Dysphagia

Dysphagia is difficulty in swallowing food or liquid. If it is not caused by catarrh due to a cold, then this is a serious symptom that fully justifies further examination of the patient (endoscopic) to exclude neoplasia. If the patient complains of a sensation of an undigested lump in the throat outside the period of swallowing food, then the diagnosis is most likely a state of anxiety - what is called globus hystericus.

A common complaint is the sensation of food "getting stuck" at the entrance to the esophagus. This condition prevents the passage of liquid, solids, or both from the pharynx to the stomach. Dysphagia is classified as oropharyngeal or esophageal depending on at what level it occurs. Dysphagia should not be confused with globus sensation (globus hystericus - hysterical lump), a feeling of a lump in the throat that is not associated with the act of swallowing and the obstruction of food passage.

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Causes of dysphagia

Causes of dysphagia include neoplasms, neurological and other factors.

Malignant neoplasms

• Esophageal cancer
• Stomach cancer
• Pharyngeal cancer
• External pressure (eg lung cancer)

Neurological causes

• Boulevard palsy (motor neuron disease)
• Lateral medullary syndrome
• "Myasthenia gravis"
• Syringomyelia

Other

• Benign strictures
• Pharyngeal diverticulum
• Achalasia of the cardia
• Systemic sclerosis
• Esophagitis

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Pharyngeal "pocket" or gill sac

This is a hernial protrusion of the mucous membrane at the "Killian's site" of the inferior constrictor. There may be bad breath, regurgitation of food, and a visible bulging sac in the neck (usually on the left). Diagnosis is by barium swallow during fluoroscopy. Treatment is surgical.

Pharyngeal cancer

Patients with oropharyngeal tumors seek medical attention only when the disease is already in an advanced stage. Symptoms: discomfort in the throat, sensation of a lump in the throat, radiating pain to the ear (otalgia) and local irritation of the throat with hot or cold food. Hypopharyngeal tumors are manifested by dysphagia, voice changes, otalgia, stridor and pain in the throat. Treatment is usually combined - surgery, chemotherapy and radiation.

Esophageal cancer

Esophageal cancer is often accompanied by achalasia, Barrett's ulcer, esophageal callus (a condition in which there is exfoliation of the skin); Plummer-Vinson syndrome; patients with esophageal cancer tend to smoke.

Dysphagia is progressive. Surgical resection is quite possible (survival for more than 5 years is very rare); as a palliative operation - intubation with a special tube (for example, Celestin).

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Benign esophageal stricture

Causes: gastroesophageal reflux, ingestion of corrosive substances, presence of foreign bodies in the esophagus, trauma. Treatment: dilation of the esophagus (endoscopic or with bougies under anesthesia).

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Achalasia

In this case, there is a violation of the peristalsis of the esophagus with insufficient relaxation of the lower esophageal sphincter. The patient is able to swallow both liquid and solid food, but very slowly. When swallowing barium, the radiologist sees early filling of the "ribbon" of the esophagus, but its expansion occurs with a delay. Such patients may have bad breath, as well as repeated lung infections due to inhalation of pathogenic microbes. After myomectomy, up to 75% of patients are cured. Pneumatic dilation of the esophagus also brings some help.

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Plummer-Visoia syndrome

This is an atrophy of the mucous membrane and the proliferation of special connective tissue in the esophagus against the background of iron deficiency anemia; it also occurs with postcricoid (located behind the cricoid carcinoma) carcinoma.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is a difficulty in moving food from the oropharynx into the esophagus; it occurs due to dysfunction proximal to the esophagus.

It most often occurs in patients with neurological disorders or muscle disorders that affect striated muscles. Neurological disorders include Parkinson's disease, stroke, multiple sclerosis, amyotrophic lateral sclerosis (L'Antebellum disease), bulbar poliomyelitis, pseudobulbar palsy, and other CNS disorders. Muscle disorders include dermatomyositis, myasthenia gravis, and muscular dystrophy.

Symptoms of dysphagia include initial difficulty swallowing, nasal regurgitation, and tracheal aspiration with cough. Diagnosis is made by direct observation of the patient and by video recording of a barium swallow. Treatment of dysphagia is directed at the underlying cause.

Esophageal dysphagia

Esophageal dysphagia is a difficult passage of food through the esophagus. It is the result of either mechanical obstruction or motility disorders.

Causes of mechanical obstruction include intrinsic esophageal lesions such as peptic stricture, esophageal cancer, and lower esophageal membrane. Mechanical obstruction may result from extrinsic pathological processes that compress the esophagus, including: an enlarged left atrium, aortic aneurysm, vascular lesions such as an aberrant subclavian artery (dysphagia cryptica), substernal goiter, cervical bony exostosis, and thoracic tumors, most commonly lung cancer. Rarely, the esophagus is affected by lymphoma, leiomyosarcoma, or metastatic cancer. Caustic ingestion often causes marked obstruction.

