Dysphagia
Dysphagia is difficulty swallowing. It includes the feeling that food is stuck in the throat or somewhere between the throat and the stomach.
Difficulty swallowing is common among all age groups but is more common among older people. Between 5% and 10% of older people who live independently have difficulty swallowing.
Swallowing becomes difficult when food does not pass normally from the mouth to the stomach. This difficulty may be temporary and disappear on its own. Or it may be caused by a disorder. Swallowing is partly under a person's control (is voluntary) and occurs partly without conscious effort (is involuntary). Problems can affect either part of the action.
Causes
A problem as simple as eating too fast, taking bites that are too big, having poorly fitting dentures, or having missing or loose teeth can make swallowing difficult. Not drinking enough water when eating or eating while lying down makes swallowing more difficult.
People with dementia may not chew food adequately or may forget to swallow it.
Disorders that damage any part of the body that is involved in swallowing?muscles, nerves, or brain?may cause difficulty swallowing. A stroke is the most common example among older people. Almost 30% of people who have had a stroke have difficulty swallowing. Parkinson's disease, myasthenia gravis, pseudobulbar palsy, systemic sclerosis, and amyotrophic lateral sclerosis (Lou Gehrig's disease) can also cause difficulty swallowing. Some drugs, especially phenothiazines (a type of antipsychotic drug), can cause difficulty swallowing because they affect the throat muscles.
Some disorders interfere with normal contractions of the esophagus. Then food cannot move through the esophagus into the stomach as it normally does. The esophagus contracts, but the contractions do not move food. This abnormal contraction can cause esophageal spasm. In about one third of people with spasms, the lower esophageal sphincter does not open normally and does not contract in coordination with the rest of the esophagus. As a result, the movement of foods and fluids into the stomach may be delayed, causing a feeling that food is stuck.
Uncommonly, the nerves that control the lower esophageal sphincter and the esophagus are abnormal, resulting in achalasia. In achalasia, the esophagus does not contract, and the lower esophageal sphincter does not relax normally to allow food to pass into the stomach. The cause of achalasia is unknown. It usually begins, almost unnoticed, between the ages of 20 and 60, then progresses gradually over many months or years. At first, people have difficulty swallowing solid foods, but eventually they also have difficulty swallowing liquids.
Swallowing may become difficult because the esophagus is narrowed or completely blocked. Progressive damage to the esophagus can cause scar tissue to form. This inflexible scar tissue (called a stricture) narrows the esophagus and restricts the movement of food through it.
The esophagus is not easily damaged. However, it can be damaged gradually by the repeated backward flow of acid from the stomach (gastroesophageal reflux) over months to years. Taking certain drugs can damage the lining of the esophagus (causing erosion) or cause deeper sores (ulcers). These drugs include bisphosphonates (used to treat osteoporosis), aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), some antibiotics (such as doxycycline, tetracycline, and clindamycin), and potassium or iron supplements. Damage by drugs is more common among older people. Part of the reason may be that the esophagus does not contract normally or that older people do not drink enough water when they take the drug.
An abnormal ring of tissue may narrow the esophagus. The most common type is Schatzki's ring, which is located near the stomach. What causes these rings to form is unclear, but they may result from damage due to reflux, abnormal contractions of the esophagus, or the use of certain drugs. These rings intermittently cause difficulty swallowing. Usually, difficulty occurs when solid foods are eaten rapidly. The solid food most commonly caught in a ring is poorly chewed meat. The result is severe pain. Because this problem often occurs when dining out, it is sometimes called steakhouse syndrome.
Thin sheets of tissue (webs) may form across the interior of the esophagus, partially blocking it. Rarely, webs may result from severe iron deficiency that is not treated. Esophageal webs are more common among older people. A few people are born with esophageal rings or webs, which do not cause symptoms until later in life. Webs, like rings, cause difficulty swallowing solid foods, not liquids.
A pouch (diverticulum) that develops just above the upper esophageal sphincter or in the wall of the esophagus may make swallowing difficult. Food is caught in the pouch, causing discomfort. If the pouch is filled, it can block the passage of food. Sometimes pouches form in response to injury or irritation. They may form if the contractions of the throat and upper sphincter are not coordinated. Sometimes the cause is unknown. The most common type is Zenker's diverticulum, which forms just above the upper esophageal sphincter. Zenker's diverticulum usually develops after age 50.
