Dysphagia

Abstract

Patients with dysphagia experience difficulty with swallowing while transferring food from the mouth into the esophagus and pharynx. Individuals suffering from this disease should be carefully examined to ensure the most accurate diagnosis and treatment. The first steps should be directed to the determination of what kinds of violations should be dealt with by healthcare providers: pharynx or esophagus.

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In general, food delay in the throat usually indicates the presence of disorders at the throat level, while the events taking place at the level of the chest are associated with esophageal disorders. Delayed food in the suprasternal holes may occur due to any of these disorders, which necessitate further examination. It is important to find out the length of the food delay. If it takes two seconds from the beginning of the pharynx, it usually indicates the esophageal dysfunction. In this regard, it is necessary to review the pathophysiology, clinical manifestations, evaluation, and treatment of dysphagia.

Keywords: dysphagia, dysfunction, esophageal disorders, patient, swallowing disorders

Dysphagia: Pathophysiology, Clinical Manifestations, Evaluation, and Treatment

Dysphagia is generally classified as either esophageal or oropharyngeal. This disorder is associated with swallowing dysfunctions. In some cases, a patient is not even able to have a drink. Dysphagia may arise only once or several times and requires timely treatment. Esophageal dysphagia arises in the esophagus due to either a motility disturbance or mechanical causes. Oropharyngeal dysphagia is caused by a disorder of the pharynx and upper esophagus, or from upper esophageal dysfunction. Their initial evaluation differs and requires a careful history and comprehensive examination.

The American Gastroenterological Association is trying to manage oropharyngeal dysphagia by issuing the guidelines for evaluation and treatment. The treatment of dysphagia is directed at the mitigation of its symptoms. The current paper aims to observe pathophysiology, clinical manifestations, evaluation, and treatment of dysphagia.

Pathophysiology of Dysphagia

Although dysphagia can arise in anyone, it is most common for babies, older adults, and people who have problems with the nervous system or the brain. Dysphagia is a sign of abnormalities with one’s throat or esophagus, which is a tube that moves liquids and food from the mouth to the stomach. Dysphagia is manifested in the difficulty or impossibility of swallowing, pain while swallowing, and the penetration of food in the nose, larynx, and trachea. Many experts determine to swallow as a process, which results in the reduction of certain muscles and the relaxation of others that transfer the bolus through the pharynx and esophagus to the stomach (Bope & Kellerman, 2015).

Swallowing is divided into three phases such as oral, pharyngeal, and esophageal. There are two types of dysphagia, including oropharyngeal dysphagia that arises as a result of the violation of food passage in the area of the oropharynx and esophageal dysphagia associated with the violation of food passage into the esophagus area (Aslam & Vaezi, 2013).

Alternatively, oropharyngeal dysphagia is divided into upper, middle, and lower. Thus, upper dysphagia causes diseases of the thyroid gland, muscles, lymph nodes, spine, and other organs, as well as disorders of the nervous regulation in the functions of the mouth, pharynx, and esophagus. The middle dysphagia arises as a result of diseases of the posterior mediastinum organs such as vessels, nerves, lymph nodes, connective tissue, pleura, heart, and others. Finally, lower esophageal dysphagia causes malfunction of the lower esophageal sphincter such as the hiatal hernia, chalasia and achalasia reflux esophagitis, ulcers, diverticular strictures, tumors, and others.

Furthermore, according to the severity of violations, the medical literature distinguishes four degrees of dysphagia: (a) periodic difficulty with swallowing solid food and pain in the course of transferring the bolus; (b) the passage of only semi-liquid food; (c) the passage of only liquid food; and (d) the inability to swallow even saliva or water (Castell, 2014). Commonly, dysphagia is considered to be a gastroesophageal reflux disease that arises when the acid stomach reaches the mucosa of the esophagus, while the deposition of the damage causes a small narrowing of the esophagus. Another type of dysphagia is benign circular membranous or narrowing of the esophagus. As a result, patients have difficulty swallowing solid food while liquid passes through the esophagus to the stomach easily.

Normally, the muscles in one’s esophagus and throat contract or squeeze to move liquids and food from the mouth to the stomach without difficulties. However, sometimes, some people may experience problems while swallowing. This medical state may lead to problems with swallowing due to various reasons. One of them involves complications with the nervous system such as Parkinson’s disease, multiple sclerosis, post-polio syndrome, and muscular dystrophy (Buttaro, Trybulsky, Bailey, & Sandberg-Cook, 2013).

