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Sunday, June 9, 2019

June is Dysphagia Awareness Month and Esophageal Dilation


Dysphagia is, according to American College of Gastroenterology,


"Dysphagia is the medical term used to describe difficulty swallowing. Dysphagia includes difficulty starting a swallow (called oropharyngeal dysphagia) and the sensation of food being stuck in the neck or chest (called esophageal dysphagia). Oropharyngeal dysphagia can result from abnormal functioning of the nerves and muscles of the mouth, pharynx (back of the throat) and upper esophageal sphincter (muscle at the top end of the swallowing tube). Diseases that involve the swallowing tube (esophagus) can cause esophageal dysphagia. When a patient is being evaluated for dysphagia, it is important for the doctor to determine which type of dysphagia is more likely, oropharyngeal or esophageal, as different tests are ordered for each type.

Dysphagia needs to be distinguished from odynophagia, which is defined as pain during swallowing. This can arise from infection or inflammation in the esophagus. Dysphagia also needs to be distinguished from globus sensation. This is a constant sensation of something being stuck at the back of the throat, which does not typically make swallowing difficult. In contrast, dysphagia is a symptom that only occurs when attempting to swallow. Globus can sometimes be seen in acid reflux disease, but more often, it is due to increased sensitivity in the throat or esophagus.









Causes of Dysphagia 

Just as there are two types of dysphagia – oropharyngeal and esophageal dysphagia – there are similarly two broad groups of causes for dysphagia. Within each broad group, there are two subgroups of causes: neuromuscular (involving the nerve or muscle), and structural, where the esophagus is narrowed or compromised.

Oropharyngeal dysphagia: Neuromuscular causes are more frequent than structural causes for this type of dysphagia. This is because the nerves controlling the muscles of the mouth, back of throat (pharynx) and top end of the esophagus (upper esophageal sphincter) have direct connections with the brain through cranial nerves, and can therefore be damaged in diseases involving the brain or cranial nerves.

Less common than neuromuscular causes are structural causes, including strictures (narrowed areas), or rarely tumors growing in the back of the throat.

Esophageal dysphagia:  In this type of dysphagia, structural causes are far more frequent than disorders involving nerves or muscles. Therefore, narrowing in the esophagus from scarring due to acid reflux disease, inflammation of the lining of the esophagus (usually from acid reflux disease but occasionally from infections), tumors within the esophagus, and compression of the esophagus from growths in the chest or sometimes even an enlarged heart can all cause dysphagia. In addition, a unique type of inflammation caused by a type of blood cell called eosinophils can cause dysphagia; this condition is called eosinophilic esophagitis.

Less common are disorders involving the nerves and muscle of the esophagus.  The esophageal muscle can be weak and sometimes unable to generate adequate pressure during contraction. In extreme situations, the muscle generates no force and is unable to squeeze – this is sometimes called scleroderma esophagus (even though scleroderma is not frequently the cause), and can be associated with dysphagia. Another disorder of the nerves and muscles is achalasia; a condition in which the muscle at the bottom end of the esophagus cannot relax during swallowing because of abnormal nerve control. The muscle in the body of the esophagus also does not squeeze normally in achalasia, and becomes weak and stretched.  When the nerves are abnormal to a lesser degree, spasm of the esophagus may result, which can also cause dysphagia.











Symptoms of Dysphagia 

By definition, dysphagia is the sensation that food or liquids do not pass normally from the mouth to the stomach. Symptoms can vary depending on the location of the abnormality causing dysphagia.

When the patient has oropharyngeal dysphagia from a neuromuscular cause, muscles involved in chewing and in pushing food to the back of the throat may also be involved. In general, dysphagia occurring within one second of trying to swallow is due to oropharyngeal dysphagia. The muscles that protect the nose and the voice box (larynx) during swallowing may be defective in their function, causing the patient to have food and drink come out through the nose or enter the airway through the larynx (voice box) while trying to swallow (called ‘aspiration’).