Food and foreign bodies may block the esophagus. The esophagus can be partially or completely blocked by a noncancerous (benign) or cancerous (malignant) tumor in the esophagus. Esophageal cancer rarely causes difficulty swallowing, but many people still fear that possibility.
See the figure Pouches and Bulges in the Digestive Tract.
Several disorders can block the esophagus by putting pressure on it from outside. For example, a heart disorder may cause part of the aorta or heart to enlarge and press on the esophagus. Cancer (most commonly, lung cancer), an aortic aneurysm, enlargement of the thyroid gland, or excessive growth of bones in the spine (vertebrae) can also put pressure on the esophagus.
Symptoms
Most people who have difficulty swallowing have difficulty swallowing solids, particularly breads and meats. After eating, people may feel as if they have a lump in their throat or tightness in their chest. They may have to swallow several times before the food feels as if it has gone down. Much later, swallowing liquids may become difficult. Some people have difficulty swallowing solids and liquids from the beginning.
People with difficulty swallowing may regurgitate food through the mouth or nose. When they lie down at night, they may cough or spit up food swallowed many hours before. They may inhale (aspirate) food into the windpipe (trachea), then cough. Aspirating food can lead to lung disorders, including airway infections and a form of pneumonia called aspiration pneumonia.
Depending on the cause of dysphagia, people may have chest pain when they eat. Chest pain may be caused by spasms of the esophagus. This pain is often described as a squeezing pain under the breastbone (sternum). The pain resembles chest pain due to coronary artery disease (angina), so the two are sometimes confused. Some people feel pain in the throat when they swallow. This pain may be caused by an infection or, rarely, cancer.
People with Zenker's diverticulum may have bad breath because food collects in the pouch. The pouch can also interfere with taking pills. Pills can become stuck in the pouch and thus are not absorbed into the bloodstream. Occasionally, the pouch causes pressure or swelling in the neck.
If people continue to have difficulty swallowing, they may lose weight and become undernourished and dehydrated.
Diagnosis
If difficulty swallowing lasts more than a few days, the person should see a doctor promptly. The doctor tries to identify the cause. Symptoms provide some clues to the cause. So the doctor usually asks whether the person has difficulty swallowing both solids and liquids, whether pain is felt, and, if so, where and when. Whether the person has vomited blood or seen blood in stool is also a concern. The throat is examined, and the person is asked to swallow to see if the throat is working normally.
Usually, tests are needed to identify the cause. Most often, the esophagus is examined with a flexible viewing tube (endoscope) that is passed down the throat. To rule out cancer, doctors may take a sample of tissue with instruments threaded through the tube. Some disorders, such as esophageal rings or webs, can be treated at the same time.
A barium study may be done before endoscopy. Or it may be done afterward if endoscopy does not provide enough information. A barium study involves swallowing a barium solution or food coated with barium. Barium can be seen on x-rays. X-rays are taken continuously as the barium passes down the throat and esophagus to the stomach (in a procedure called fluoroscopy). This study is painless, and the barium passes through the digestive system and out of the body, causing no harm. A barium study can detect esophageal webs and rings, other blockages, and pouches. It can also detect tumors, ulcers, and evidence of spasm. This study helps doctors assess the function of the nerves and muscles involved in swallowing. Thus, doctors can determine whether a disorder that affects these muscles or nerves, such as a stroke, could be the cause.
Additional tests may be done, depending on the suspected cause. If the cause could be abnormal contractions of the esophagus (such as esophageal spasm), pressures in the esophagus may be measured with a tube placed in the esophagus. This test is called manometry. During the test, a person is asked to swallow water or a semisolid material or is given an injection of edrophonium, a drug that may trigger a spasm. This test helps doctors determine whether the pain is caused by spasms.
Treatment
Treatment focuses on helping the person swallow safely (including how to avoid aspiration) and on treating the disorder causing the problem if possible. Effective treatment enables a person to eat enough types of foods to get a well-balanced, adequate diet. Sometimes simple measures are the only treatment needed. For example, chewing food thoroughly and then sipping water can help prevent symptoms. Sitting upright while eating can help. Foods with certain textures, such as thick creamed soups or pureed fruits, may be easier to swallow. The best consistency is often found by trial and error. Using appropriate eating utensils may help. For example, using a small straw or small spoon can limit the amount of food put in the mouth. A smaller amount is easier to swallow.
