Dysphagia

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Dysphagia
Specialty Gastroenterology

Dysphagia is difficulty in swallowing. [1] [2] Although classified under "symptoms and signs" in ICD-10, [3] in some contexts it is classified as a condition in its own right. [4] [5] [6] People with dysphagia are sometimes unaware of having it. [7] [8]

Swallowing, sometimes called deglutition in scientific contexts, is the process in the human or animal body that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is an important part of eating and drinking. If the process fails and the material goes through the trachea, then choking or pulmonary aspiration can occur. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex.

Symptom departure from normal function or feeling which is noticed by a patient, reflecting the presence of an unusual state, or of a disease; subjective, observed by the patient, cannot be measured directly

A symptom is a departure from normal function or feeling which is apparent to a patient, reflecting the presence of an unusual state, or of a disease. A symptom can be subjective or objective. Tiredness is a subjective symptom whereas cough or fever are objective symptoms. In contrast to a symptom, a sign is a clue to a disease elicited by an examiner or a doctor. For example, paresthesia is a symptom, whereas erythema is a sign. Symptoms and signs are often nonspecific, but often combinations of them are at least suggestive of certain diagnoses, helping to narrow down what may be wrong. In other cases they are specific even to the point of being pathognomonic.

A medical sign is an objective indication of some medical fact or characteristic that may be detected by a patient or anyone, especially a physician, before or during a physical examination of a patient. For example, whereas a tingling paresthesia is a symptom, erythema is a sign. Symptoms and signs are often nonspecific, but often combinations of them are at least suggestive of certain diagnoses, helping to narrow down what may be wrong. In other cases they are specific even to the point of being pathognomonic.

Contents

It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, [9] 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, [10] 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.

Mouth first portion of the alimentary canal that receives food

In animal anatomy, the mouth, also known as the oral cavity, buccal cavity, or in Latin cavum oris, is the opening through which many animals take in food and issue vocal sounds. It is also the cavity lying at the upper end of the alimentary canal, bounded on the outside by the lips and inside by the pharynx and containing in higher vertebrates the tongue and teeth. This cavity is also known as the buccal cavity, from the Latin bucca ("cheek").

Stomach digestive organ

The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital digestive organ. In the digestive system the stomach is involved in the second phase of digestion, following mastication (chewing).

Pharynx part of the throat that is behind the mouth and nasal cavity

The pharynx is the part of the throat behind the mouth and nasal cavity and above the esophagus and larynx, or the tubes going down to the stomach and the lungs. It is found in vertebrates and invertebrates, though its structure varies across species.

Signs and symptoms

Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease. [11] When dysphagia goes undiagnosed or untreated, patients are at a high risk of pulmonary aspiration and subsequent aspiration pneumonia secondary to food or liquids going the wrong way into the lungs. Some people present with "silent aspiration" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and renal failure.

Pulmonary aspiration

Pulmonary aspiration is the entry of material from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract. A person may either inhale the material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe."

Aspiration pneumonia bronchopneumonia that develops due to the entrance of foreign materials into the lungs usually oral or gastric contents

Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may include lung abscess. Some include chemical pneumonitis as a subtype, which occurs from acidic but non-infectious stomach contents entering the lungs.

Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty). [11] When asked where the food is getting stuck, patients will often point to the cervical (neck) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.

Pneumonia Infection of the lungs

Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Typically symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable.

Neck part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk

The neck is the part of the body, on many vertebrates, that separates the head from the torso. It contains blood vessels and nerves that supply structures in the head to the body. These in humans include part of the esophagus, the larynx, trachea, and thyroid gland, major blood vessels including the carotid arteries and jugular veins, and the top part of the spinal cord.

The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated. Pain on swallowing or odynophagia is a distinctive symptom that can be highly indicative of carcinoma, although it also has numerous other causes that are not related to cancer.

Odynophagia is pain when swallowing. The pain may be felt in the mouth or throat and can occur with or without difficulty swallowing. The pain may be described as an ache, burning sensation, or occasionally a stabbing pain that radiates to the back. Odynophagia often results in inadvertent weight loss. The term is from odyno- "pain" and phagō "to eat".

Carcinoma A category of types of cancer that develops from epithelial cells

Carcinoma is a category of types of cancer that develop from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesodermal or ectodermal germ layer during embryogenesis.

Achalasia is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the Auerbach's (Myenteric) plexus of the entire esophagus, which results in functional narrowing of the lower esophagus, and peristaltic failure throughout its length.

