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Encyclopedia > Dysphagia
Name of Symptom/Sign:
Dysphagia
Classifications and external resources
ICD-10 R13.
ICD-9 787.2
DiseasesDB 17942
MedlinePlus 003115
eMedicine pmr/194 

Dysphagia (/dɪsˈfe(ɪ)ʒjə/) is a medical term defined as "difficulty swallowing." It derives from the Greek root dys meaning difficulty or disordered, and phagia meaning "to eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach.[1] Dysphagia is distinguished from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A psychogenic dysphagia is known as phagophobia. The term symptom (from the Greek meaning chance, mishap or casualty, itself derived from συμπιπτω meaning to fall upon or to happen to) has two similar meanings in the context of physical and mental health: Strictly, a symptom is a sensation or change in health function experienced by a patient. ... In medicine, a sign is a feature of disease as detected by the doctor during physical examination of a patient. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). ... // R00-R99 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R09) Symptoms and signs involving the circulatory and respiratory systems (R00) Abnormalities of heart beat (R000) Tachycardia, unspecified (R001) Bradycardia, unspecified (R002) Palpitations (R008) Other and unspecified abnormalities of heart beat (R01) Cardiac murmurs and other... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... It has been suggested that this article or section be merged with mouth (human). ... In anatomy, the stomach is a bean-shaped hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. ... Odynophagia refers to a medical term that describes a painful swallowing experience. ... Globus Pharyngis (also known as Globus Sensation, Globus or, somewhat outdatedly, Globus Hystericus; commonly referred to as having a lump in ones throat) is the persistent sensation of having phlegm or some other sort of obstruction in the throat when there is none. ... The English suffix -phobia is used to describe fear or hatred (the latter is often ignored) of a particular thing or subject. ...


It is also worthwhile to refer to the physiology of swallowing in understanding dysphagia. Swallowing, known scientifically as deglutition, is the reflex in the human body that makes something pass from the mouth, to the pharynx, into the esophagus, with the shutting of the epiglottis. ...

Contents

Epidemiology

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions (Logemann, 1998). Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly,[2] in patients who have had strokes,[3] and in patients who are admitted to acute care hospitals or chronic care facilities. Other causes of dysphagia include head and neck cancer and progressive neurologic diseases like Parkinson's disease, Multiple sclerosis, or Amyotrophic lateral sclerosis. Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history by the treating physician.[4] It should be noted that some patients with dysphagia are not aware of the problem (Logemann, 1998). In general use, a complaint is an expression of displeasure, such as poor service at a store, or from a local government, for example. ... In optics one considers angles of incidence. ... Old age consists of ages nearing the average lifespan of human beings, and thus the end of the human life cycle. ... Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function due to an interruption in the blood supply to all or part of the brain. ... A hospital today is an institution for professional health care provided by physicians and nurses. ... Chronic care refers to medical care which addresses preexisting or long term illness, as opposed to acute care which is concerned with short term or severe illness of brief duration. ... Head and neck cancers are malignant growths originating in the lip and oral cavity (mouth), nasal cavity, pharynx, larynx, thyroid, paranasal sinuses, salivary glands and cervical lymph nodes of the neck. ... Amyotrophic lateral sclerosis (ALS, sometimes called Lou Gehrigs Disease, Maladie de Charcot or motor neurone disease) is a progressive, fatal, neurodegenerative disease caused by the degeneration of motor neurons, the nerve cells in the central nervous system that control voluntary muscle movement. ... HIStory - Past, Present and Future, Book I is a double-disc album (one half greatest hits, one half studio album) by American musician Michael Jackson released in June of 1995 by the Epic Records division of Sony BMG. The first disc, (HIStory Begins) contains fifteen hit singles from the past... The Doctor by Luke Fildes This article is about the term physician, one type of doctor; for other uses of the word doctor see Doctor. ...


Dysphagia is classified into two major types: oropharyngeal dysphagia (or transfer dysphagia) and esophageal dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having functional dysphagia.


Oropharyngeal dysphagia

Arises from abnormalities of the upper esophagus, pharynx, and oral cavity.


