“If this blog helped you out, don’t keep it to yourself—share the link on your socials!” 👍 “Like what you read? Spread the love and share this blog on your social media.” 👍 “Found this useful? Hit share and let your friends know too!” 👍 “If you enjoyed this post, please share the URL with your friends online.” 👍 “Sharing is caring—drop this link on your social media if it helped you.”

Saturday, August 23, 2025

Dysphagia (swallowing problems)


Introduction

Dysphagia refers to difficulty in swallowing solids, liquids, or both. It is a common complaint, especially in the elderly, and may significantly impair nutrition, hydration, and quality of life. In some cases, it indicates life-threatening diseases such as stroke, neuromuscular disease, or esophageal carcinoma.

It is essential to differentiate between:

  • Oropharyngeal dysphagia: Difficulty initiating swallow, coughing, aspiration.

  • Esophageal dysphagia: Sensation of food sticking or delayed passage down the esophagus.

Physiology of Swallowing

Swallowing occurs in three coordinated phases:

  1. Oral phase (voluntary): Mastication and propulsion of bolus to oropharynx.

  2. Pharyngeal phase (involuntary): Soft palate elevates, epiglottis covers airway, pharyngeal muscles contract.

  3. Esophageal phase (involuntary): Peristaltic waves carry bolus into stomach; lower esophageal sphincter relaxes.

Disruption in any phase may cause dysphagia.

Causes of Dysphagia

1. Oropharyngeal Dysphagia (Neurological/Muscular)

  • Stroke (CVA): Commonest cause in adults.

  • Parkinson’s disease.

  • Motor neuron disease (ALS).

  • Multiple sclerosis.

  • Myasthenia gravis.

  • Muscular dystrophies.

  • Structural causes: Zenker’s diverticulum, pharyngeal tumors, enlarged thyroid.

2. Esophageal Dysphagia

a. Mechanical Obstruction

  • Esophageal cancer.

  • Peptic stricture (due to GERD).

  • Schatzki ring.

  • Eosinophilic esophagitis.

  • Foreign body.

b. Motility Disorders

  • Achalasia (failure of lower esophageal sphincter to relax).

  • Diffuse esophageal spasm.

  • Scleroderma (hypomotility due to fibrosis).

c. Inflammatory/Infective

  • Reflux esophagitis (GERD).

  • Infective esophagitis (Candida, HSV, CMV).

  • Caustic ingestion (corrosives).

Clinical Presentation

  • Oropharyngeal dysphagia: Difficulty initiating swallow, nasal regurgitation, coughing, choking, aspiration, recurrent pneumonia.

  • Esophageal dysphagia: Food “sticks” after swallowing, sensation behind sternum, may affect solids first then liquids (mechanical obstruction) or both (motility disorder).

  • Associated symptoms:

    • Weight loss: Malignancy, severe obstruction.

    • Odynophagia (painful swallowing): Infection, ulcer, severe esophagitis.

    • Heartburn/regurgitation: GERD.

    • Neurological deficits: Stroke, neuromuscular disease.

Diagnostic Approach

1. History

  • Solids vs liquids, progressive vs intermittent.

  • Associated chest pain, heartburn, regurgitation, coughing.

  • Neurological symptoms.

  • Risk factors (smoking, alcohol, caustic ingestion).

2. Physical Examination

  • Oral cavity, dentition, tongue mobility.

  • Cranial nerve assessment.

  • Neurological examination.

  • Signs of malnutrition or dehydration.

3. Investigations

  • Barium swallow (esophagogram): Shows structural/motility disorders.

  • Upper endoscopy (EGD): Direct visualization, biopsy for malignancy/inflammation.

  • Esophageal manometry: Gold standard for motility disorders (achalasia, spasm).

  • Videofluoroscopic swallowing study: Oropharyngeal dysphagia assessment.

  • Blood tests: CBC, electrolytes, thyroid function.

Management and Treatment

Treatment is tailored to the cause.

A. General Supportive Measures

  • Dietary modifications: soft or pureed foods, thickened liquids.

  • Swallowing therapy (speech-language pathologist).

  • Postural changes: chin-tuck technique for aspiration prevention.

  • Nutritional support: nasogastric feeding or PEG tube if severe.

B. Oropharyngeal Dysphagia

1. Stroke-related Dysphagia

  • Swallowing rehabilitation exercises.

  • Thickened fluids to prevent aspiration.

  • Feeding tube if unsafe swallowing persists.

2. Neuromuscular Disorders

  • Myasthenia gravis:

    • Pyridostigmine: 60 mg orally every 4–6 h.

    • Immunosuppressants (prednisone 10–60 mg daily, azathioprine 1–3 mg/kg daily).

  • Parkinson’s disease:

    • Levodopa/carbidopa: Individualized dosing, often 100/25 mg orally 3–4 times daily.

    • Speech and swallow therapy.

3. Zenker’s Diverticulum

  • Surgical/endoscopic diverticulectomy.

C. Esophageal Dysphagia

1. Mechanical Obstruction

  • Esophageal cancer: Surgery, radiotherapy, chemotherapy; palliative stenting.

  • Peptic stricture (GERD-related): Endoscopic dilation + acid suppression.

    • Omeprazole: 20–40 mg orally once or twice daily.

  • Eosinophilic esophagitis:

    • Swallowed topical corticosteroids (fluticasone 440–880 mcg/day or budesonide 1–2 mg/day).

    • Elimination diet.

  • Schatzki ring: Endoscopic dilation.

2. Motility Disorders

  • Achalasia:

    • Pneumatic dilation, Heller myotomy, or POEM (endoscopic myotomy).

    • Nifedipine 10–30 mg orally before meals or Isosorbide dinitrate 5 mg sublingual before meals for temporary relief.

  • Diffuse esophageal spasm:

    • Calcium channel blockers (diltiazem 30–60 mg orally three times daily).

    • Nitrates: Isosorbide dinitrate 5 mg sublingual.

    • Botox injection into LES in refractory cases.

3. Inflammatory/Infective

  • GERD:

    • Lifestyle: weight loss, avoid alcohol, spicy food, late meals.

    • PPIs (omeprazole 20–40 mg orally daily, lansoprazole 30 mg daily).

  • Candida esophagitis:

    • Fluconazole 200 mg orally loading, then 100–200 mg daily for 14–21 days.

  • Herpes esophagitis:

    • Acyclovir 400 mg orally five times daily for 14–21 days.

  • CMV esophagitis:

    • Ganciclovir 5 mg/kg IV every 12 h for 14–21 days.

D. Retrograde and Aspiration Management

  • In high-risk aspiration: speech therapy, diet modification, PEG tube.

  • Antibiotics if aspiration pneumonia develops:

    • Amoxicillin–clavulanate 875/125 mg orally twice daily for 7–10 days.

Complications

  • Malnutrition, dehydration, weight loss.

  • Aspiration pneumonia.

  • Strictures or fistulas.

  • Underlying malignancy progression.

Prognosis

  • Stroke-related dysphagia: Many recover within weeks to months, though some remain chronic.

  • GERD-related strictures: Good prognosis with dilation and PPI therapy.

  • Achalasia: Treatable with surgery/endoscopy; lifelong follow-up needed.

  • Esophageal cancer: Prognosis depends on stage; often poor if diagnosed late.

Patient Education

  • Chew food thoroughly, eat slowly.

  • Modify diet (soft foods, thickened liquids).

  • Sit upright while eating; remain upright after meals.

  • Avoid alcohol, smoking, reflux-inducing foods if GERD.

  • Report red-flag symptoms: weight loss, progressive dysphagia, hematemesis.



on

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)