Motility disorders are a cause of dysphagia when the smooth muscle function of the esophagus is impaired (i.e., esophageal peristalsis and esophageal sphincter function). Motility disorders include achapasia and diffuse esophageal spasm. Systemic sclerosis may be a cause of motility disorders.

Motility disorders cause dysphagia to solids and liquids; mechanical obstruction causes dysphagia to solids only. Patients have the greatest difficulty eating meat and bread; however, some patients cannot eat any solids. Patients complaining of lower esophageal dysphagia usually correctly localize the cause, while those complaining of upper esophageal dysphagia are often vague.

Dysphagia may be intermittent (eg, lower esophageal sphincter dysfunction, lower esophageal ring, or diffuse esophageal spasm), rapidly progressive over weeks or months (eg, esophageal cancer), or progressive over years (eg, peptic stricture). Patients with dysphagia due to peptic stricture usually have a history of gastroesophageal reflux disease.

Dysphagia for liquids or solids helps differentiate motor disorders from obstruction. A barium swallow (a hard bread pellet mixed with barium, usually in the form of a capsule or tablet) should be performed. If the study reveals obstruction, endoscopy (and possibly biopsy) is indicated to exclude malignancy. If the barium study is negative or a motor disorder is suspected, esophageal motility studies should be performed. Treatment of dysphagia is directed at the cause.

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Cricopharyngeal incoordination

In cricopharyngeal incoordination, there is an uncoordinated contraction of the cricopharyngeal muscle (upper esophageal sphincter). This disorder can cause a Zenker diverticulum; repeated aspiration of the diverticulum contents can lead to chronic lung disease. The cause can be corrected by surgery to cut the cricopharyngeal muscle.

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Mysterious Dysphagia

Mysterious dysphagia occurs as a result of compression of the esophagus by vessels due to their various congenital anomalies.

The vascular anomaly is usually an aberrant right subclavian artery arising from the left side of the aortic arch, a duplication of the aortic arch, or a right aortic arch with a left arterial ligament. Dysphagia may appear in childhood or later as a result of atherosclerotic changes in the aberrant vessel. Barium swallow shows extrinsic compression, but arteriography is needed for definitive diagnosis. Most often, no specific treatment is required, but surgical correction is occasionally necessary.

How is dysphagia diagnosed?

"The key to diagnosis" obtained from the anamnesis

If the patient is able to drink liquid as easily and quickly as usual (except for situations when dense food has stuck to the mucous membrane of the esophagus), this indicates strictures; if not, assume a disorder of the motor function of the esophagus (achalasia, neurological cases). If the patient has difficulty making swallowing movements, bulbar paralysis should be suspected. If dysphagia is constant or very painful, strictures caused by a malignant neoplasm cannot be ruled out. If gurgling sounds are heard from the patient's throat while taking liquid, and a protrusion appears on the neck, then one should think about the presence of a "pharyngeal pocket" (food from it can regurgitate, be thrown back into the upper part of the pharynx).

Pharyngeal pathology does not present any difficulties for differential diagnostics. Diagnostic tasks include determining the nature of dysphagia - functional or organic.

Functional dysphagia is characterized by episodic or transient occurrence and is provoked by irritating food, most often liquid, cold, hot, spicy, sour, etc. At the same time, dense food does not cause attacks of esophageal spasm. The severity of manifestations does not change over time. The time of occurrence does not depend on the stage of food passage through the esophagus.

Dysphagia caused by organic pathology is characterized by slow development, with gradual aggravation. It is provoked by the passage of dense food, difficulty in the passage of liquids is noted in advanced cases of stenosis. Drinking water with food brings relief. Vomiting is noted already in advanced cases; The level of damage can be determined by the time of occurrence, pain behind the sternum after swallowing food: in the cervical region - after 1-1.6 seconds; in the thoracic - after 5-6 seconds; in the cardiac - after 7-8 seconds. Sharp pain is characteristic of ulcerative esophagitis, reflux esophagitis, diverticulitis - foreign bodies, rarely occurs with cancer.

Dysphagia of organic origin, even very weakly expressed, should alert with respect to cancer, since it is the earliest and, perhaps, the only early manifestation. The mandatory complex of examinations should include FEGS and contrast X-ray of the esophagus. In case of detection of organic pathology, additional examinations are carried out by thoracic surgeons or, if available in the region, specialists of esophageal and mediastinal surgery centers.

Examination of patients

Complete blood count,ESR determination, X-ray with barium swallow; endoscopy with biopsy; examination of the contractility of the esophagus (the patient must swallow a catheter with a special sensor).

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