Food entering the larynx can cause choking, coughing, or even lead to a type of pneumonia called aspiration pneumonia. There may be a change in the patient’s voice (husky voice or hoarse voice) because of involvement of nerves that control the vocal cords. The trouble swallowing is typically felt in the region of the back of the throat.

With esophageal dysphagia, food may be swallowed normally, but may get stuck in the neck or chest. Sometimes, swallowed food comes back up (regurgitation), when it may taste like the food just eaten. Difficulty swallowing is usually worse with solids than with liquids. Symptoms of acid reflux disease such as heartburn may also be present, since reflux is the most common cause of narrowing in the esophagus causing dysphagia. Even though the abnormality may be at the bottom end of the esophagus, the sensation of food being stuck may be felt higher up in the chest or even in the neck region.

Rarely, food may actually block the esophagus (food impaction) – this will result in a total inability to swallow, including liquids, and usually requires urgent endoscopy to remove the food bolus. Achalasia, a condition where the esophagus fails to relax and allow food to pass, may be difficult to diagnose because symptoms progress slowly. In achalasia, difficulty may occur with both solids and liquids, and symptoms may be severe enough to cause weight loss. Patients with esophageal spasm can have chest pain as well.



Image Source: https://images.agoramedia.com/everydayhealth/gcms/How-to-Manage-Swallowing-Difficulties-With-MS-1440x810.jpg?width=722





Image Source: https://st4.depositphotos.com/3900811/20224/v/1600/depositphotos_202245526-stock-illustration-vector-illustration-about-dysphagia-and.jpg








Image Source: https://understandingmyositis.org/wp-content/uploads/2016/01/dysphagia-image.jpg






Diagnosis of Dysphagia 
The first step is to distinguish between oropharyngeal dysphagia and esophageal dysphagia from the patient’s symptoms. The evaluation begins with a careful history from the patient, which can provide direction towards the cause of dysphagia in the majority of patients. Tests performed on patients with dysphagia depend on whether the doctor thinks that the patient has oropharyngeal or esophageal dysphagia.

Investigation of oropharyngeal dysphagia starts with a careful neurologic examination to identify which nerves and muscles might be abnormal. Swallowing function testing of the mouth and throat can be performed with videofluoroscopy or modified barium swallow. This test involves giving the patient food items of different consistency (e.g. cookie, marshmallow) containing barium and observing the swallow on an x-ray screen (fluoroscopy). This test can show if the barium enters the larynx (opening to the breathing tube) while attempting to swallow, or if it passes normally through the upper esophageal sphincter, and can help determine how the patient can position his or her head or neck to make each swallow effective.

A tiny endoscope can be introduced through the nose to the back of the throat to see the act of swallowing – this test is called nasal endoscopy. This test can also be used to stimulate the back of the throat with a jet of air to see if the muscle responds or if it is paralyzed. When tumors of the back of the throat or back of the brain are suspected, a CT scan or a MRI scan of the head and neck may be useful. Measurement of pressures within the back of the throat during swallowing (manometry) is less useful, but the newer high resolution manometry techniques can be considered if other tests fail to find an abnormality. Finally, blood tests can be useful to diagnose myasthenia gravis, polymyositis and other muscle disorders.

Endoscopy (examination of the esophagus using a tube with a light and a video camera at the end) is one of the tests used in the evaluation of esophageal dysphagia. This test not only allows the doctor to inspect the lumen and lining of the esophagus, but samples of abnormal tissue can be taken for examination and if appropriate, treatment can be performed by stretching out narrowed areas. Another test that can be used is to take x-rays while the patient swallows barium (barium swallow or esophagram). This is most useful when the esophagus is expected to have very tight narrowing. If a narrowing is not seen on either endoscopy or barium swallow, measurement of pressures within the esophagus while swallowing sips of water (manometry) can help find out if the muscle of the esophagus squeezes or relaxes abnormally while swallowing, and can diagnose conditions like achalasia or esophageal spasm.