Signs and symptoms

Some signs and symptoms of swallowing difficulties or dysphagia include the inability to recognize food and taste it, difficulty placing food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and patient complaint of swallowing difficulty (Logemann, 1998). When asked where the food is getting stuck patients will often point to the cervical (neck) region as the site of the obstruction. However, this may be misleading due to patients' inaccurate sensation of the site of obstruction (with obstructions / dysmotilities lower in the esophagus being common). Pneumonia is an illness of the lungs and respiratory system in which the alveoli (microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere) become inflamed and flooded with fluid. ... In anatomy, cervical is an adjective that has two meanings: of or pertaining to the neck. ...


Complications

If left untreated, dysphagia can potentially cause aspiration pneumonia, malnutrition, or dehydration, all of which can be symptoms of dysphagia as well (Logemann, 1998). Aspiration pneumonia is a specific form of lung infection (pneumonia) that develops when oral or gastric contents (including food, saliva, or nasal secretions) enter the bronchial tree. ... Percentage of population affected by malnutrition by country, according to United Nations statistics. ... Dehydration (hypohydration) is the removal of water (hydro in ancient Greek) from an object. ...


Etiology and Differential Diagnosis (causes)

  • A stroke can trigger a rapid onset of dysphagia with a high occurrence of aspiration. The function of normal swallowing may or may not return completely following an acute phase lasting approximately 6 weeks (Murray, 1999).
  • Parkinson's disease can cause "multiple prepharyngeal, pharyngeal, and esophageal abnormalities". The severity of the disease most often correlates with the severity of the swallowing disorder (Murray, 1999).
  • Neurologic disorders such as stroke, Parkinson's disease, amyotrophic lateral sclerosis, Bell's palsy, or myasthenia gravis can cause weakness of facial and lip muscles that are involved in coordinated mastication as well as weakness of other important muscles of mastication and swallowing.
  • Oculopharyngeal muscular dystrophy is a genetic disease with palpebral ptosis, oropharyngeal dysphagia, and proximal limb weakness.
  • Decrease in salivary flow, which can lead to dry mouth or xerostomia, can be due to Sjogren's syndrome, anticholinergics, antihistamines, or certain antihypertensives and can lead to incomplete processing of food bolus.
  • Xerostomia can reduce the volume and increase the viscosity of oral secretions making bolus formation difficult as well as reducing the ability to initate and swallow the bolus (Murray, 1999).
  • Dysphagia can occur when the drug marijuana is taken, due to dry mouth and lack of fine muscle control.
  • Dental problems can lead to inadequate chewing.
  • Abnormality in oral mucosa such as from mucositis, aphthous ulcers, or herpetic lesions can interfere with bolus processing.
  • Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, or cervical osteophytes.
  • Increased upper esophageal sphincter tone can be due to Parkinson's disease which leads to incomplete opening of the UES. This may lead to formation of a Zenker's diverticulum.
  • Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents. These pouches are also marked by malodorous breath due to decomposing foods residing in the pouches. (See Zenker's diverticulum)
  • Dysphagia is often a side effect of surgical procedures like anterior cervical spine surgery, carotid endarterectomy, head and neck resection, oral surgeries like removal of the tongue, and parital laryngectomies (Murray, 1999).
  • Radiotherapy, used to treat head and neck cancer, can cause tissue fibrosis in the irradiated areas. Fibrosis of tongue and larynx lead to reduced tongue base retraction and laryngeal elevation during swallowing (Murray, 1999).
  • Infection may cause pharyngitis which can prevent swallowing due to pain.
  • Medications can cause central nervous system effects that can result in an oropharyngeal dysphagia. Examples: sedatives, hypnotic agents, anticonvulsants, antihistamines, neuroleptics, barbiturates, and antiseizure medication. Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples: corticosteroids, L-tryptophan, and anticholinergics (Murray, 1999).