If the cause is a disorder that impairs the muscles or nerves involved in swallowing, speech therapists may suggest exercises to strengthen the muscles or improve coordination and techniques to use when eating. If the cause is esophageal spasms or achalasia, drugs that relax the muscles of the esophagus may help relieve symptoms. Examples are nitroglycerin, long-acting nitrates, and calcium channel blockers (such as nifedipine). Some of these drugs?those with anticholinergic effects (such as dicyclomine)?are rarely used for older people because of side effects.
Usually, achalasia requires additional treatment. Doctors may inject botulinum toxin into the lower esophageal sphincter. Botulinum toxin paralyzes the sphincter, enabling it to relax and allow food to pass through. This treatment may provide more sustained symptom relief for older people than for younger people. The effects usually last 6 to 24 months, so injections need to be repeated. After two to three injections, they usually become ineffective. So injections cannot be used indefinitely. Alternatively, doctors may widen the passageway with a balloon dilator (called a bougie). This dilator is a tube with a deflated balloon attached to one end. It is passed down the throat to the lower esophageal sphincter, then inflated and deflated once. This procedure may provide long-lasting relief, sometimes permanently. If symptoms recur, the procedure can be repeated.
When these treatments are ineffective or symptoms are substantial, surgery may be done to correct achalasia. For this procedure (called myotomy), the muscular fibers in the lower esophageal sphincter are cut. As a result, the abnormal tightness of the sphincter is relieved. Myotomy can often be done with instruments threaded through a viewing tube called a laparoscope. The laparoscope is inserted through a small incision in the abdomen. This procedure is successful in most people. If needed, surgery to prevent reflux is usually done at the same time. Before surgery is done, a specialist is usually consulted.
If an esophageal web is due to iron deficiency, treating the deficiency usually results in disappearance of the web. For other esophageal webs and esophageal rings, an endoscope or dilators are used to clear or widen the esophagus.
If Zenker's diverticulum is large and causes symptoms, surgery to eliminate the pouch is usually recommended. Surgery may be done through an incision in the neck (open surgery) or through an endoscope inserted through the mouth. Using an endoscope may be preferred because it is faster, relieves symptoms equally well, and may not require an overnight stay in the hospital.
Dysphagia is difficulty swallowing. It includes the feeling that food is stuck in the throat or somewhere between the throat and the stomach.
Difficulty swallowing is common among all age groups but is more common among older people. Between 5% and 10% of older people who live independently have difficulty swallowing.
Swallowing becomes difficult when food does not pass normally from the mouth to the stomach. This difficulty may be temporary and disappear on its own. Or it may be caused by a disorder. Swallowing is partly under a person's control (is voluntary) and occurs partly without conscious effort (is involuntary). Problems can affect either part of the action.
Causes
A problem as simple as eating too fast, taking bites that are too big, having poorly fitting dentures, or having missing or loose teeth can make swallowing difficult. Not drinking enough water when eating or eating while lying down makes swallowing more difficult.
People with dementia may not chew food adequately or may forget to swallow it.
Disorders that damage any part of the body that is involved in swallowing?muscles, nerves, or brain?may cause difficulty swallowing. A stroke is the most common example among older people. Almost 30% of people who have had a stroke have difficulty swallowing. Parkinson's disease, myasthenia gravis, pseudobulbar palsy, systemic sclerosis, and amyotrophic lateral sclerosis (Lou Gehrig's disease) can also cause difficulty swallowing. Some drugs, especially phenothiazines (a type of antipsychotic drug), can cause difficulty swallowing because they affect the throat muscles.
Some disorders interfere with normal contractions of the esophagus. Then food cannot move through the esophagus into the stomach as it normally does. The esophagus contracts, but the contractions do not move food. This abnormal contraction can cause esophageal spasm. In about one third of people with spasms, the lower esophageal sphincter does not open normally and does not contract in coordination with the rest of the esophagus. As a result, the movement of foods and fluids into the stomach may be delayed, causing a feeling that food is stuck.
Uncommonly, the nerves that control the lower esophageal sphincter and the esophagus are abnormal, resulting in achalasia. In achalasia, the esophagus does not contract, and the lower esophageal sphincter does not relax normally to allow food to pass into the stomach. The cause of achalasia is unknown. It usually begins, almost unnoticed, between the ages of 20 and 60, then progresses gradually over many months or years. At first, people have difficulty swallowing solid foods, but eventually they also have difficulty swallowing liquids.