Myenteric plexus part of the enteric nervous system

The myenteric plexus provides motor innervation to both layers of the muscular layer of the gut, having both parasympathetic and sympathetic input, whereas the submucous plexus has only parasympathetic fibers and provides secretomotor innervation to the mucosa nearest the lumen of the gut.

Esophagus organ in vertebrates

The esophagus or oesophagus, commonly known as the food pipe or gullet (gut), is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 centimetres long in adults, which travels behind the trachea and heart, passes through the diaphragm and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word esophagus is the Greek word οἰσοφάγος oisophagos, meaning "gullet".

Complications

Complications of dysphagia may include aspiration, pneumonia, dehydration, and weight loss.

Classification

Dysphagia is classified into the following major types: [12]

  1. Oropharyngeal dysphagia
  2. Esophageal and obstructive dysphagia
  3. Neuromuscular symptom complexes
  4. Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.

Following table enumerates possible causes of dysphagia:

Difficulty with or inability to swallow may be caused or exacerbated by usage of opiate and/or opioid drugs. [13]

Diagnostic approach

In people admitted to hospital, a bedside "water swallow test" is often performed to determine whether there might be need for more detailed swallowing assessment. The test is more reliable when larger amounts of fluid are used. When assessing the swallowing, the test is abnormal if there is coughing or choking, or if the voice changes because of aspirated fluid resting on the vocal cords. [14] [15]

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.[ citation needed ]

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.[ citation needed ]

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. [ citation needed ]

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.[ citation needed ]

Differential diagnosis

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

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 [17] and ALS, [18] or due to rapid iatrogenic correction of an electrolyte imbalance. [19]

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. [11] 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.

Treatment strategies

The implementation of a treatment strategy should be based on a thorough evaluation by the multidisciplinary team. Treatment strategies will differ on a patient to patient basis and should be structured to meet the specific needs of each individual patient. Treatment strategies are chosen based on a number of different factors including diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation and interest. [11]

Oral vs. nonoral feeding

Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain, or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). [11] If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy. [11]

Treatment procedures

Compensatory Treatment Procedures - designed to change the flow of the food/liquids and eliminate symptoms, do not directly change the physiology of the swallow. [11]

  • Postural Techniques
  • Food Consistency (Diet) Changes
  • Modifying Volume and Speed of Food Presentation
  • Technique to Improve Oral Sensory Awareness
  • Intraoral Prosthetics

Therapeutic Treatment Procedures - designed to change and/or improve the physiology of the swallow. [11]

  • Oral and Pharyngeal Range-of-Motion Exercises
  • Resistance Exercises
  • Bolus Control Exercises
  • Swallowing Maneuvers
    • Supraglottic swallow
    • Super-supraglottic swallow
    • Effortful swallow
    • Mendelsohn maneuver

Patients may need a combination of treatment procedures to maintain a safe and nutritionally adequate swallow. For example, postural strategies may be combined with swallowing maneuvers to allow the patient to swallow in a safe and efficient manner.

The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are texture modification of foods, thickening fluids and positioning changes during swallowing. [20] The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. [21] Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures.  However, in 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0-7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. [22] It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with carers and will lead to greater standardisation of modified diets

Epidemiology

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. [11] Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, [23] [24] [25] in patients who have had strokes, [26] and in patients who are admitted to acute care hospitals or chronic care facilities. Dysphagia is a symptom of many different causes, which can usually be elicited through a careful history by the treating physician. A formal oropharyngeal dysphagia evaluation is performed by a medical speech pathologist or occupational therapist. [27]

Etymology

The word "dysphagia" is derived from the Greek dys meaning bad or disordered, and the root phag- meaning "eat".

See also

Related Research Articles

Esophageal achalasia esophageal disease characterized by an inability of the esophagus to move food toward the stomach resulting from the lower esophogeal sphincter not fully relaxing during swallowing

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease.

Heller myotomy is a surgical procedure in which the muscles of the cardia are cut, allowing food and liquids to pass to the stomach. It is used to treat achalasia, a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.

An esophageal motility disorder (EMD) is any medical disorder causing difficulty in swallowing, regurgitation of food and a spasm-type pain which can be brought on by an allergic reaction to certain foods. The most prominent one is dysphagia. It is a part of CREST syndrome, referring to the five main features: calcinosis, Raynaud syndrome, esophageal dysmotility, sclerodactyly and telangiectasia.

Esophageal motility study

An esophageal motility study (EMS) or esophageal manometry is a test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).