Etiology (alternately aetiology, aitiology) is the study of causation. ... This article or section does not cite any references or sources. ... Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function due to an interruption in the blood supply to all or part of the brain. ... Swallowing, known scientifically as deglutition, is the reflex in the human body that makes something pass from the mouth, to the pharynx, into the esophagus, with the shutting of the epiglottis. ... Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function due to an interruption in the blood supply to all or part of the brain. ... Amyotrophic lateral sclerosis (ALS, sometimes called Lou Gehrigs Disease, Maladie de Charcot or motor neurone disease) is a progressive, fatal, neurodegenerative disease caused by the degeneration of motor neurons, the nerve cells in the central nervous system that control voluntary muscle movement. ... Bells palsy (or facial palsy) is characterised by facial drooping on the affected half, due to malfunction of the facial nerve (VII cranial nerve), which controls the muscles of the face. ... Myasthenia gravis (sometimes abbreviated MG; from the Greek myastheneia, lit. ... Mastication is a name for the process of breaking up of food and mixing it with saliva. ... Oculopharyngeal dystrophy (OPD), or oculopharyngeal muscular dystrophy, is a form of muscular dystrophy characterized in some stages by deformation of the eyelid, speech impediment, and difficulty swallowing due to dystrophia of the pharynx. ... Ptosis is the paralysis of the muscles of the eyelid. ... Xerostomia is the medical term for a dry mouth due to a lack of saliva. ... Sjögrens syndrome is an autoimmune disorder in which immune cells attack and destroy the glands that produce tears and saliva. ... An anticholinergic agent is a member of a class of pharmaceutical compounds which serve to reduce the effects mediated by acetylcholine in the central nervous system and peripheral nervous system. ... An antihistamine is a drug which serves to reduce or eliminate effects mediated by histamine, an endogenous chemical mediator released during allergic reactions, through action at the histamine receptor. ... In medicine and pharmacology, antihypertensives are a class of drugs that are used in the treatment of arterial hypertension. ... Xerostomia is the medical term for a dry mouth due to a lack of saliva. ... Viscosity is a measure of the resistance of a fluid to deform under shear stress. ... Look up bolus in Wiktionary, the free dictionary. ... Mucositis is the painful inflammation and ulceration of the mucous membranes lining the digestive tract. ... Endoscopic images of a duodenal ulcer. ... Species Herpes simplex virus 1 (HSV-1) Herpes simplex virus 2 (HSV-2) This article is about the virus. ... Look up bolus in Wiktionary, the free dictionary. ... In anatomy, Zenkers diverticulum is a diverticulum of the mucous membrane of the oesophagus through a defect in the wall of oesophagus. ... A pharyngeal pouch is a pulsion diverticulum of the pharyngeal mucosa through Killians dehiscence. ... In anatomy, Zenkers diverticulum is a diverticulum of the mucous membrane of the oesophagus through a defect in the wall of oesophagus. ... A cervical vertebra Cervical vertebrae (Vertebrae cervicales) are the smallest of the true vertebrae, and can be readily distinguished from those of the thoracic or lumbar regions by the presence of a foramen (hole) in each transverse process. ... Carotid entarterectomy is a surgical procedure used to correct carotid stenosis (obstruction of the carotid artery by atheroma), used particularly when this causes medical problems, such as transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs, strokes). ... Radiation therapy (or radiotherapy) is the medical use of ionizing radiation as part of cancer treatment to control malignant cells (not to be confused with radiology, the use of radiation in medical imaging and diagnosis). ... Fibrosis is the formation or development of excess fibrous connective tissue in an organ or tissue as a reparative or reactive process, as opposed to formation of fibrous tissue as a normal constituent of an organ or tissue. ... This article includes a list of works cited or a list of external links, but its sources remain unclear because it lacks in-text citations. ... The larynx (plural larynges), colloquially known as the voicebox, is an organ in the neck of mammals involved in protection of the trachea and sound production. ... Pharyngitis (far-in-jÄ« tis) is a painful inflammation of the pharynx, and is colloquially referred to as a sore throat. ... “Hurting” redirects here. ... A diagram showing the CNS: 1. ... A sedative is a drug that depresses the central nervous system (CNS), which causes calmness, relaxation, reduction of anxiety, sleepiness, slowed breathing, slurred speech, staggering gait, poor judgment, and slow, uncertain reflexes. ... The anticonvulsants, sometimes also called antiepileptics, belong to a diverse group of pharmaceuticals used in prevention of the occurrence of epileptic seizures. ... An antihistamine is a drug which serves to reduce or eliminate effects mediated by histamine, an endogenous chemical mediator released during allergic reactions, through action at the histamine receptor. ... The term antipsychotic is applied to a group of drugs used to treat psychosis. ... Barbiturates are drugs that acts as central nervous system (CNS) depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. ... The peripheral nervous system or PNS, is part of the nervous system, and consists of the nerves and neurons that reside or extend outside the central nervous system (the brain and spinal cord) to serve the limbs and organs, for example. ... In physiology, corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. ... Tryptophan is an amino acid and essential in human nutrition. ... An anticholinergic agent is a member of a class of pharmaceutical compounds which serve to reduce the effects mediated by acetylcholine in the central nervous system and peripheral nervous system. ...

