Dysphagia

Definition

Dysphagia is a pathological condition in which the act of swallowing is disturbed. It is manifested by difficulty swallowing solid food, liquids, and saliva, their ingress into the respiratory organs, increased saliva production, pain behind the sternum, hoarseness of voice, and throat congestion. It is diagnosed by pharyngoscopy, esophageal radiography, esophagogastroscopy, pH-metry, and esophageal manometry. Treatment involves the appointment of pathogenetic therapy for the disease complicated by dysphagia. Surgical interventions are performed when the disorder occurs against severe organic changes in the pharynx, esophagus, and adjacent organs.

General information

Dysphagia is a secondary pathologic process that develops against the background of other diseases. Swallowing disorders are detected in all age groups, but the incidence increases with age. According to observations, the prevalence of pathology is 11% in the general population and reaches 13% in patients over 65 years of age.

At a young age, dysphagia more often complicates the course of trauma, malignant neoplasia of the head and neck. In elderly patients, the leading causes of impaired swallowing are disorders of cerebral circulation and neurodegenerative diseases. The relevance of timely diagnosis of dysphagia syndrome is due to a significant deterioration in the quality of life of patients and a high risk of mortality in case of complications.

Causes of dysphagia

Specialists in the field of modern gastroenterology separately consider the etiological factors that lead to the development of oropharyngeal (“high”) and esophageal (“lower”) swallowing disorders. However, some of them are detected in both types of pathology. The passage of the food clump through the pharynx and proximal esophagus is disturbed under the influence of such causes as:

• Mechanical obstruction. Violation of the oropharyngeal phase of swallowing can be caused by inflammatory processes (pharyngeal abscess, tonsillitis), hyperplasia of the thyroid gland, enlarged lymph nodes, hypopharyngeal diverticulum, cervical osteophytes, muscle fibrosis, finger-pharyngeal adhesions. Constriction of the upper digestive tract is also observed in malignant neoplasia of the oral cavity, pharynx, and larynx, the consequences of their surgical treatment and radiation therapy.
• Neuromuscular disorders. Oropharyngeal dysphagia develops in the acute phase of cerebral stroke in 42-67% of patients; its severity directly correlates with the severity of cerebral circulatory disorders. Half of patients with parkinsonism have clinical symptoms of impaired oropharyngeal swallowing, and latent signs of the disorder are detected instrumentally in another 45% of patients. 

Esophageal swallowing disorders are often caused by esophageal pathology, chronic diseases of the GI organs, and mediastinum. Normal passage of solid and liquid food through the esophagus to the stomach can be hindered:

• Narrowing of the esophagus. The lumen of the organ decreases with eosinophilic pharyngitis, malignant tumors of the esophagus, gastric cancer with cardiac lesions, and a complicated course of gastroesophageal reflux disease. Scar stenosis develops after radiotherapy of thoracic oncologic diseases, chemical burns with acidic compounds, potassium chloride, salicylates, and some other drugs. 
• External compression of the esophagus. Bulky masses exerting pressure on the esophageal wall obstruct the passage of food. Esophageal dysphagia is often found in tumors, enlargement of mediastinal lymph nodes, goiter, tuberculosis, and paraesophageal hernia. Swallowing difficulties are detected in cardiac pathology—mitral valve defects and vascular compression.
• Disorders of contractile activity of the esophagus. Esophageal swallowing disorders complicate achalasia, diffuse esophageal spasm, and corkscrew deformity of the organ. Pathologic changes in motility are noted in patients with systemic scleroderma, Chagas disease, and diabetes mellitus. 

Classification

The existing systematization of clinical forms of dysphagia takes into account both the anatomical level of swallowing disorders and the degree of their severity. This approach facilitates the identification of the root cause of disorders, allows the assessment of the prognosis, and develops the optimal tactics for patient management. Gastroenterologists distinguish the following types of the disease:

• According to the anatomical level, oropharyngeal and esophageal dysphagia are different. In the first case, the formation of a food clump, its movement towards the throat, and initial swallowing movements are disturbed. In the second case, the passage of food through the esophagus and its entry into the stomach is impeded.
• There are four degrees of dysphagia, according to severity. In degree I, the patient has difficulty swallowing solid foods; in degree II, only liquid food is swallowed. In patients with dysphagia of the III-degree, swallowing is disturbed not only by solid food but also by liquids and saliva. In the IV degree, it becomes impossible to swallow any food.