Esophagitis is a disease characterized by inflammation of the esophagus. The esophagus is a tube composed of a mucosal lining, and longitudinal and circular smooth muscle fibers. It connects the pharynx to the stomach; swallowed food and liquids normally pass through it.

A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the esophagus, just above the cricopharyngeal muscle. It is a pseudo diverticulum.

Plummer–Vinson syndrome (PVS), is a rare disease characterized by difficulty in swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome.

Esophageal web congenital disorder of digestive system

Esophageal webs are thin membranes occurring anywhere along the esophagus.

Megaesophagus abnormal dilation of the esophagus not due to obstruction

Megaesophagus, also known as esophageal dilatation, is a disorder of the esophagus in humans and other mammals, whereby the esophagus becomes abnormally enlarged. Megaesophagus may be caused by any disease which causes the muscles of the esophagus to fail to properly propel food and liquid from the mouth into the stomach. Food can become lodged in the flaccid esophagus, where it may decay, be regurgitated, or may be inhaled into the lungs.

Thickened fluids and thickened drinks are often used for people with dysphagia, a disorder of swallowing function. The thicker consistency makes it less likely that an individual will aspirate while they are drinking. Individuals with difficulty swallowing may find liquids cause coughing, spluttering or even aspiration and thickening drinks enables them to swallow safely. Patients may be advised to consume thickened liquids after being extubated. Liquid thickness may be measured by two methods, with a viscometer or by line spread test.

Oropharyngeal dysphagia arises from abnormalities of muscles, nerves or structures of the oral cavity, pharynx, and upper esophageal sphincter.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

Schatzki ring congenital disorder of digestive system

A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue or muscular tissue. A Schatzki ring is a specific type of "esophageal ring", and Schatzki rings are further subdivided into those above the esophagus/stomach junction, and those found at the squamocolumnar junction in the lower esophagus.

Nutcracker esophagus human disease

Nutcracker esophagus, or hypertensive peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age, but is more common in the sixth and seventh decades of life. The diagnosis is made by an esophageal motility study, which evaluates the pressure of the esophagus at various points along its length. The term "nutcracker esophagus" comes from the finding of increased pressures during peristalsis, with a diagnosis made when pressures exceed 180 mmHg; this has been likened to the pressure of a mechanical nutcracker. The disorder does not progress, and is not associated with any complications; as a result, treatment of nutcracker esophagus targets control of symptoms only.

Diffuse esophageal spasm

Diffuse esophageal spasm (DES) is a condition characterized by uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may cause symptoms such as chest pain, similar to heart disease. The cause of DES remains unknown.

Presbyphagia refers to characteristic changes in the swallowing mechanism of otherwise healthy older adults. Although age-related changes place older adults at risk swallowing disorders, an older adult’s swallow is not necessarily an impaired swallow. Clinicians are becoming more aware of the need to distinguish among swallowing disorders, presbyphagia and other related diagnoses in order to avoid over diagnosing and over treating presbyphagia. Older adults are more vulnerable and with the increased threat of acute illnesses, medications and any number of age-related conditions, they can cross the line from having a healthy older swallow to being dysphagic.

Aphagia is the inability or refusal to swallow. The word is derived from the Ancient Greek prefix α, meaning "not" or "without," and the suffix φαγία, derived from the verb φαγεῖν, meaning "to eat." It is related to dysphagia which is difficulty swallowing, and odynophagia, painful swallowing. Aphagia may be temporary or long term, depending on the affected organ. It is an extreme, life-threatening case of dysphagia. Depending on the cause, untreated dysphagia may develop into aphagia.

Esophageal intramural pseudodiverticulosis

Esophageal intramucosal pseudodiverticulosis is a rare condition wherein the wall of the esophagus develops numerous small outpouchings (pseudodiverticulae). Individuals with the condition typically develop difficulty swallowing. The outpouchings represent the ducts of submucosal glands of the esophagus. It typically affects individuals in their sixth and seventh decades of life. While it is associated with certain chronic conditions, particularly alcoholism, diabetes and gastroesophageal reflux disease, the cause of the condition is unknown. Treatment involves medications to treat concomitant conditions such as reflux and esophageal spasm, and dilation of strictures in the esophagus.

Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), or laryngopharyngeal sensory testing, is a technique used to directly examine motor and sensory functions of swallowing so that proper treatment can be given to patients with swallowing difficulties to decrease their risk of aspiration and choking. FEESST was invented by Dr. Jonathan E. Aviv MD, FACS in 1993, and has been used by otolaryngologists, pulmonologists, gastroenterologists, intensivists and speech-language pathologists for the past 20 years.

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Classification
D
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