Assessment of adults

A Speech Language Pathologist is most often the first person called upon to evaluate a patient with suspected dysphagia. During this informal examination, medical history is obtained, the mini-mental state examination is administered, and oral and facial sensorimotor function, speech, and swallowing are evaluated non-instrumentally. // Scope of Practice The practice of speech-language pathology includes prevention, diagnosis, habilitation, and rehabilitation of communication, swallowing, or other upper aerodigestive disorders; elective modification of communication behaviors; and enhancement of communication. ... The mini-mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to assess cognition. ...


A patient needing further investigation will most likely receive a Modified Barium Swallow (MBS). Different consistencies of liquid and food mixed with barium sulfate are fed to the patient by spoon, cup or syringe, and x-rayed using videofluoroscopy. A patient's swallowing then can be rated using the Penetration Aspiration Scale. The scale was developed to describe the disordered physiology of a person's swallow using the numbers 1-8 (Rosenbek et al., 1996). Not all examiners will use this scale. General Name, Symbol, Number barium2, Ba, 56 Chemical series alkaline earth metals Group, Period, Block 2, 6, s Appearance silvery white Standard atomic weight 137. ...


A patient can also be assessed using videoendoscopy, also known as flexible fiberoptic endoscopic examination of swallowing (FEES). The instrument, is placed into the nose until the clinician can view the pharynx and then he or she examines the pharynx and larynx before and after swallowing. During the actual swallow, the camera is blocked from viewing the anatomical structures. A rigid scope, placed into the oral cavity to view the structures of the pharynx and larynx, can also be used, however; the patient cannot swallow (Logemann, 1998). The pharynx (plural: pharynges) is the part of the neck and throat situated immediately posterior to the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea. ... The larynx (plural larynges), colloquially known as the voicebox, is an organ in the neck of mammals involved in protection of the trachea and sound production. ...


Other less frequently used assessments of swallowing are imaging studies, ultrasound and scintigraphy and nonimaging studies, electromyography (EMG), electroglottography (EGG)(records vocal fold movement), cervical auscultation, and pharyngeal manometry (Logemann, 1998). Ultrasound is a form of cyclic sound pressure with a frequency greater than the upper limit of human hearing, this limit being approximately 20 kilohertz (20,000 hertz). ... Nuclear medicine is the branch of medicine that uses unsealed radioactive substances in diagnosis and therapy. ... Electromyography (EMG) is a medical technique for evaluating and recording physiologic properties of muscles at rest and while contracting. ... Auscultation is the technical term for listening to the internal sounds of the body, usually using a stethoscope. ... In medicine, manometry is a study performed to examine the pression of one part of the body, generally the muscle function of the esophagus. ...


Treatment

After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly. The Speech Language Pathologist will also advise staff/caregivers and give information about what signs to look for to know if the client is aspirating (e.g. coughing, choking, voice quality becoming 'wet' or 'gurgly', chest colds, recurrent pneumonia) and feeding instructions if required, including posture while eating, consistency of food, and size of mouthfuls.


