Dysphagia

Not to be confused with Dysphasia.

Dysphagia

ICD-10	R13
ICD-9	438.82, 787.2
DiseasesDB	17942
MedlinePlus	003115
eMedicine	pmr/194
MeSH	D003680

Dysphagia is the medical term for the symptom of difficulty in swallowing.^[1][2][3] Although classified under "symptoms and signs" in ICD-10,^[4] the term is sometimes used as a condition in its own right.^[5][6][7] Sufferers are sometimes unaware of their dysphagia.^[8][9]

It is derived from the Greek dys meaning bad or disordered, and phago meaning "eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach.^[10] Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing,^[11] and globus, which is the sensation of a lump in the throat. A psychogenic dysphagia is known as phagophobia.

It is also worthwhile to refer to the physiology of swallowing in understanding dysphagia.

Signs and symptoms

Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease.^[12] When dysphagia goes undiagnosed or untreated, patients are at a high risk of pulmonary aspiration and subsequent aspiration pneumonia secondary to food or liquids going the wrong way into the lungs. Some people present with "silent aspiration" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and renal failure.

Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling 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 dysphagia (patient complaint of swallowing difficulty).^[12] When asked where the food is getting stuck, patients will often point to the cervical (neck) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.

The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated.

Pain on swallowing or odynophagia is a distinctive symptom that can be highly indicative of carcinoma, although it also has numerous other causes that are not related to cancer.

Achalasia is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the auerbach submucosal plexus of the entire esophagus, which results in functional narrowing of the lower esophagus, and peristaltic failure throughout its length.

Differential diagnosis

Dysphagia is classified into two major types:

1. oropharyngeal dysphagia and
2. esophageal dysphagia.^[13]
3. functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.

Causes of oropharyngeal dysphagia include:

• Cerebrovascular Stroke
• Multiple Sclerosis
• Myasthenia gravis
• Parkinson's disease & Parkinsonism syndromes
• Amyotrophic Lateral Sclerosis
• Bell's palsy
• Bulbar Palsy & Pseudobulbar palsy
• Xerostomia
• Radiation
• Neck malignancies
• Neurotoxins (e.g. snake venom)
• Eosinophilic esophagitis
• Pharyngitis, etc.

Please refer to Etiology and Differential Diagnosis on the oropharyngeal dysphagia page for a more extensive list.

Causes of esophageal dysphagia can be divided into mechanical and functional causes.

• Functional causes include
  • achalasia,
  • myasthenia gravis, and
  • bulbar or pseudobulbar palsy.
• Mechanical causes include
  • peptic esophagitis,
  • carcinoma of the esophagus or gastric cardia
  • external compression of the esophagus, such as obstruction by lymph node and left atrial dilatation in mitral stenosis.
  • Candida esophagitis,
  • pharyngeal pouch,
  • esophageal web,
  • esophageal leiomyoma,
  • systemic sclerosis

Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from thickened fluids.

Diagnostic approach

The gold-standard for diagnosing oropharyngeal dysphagia in countries of the Commonwealth are via a Modified Barium Swallow Study or Videofluoroscopic Swallow Study (Fluoroscopy). This is a lateral video X-ray that provides objective information on bolus transport, safest consistency of bolus (honey, nectar, thin, pudding, puree, regular), and possible head positioning and/or maneuvers that may facilitate swallow function depending on each individual's anatomy and physiology. This study is performed by a Speech-Language Pathologist and a Radiologist.

Chest X-ray: to exclude bronchial carcinoma.

OGD: direct inspection and biopsy to look for any mass or ulceration.

Barium swallow and meal: look at mucosal lining and detect achalasia.