Furthermore, when a person had a brain or spinal cord injury as well as stroke, it can result in swallowing problems. Moreover, certain immune system problems such as dermatomyositis or polymyositis can also lead to dysphagia (Castell, 2014). Consequently, the muscles of the esophagus experience spasm that prevents foods and liquids from reaching the stomach. In such situations, a patient feels that something is blocking his or her throat and esophagus.

The literature asserts that it may happen because of gastroesophageal reflux disease that is manifested in heartburn that arises when stomach acid comes back up into the patient’s throat and mouth (Buttaro et al., 2013). Furthermore, in case the esophagus tissues become narrow and hard, the esophageal muscle becomes weak, which may result in the swallowing problems. In some cases, dysphagia occurs in individuals due to inflammation of the esophagus (esophagitis), which is usually caused by various problems such as allergic reactions, getting a pill stuck, or infections in the esophagus (Ekberg, 2012).

The most dangerous reason for the disease is esophagus tumors that may be cancerous. Moreover, a dry mouth can worsen the physical state of patients because they may not have enough salvia to move food. This condition may be caused by different health problems or improper medicine. All the reasons mentioned above lead to the clinical manifestations of dysphagia.

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Clinical Manifestations

Dysfunctions leading to dysphagia usually affect the pharyngeal, oral, or esophageal phases of swallowing. Delayed food in the throat usually indicates the presence of disorders at the throat level, but when such symptoms take place in the chest, they are associated with esophageal disorders (Fass, 2016). A careful history and thorough examination should be provided to diagnose and treat the disease. Patients with dysphagia suffer from a variety of signs and symptoms. Thus, cough, regurgitation in the nose, and possibly serious diseases of the central nervous system indicate the disorders at the level of the pharynx. They may also report hoarseness and the abnormal sensation of food sticking either in the back of the throat or upper chest while swallowing. Admittedly, some of these symptoms can be subtle or absent.

The literature reveals that symptoms of pharyngeal or oral dysphagia may include chocking or coughing while swallowing, food sticking in the throat, sudden weight loss, sialorrhea, recurrent pneumonia, nasal regurgitation, changes in dietary habits as well as changes in voice or speech (Ekberg, 2012). Furthermore, symptoms of esophageal dysphagia include food sticking in the chest or throat, recurrent pneumonia, and changes in dietary habits (Huether & McCance, 2013). Signs and symptoms of gastroesophageal reflux disease include belching, heartburn, water brash, and sour regurgitation (Malagelada et al., 2014). Other associated signs of the disease include mental status changes, general weakness, and morbidity. Relevant patient history such as hypertension, neuromuscular disease, cancer, diabetes mellitus, and some others may also cause dysphagia.

According to Fass (2016), difficulties with swallowing solid and liquid food point to a violation of the motor activity of the esophagus. Sometimes, patients complain that they have chest pain, night cough, and regurgitation or aspiration that are associated with the stagnation of food in the esophagus. In some cases, patients have increased the production of mucus. The periodic pain with symptoms of dysphagia that may occur only during a pain attack indicates diffuse esophageal spasm. Furthermore, the additional features of scleroderma are thinning of the skin and translucence of vessels through the skin, ischemic changes in fingers and toes, as well as the decrease in the amplitude of respiratory movements.

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Huether and McCance (2013) reported that violation of the swallowing function oftentimes entails problems with the nervous system, and may indicate the causes of psychological nature. If the violation in the act of swallowing and the passage of food through the esophagus is aggravated, the patient may gradually develop nutritional deficiencies in the body, and even exhaustion. In such cases, patients should adjust their nutrition. According to the research, the process of swallowing involves alternating contraction and relaxation of muscles, which leads to the food entering the stomach through the throat and then through the esophagus.

However, in the case of dysphagia, these processes are violated. Pain while swallowing food is quite often accompanied by other characteristics. Due to the fact that pain is manifested in the throat while swallowing, a coughing person can link it to the nasopharynx. Sometimes, food can go back and pour out through the nose. At a time when the food passes through the esophagus, a person may feel that there is severe pain in Adam’s apple.

Obviously, there are different causes of dysphagia, and timely diagnosis and adequate treatment help to research the characteristics of swallowing disorders. In the presence of esophageal dysphagia, patients cannot always identify the affected area. Thus, only 60-70 percent of them may correctly indicate the level of the food delay in the esophagus. Malagelada et al. (2014) believe that clarification of dysphagia localization has a diagnostic value when patients describe it as tightness in the chest, usually behind the breastbone, which corresponds to the level of esophageal obstruction.