Swallowing may become difficult because the esophagus is narrowed or completely blocked. Progressive damage to the esophagus can cause scar tissue to form. This inflexible scar tissue (called a stricture) narrows the esophagus and restricts the movement of food through it.
The esophagus is not easily damaged. However, it can be damaged gradually by the repeated backward flow of acid from the stomach (gastroesophageal reflux) over months to years. Taking certain drugs can damage the lining of the esophagus (causing erosion) or cause deeper sores (ulcers). These drugs include bisphosphonates (used to treat osteoporosis), aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), some antibiotics (such as doxycycline, tetracycline, and clindamycin), and potassium or iron supplements. Damage by drugs is more common among older people. Part of the reason may be that the esophagus does not contract normally or that older people do not drink enough water when they take the drug.
An abnormal ring of tissue may narrow the esophagus. The most common type is Schatzki's ring, which is located near the stomach. What causes these rings to form is unclear, but they may result from damage due to reflux, abnormal contractions of the esophagus, or the use of certain drugs. These rings intermittently cause difficulty swallowing. Usually, difficulty occurs when solid foods are eaten rapidly. The solid food most commonly caught in a ring is poorly chewed meat. The result is severe pain. Because this problem often occurs when dining out, it is sometimes called steakhouse syndrome.
Thin sheets of tissue (webs) may form across the interior of the esophagus, partially blocking it. Rarely, webs may result from severe iron deficiency that is not treated. Esophageal webs are more common among older people. A few people are born with esophageal rings or webs, which do not cause symptoms until later in life. Webs, like rings, cause difficulty swallowing solid foods, not liquids.
A pouch (diverticulum) that develops just above the upper esophageal sphincter or in the wall of the esophagus may make swallowing difficult. Food is caught in the pouch, causing discomfort. If the pouch is filled, it can block the passage of food. Sometimes pouches form in response to injury or irritation. They may form if the contractions of the throat and upper sphincter are not coordinated. Sometimes the cause is unknown. The most common type is Zenker's diverticulum, which forms just above the upper esophageal sphincter. Zenker's diverticulum usually develops after age 50.
Food and foreign bodies may block the esophagus. The esophagus can be partially or completely blocked by a noncancerous (benign) or cancerous (malignant) tumor in the esophagus. Esophageal cancer rarely causes difficulty swallowing, but many people still fear that possibility.
See the figure Pouches and Bulges in the Digestive Tract.
Several disorders can block the esophagus by putting pressure on it from outside. For example, a heart disorder may cause part of the aorta or heart to enlarge and press on the esophagus. Cancer (most commonly, lung cancer), an aortic aneurysm, enlargement of the thyroid gland, or excessive growth of bones in the spine (vertebrae) can also put pressure on the esophagus.
Symptoms
Most people who have difficulty swallowing have difficulty swallowing solids, particularly breads and meats. After eating, people may feel as if they have a lump in their throat or tightness in their chest. They may have to swallow several times before the food feels as if it has gone down. Much later, swallowing liquids may become difficult. Some people have difficulty swallowing solids and liquids from the beginning.
People with difficulty swallowing may regurgitate food through the mouth or nose. When they lie down at night, they may cough or spit up food swallowed many hours before. They may inhale (aspirate) food into the windpipe (trachea), then cough. Aspirating food can lead to lung disorders, including airway infections and a form of pneumonia called aspiration pneumonia.
Depending on the cause of dysphagia, people may have chest pain when they eat. Chest pain may be caused by spasms of the esophagus. This pain is often described as a squeezing pain under the breastbone (sternum). The pain resembles chest pain due to coronary artery disease (angina), so the two are sometimes confused. Some people feel pain in the throat when they swallow. This pain may be caused by an infection or, rarely, cancer.
People with Zenker's diverticulum may have bad breath because food collects in the pouch. The pouch can also interfere with taking pills. Pills can become stuck in the pouch and thus are not absorbed into the bloodstream. Occasionally, the pouch causes pressure or swelling in the neck.
If people continue to have difficulty swallowing, they may lose weight and become undernourished and dehydrated.
Diagnosis
If difficulty swallowing lasts more than a few days, the person should see a doctor promptly. The doctor tries to identify the cause. Symptoms provide some clues to the cause. So the doctor usually asks whether the person has difficulty swallowing both solids and liquids, whether pain is felt, and, if so, where and when. Whether the person has vomited blood or seen blood in stool is also a concern. The throat is examined, and the person is asked to swallow to see if the throat is working normally.
