Swallowing Disorders

Trouble swallowing (dysphagia) is a symptom where there is resistance to passage of food from the mouth to the stomach. It may take the individual more effort than normal to move food through the esophagus. Patients may feel food sticking in the neck or chest, which may come back up into the mouth.  Rarely, patients may not be able to swallow at all, and may lose weight because of this.

When an individual has trouble swallowing frequently or for an extended period of time, testing is needed to find out the cause and to plan treatment.  There are many causes for dysphagia (trouble swallowing).

SYMPTOMS OF SWALLOWING DISORDERS

Patients may experience some of the following symptoms of dysphagia:

• Sensation of food getting stuck in the throat, chest, or behind the breastbone

• Food coming back up to the mouth (this typically tastes just like the food just eaten)

• Chest pain when the food is stuck

• Weight loss, if the symptom persists for a long time

• Heartburn, especially if the cause of dysphagia is a complication of acid reflux disease

• Hoarseness

• Drooling

• Coughing or gagging when swallowing

• Pain while swallowing, especially if esophageal infection or inflammation is to blame

• Not being able to swallow altogether

• Choking or aspiration into the lungs, which can cause aspiration pneumonia

WHEN SHOULD I SEE A DOCTOR?

If someone is choking and cannot breathe, call for emergency help.  Choking is not usually caused just by dysphagia, and typically requires aspiration into the airway

Occasional trouble with swallowing is not an emergency. If someone has regular trouble swallowing or trouble swallowing for an extended period of time and shows any of the above symptoms, they may benefit from contacting a gastroenterologist.

CAUSES OF SWALLOWING DISORDERS

Depending on the characteristics of the trouble swallowing and the location of the problem causing the symptom, the gastroenterologist will categorize the dysphagia as either esophageal or oropharyngeal.

ESOPHAGEAL DYSPHAGIA

This means that the food gets stuck in the esophagus, and not at the back of the throat. This is usually due to either a narrowing of the lumen of the esophagus (the "open cavity" through which food travels), or to abnormal muscle contraction in the esophagus. Causes of esophageal dysphagia include:

• Esophageal stricture: the esophagus narrows – possibly due to scar tissue development from GERD or tumors – and prevents food from moving down the esophagus into the stomach. This is one of the most common causes of dysphagia.

• Gastroesophageal reflux disease (GERD): stomach acid backing up into the esophagus can cause inflammation which by itself can cause dysphagia, even without scar tissue and narrowing

• Esophageal tumors: Tumors can occupy the lumen of the esophagus and block food from moving down

• Radiation: if a patient is treated for lung cancer, lymphoma or even esophageal cancer using radiation, the esophagus can become stiff and narrowed

• Achalasia: the muscles at the bottom end of the esophagus (lower esophageal sphincter) do not relax properly during swallowing, preventing food from entering the stomach. The food can then remain in the esophagus or come back into the mouth (regurgitation) 

• Diffuse spasm: after a person swallows the esophageal muscles may contract in a discoordinated fashion, causing food sticking and discomfort

OROPHARYNGEAL DYSPHAGIA

Muscles or nerves in the mouth, tongue and back of throat can weaken, causing the sensation of choking or coughing when swallowing is attempted. Food may feel like it is “going down the wrong pipe” instead of down the esophagus normally.

• Stroke: This can damage nerve control of the muscles required to chew food, push food to the back of the throat, and start the process of swallowing.  This is the most common cause of oropharyngeal dysphagia.  Stroke victims may need help redeveloping their ability to swallow normally again

• Neurological disorders: such as multiple sclerosis, muscular dystrophy, and Parkinson’s disease can weaken the muscles of the mouth, tongue and back of the throat

• Pharyngeal diverticula: a small pouch can form in the throat, above the esophagus, that catches food particles and cause difficulty swallowing, gurgling sounds, and chronic coughing.  This is usually due to abnormal opening of the sphincter muscle at the top end of the esophagus (upper esophageal sphincter)

DIAGNOSING SWALLOWING DISORDERS

The gastroenterologist may perform tests in addition to a physical exam to diagnose a swallowing disorder. Possible tests include the following:

• Endoscopy: the doctor uses an endoscope, inserted through the mouth and guided down the throat, to take pictures or video of the esophagus and stomach. This has the highest diagnostic yield in esophageal dysphagia

• Barium swallow: the patient swallows a fluid called barium (a metallic, chalky liquid) that will coat the inside of the esophagus. The doctor will take x-rays to examine any abnormalities in the esophagus, which shows up clearly on the x-ray due to the barium coating 

• Esophageal manometry: the doctor guides a thin tube through the patient’s nostril and into his/her stomach. The patient will swallow and sensors on the tube will measure pressure within the esophagus from esophageal muscle contraction.  By looking at the pressure patterns, abnormal muscle function causing dysphagia can be diagnosed

• Dynamic swallowing study: the patient swallows foods – of several consistencies – coated with barium. The doctor can follow those foods as they travel down the esophagus and into the stomach. This is typically performed for oropharyngeal dysphagia

DYSPHAGIA TREATMENT

Individual dysphagia treatment is prescribed according to the patient’s situation.

Possible treatments for Esophageal Dysphagia:

• Esophageal dilation for Esophageal stricture: the gastroenterologist will gently stretch the esophagus by using a special balloon passed through the endoscope, or by passing dilators (long rubber stretching devices) through the mouth into the throat, sometimes using a guide wire placed during endoscopy as a guide

• Esophageal dilation for Achalasia:  Forceful dilation of the esophagus with intent to tear the muscle at the bottom end of the esophagus is a form of therapy for achalasia that can improve dysphagia symptoms

• Surgery may be performed for achalasia, cancer, other tumors and for diverticula

• Medications: acid-suppressing medication may be prescribed long-term for conditions related to GERD.  Esophageal infections may be treated with antifungal or antiviral agents depending on the cause

Possible treatments for Oropharyngeal Dysphagia:

• Speech or swallowing therapist: the therapist will recommend certain exercises to strengthen or coordinate the esophagus muscles and nerves as well as teach swallowing techniques to help prevent swallowing difficulty as much as possible

If severe dysphagia makes swallowing difficult enough that the patient cannot eat/drink and weight loss ensues, the gastroenterologist may recommend a temporary liquid diet, or even a feeding tube placed into the stomach if there is a high probability of malnutrition.