Thus, specific questions about the onset, duration, and severity of dysphagia as well as the variety of associated symptoms may help to narrow the differential diagnosis. Therefore, healthcare providers aim to review the patient’s general health information, including long-term illnesses, and currently prescribed medications.

It should be noted that the neck pain while swallowing can be also observed in viral infections such as flu or cold. In these cases, dysphagia is accompanied by other symptoms such as an acute sore throat, fever, muscle pain, weakness, and others (Nordqvist, 2016).

Evaluation of Dysphagia

Clinical non-instrumental evaluation, which is called “bedside examination,” is an important tool in making a diagnosis. As a rule, it aims to evaluate the severity of the disease, plan the rehabilitation, the reasons which cause it, and the treatment outcomes. According to the research, patients with dysphagia are usually divided into two groups that involve neurologic and operated (Bope & Kellerman, 2015). The neurologic group includes patients that are affected by this disorder due to neurologic diseases such as stroke, cranial trauma, and neurosurgical treatment. As for the second group, operated patients experience dysphagia as a result of maxilla-facial surgery. To assess the anamnesis, healthcare providers first examine the patient’s general data, i.e. his or her age. Admittedly, premature babies, patients with a history of illnesses of the brain or central nervous system, and elderly people belong to the risk groups.

Furthermore, it is important to identify the patient’s general conditions such as breathing functionality and nutritional situation. The next step may include the development of neurologic diagnosis and neuropsychological conditions. The history of oncologic intervention or surgical procedures on the digestive airways should also be taken into consideration. Besides, the patient’s eating preferences, duration of meals, speech articulation, and social environment are also important factors for the observer. Many studies assert that evaluation is different in the operated disphogical patients compared to neurologic patients (Aslam & Vaezi, 2013). Thus, in the case of the former, physicians make the evaluation of the outcomes of the surgical treatment, while the latter requires a scrupulous examination of coordination, motricity and reflexes, collaboration, and communicative abilities.

Epidemiology of this dysfunction indicates that it is among 50 reasons when individuals seek medical assistance, and generally rank alongside such impairments as bronchitis, pneumonia, and otitis media (Nordqvist, 2016). Conditions that lead to dysphagia often produce the nutritional deficit, esophageal rupture, and aspiration pneumonia. Admittedly, the geriatric population is at the highest risk because the disease causes complications such as silent aspiration. Many researchers indicate that dysphagia should not be confused with odynophagia, i.e. painful swallowing and globus that is a constant sensation of a lump in the patient’s throat (Ward, Nam, & Cool, 2015).

The recent medical literature suggests that the causes of dysphagia can be diseases and injuries of the pharynx such as acute tonsillitis, peritonsillar abscess, and allergic swelling of throat tissues, as well as damage of the nervous system and the muscles involved in the act of swallowing (e.g. rabies, bulbar paralysis, tetany, botulism, hypoglossal nerve neuritis, etc.) (Walshe, 2014). Causes of failure to swallow involve different reasons; often the reason for this phenomenon may be a serious illness. Therefore, there may be a violation of swallowing in case of stroke, osteochondritis, and others. Admittedly, in some diseases, dysphagia should be treated without delay since it can lead to serious complications. For example, a violation of swallowing after a stroke can trigger the start of aspiration pneumonia.

In fact, there are numerous reasons that can prevent the esophagus or throat from working properly. Some of these problems may be of a singular nature while others may happen on a regular basis. If a person has difficulty with swallowing quite seldom, he or she may not necessarily have a medical problem. However, if these difficulties repeat on a regular basis, they may indicate serious health problems that require treatment.

 

Diagnostics of Dysphagia

A detailed examination is the key diagnostic element that can often help to establish a precise diagnosis. Therefore, the first step is to determine the location in which the patient feels difficulty with swallowing, namely oropharyngeal or esophageal. According to the research, the timed water-swallow test is potentially the most useful basic screening test that complements the results obtained while studying the history and making clinical examination (Paik, 2014).

During this test, the patient drinks 150 ml of water as quickly as possible, with the doctor recording the time and number of swallows. Based on these data, the average volume of the pharynx can be calculated. Many researchers consider that a fluoroscopic swallowing study process is the gold standard in the diagnosis of oropharyngeal dysphagia and the investigation of violations of motor functions in the upper esophageal sphincter (McCance, Huether, Brashers, & Rote, 2009).