-Postural techniques (Logemann, 1998)

  • Head back (extension) – used when movement of the bolus from the front of the mouth to the back is inefficient; this allows gravity to help move the food.
  • Chin down (flexion) – used when there is a delay in initiating the swallow; this allows the valleculae to widen, the airway to narrow, and the epiglottis to be pushed towards the back of the throat to better protect the airway from food.
  • Chin down (flexion) – used when the back of the tongue is too weak to push the food towards the pharynx; this causes the back of the tongue to be closer to the pharyngeal wall.
  • Head rotation (turning head to look over shoulder) to damaged or weaker side with chin down – used when the airway is not protected adequately causing food to be aspirated; this causes the epiglottis to be put in a more protective position, it narrows the entrance of the airway, and it increases vocal fold closure.
  • Lying down on one side – used when there reduced contraction of the pharynx causing excess residue in the pharynx; this eliminates the pull of gravity that may cause the residue to be aspirated when the patient resumes breathing.
  • Head rotation to damaged or weaker side – used when there is paralysis or paresis on one side of the pharyngeal wall; this causes the bolus to go down the stronger side.
  • Head tilt (ear to shoulder) to stronger side – used when there is weakness on one side of the oral cavity and pharyngeal wall; this causes the bolus to go down the stronger side.

-Swallowing Maneuvers (Logemann, 1998) In medicine, aspiration is the entry of secretions or foreign material into the trachea and lungs. ... The vocal cords, also known as vocal folds, are composed of twin infoldings of mucous membrane stretched horizontally across the human larynx. ... Paralysis is the complete loss of muscle function for one or more muscle groups. ... Paresis is a condition typified by partial loss of movement, or impaired movement. ...

  • Supraglottic swallow - The patient is asked to take a deep breath and hold their breath. While still holding their breath they are to swallow and then immediately cough after swallowing. This technique can be used when there is reduced or late vocal fold closure or there is a delayed pharyngeal swallow.
  • Super-supraglottic swallow - The patient is asked to take a breath, hold their breath tightly while bearing down, swallow while still holding the breath hold, and then coughing immediately after the swallow. This technique can be used when there is reduced closure of the airway.
  • Effortful swallow - The patient is instructed to squeeze their muscles tightly while swallowing. This may be used when there is reduced posterior movement of the tongue base.
  • Mendelsohn maneuver - The patient is taught how to hold their adam's apple up during a swallow. This technique may be used when there is reduced laryngeal movement or a discoordinated swallow.

-Diet modification may be warranted. Some patients require a soft diet that is easily chewed, and some require liquids of a thickened or thinned consistency. For other uses, see Adams apple (disambiguation). ... A soft diet is recommended in many situations, including some types of dysphagia (difficulty swallowing), surgery involving the mouth or gastrointestinal tract, and pain from newly adjusted braces. ...


-Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example: having the patient use a straw while drinking liquids, putting a pillow behind the patient's head during feeding, removing distractors like too many people in the room or turning off the TV during feeding, etc.


-Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile agnosia for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal swallow (Logemann, 1998). Agnosia (a-gnosis, non-knowledge) is a loss of ability to recognize objects, persons, sounds, shapes or smells while the specific sense is not defective nor is there any significant memory loss. ...

  • pressure of a spoon against tongue
  • using a sour bolus
  • using a cold bolus
  • using a bolus that requires chewing
  • using a bolus larger than 3mL
  • thermal-tactile stimulation (controversial)

-Vitalstim Therapy ([1]) or electrical stimulation (E-stim) is targeted for oropharyngeal dysphagia and uses electrical stimulation to retrain the muscles used in swallowing. This type of therapy being used in a clinical setting is also very controversial because it lacks evidence of effectiveness. Please see external links for more information.


- Prosthetics

-Surgical treatments are usually only recommended as a last resort. A palatal lift is an oral prosthesis which elevates the soft palate superiorly and aids in restoration of soft palate functions which may be lost due to an acquired, congenital or developmental defect. ... This page is a candidate to be copied to Wiktionary. ...

