Dysphagia

Swallowing disorders are a common symptom of many diseases and should not be underestimated. Dysphagia is term used for general difficulty in swallowing and if there is present pain, we speak about odynophagia.

Causes

Gastroesophageal reflux disease (GERD)

Complications of this condition include inflammation of esophageal mucosa that can cause both dysphagia and odynophagia. Diagnose is usually confirmed by gastroscopy. Chronic GERD may be accompanied with strictures (see below).

Esophageal narrowing

Narrowing of the esophagus may be causes by chronic irritation by acidic juice leaking into esophagus in GERD. Other important and serious cause of esophageal stricture is esophageal cancer. This is the reason why every narrowing should be cautiously examined by gastroscopy including biopsy. A special and less frequent disease related to esophageal narrowing is the so-called eosinophilic esofagitis. Esophagus may get obstructed also by a piece of food (usually beef meat) that gets stuck.

Achalasia

Achalasia is an interesting and still not fully understood disease. It is caused by gradual deterioration and necrosis on neural plexuses located in wall of the esophagus. Esophagus looses the ability to move digested bite into stomach and lower esophageal sphincter is unable to relax. First there comes impaired passage of solid food and later in advanced stages even of fluid.

Zenker's diverticulum

In some people (especially the elderly) the posterior wall of the pharynx may get weakened and intraluminal pressure gives birth to a bag-like pouch protruding from the digestive tube. This pouch can accumulate swallowed food. Affected people feel pressure in pharynx and upper esophagus after eating, suffer from dyphagia and sometimes they even throw up pouch content. Bad breath often accompanies this condition. Zenker's diverticulum can cause a fatal complication of gastroscopy. When the tube-like endoscopic device is inserted into the pouch, it may cause a sudden rupture and perforation of upper digestive tract with severe infectious consequences.

Oppression of esophagus from the outside

Esophageal compression by adjacent anatomical structures can cause dysphagia. This may include enlarged thyroid gland (goiter), bony outgrows of neck spinal column, benign and malignant tumors of the neck, extensive lung tumors, etc.

Neurologic disorders

Neurological diseases that disrupt innervations of pharyngeal muscles are often related to troubles with swallowing. It is present for example in stroke and multiple sclerosis.

Myasthenia gravis

Myasthenia gravis is a relatively rare autoimmune disease causing disruption of neuromuscular transmission. The basic symptoms include abnormally rapid fatigue, double vision, slurred speech and swallowing disorders.

Psychological causes

Some anxious people may feel a "foreign object in the throat" and suffer from various swallowing disorders without any objective finding.

Diagnostic approach

Medical history should start the diagnostic approach and physical examination shall follow. Information about relation of swallowing disorders with other symptoms is also important as well as information about other known diseases and current medication. Chest X-ray shows basic information about chest anatomy; neck ultrasound is advisable in suspicion on goiter. Upper part of pharynx may be examined by an otolaryngologist, esophagus endoscopically by a gastroenterologist. Esophagogastroduodenoscopy or “upper GI endoscopy” is an excellent method to visualize the esophagus from within and take biopsies from every suspicious lesion. Especially when there is suspicion on upper swallowing disorder, it is wise not to perform the upper GI endoscopy (because of risk of perforation), but rather the barium swallow. The patient swallows a contrast agent and we evaluate its passage through esophagus to confirm diverticuli (including Zenker's diverticulum) and narrowed parts. Neurological examination should be performed always when there is a risk of nervous system disease.

Treatment

Treatment should be targeted on therapy of the underlying cause of swallowing difficulties. If this is not possible we have to evaluate the patient's ability to intake food or fluids and in case of need resort to PEG. PEG means feeding by a tube inserted into stomach through abdominal wall.