Epidemiology

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions.^[12] Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly,^[14] in patients who have had strokes,^[15] and in patients who are admitted to acute care hospitals or chronic care facilities. Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history by the treating physician. A formal oropharyngeal dysphagia evaluation is performed by a speech-language pathologist.^[16]

References

1. ^ dysphagia at eMedicine Dictionary
2. ^ Smithard DG, Smeeton NC, Wolfe CD (2007). "Long-term outcome after stroke: does dysphagia matter?". Age Ageing 36 (1): 90–4. doi:10.1093/ageing/afl149. PMID 17172601. 
3. ^ Brady A (2008). "Managing the patient with dysphagia". Home Healthc Nurse 26 (1): 41–6; quiz 47–8. doi:10.1097/01.NHH.0000305554.40220.6d. PMID 18158492. 
4. ^ "ICD-10:". http://www.who.int/classifications/apps/icd/icd10online/?gr10.htm+r13. Retrieved 2008-02-23. 
5. ^ Boczko F (2006). "Patients' awareness of symptoms of dysphagia". J Am Med Dir Assoc 7 (9): 587–90. doi:10.1016/j.jamda.2006.08.002. PMID 17095424. http://linkinghub.elsevier.com/retrieve/pii/S1525-8610(06)00377-X. 
6. ^ "Dysphagia at University of Virginia". http://www.healthsystem.virginia.edu/uvahealth/peds_digest/dysphagi.cfm. Retrieved 2008-02-24. 
7. ^ "Swallowing Disorders - Symptoms of Dysphagia at New York University School of Medicine". Archived from the original on 2007-11-14. http://web.archive.org/web/20071114045939/http://www.med.nyu.edu/rusk/services/swallowing/diagnosis.html. Retrieved 2008-02-24. 
8. ^ Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG (2004). "Awareness of dysphagia by patients following stroke predicts swallowing performance". Dysphagia 19 (1): 28–35. doi:10.1007/s00455-003-0032-8. PMID 14745643. 
9. ^ Rosenvinge SK, Starke ID (2005). "Improving care for patients with dysphagia". Age Ageing 34 (6): 587–93. doi:10.1093/ageing/afi187. PMID 16267184. http://ageing.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16267184. 
10. ^ Sleisenger, Marvin H.; Feldman, Mark; Friedman, Lawrence M. (2002). Sleisenger & Fordtran's Gastrointestinal & Liver Disease, 7th edition. Philadelphia, PA: W.B. Saunders Company. Chapter 6, p. 63. ISBN 0721600107. 
11. ^ "Dysphagia at University of Texas Medical Branch". http://www.utmb.edu/otoref/grnds/Dysphagia-2001-11/Dysphagia-2001-11.htm. Retrieved 2008-02-23. 
12. ^ ^{a b c} Logemann, Jeri A. (1998). Evaluation and treatment of swallowing disorders. Austin, Tex: Pro-Ed. ISBN 0-89079-728-5. 
13. ^ Spieker MR (June 2000). "Evaluating dysphagia". Am Fam Physician 61 (12): 3639–48. PMID 10892635. http://www.aafp.org/afp/20000615/3639.html. 
14. ^ Shamburek RD, Farrar JT (1990). "Disorders of the digestive system in the elderly". N. Engl. J. Med. 322 (7): 438–43. doi:10.1056/NEJM199002153220705. PMID 2405269. 
15. ^ Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005). "Dysphagia after stroke: incidence, diagnosis, and pulmonary complications". Stroke 36 (12): 2756–63. doi:10.1161/01.STR.0000190056.76543.eb. PMID 16269630. http://stroke.ahajournals.org/cgi/pmidlookup?view=long&pmid=16269630. 
16. ^ Ingelfinger FJ, Kramer P, Soutter L, Schatzki R (1959). "Panel discussion on diseases of the esophagus". Am. J. Gastroenterol. 31 (2): 117–31. PMID 13617241. 

External links

• Dysphagia at the Open Directory Project
• Overview of Feeding Problems in Children
• Dysphagia Guideline at the World Gastroenterology Organisation (WGO)
• Speech Language Pathology Scope of Practice
• American Speech-Language-Hearing Association
• Swallowing and Feeding