Furthermore, X-ray examination of the esophagus with contrast barium reveals filling defects in the esophagus and helps to identify areas of obstruction, connective membranes, and rings. During this study, the presence of achalasia in patients, as well as segmental and diffuse spasm, is verified. Furthermore, for more detailed visualization of the mucosa of the upper gastrointestinal tract, endoscopy is performed. Admittedly, the introduction of the scope into the gastric cavity helps exclude pseudo-achalasia associated with tumor esophageal-gastric junction.

The current high-tech research method of the motor function of the esophagus is commonly used in the leading research centers. It involves a high-resolution manometry and volumetric 3D-manometry. This test uses a multichannel probe, which represents sensors located at a distance of 1 cm from each other in order to obtain quantitative indicators on total peristaltic activity (McCance et al., 2009).

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Treatment of Dysphagia

Since dysphagia is a symptom and not an independent disease, it is important to provide a careful diagnosis to identify the disorder that has become its cause. First of all, a gastroenterological examination should be performed, the main method of which is the endoscopic examination that allows the examination of the mucosa of the upper part of the gastrointestinal tract and to identify the existing pathology (Nelms, Sucher, & Lacey, 2015). In the event of a tumor or ulcer, the biopsy is performed followed by histological examination.

Furthermore, in the case of the detection of esophagitis symptoms, the contents of the esophagus are taken for bacteriological seeding in order to identify the causative agent. If the cause was not detected through a gastroenterological examination, medical professionals conduct a neurological examination to identify the affected nerve structures.

In general, treatment is conducted in relation to the disease, which causes dysphagia. According to the research, treatment often consists of emergency measures in the event of acute symptoms of dysphagia (Frakking, Chang, O’Grady, Walker-Smith, & Weir, 2013). Thus, in the event of true dysphagia, a patient should thoroughly clean his or her airway from food trapped there. Further treatment of dysphagia requires a hospital stay during which a healthcare professional will introduce food and water into the esophagus through a tube. Emergency treatment of dysphagia caused by the inflammation of the esophagus comprises the introduction of antacid aluminum-containing agents or intake of Zantac effervescent tablets dissolved in a glass of water (Lembo, 2015). Therefore, subsequent treatment of dysphagia is the treatment of esophagitis.

First of all, dysphagia patients should adhere to certain rules of eating and dieting. In this regard, it is recommended to split meals into small portions, at least four times a day. Moreover, food should not be dry and hard for the patient to be able to chew it easily. Furthermore, patients should not eat prohibited meals and cold food. After a meal, a patient should avoid leaning forward for 1.5-2 hours to prevent regurgitation (Frakking et al., 2013). It should be taken into consideration that the last meal must be taken no later than two hours before bedtime.

If the patient has esophageal dysphagia, his or her diet should consist of easy to digest food such as vegetables, boiled or steamed lean meats, fish, and poultry. Remarkably, preference should be given to white meat, excluding oily, fried, and smoked foods, as well as acute and spicy. Nutritionists also prohibit fast food and all kinds of fizzy drinks, as well as a strong coffee and tea (Nelms et al., 2015). Alcohol should be completely eliminated and substituted by milk and milk products. Generally, the preference should be given to a milk-vegetable diet with the addition of mucous soups and porridges.

Treatment of dysphagia depends primarily on the cause of its development. Thus, if swallowing difficulties were manifested due to the penetration of a foreign body into the esophagus or throat, treatment of dysphagia consists of its removal. In the case of the tumor, it is necessary to provide a consultation with the oncologist. Sometimes, the tumor is removed surgically or through radiation therapy. Other methods are also used to suspend the progression of cancer. The study asserts that if dysphagia is a consequence of gastroesophageal reflux or esophagitis, patients are administered medicines that reduce stomach acidity (Lembo, 2015). Sometimes, swallowing disorders disappear after a person takes antacids. In the most severe cases, the patient is prescribed to receive food through a tube, or nutrients are administered intravenously.

Conclusion

Dysphagia is associated with swallowing dysfunctions that may vary according to their severity. It mostly affects elder individuals, premature babies, and persons who have problems with the nervous system or the brain. In some cases, a patient cannot even have a drink. There are different types of dysphagia such as oropharyngeal, esophageal, and functional dysphagia. Their initial evaluation differs and requires a careful history and comprehensive examination. To avoid further complications, it is necessary to provide a thorough diagnosis through specific tests and provide timely treatment, which is directed at the elimination of its symptoms.

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