Completed tracheostomy: 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff A tracheotomy or tracheostomy is a surgical procedure performed on the neck to open a direct airway through an incision in the trachea (the windpipe). ... Tracheotomy is a surgical procedure used to cut a hole in the trachea through which a small tube is inserted. ... Laryngectomy is the surgical removal of the larynx and separation of the airway from the mouth, nose, and esophagus. ... A palatoplasty is a surgical procedure used to correct or reconstruct the palate in a person with a cleft palate. ... A percutaneous endoscopic gastrostomy (PEG) is the making of access to the digestive tract through the abdominal wall. ...

Esophageal dysphagia

Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems.


Symptoms, signs, and evaluation

Patients usually experience food getting stuck several seconds after swallowing, and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once a distinction has been made between a motility problem and a mechanical obstruction, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia likely can be diffuse esophageal spasm (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia disorders include scleroderma or achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss. Intermittent mechanical dysphagia is likely to be an esophageal ring. Progressive mechanical dysphagia is most likely due to peptic stricture or esophageal cancer. Diffuse esophageal spasm is a condition in which uncoordinated contractions of the esophagus occur. ... Scleroderma is a rare, chronic disease characterized by excessive deposits of collagen in the skin or other organs. ... Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder. ... Esophageal cancer is malignancy of the esophagus. ...


Tree diagram of esophageal dysphagia

Schematically the above can be presented as a tree diagram:

 
 
 
 
 
 
 
 
 
 
 
 
 
Esophageal
dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Solids & liquids
(Neuromuscular)
 
 
 
 
 
 
 
 
 
Solids only
(Mechanical obstruction)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Progressive
 
 
 
 
 
Intermittent
 
Intermittent
 
 
 
 
 
Progressive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Scleroderma
 
 
 
Achalasia
 
 
Diffuse esophageal
spasm
 
Lower esophageal ring
 
 
Cancer
 
 
 
Peptic stricture

Scleroderma is a rare, chronic disease characterized by excessive deposits of collagen in the skin or other organs. ... Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder. ... Esophageal cancer is malignancy of the esophagus. ...

Etiology and differential diagnosis (causes)

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia.
Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia.

Peptic stricture, or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to gastroesophageal reflux (GERD). These patients are usually older and have had GERD for a long time. Acid reflux can also be due to other causes, such as Zollinger-Ellison syndrome, NG tube placement, and scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present. Etiology (alternately aetiology, aitiology) is the study of causation. ... This article or section does not cite any references or sources. ... Image File history File links Peptic_stricture. ... Image File history File links Peptic_stricture. ... In medicine (gastroenterology), esophagogastroduodenoscopy (EGD) or upper endoscopy is a diagnostic endoscopic procedure that visualises the upper part of the gastrointestinal tract. ... The esophagus (also spelled oesophagus/œsophagus, Greek ), or gullet is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. ... In anatomy, the stomach is a bean-shaped hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. ... Gastroesophageal Reflux Disease (GERD, or GORD when -oesophageal, the BE form, is substituted) is injury to the esophagus that develops from chronic exposure of the esophagus to acid coming up from the stomach (reflux). ... Skírnir tries to woo Gerd for Freyr as related in Skírnismál. ... Zollinger-Ellison syndrome is a disorder where increased levels of the hormone gastrin are produced, causing the stomach to produce excess hydrochloric acid. ...

Main article: peptic stricture

Esophageal cancer also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or adenocarcinoma. Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed Barrett's esophagus (intestinal metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use. Esophageal cancer is malignancy of the esophagus. ... Adenocarcinoma is a form of carcinoma that originates in glandular tissue. ... Endoscopic image of Barretts esophagus, which is the area of red mucosa projecting like a tongue. ... Metaplasia is the replacement of one differentiated cell type with another differentiated cell type. ...

Main article: esophageal cancer

Esophageal rings and webs, are actual rings and webs of tissue that may occlude the esophageal lumen. Esophageal cancer is malignancy of the esophagus. ... Esophageal webs are thin membranes located in the middle or upper esophagus. ...