Usually, tests are needed to identify the cause. Most often, the esophagus is examined with a flexible viewing tube (endoscope) that is passed down the throat. To rule out cancer, doctors may take a sample of tissue with instruments threaded through the tube. Some disorders, such as esophageal rings or webs, can be treated at the same time.
A barium study may be done before endoscopy. Or it may be done afterward if endoscopy does not provide enough information. A barium study involves swallowing a barium solution or food coated with barium. Barium can be seen on x-rays. X-rays are taken continuously as the barium passes down the throat and esophagus to the stomach (in a procedure called fluoroscopy). This study is painless, and the barium passes through the digestive system and out of the body, causing no harm. A barium study can detect esophageal webs and rings, other blockages, and pouches. It can also detect tumors, ulcers, and evidence of spasm. This study helps doctors assess the function of the nerves and muscles involved in swallowing. Thus, doctors can determine whether a disorder that affects these muscles or nerves, such as a stroke, could be the cause.
Additional tests may be done, depending on the suspected cause. If the cause could be abnormal contractions of the esophagus (such as esophageal spasm), pressures in the esophagus may be measured with a tube placed in the esophagus. This test is called manometry. During the test, a person is asked to swallow water or a semisolid material or is given an injection of edrophonium, a drug that may trigger a spasm. This test helps doctors determine whether the pain is caused by spasms.
Treatment
Treatment focuses on helping the person swallow safely (including how to avoid aspiration) and on treating the disorder causing the problem if possible. Effective treatment enables a person to eat enough types of foods to get a well-balanced, adequate diet. Sometimes simple measures are the only treatment needed. For example, chewing food thoroughly and then sipping water can help prevent symptoms. Sitting upright while eating can help. Foods with certain textures, such as thick creamed soups or pureed fruits, may be easier to swallow. The best consistency is often found by trial and error. Using appropriate eating utensils may help. For example, using a small straw or small spoon can limit the amount of food put in the mouth. A smaller amount is easier to swallow.
If the cause is a disorder that impairs the muscles or nerves involved in swallowing, speech therapists may suggest exercises to strengthen the muscles or improve coordination and techniques to use when eating. If the cause is esophageal spasms or achalasia, drugs that relax the muscles of the esophagus may help relieve symptoms. Examples are nitroglycerin, long-acting nitrates, and calcium channel blockers (such as nifedipine). Some of these drugs?those with anticholinergic effects (such as dicyclomine)?are rarely used for older people because of side effects.
Usually, achalasia requires additional treatment. Doctors may inject botulinum toxin into the lower esophageal sphincter. Botulinum toxin paralyzes the sphincter, enabling it to relax and allow food to pass through. This treatment may provide more sustained symptom relief for older people than for younger people. The effects usually last 6 to 24 months, so injections need to be repeated. After two to three injections, they usually become ineffective. So injections cannot be used indefinitely. Alternatively, doctors may widen the passageway with a balloon dilator (called a bougie). This dilator is a tube with a deflated balloon attached to one end. It is passed down the throat to the lower esophageal sphincter, then inflated and deflated once. This procedure may provide long-lasting relief, sometimes permanently. If symptoms recur, the procedure can be repeated.
When these treatments are ineffective or symptoms are substantial, surgery may be done to correct achalasia. For this procedure (called myotomy), the muscular fibers in the lower esophageal sphincter are cut. As a result, the abnormal tightness of the sphincter is relieved. Myotomy can often be done with instruments threaded through a viewing tube called a laparoscope. The laparoscope is inserted through a small incision in the abdomen. This procedure is successful in most people. If needed, surgery to prevent reflux is usually done at the same time. Before surgery is done, a specialist is usually consulted.
If an esophageal web is due to iron deficiency, treating the deficiency usually results in disappearance of the web. For other esophageal webs and esophageal rings, an endoscope or dilators are used to clear or widen the esophagus.
If Zenker's diverticulum is large and causes symptoms, surgery to eliminate the pouch is usually recommended. Surgery may be done through an incision in the neck (open surgery) or through an endoscope inserted through the mouth. Using an endoscope may be preferred because it is faster, relieves symptoms equally well, and may not require an overnight stay in the hospital.
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