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Sunday, August 17, 2025

Swallowing problems,Dysphagia


Introduction
Dysphagia, the medical term for swallowing difficulties, is a symptom rather than a disease itself. It can manifest as pain, discomfort, or a sensation of food sticking in the throat or chest when attempting to swallow. Dysphagia may affect the oral phase (preparing food in the mouth), the pharyngeal phase (moving food through the throat), or the esophageal phase (moving food down into the stomach). It can be acute or chronic and may significantly impact nutrition, hydration, and quality of life.

Causes of Dysphagia

1. Neurological causes

  • Stroke

  • Parkinson’s disease

  • Multiple sclerosis

  • Amyotrophic lateral sclerosis (ALS)

  • Cerebral palsy

2. Structural abnormalities

  • Esophageal strictures (narrowing due to scarring or chronic acid reflux)

  • Esophageal cancer

  • Schatzki rings (narrow rings of tissue in the esophagus)

  • Zenker’s diverticulum (pouch in the throat wall)

3. Muscle disorders

  • Achalasia (failure of lower esophageal sphincter to relax)

  • Diffuse esophageal spasm

  • Scleroderma (connective tissue disorder affecting esophagus motility)

4. Infections and inflammation

  • Gastroesophageal reflux disease (GERD) causing esophagitis

  • Candidiasis of the esophagus (common in immunocompromised patients)

  • Eosinophilic esophagitis

5. Mechanical obstructions

  • Foreign body impaction

  • Enlarged thyroid gland or mediastinal masses pressing on the esophagus

Symptoms

  • Difficulty initiating a swallow

  • Sensation of food sticking in throat or chest

  • Painful swallowing (odynophagia)

  • Regurgitation of food

  • Coughing or choking when eating or drinking

  • Unexplained weight loss due to poor intake

  • Hoarseness or recurrent chest infections (due to aspiration)

Diagnosis

  1. Clinical assessment

    • Medical history and physical examination

    • Neurological examination if a nervous system disorder is suspected

  2. Investigations

    • Barium swallow X-ray: highlights narrowing or obstruction in the esophagus

    • Endoscopy (esophagogastroduodenoscopy, EGD): direct visualization of abnormalities

    • Esophageal manometry: measures pressure and muscle contractions in the esophagus

    • Videofluoroscopic swallowing study: evaluates swallowing mechanism, often with a speech therapist

Treatment

Treatment depends on the underlying cause, severity, and phase of swallowing affected.

1. Dietary and lifestyle modifications

  • Eating soft or pureed foods

  • Taking smaller bites and chewing thoroughly

  • Sitting upright during meals

  • Avoiding foods that worsen symptoms (e.g., dry bread, sticky foods)

2. Medications

  • GERD-related dysphagia:

    • Omeprazole (20–40 mg daily, proton pump inhibitor)

    • Ranitidine (150 mg twice daily, H2 receptor antagonist, less commonly used now due to safety concerns)

  • Esophageal candidiasis:

    • Fluconazole (200 mg loading dose, then 100–200 mg daily for 14–21 days)

    • Nystatin suspension (swish and swallow, 4–6 mL four times daily)

  • Eosinophilic esophagitis:

    • Topical corticosteroids (fluticasone inhaler used off-label by swallowing the spray, typically 440–880 mcg daily)

    • Prednisone (30–40 mg daily for short-term use in severe cases)

  • Achalasia:

    • Nifedipine (10–30 mg orally before meals, calcium channel blocker to relax the esophageal sphincter)

    • Isosorbide dinitrate (5–10 mg sublingual before meals, nitrate that reduces sphincter pressure)

3. Procedures and surgeries

  • Esophageal dilation:

    • Performed during endoscopy to widen narrowed areas of the esophagus

  • Botulinum toxin injection:

    • Injected into the lower esophageal sphincter to relax it, particularly in achalasia

  • Heller myotomy:

    • Surgical procedure for achalasia where the sphincter muscle is cut to allow easier swallowing

  • Esophageal stent placement:

    • Used in patients with obstructive cancers to maintain esophageal patency

4. Supportive therapies

  • Speech and language therapy for patients with neurological disorders

  • Nutritional support (feeding tubes such as nasogastric tube or PEG tube in severe cases)

Complications if Untreated

  • Aspiration pneumonia (due to inhalation of food or fluids)

  • Severe weight loss and malnutrition

  • Dehydration

  • Social isolation and reduced quality of life

  • Worsening of underlying diseases (such as cancer or neurological disorders)

Prognosis

  • Prognosis depends on the underlying cause.

  • Dysphagia due to temporary causes (such as infection or reflux) usually improves with treatment.

  • Neurological or structural causes may require long-term management, and in some cases, swallowing function may not fully return.




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