Image Source: https://matsusurgical.com/wp-content/uploads/sites/450/2018/01/Dysphagia.jpg






Treatment of Dysphagia


For the most part, the treatment of dysphagia depends on the cause. Treatment often involves making a change in the foods eaten or the consistency of food. The modified barium swallow may identify foods of certain consistencies that can be swallowed better than others. The test can also identify head and neck positions that facilitate swallowing.

Patients with narrowing of the esophagus benefit from stretching (dilating) the esophagus. Several techniques are available for dilation. Balloons can be passed through the endoscope and distended to stretch the narrowing, or dilators (long rubber or plastic cylinders of various sizes) can be passed through the mouth, sometimes over a guide wire. Since narrowing is usually related to acid reflux disease, treatment with an acid lowering agent is usually recommended. 

Patients with eosinophilic esophagitis are treated with acid lowering agents or steroid preparations sprayed to the back of the throat and swallowed. Dilation is also affective but should be performed with caution to avoid tears; dilation is usually done if steroid preparations do not improve dysphagia in eosinophilic esophagitis. When the narrowing is from inoperable cancer, wire or metal stents (thin expandable tubes) can be placed during endoscopy to keep the lumen of the esophagus open allowing food and liquid to pass through. Patients with achalasia improve when the muscle at the bottom end of the esophagus is disrupted, either with a large balloon (pneumatic dilation) or during surgery where the muscle is cut (myotomy). Sometimes, botulinum toxin (BOTOX®) can be injected into the muscle at the bottom end of the esophagus to make it relax, but this treatment only results in short term improvement in achalasia.
 


Author(s) and Publication Date(s)

C. Prakash Gyawali, MD, MRCP, FACG, Washington University School of Medicine, St. Louis, MO – Published November 2010."










Here is a video below that explains Dysphagia:



Video Source: https://youtu.be/MrbEUDO6S5U




My friend Nancy was brave enough to share her story:

"My journey into the area of Dysphagia came literally out of nowhere!  I came home from my visit at Mayo Clinic in Florida with new symptoms, one of them being was this scared feeling I couldn’t swallow.

I contacted the doctor who had diagnosed me with pelvic floor dysfunction and dyspepsia.  He sent me home and then I was lost.  After a brief conversation with him he told me, oh sure,  you could have Dyspepsia and Dysphagia.   It’s like fibromyalgia in the gut.   I was speechless and confused to say the least.   He also suggested I find a GI (gastroenterologist) closer to my area of Florida who could attend to me.   

So for the next few years I just lived with the fear and anxiety about eating.   I still had the suspicion I had gastroparesis which I had been diagnosed with about four years prior to this visit.  But the doctor at Mayo said no, and took me off domperidone.

Luckily about nine years ago I saw a post that a fabulous GI doctor had relocated to the University of Miami.  She had performed some of my procedures at University of Florida Shane’s Hospital.  I contacted the department and saw her immediately.

This is when my life turned around.  Dr. Moshiree became my life line as she discovered that I had motility disorders from literally my mouth to my rectum.   We came up with some sort of management plan but over the years it has been tweaked.   
Unfortunately Dr. Moshiree has moved to another location so I cannot see her.  However, she did leave me in food hands with her best friend who is a GI doctor in my town.

The flare ups  and swallow and spasms are very difficult for me.  I have figured out a soft diet of sorts and try to be a nutritious as possible.  But after twelve years of this, it has been tough and I will admit I have a very healthy fear of eating."








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Image Source: https://i.pinimg.com/originals/2c/55/b9/2c55b96c3f6f165738e2585544c67c44.jpg




According to the National Foundation of Swallowing Disorders,

"The numbers: The prevalence of dysphagia is unknown, but Epidemiologic studies indicate that the numbers may be as high as 22% of the population over 50 years of age. Several studies conclude that between 300,000 and 600,000 individuals in the United States are affected by neurogenic dysphagia each year. Plus, 10 million Americans are evaluated each year for swallowing difficulties. Because this disorder cuts across so many diseases, dysphagia is poorly understood and often under diagnosed.
Our society revolves around food and meals. For people with dysphagia, life as you know it ceases to exist. Dysphagia can cause depression, low self esteem, lost wages, poor social performance, and increasing health risks such as aspiration pneumonia. Working through the mental aspects of this disorder is, in many ways, as challenging as addressing the physical limitations.