Symptoms of dysphagia

At the initial stage of the disease, patients usually complain of difficulty swallowing solid food, accompanied by discomfort in the pharynx and esophagus. There may also be painful sensations along the esophagus, increased salivation, and a feeling of distention behind the sternum. Characteristic symptoms of the disease are hoarseness of the voice, shortness of breath, dry cough, and throat congestion. Progression of dysphagia leads to disorders of swallowing liquid food and its ingestion into the respiratory organs of the patient. Sometimes, the disease is accompanied by heartburn. With a prolonged course, there is a deterioration in the patient’s general condition and a significant loss of body weight due to lack of food.

Diagnosis

Detection of swallowing disorders is usually relatively easy due to the typical clinical picture of the pathologic condition. However, the critical task of diagnostic search in dysphagia is the diagnosis of diseases that may have caused the disorder. Examination of the patient is carried out comprehensively and includes the following methods:

• Examination of the pharynx. Pharyngoscopy reveals the causes of oropharyngeal dysphagia: tonsillitis, glossitis, neoplasms, and foreign bodies. 
• Esophagography. Radiography of the esophagus with oral administration of a contrast agent reveals disorders of the involuntary phase of swallowing and changes in esophageal motility characteristic of dysphagia. 
• Esophagogastroscopy. During EGD, the mucosa of the esophagus and gastric cardia are well visualized, which helps to detect macroscopic changes in the epithelium that cause dysphagia. At the same time, tissue biopsy for histologic examination is performed.
• Determination of hydrogen index. Daily pH-metry is the most accurate study for diagnosing reflux esophagitis to confirm the organic nature of dysphagia. In addition, esophageal manometry may be performed to detect disorders of the lower gastroesophageal sphincter.

Treatment of dysphagia

The etiology and course of the disorder significantly influence the choice of medical tactics. The main therapeutic objectives are restoration of swallowing and prevention of possible complications, primarily aspiration in oropharyngeal dysphagia of neuromuscular genesis. Patients with acute forms of swallowing disorders, usually occurring with mechanical obstruction of the esophagus, are indicated for urgent care for foreign body removal.

Correction of long-standing disorders involves complex etiopathogenetic treatment of pathology complicated by dysphagia. The following drugs are usually used:

• Agents to improve neuroregulation. To restore swallowing, patients with parkinsonism are prescribed agonists and dopamine precursors, central H-choline blockers. Manifestations of dysphagia in myasthenia gravis are reduced by taking anticholinesterase agents. 
• Calcium channel blockers reduce the concentration of calcium ions in muscle fibers, eliminating spasticity (diffuse esophageal spasm, achalasia) and improving the passage of food. If necessary, dysphagia therapy is supplemented with nitrates that have a relaxant effect, anticholinergic agents, and phosphodiesterase inhibitors that affect neuromuscular regulation.
• Antisecretory drugs are recommended when dysphagia is combined with GERD or eosinophilic esophagitis. Proton pump inhibitors, which reduce the secretion of hydrochloric acid, are most often used. These drugs reduce the irritation of the esophageal mucosa by gastric secretion. In the presence of eosinophilic esophagitis, aerosolized forms of local steroid drugs are additionally used.

In cases of proven infectious genesis of the disease accompanied by dysphagia, antibacterial and antiviral therapy is indicated. Most patients require dietary correction—replacement of solid foods with soft foods and restrictive diet in the presence of hypersecretory disorders. 

In several patients, persistent dysphagia can be eliminated only by surgery. The affected organs are resected or removed in neoplasms, compressing the esophagus. When indicated, surgery is supplemented with chemotherapy and radiotherapy. 

Bouching, balloon dilatation, esophageal stenting, and endoscopic dissection of strictures allow the restoration of the esophageal lumen in cases of scar narrowing or compression by adjacent organs. Esophagocardiomyotomy is performed to treat therapeutically resistant achalasia. In cases of dysphagia associated with irreversible changes in the esophagus, esophagoplasty is performed.

All these treatment options are available in more than 570 hospitals worldwide (https://doctor.global/results/diseases/dysphagia). For example, Esophageal dilation can be done in 38 clinics across Germany for an approximate price of $4,4K (https://doctor.global/results/europe/germany/all-cities/all-specializations/procedures/esophageal-dilation). 

Prognosis and prevention

The likelihood of full recovery depends on the cause that led to the development of dysphagia. The prognosis is considered relatively favorable if the symptomatology is caused by increased acidity of gastric juice and other conditions that are well amenable to drug therapy. Prevention of dysphagia includes timely treatment of diseases of the digestive tract (peptic ulcer disease, GERD), refusal to eat very hot, fried food or alcohol, cessation of smoking, careful supervision of children, and excluding the swallowing of small objects and toys by the child.