter the consistency of bolus (i.e., thickening the liquid to mildly thick/nectar thick liquid, moderately thick/honey thick liquid, or extremely thick/pudding thick liquid). If there is a lot of residue after the swallow, there are also techniques that will be tested to reduce this. See treatment section below for more on compensatory strategies versus rehabilitation techniques for the swallow.

Another gold-standard for diagnosing dysphagia is the Fiberoptic Endoscopic Evaluation of Swallowing (FEES). This involves similar testing of foods and liquids, along with implementation of strategies to find out why the dysphagia is occurring and what can be done about it. The duration of the examination is not limited by radiation exposure; therefore, the person could be watched in a more natural environment over the course of a meal. The endoscope is very thin and usually well tolerated even without numbing the nose.

A barium swallow study/esophagram/upper GI study can best evaluate the entire esophagus. The barium is given in large volumes to fully distend and evaluate the esophageal lumen. This study can also evaluate for reflux, unlike the VFSS. A Zenker’s diverticulum can be seen on the VFSS and on an esophagram. The, barium may fills the pouch and then overflow, with food/liquid returning to the pharynx with risk for aspiration after the swallow. Achalasia is best evaluated on the barium swallow/esophagram, and it shows “bird-beak” tapering of distal esophagus, this is also described as a “rat’s tail” appearance. In esophageal strictures, liquid barium may remain above the stricture and then gradually trickles down. Strictures can sometimes be seen on a VFSS if the clinician suspects stricture or esophageal dysmotility. The clinician can scan down the esophagus after giving solid foods like cookie or bread. It is helpful to scan the esophagus on the VFSS as this is the exam that can test a full array of solids. The barium swallow/esophagram typically only tests barium liquids and a barium tablet.

* Esophagoscopy and laryngoscopy can give direct view of lumens.

* Chest radiograph may show air-fluid level in mediastinum. Pott’s disease and calcified aneurysms of aorta can be easily diagnosed.

* Esophageal motility study is useful in cases of achalasia and diffuse esophageal spasms.

* Exfoliative cytology can be performed on esophageal lavage obtained by esophagoscopy. It can detect malignant cells in early stage.

* Ultrasonography and CT scan are not very useful in finding cause of dysphagia; but can detect masses in mediastinum and aortic aneurysms.

* FEES (Fibreoptic endoscopic evaluation of swallowing), sometimes with sensory evaluation, is done usually by a Medical Speech Pathologist or Deglutologist. This procedure involves the patient eating different consistencies as above.

* Swallowing sounds and vibrations could be potentially used for dysphagia screening, but these approaches are in the early research stages.

Differential diagnosis:

All causes of dysphagia are considered as differential diagnoses. Some common ones are:

• * Esophageal atresia
• * Paterson-Kelly syndrome
• * Zenker’s diverticulum
• * Esophageal varices
• * Benign strictures
• * Achalasia
• * Esophagial diverticula
• *Scleroderma
• * Diffuse esophageal spasm
• * Polymyositis
• * Webs and rings
• * Esophageal cancer
• * Eosinophilic esophagitis
• * Hiatus hernia, especially paraesophageal type
• * Dysphagia lusoria
• *Gastroesophageal reflux
• *Parkinson’s disease
• *Multiple Sclerosis

Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from thickened fluids if the person is more comfortable with those liquids, although, so far, there are no scientific study that proves that those thickened liquids are beneficial.

Dysphagia may manifest as the result of autonomic nervous system pathologies including stroke^.  and ALS,   or due to rapid iatrogenic correction of an electrolyte imbalance.

Treatments:

There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders (swallowing therapist), primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist.  The role of the members of the multidisciplinary team will differ depending on the type of swallowing disorder present. For example, the swallowing therapist will be directly involved in the treatment of a patient with oropharyngeal dysphagia, while a gastroenterologist will be directly involved in the treatment of an esophageal disorder.

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CLICK TO SEE : Natural Remedies for Achalasia and Dysphagia

Prevention:

Although swallowing difficulties can’t be prevented, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:

https://www.mayoclinic.org/diseases-conditions/dysphagia/symptoms-causes/syc-20372028

https://en.wikipedia.org/wiki/Dysphagia