Dysphagia symptoms: Each person is different, but some of the common symptoms of this disorder are as follows:
  • coughing during or right after eating or drinking
  • wet or gurgly sounding voice during or after eating or drinking
  • extra effort or time needed to chew or swallow
  • food or liquid leaking from the mouth or getting stuck in the mouth
  • recurring pneumonia or chest congestion after eating
  • weight loss or dehydration from not being able to eat enough

Diagnostic tests for dysphagia: These tests are generally performed by speech-language pathologist. The most commonly used tests are:
  • Modified barium swallow study – the patient eats or drinks food or liquid with barium in it and the swallowing process is viewed on an x-ray  (search Google for “modified barium swallow study” for dozens of articles and videos showing this exam)
  • Endoscope assessment – using a lighted scope inserted through the nose, the swallow can be viewed on a screen (search Google for “endoscope assessment” for dozens of articles and YouTube for dozens of videos showing this exam)

Dysphagia treatment: Treatment depends on the cause, symptoms, and type of swallowing problem. A speech-language pathologist may recommend:
  • specific swallowing treatment (e.g., exercises to improve muscle movement)
  • positions or strategies to help the individual swallow more effectively
  • specific food and liquid textures that are easier and safer to swallow"


According to the Mayo Clinic,

"Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your mouth to your stomach. Dysphagia may also be associated with pain. In some cases, swallowing may be impossible.

Occasional difficulty swallowing, which may occur when you eat too fast or don't chew your food well enough, usually isn't cause for concern. But persistent dysphagia may indicate a serious medical condition requiring treatment.

Dysphagia can occur at any age, but it's more common in older adults. The causes of swallowing problems vary, and treatment depends on the cause.

Symptoms

Signs and symptoms associated with dysphagia may include:
  • Having pain while swallowing (odynophagia)
  • Being unable to swallow
  • Having the sensation of food getting stuck in your throat or chest or behind your breastbone (sternum)
  • Drooling
  • Being hoarse
  • Bringing food back up (regurgitation)
  • Having frequent heartburn
  • Having food or stomach acid back up into your throat
  • Unexpectedly losing weight
  • Coughing or gagging when swallowing
  • Having to cut food into smaller pieces or avoiding certain foods because of trouble swallowing






Image Source: https://www.verywellhealth.com/thmb/wX04kGlPCwbucyaeH8kMtan3oRs=/1500x1000/filters:no_upscale():max_bytes(150000):strip_icc()/problems-swallowing-dysphagia-and-multiple-sclerosis-2440815-V2_A-01-33a5bbe6aea1407c991c2f3d8c7db7c8.png

 

When to see a doctor

See your doctor if you regularly have difficulty swallowing or if weight loss, regurgitation or vomiting accompanies your dysphagia.
If an obstruction interferes with breathing, call for emergency help immediately. If you're unable to swallow because you feel that the food is stuck in your throat or chest, go to the nearest emergency department.


Causes

Swallowing is complex, and a number of conditions can interfere with this process. Sometimes the cause of dysphagia can't be identified. However, dysphagia generally falls into one of the following categories.

