Dysphagia

Definition and description
Dysphagia means difficulty with swallowing. It is a subjective sensation of something being stuck in the throat or upper chest, usually behind the breastbone. Pain may accompany the dysphagia. Swallowing difficulties may concern solids, fluids or both.
Difficulty swallowing may be due to an obstruction, or to neuro-muscular problems involving the mouth and oro-pharynx, or the oesophagus itself.
Dysphagia is considered an “alarm symptom” warranting immediate investigation, especially in older patients.

Diagnosis
The patient can usually provide a clear description of the problem, and may point to a site of maximal discomfort. Associated problems like coughing after ingestion are significant.
Examination may show signs of weight loss if the problem is chronic or severe, and may also reveal other signs of an underlying cause, like Parkinson’s disease. Sometimes no organic cause can be found, and the condition is referred to as globus, a psychological condition linked to anxiety or emotional disorders.

Causes and associated conditions
The swallowing of food may be obstructed by:

1. Tumours,
2. Narrowing of the pathway following radiation, ulcers, chemical damage,
3. Zenker’s diverticulum,
4. Oesophageal webs,
5. Foreign bodies,
6. Drug side effects: some anticholinergics and antihistamines reduce salivary flow so much that swallowing is hindered, or
7. Sjögren’s syndrome, an auto-immune condition.

Neuromuscular causes include:

1. Achalasia,
2. Oesophageal spasm,
3. Parkinson’s disease, multiple sclerosis and muscular dystrophy,
4. Myasthenia gravis,
5. Scleroderma,
6. Previous infections such as polio,
7. Hypertensive lower oesophageal sphincter (valve muscle),
8. Nutcracker oesophagus, and
9. Gastro-oesophageal reflux.

Investigations
The gold standard in oesophageal motility imaging is the barium swallow, which is a kind of video X-ray study, showing the function and anatomy of the oesophagus.
Fibre-optic endoscopy allows inspection of the lining of the oesophagus, and can confirm retained food and anatomical abnormalities. Biopsies of suspicious areas can also be taken for analysis.
Manometry is done to measure pressures within the oesophagus.
A CT or MRI scan can also be done to confirm findings, and detect secondary spread of suspected tumours.

Treatment
This is aimed at facilitating swallowing, and preventing food from being aspirated into the airways. The type of treatment will be dictated by the findings of the investigations.
Tumours will either be surgically removed, irradiated or receive chemotherapy.
Neurologic disorders patients will benefit from rehabilitative training, in which techniques are taught to improve swallowing without discomfort.
Myasthenia gravis can be treated with mestinon or plasmapharesis, a highly specialised technique
Achalasia is managed either medically or surgically, and other muscular problems may benefit from a myotomy (division of the muscles). Some cases respond well to injection of botulinum toxin.

(Dr AG Hall)