Dysphagia

Definition

Generally defined as difficulty in swallowing (or the sensation of difficulty in swallowing), dysphagia reflects an esophageal or pharyngeal transport disorder, either from anatomical malformations or from a disruption of the physiological events in swallowing. Dysphagia can be subdivided into the following two distinct types, which can occur independently.

Oropharyngeal dysphagia: Difficulty initiating the act of swallowing, of moving food from the mouth to the upper esophagus (generally from abnormalities of the pharynx and upper esophageal sphincter)

Esophageal dysphagia: Difficulty moving food through the esophagus

The lifetime incidence of dysphagia is less than 10%. Although all ages are affected, the prevalence increases with age. No sex differentiation.

Etiology

The causes of oropharyngeal dysphagia (dysphagia for solids or liquids) include the following.

CNS: cerebrovascular accident (CVA), Parkinson’s disease, brainstem tumors

Muscle: myasthenia, polymyositis, thyroid disease, systemic lupus erythematosus

Structural: web, Zenker’s diverticulum, extrinsic compression

The causes of esophageal dysphagia include the following.

Dysphagia for solids only, intermittent: webs, rings, diverticulum, esophagitis

Solids only, continuous/progressive: carcinoma (particularly under age 40), stricture

Solids and liquids: motility disorder such as diffuse esophageal spasm, tumor, stricture, esophagitis

Dysphagia in children usually indicates the following.

Congenital malformations: esophageal atresia, choanal atresia

Acquired malformations: corrosive or herpetic esophagitis

Neuromuscular/neurologic conditions: cerebral palsy, muscular dystrophy

GERD

Dysphagia in adults usually indicates the following.

Structural: tumors (benign and malignant), strictures, rings and webs, extrinsic compression

Neuromuscular: achalasia, diffuse esophageal spasm, scleroderma, myasthenia gravis

Gastroesophageal reflux disease (GERD)

Risk Factors

Smoking

Recurrent or chronic GERD

Medications (such as quinine, potassium chloride, vitamin C, tetracycline, NSAIDs)

Poor dentition

Ill-functioning dentures

Excessive alcohol consumption

Achalasia

Esophageal cancer

Plummer-Vinson syndrome

Barrett’s mucosa

Hereditary or congenital malformations

Signs and Symptoms

Oropharyngeal dysphagia is characterized by the following.

Difficulty initiating swallowing

Inability to move food into the esophagus

Choking or aspiration while swallowing

Coughing while swallowing

Regurgitation of liquid through the nose

Aspiration with swallowing

Weak voice

Weight loss

Esophageal dysphagia is characterized by the following.

Pressure sensation in mid-chest

Sensation of food stuck in the esophagus

Retrosternal fullness after swallowing

Chest pain and other GERD symptoms

Extended period of time required for eating

Differential Diagnosis

Cardiac-associated chest pain

Globus hystericus

Scleroderma

Diagnosis

Because dysphagia is symptomatic of a structural or functional abnormality, determining the etiology is essential for effective treatment. Avoid dismissing the symptom as psychosomatic or “globus hystericus.” Consultation with a gastroenterologist is advised.

Physical Examination

Determine precisely where the patient’s symptoms are felt; whether symptoms appear with solids, liquids, or both; if the symptoms are intermittent or progressive. Also, question patients about length of time spent eating (i.e., unconsciously chewing food thoroughly). For infants/children, observe sucking and eating practices.

During evaluation, consider the following.

Esophageal patency, inflammation

Airway function

Pulmonary function

Cardiac disease

Nutritional status

Evidence of aspiration pneumonia

Symptoms of heartburn

Pathology/Pathophysiology

Mass lesion, including squamous cell carcinoma and adenocarcinoma

Barrett’s metaplasia

Fibrous tissue from a ring, web, or stricture

Heterotopic gastric mucosa

Acute or chronic inflammatory change

Deformities or scars

Imaging

For infants and children:

X ray of neck, chest

Contrast X ray

For adults:

X ray of neck, chest, abdomen

Barium swallow (cine/video esophagogram)

Contrast X ray: esophagogram, cine-esophagogram, modified cine-esophagogram

CT scan

Other Diagnostic Procedures

In addition to physical assessment and history, these special tests may be done:

Esophagoscopy: particularly relevant for patients with persistent difficulty swallowing solid food. Disruption of webs and rings during endoscopy can be therapeutic.

Esophageal manometry: preferred procedure for esophageal motor function evaluation (affected by anticholinergics, calcium-channel blockers, nitrates, prokinetics, sedatives)

Endoscopic ultrasonography: to diagnose and stage benign and malignant esophageal neoplasms

Infants and children: nasogastric tube assessment of esophagus patency

Treatment Strategy

Outpatient care is appropriate for patients capable of maintaining nutrition and with low risk of complications. Hospitalization may be necessary for infants and children, and for adults with total or near-total obstruction of the esophageal lumen.