Esophageal dysphagia

Esophageal dysphagia refers to the sensation of food sticking or getting hung up in the base of your throat or in your chest after you've started to swallow. Some of the causes of esophageal dysphagia include:
  • Achalasia. When your lower esophageal muscle (sphincter) doesn't relax properly to let food enter your stomach, it may cause you to bring food back up into your throat. Muscles in the wall of your esophagus may be weak as well, a condition that tends to worsen over time.
  • Diffuse spasm. This condition produces multiple high-pressure, poorly coordinated contractions of your esophagus, usually after you swallow. Diffuse spasm affects the involuntary muscles in the walls of your lower esophagus.
  • Esophageal stricture. A narrowed esophagus (stricture) can trap large pieces of food. Tumors or scar tissue, often caused by gastroesophageal reflux disease (GERD), can cause narrowing.
  • Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.
  • Foreign bodies. Sometimes food or another object can partially block your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food may be more likely to have a piece of food become lodged in the throat or esophagus.
  • Esophageal ring. A thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods.
  • GERD. Damage to esophageal tissues from stomach acid backing up into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus.
  • Eosinophilic esophagitis. This condition, which may be related to a food allergy, is caused by an overpopulation of cells called eosinophils in the esophagus.
  • Scleroderma. Development of scar-like tissue, causing stiffening and hardening of tissues, can weaken your lower esophageal sphincter, allowing acid to back up into your esophagus and cause frequent heartburn.
  • Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus.



Image Source: https://www.researchgate.net/profile/Roberto_Grassi/publication/5267464/figure/tbl1/AS:601801187409937@1520491992460/Causes-of-dysphagia.png






Oropharyngeal dysphagia

Certain conditions can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus when you start to swallow. You may choke, gag or cough when you try to swallow or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia.


Causes of oropharyngeal dysphagia include:
  • Neurological disorders. Certain disorders — such as multiple sclerosis, muscular dystrophy and Parkinson's disease — can cause dysphagia.
  • Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can affect your ability to swallow.
  • Pharyngoesophageal diverticulum (Zenker's diverticulum). A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.
  • Cancer. Certain cancers and some cancer treatments, such as radiation, can cause difficulty swallowing.

Risk factors

The following are risk factors for dysphagia:
  • Aging. Due to natural aging and normal wear and tear on the esophagus and a greater risk of certain conditions, such as stroke or Parkinson's disease, older adults are at higher risk of swallowing difficulties. But, dysphagia isn't considered a normal sign of aging.
  • Certain health conditions. People with certain neurological or nervous system disorders are more likely to experience difficulty swallowing.

Complications

Difficulty swallowing can lead to:
  • Malnutrition, weight loss and dehydration. Dysphagia can make it difficult to take in adequate nourishment and fluids.
  • Aspiration pneumonia. Food or liquid entering your airway when you try to swallow can cause aspiration pneumonia, because the food can introduce bacteria to the lungs.
  • Choking. When food becomes impacted, choking can occur. If food completely blocks the airway, and no one intervenes with a successful Heimlich maneuver, death can occur.

Prevention

Although swallowing difficulties can't be prevented, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.

Dysphagia care at Mayo Clinic
Feb. 03, 2018

Dysphagia




Image Source: https://images.agoramedia.com/everydayhealth/gcms/How-to-Manage-Swallowing-Difficulties-With-MS-1440x810.jpg?width=722

















I had Dysphagia before I was officially diagnosed with Gastroparesis.  I had to have my esophagus stretched because I had such a hard time and difficulty swallowing. It always felt like food got stuck in my throat, which led to a choking feeling.  I am pretty sure I had Gastroparesis at this time, but since no one knew what it really was, the doctors I saw did the best that they could for me.  I have to say, the esophageal stretching is painful.  I'll put some information about it below:


"Understanding Esophageal Dilation 

 



What is Esophageal Dilation?

Esophageal dilation is a procedure that allows your doctor to dilate, or stretch, a narrowed area of your esophagus [swallowing tube]. Doctors can use various techniques for this procedure. Your doctor might perform the procedure as part of a sedated endoscopy. Alternatively, your doctor might apply a local anesthetic spray to the back of your throat and then pass a weighted dilator through your mouth and into your esophagus.

Why is Esophageal Dilation Done?

The most common cause of narrowing of the esophagus, or stricture, is scarring of the esophagus from reflux of stomach acid occurring in patients with heartburn. Patients with a narrowed portion of the esophagus often have trouble swallowing; food feels like it is “stuck” in the chest region, causing discomfort or pain. Less common causes of esophageal narrowing are webs or rings (which are thin layers of excess tissue), cancer of the esophagus, scarring after radiation treatment or a disorder of the way the esophagus moves [motility disorder].