  • Rings --- Also known as Schatzki rings from the discoverer, these rings are usually mucosal rings rather than muscular rings, and are located near the gastroesophageal junction at the squamo-columnar junction. Presence of multiple rings may suggest eosinophilic esophagitis. Rings cause intermittent mechanical dysphagia, meaning patients will usually present with transient discomfort and regurgitation while swallowing solids and then liquids, depending on the constriction of the ring.
  • Webs --- Usually squamous mucosal protrusion into the esophageal lumen, especially anterior cervical esophagus behind the cricoid area. Patients are usually asymptomatic or have intermittent dysphagia. An important association of esophageal webs is to the Plummer-Vinson syndrome in iron deficiency, in which case patients will also have anemia, koilonychia, fatigue, and other symptoms of anemia.
Main article: esophageal web

Achalasia is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of peristalsis in the distal esophagus, which is mostly smooth muscle. Both of these features impair the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids, in particular, is a characteristic of achalasia. Other symptoms of achalasia include regurgitation, night coughing, chest pain, weight loss, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. In most cases the cause is unknown (idiopathic), but in some regions of the world, achalasia can also be caused by Chagas disease due to infection by Trypanosoma cruzi. Endoscopic image of Schatzki ring, seen in the esophagus with the gastro-esophageal junction in the background. ... Endoscopic image of esophagus in a case of eosinophilic esophagitis. ... The cricoid cartilage, or simply cricoid, is the only complete ring of cartilage around the trachea. ... The Plummer-Vinson syndrome, also called Paterson-Kelly syndrome or sideropenic dysphagia is a disorder linked to severe, long-term iron deficiency anemia, which causes swallowing difficulty (dysphagia) due to web-like membranes of tissue growing in the throat (esophageal webs). ... Iron deficiency can refer to: Iron deficiency (plant disorder) Iron deficiency (medicine) This is a disambiguation page — a navigational aid which lists other pages that might otherwise share the same title. ... Anemia (AmE) or anæmia (BrE), from the Greek () meaning without blood, is a deficiency of red blood cells (RBCs) and/or hemoglobin. ... Esophageal webs are thin membranes located in the middle or upper esophagus. ... Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder. ... In much of the digestive tract, muscles contract in sequence to produce a peristaltic wave which forces food (called bolus while in the esophagus and chyme below the esophagus) along the alimentary canal. ... Trypanosoma cruzi is a species of parasitic protozoan trypanosomes. ...

Main article: achalasia

Scleroderma is a disease characterized by atrophy and sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux. Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder. ... Scleroderma is a rare, chronic disease characterized by excessive deposits of collagen in the skin or other organs. ... Atrophy is the partial or complete wasting away of a part of the body. ... Multiple sclerosis (MS) is a demyelinating disease, a non-contagious chronic autoimmune disorder of the central nervous system which can present with a variety of neurological symptoms occurring in attacks or slowly progressing over time. ...

Main article: scleroderma

Spastic motility disorders include diffuse esophageal spasm (DES), nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific spastic esophageal motility disorders (NEMD). Scleroderma is a rare, chronic disease characterized by excessive deposits of collagen in the skin or other organs. ... Diffuse esophageal spasm is a condition in which uncoordinated contractions of the esophagus occur. ... Time space graph of normal peristalsis. ...

  • DES can be caused by many factors that affect muscular or neural functions, including acid reflux, stress, hot or cold food, or carbonated drinks. Patients present with intermittent dysphagia, chest pain, or heartburn.

Rare causes of esophageal dysphagia not mentioned above

A diverticulum (plural: diverticula) is medical term for an outpouching of a hollow (or a fluid filled) structure in the body. ... Normal anatomical locations of right and left subclavian arteries Aberrant subclavian artery, or aberrant subclavian artery syndrome refers to a rare anatomical variant of the origin of the right or left subclavian artery. ... Image of aortic anatomy showing proximity of vagus nerve and its recurrent branch to the aorta Ortners syndrome is a rare cardiovocal syndrome and refers to recurrent laryngeal nerve palsy from cardiovascular disease [1]. It was first described by N. Ortner, a Dutch anatomist, in 1897. ... The introduction to this article provides insufficient context for those unfamiliar with the subject matter. ...