Treatment can include drug therapies, esophageal dilatation, and surgery.

Drug Therapies

Check manufacturers’ profiles for possible drug interactions. Liquid forms of medications may be necessary.

For spasms:

Nitrates: nitroglycerin, isosorbide (contraindications: early myocardial infarction, severe anemia, increased intracranial pressure)

Anticholinergics: dicyclomine (Bentyl) or hyoscyamine sulfate (Lepsin) (contraindications: obstructive uropathy, glaucoma, myasthenia gravis, achalasia)

Calcium-channel blockers: nifedipine (Procardia), diltiazem (Cardizem)

Sedatives/antidepressants: diazepam (Valium), trazodone (Desyrel), doxepin (Sinequan)

Smooth-muscle relaxants: hydralazine

For esophagitis:

H2-blockers: cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), famotidine (Pepcid)

Proton-pump inhibitors (for failure of H2-blockers or as initial therapy): omeprazole (Prilosec), lansoprazole (Prevacid)

Prokinetic agents: metoclopramide (Reglan), cisapride (Propulsid); adjunct to acid-suppressive therapy

Complementary and Integrative Therapies

Herbs can be very effective at decreasing spasms and healing esophagitis. Homeopathics could be used concurrently for symptomatic relief.

Herbs

Herbs are generally a safe way to strengthen and tone the body’s systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Licorice (Glycyrrhiza glabra): an anti-inflammatory, antispasmodic, and analgesic specific for the gastrointestinal tract. Glycyrrhetinic acid has been shown in studies to aid healing of gastric, peptic, and mouth ulcers. In patients with hypertension, use deglycerinated licorice to prevent aggravating hypertension. Prolonged use may lead to pseudoaldosteronism, which resolves with discontinuation of the herb. The dose is 380 to 1,140 mg/day. Chewable lozenges may be the best form of licorice for treating GERD.

Slippery elm (Ulmus fulva): demulcent (protects irritated tissues and promotes their healing); dose is 60 to 320 mg/day. One tsp. powder may be mixed with water tid to qid.

Marshmallow (Althaea officinalis), as a tea, for demulcent and emollient effects. The dose is one cup of tea 3 times per day. To make tea, steep 2 – 5 g of dried leaf or 5 g dried root in one cup of boiling water. Strain and cool. Avoid marshmallow if you have diabetes.

In addition, a combination of four of the following herbs may be used as either a tea or tincture. Use equal parts of the herbs, either 1 tsp. of each per cup of water and steep 10 minutes tid, or equal parts of tincture 30 to 60 drops tid.

Valerian (Valeriana officinalis): bitter, sedative, especially where there is anxiety and/or depression and poor digestion

Wild yam (Dioscorea villosa): antispasmodic, anti-inflammatory, especially where there is fatigue from long-term stress or maldigestion

St. John’s wort (Hypericum perforatum): analgesic, antidepressant, historically used to treat adhesions, especially where there is anxiety and/or pain

Skullcap (Scutellaria lateriflora): antispasmodic, sedative, nervine, especially with disturbed sleep

Linden flowers (Tilia cordata): antispasmodic, mild diuretic, gentle bitter, especially with dyspepsia

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

Baptesia tinctoria for patients who can only swallow liquids and gag on the smallest amount of solids; especially with a red inflamed throat that is relatively pain free.

Baryta carbonica for huge tonsils that make it difficult to swallow even liquids; especially with shyness

Carbo vegatabilis for bloating and indigestion that is worse from lying down; especially with flatulence and fatigue

Ignatia imara for “lump in the throat,” back spasms, spasmodic cough; especially when symptoms appear after grieving

Lachesis for difficulty swallowing, intolerance to touch around the throat, and tight clothes

Acupuncture

Several clinical studies have reported that acupuncture can stimulate the swallowing reflex in people who have dysphagia due to stroke. However, other studies show no benefit. More research is needed to evaluate the therapeutic effect of acupuncture on dysphagia after stroke.

Patient Monitoring

Discuss etiology and prognosis with patients, including possible need for repeat dilatations. Dysphagia should not require limits on patients’ activities. Depending on the degree of obstruction, diet may have to be restricted.

Prevention

Counsel patients (and/or caregivers) to do the following:

Avoid exacerbating drugs

Chew thoroughly

Avoid extremely hot or cold foods

Do not drink alcohol in excess

Correct poorly fitting dentures

Observe infants/children carefully when eating

Complications/Sequelae

Aspiration

Esophageal “asthma”

Pneumonia

Barrett’s syndrome; esophageal cancer

Prognosis

Prognosis varies from good for relatively uncomplicated dysphagia (e.g., peptic strictures) to poor for dysphagia with cancer etiologies. Speech therapy may be appropriate for patients who need to learn swallowing techniques.

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