How Should I Prepare for the Procedure?

An empty stomach allows for the best and safest examination, so you should have nothing to drink, including water, for at least six hours before the examination. Your doctor will tell you when to start fasting.

Tell your doctor in advance about any medications you take, particularly aspirin products or anticoagulants (blood thinners such as warfarin or heparin), or clopidogrel. Most medications can be continued as usual, but you might need to adjust your usual dose before the examination. Your doctor will give you specific guidance. Tell your doctor if you have any allergies to medications as well as medical conditions such as heart or lung disease. Also, tell your doctor if you require antibiotics prior to dental procedures, because you might need antibiotics prior to esophageal dilation as well.

What Can I Expect during Esophageal Dilation?

Esophageal Dilation image 1 Your doctor might perform esophageal dilation with sedation along with an upper endoscopy. Your doctor may spray your throat with a local anesthetic spray, and then give you sedatives to help you relax. Your doctor then will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope does not interfere with your breathing. At this point your doctor will determine whether to use a dilating balloon or plastic dilators over a guiding wire to stretch your esophagus. You might experience mild pressure in the back of your throat or in your chest during the procedure. Alternatively, your doctor might start by spraying your throat with a local anesthetic. Your doctor will then pass a tapered dilating instrument through your mouth and guide it into the esophagus. Your doctor may also use x-rays during the esophageal dilation procedure.

What Can I Expect after Esophageal Dilation?

After the dilation is done, you will probably be observed for a short period of time and then allowed to return to your normal activities. You may resume drinking when the anesthetic no longer causes numbness to your throat, unless your doctor instructs you otherwise. Most patients experience no symptoms after this procedure and can resume eating the next day, but you might experience a mild sore throat for the remainder of the day.

If you received sedatives, you probably will be monitored in a recovery area until you are ready to leave. You will not be allowed to drive after the procedure even though you might not feel tired. You should arrange for someone to accompany you home, because the sedatives might affect your judgment and reflexes for the rest of the day.

What are the Potential Complications of Esophageal Dilation?

Although complications can occur even when the procedure is performed correctly, they are rare when performed by doctors who are specially trained. A perforation, or hole, of the esophagus lining occurs in a small percentage of cases and may require surgery. A tear of the esophagus lining may occur and bleeding may result. There are also possible risks of side effects from sedatives.
It is important to recognize early signs of possible complications. If you have chest pain, fever, trouble breathing, difficulty swallowing, bleeding or black bowel movements after the test, tell your doctor immediately.

Will Repeat Dilations be Necessary?

Depending on the degree and cause of narrowing of your esophagus, it is common to require repeat dilations. This allows the dilation to be performed gradually and decreases the risk of complications. Once the stricture, or narrowed esophagus, is completely dilated, repeat dilations may not be required. If the stricture was due to acid reflux, acid-suppressing medicines can decrease the risk of stricture recurrence. Your doctor will advise you on this.

IMPORTANT REMINDER: This information is intended only to provide general guidance. It does not provide definitive medical advice. It is very important that you consult your doctor about your specific condition."




















For more information, please visit these Facebook pages:

https://www.facebook.com/bcsswallowing/

https://www.facebook.com/dysphagiacafe

https://www.facebook.com/DysphagiaRamblings



 I want to thank all three of these pages for their kindness to me in my research on this topic.  They have given me permission to share a lot of their information. I just wanted to say a personal thank you to everyone I have contacted to help me write this article, and I hope it will help spread awareness and understanding.












If anyone would like to share their stories of their issues with Dysphagia, please email me at: emilysstomach@gmail.com.  I would love to include as many personal stories as I can because you never know whose life you may touch, and you may have symptoms that helps someone else realize they might need to talk to their doctor about this issue.

Thank you for everyone who has given me their time and help in order for me to write this article.  I want to show my support for Dysphagia Awareness Month.



You can also fill out a survey that I've made below:





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