Diagnostic tools

Once esophageal dysphagia has been implicated, the next step is either a barium swallow or an upper endoscopy. If there is any suspicion of a proximal lesion such as: A barium meal is a procedure in which barium barium sulfate is ingested by a patient and, in conjunction with X-rays, images depicting the the distal esophagus, stomach and duodenum can be obtained digestive system. ... In medicine (gastroenterology), esophagogastroduodenoscopy (EGD) or upper endoscopy is a diagnostic endoscopic procedure that visualises the upper part of the gastrointestinal tract. ...

  • history of surgery for laryngeal or esophageal cancer
  • history of radiation or irritating injury
  • achalasia
  • Zenker's diverticulum

a barium swallow should be performed first instead of endoscopy to prevent any perforation. If achalasia suspected on barium swallow, manometry is performed next to confirm. If a stricture is suspected, endoscopy is performed. Any other lesions found are treated as such. In medicine, manometry is a study performed to examine the pression of one part of the body, generally the muscle function of the esophagus. ...


If there is no suspicion of any of the above, endoscopy can be performed first. Any structural or mucosal abnormality is treated. A normal endoscopy should be followed by manometry; and if manometry is also normal, the diagnosis is functional dysphagia.


Treatment

The patient is generally sent for a GI, pulmonary, ENT, or oncology consult, depending on the suspected underlying cause. A consultation with a dietician may also be needed, as many patients may need dietary modifications.


See also

Swallowing, known scientifically as deglutition, is the reflex in the human body that makes something pass from the mouth, to the pharynx, into the esophagus, with the shutting of the epiglottis. ... Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function due to an interruption in the blood supply to all or part of the brain. ... Neurodegenerative disease (Greek νέυρο-, néuro-, nerval and Latin dēgenerāre, to decline or to worsen) is a condition in which cells of the brain and spinal cord are lost. ... Gastroesophageal Reflux Disease (GERD; or GORD when spelling œsophageal, the BrE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus[1]. This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. ... Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder. ... // Although age-related changes place older adults at risk for dysphagia, an older adult’s swallow is not necessarily an impaired swallow. ...

References

  • Logemann, J. A. (1998). Evaluation and Treatment of Swallowing Disorders, 2nd Edition. Austin, Texas: Pro-ed.
  • Murray, J. (1999). Manual of Dysphagia Assessment in Adults. San Diego: Singular Publishing.
  • Palmer, J.B., Drennan, J. (2000). Evaluation and treatment of swallowing impairments. American Family Physician 61, 2453-2462.
  • Rosenbek, J. C., Robbins J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration aspiration scale. "Dysphagia, 11," 93-98.
  1. ^ Sleisinger and Fordtran's Gastrointestinal and Liver Disease, 7th edition, Chapter 6, p. 63
  2. ^ Shamburek RD; Farrar JT. Disorders of the digestive system in the elderly. N Engl J Med 1990 Feb 15;322(7):438-43.
  3. ^ Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005 Dec;36(12):2756-63. Epub 2005 Nov 3.
  4. ^ Schatzki R. Panel discussion on diseases of the esophagus. Am J Gastro. 31:117 (1959).

External links


  Results from FactBites:
 
Dysphagia (964 words)
Dysphagia is the medical term for difficulty swallowing, or the feeling that food is "sticking" in your throat or chest.
Dysphagia in children is often due to malformations, conditions such as cerebral palsy or muscular dystrophy, or gastroesophageal reflux disease (GERD).
Dysphagia in adults is often due to tumors (benign or cancerous), conditions that cause the esophagus to narrow, neuromuscular conditions, or GERD.
Senior Living: Dysphagia (1539 words)
Dysphagia, or difficulty in swallowing, is not a disease in itself but a condition that can be brought on by many different causes because swallowing is a delicate process, easily disturbed.
Esophageal dysphagia is usually caused by reflux esophagitis motility disorders (abnormal coordination of contractions) and the presence of nearby tumors.
Dysphagia that grows worse and worse, on the other hand, is more typically caused by cancer, esophageal spasm or achalasia (failure of the LES to relax and allow food or drink to pass through to the stomach).
  More results at FactBites »

 
 

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