Dysphagia Disease

BASICS

DESCRIPTION

The sensation of difficulty swallowing. This is a disorder of esophageal transport and is a symptom of an underlying process. The problem is commonly divided into oropharyngeal and esophageal types.

System(s) affected: Gastrointestinal, Nervous
Genetics: N/A
Incidence/Prevalence in USA: 7% incidence lifetime; increasing prevalence with age
Predominant age: All ages
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Oropharyngeal type
- Choking with swallowing
- Coughing with swallowing
- Weak voice
- Aspiration pneumonia
- Weight loss
Esophageal type
- Pressure sensation in mid-chest (patient may localize pathology to correct anatomic site)
- Symptoms should distinguish whether dysphagia is for solids or liquids or both
- Aspiration pneumonia
- Weight loss
- Symptoms of GERD
- Longer time required to eat meals (patient unconsciously chews food more thoroughly)

CAUSES

In children
- Malformations - congenital (esophageal atresia, choanal atresia)
- Malformations - acquired (corrosive or herpetic esophagitis)
- Neuromuscular/neurologic - delayed maturation, cerebral palsy, muscular dystrophy
- Gastroesophageal reflux disease
In adults
- Structural - tumors (cancer or benign), strictures (peptic, chemical, trauma, radiation), rings & webs, extrinsic compression (goiter)
- Gastroesophageal reflux disease
- Neuromuscular - achalasia, diffuse esophageal spasm, scleroderma, myasthenia gravis

RISK FACTORS

Children - hereditary and/or congenital malformations
Adults - age > 50 years, when cancer of the esophagus is more likely
Smoking
Long history of gastroesophageal reflux disease
Medications (quinine, potassium chloride, vitamin C, tetracycline, nonsteroidal anti-inflammatory drugs, and others)

DIAGNOSIS

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Squamous cell or adenocarcinoma
Barrett's metaplasia
Fibrous tissue of a ring, web or stricture
Acute or chronic inflammatory change
Heterotopic gastric mucosa (inlet patch)

SPECIAL TESTS

In infants/children
- Observe sucking/eating
- Attempt to pass nasogastric tube to assess esophageal patency
- X-ray neck and chest
- Contrast x-ray
- Endoscopy
In adults
- X-ray of neck and chest
- Endoscopy
- Barium cine/video esophagogram
- Ambulatory, 24 hour pH testing

IMAGING

X-ray: chest, neck, abdomen
Contrast x-ray: esophagram, cine-esophagram, modified cine-esophagram (cookie swallow)
CT scan of chest

DIAGNOSTIC PROCEDURES

Endoscopy with biopsy
Esophageal manometry (altered by anticholinergics [propantheline], calcium channel blockers [nifedipine], nitrates [nitroglycerin], prokinetic [metoclopramide], sedatives [diazepam])
Esophageal pH monitoring (altered by anticholinergics [propantheline], H2 receptor antagonists [cimetidine], proton pump inhibitors [omeprazole], prokinetic [metoclopramide])

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient for those conditions where the patient is able to maintain nutrition and where there is little risk of complication
Hospitalization may be required for either infants or adults where dysphagia is associated with total or near total obstruction of the esophageal lumen
Endoscopy and/or esophageal dilatation may be needed for stenoses
Surgery may be needed in either benign or malignant processes

GENERAL MEASURES

Determine esophageal patency to exclude inflammation
Ensure airway and pulmonary function
Exclude cardiac disease
Assess nutritional status

SURGICAL MEASURES

Esophageal dilatation (pneumatic or bougie)
Esophageal stent; laser for late cancer

ACTIVITY

No restriction

DIET

Varies from nothing by mouth to near normal, depending on the degree of obstruction.

PATIENT EDUCATION

Counsel on avoiding irritating drugs
Counsel on chewing, consistency of food
In infants/children - discuss underlying problem and therapy for recurrent aspiration
In adults - discuss etiology and therapy (need for repeat dilatations). Speech therapy may be helpful in teaching swallowing techniques.

FOLLOW UP

PREVENTION/AVOIDANCE

Very hot or very cold foods may worsen.
Observe feeding of infants closely for aspirations - have suction available
Advise for correction of poorly fitting dentures in adults or elderly
Avoid drinking alcohol with meals

POSSIBLE COMPLICATIONS

Aspiration
Esophageal "asthma"
Pneumonia
Barrett's esophagus
Death

EXPECTED COURSE AND PROGNOSIS

Course and prognosis varies with the specific diagnosis (cancer - poor; esophageal peptic stricture - good)

MISCELLANEOUS

ASSOCIATED CONDITIONS

Esophageal carcinoma
Gastroesophageal reflux disease
Dysphagia lusoria
Achalasia
Symptomatic diffuse esophageal spasm
Scleroderma
Myasthenia gravis
CVA

AGE-RELATED FACTORS

Pediatric: Congenital malformations
Geriatric:

Poor dentition and/or dentures
Drug induced

Others: N/A

PREGNANCY

N/A

OTHER NOTES

This is a symptom of an abnormal process. A search for the etiology is of great importance.

ABBREVIATIONS

GERD = gastroesophageal reflux disease

Clinical Investigations

ROLE OF HOMOEOPATHY

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