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Dysphagia
Last reviewed: 23.04.2024
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Dysphagia is a difficulty in swallowing food or liquids. If it is not due to catarrh due to a cold, it is a serious symptom that justifies further examination of the patient (endoscopic) to exclude neoplasia. If a patient complains of a feeling of an un-clotted lump in the throat outside the period of ingestion of food, then the diagnosis is most likely a state of anxiety - what is called globus hystericus.
A common complaint is the feeling of "stuck" food at the entrance to the esophagus. This condition prevents the movement of liquids, solid foods or both from the pharynx to the stomach. Dysphagia is classified into oropharyngeal or esophageal depending on the level at which it occurs. Dysphagia should not be confused with globus sensation (the hysterical globus is a hysterical lump), the feeling of having a lump in the throat that is not associated with the act of swallowing and the violation of the passage of food.
Causes of dysphagia
Among the causes of dysphagia are neoplasms, neurological and other factors.
Malignant neoplasms
- Esophageal carcinoma
- Stomach cancer
- Throat Cancer
- External pressure (for example, lung cancer)
Neurological causes
- Boulevard paralysis (motor neuron disease)
- Lateral medullary syndrome
- «Myasthenia gravis»
- Syringomyelia
Other
- Benign strictures
- Thyroid diverticulum
- Achalasia cardia
- Systemic sclerosis
- Esophagitis
Pharyngeal "pocket", or gill sac
This is hernial protrusion of the mucosa in the "site of the exposure of Killian" of the lower constrictor. This can be bad breath, regurgitation of food and visible on the neck protruding bag (usually on the left). The diagnosis is made when ingestion of barium during fluoroscopy. Treatment is surgical.
Throat Cancer
Patients with oropharyngeal tumors consult a doctor only when the disease is already in a far-reaching stage. Symptoms: discomfort in the throat, sensation of a lump in the throat, radiating pain in the ear (otalgia) and local irritation of the pharynx of hot or cold food. Hypopharyngeal tumors manifest dysphagia, changes in voice, otalgia, stridor and pain in the pharynx. Treatment is usually combined - surgical, chemotherapeutic and radiation.
Esophageal carcinoma
Esophagus cancer is often accompanied by achalasia, Barrett's ulcer, ozomization of the esophageal mucosa (a condition in which exfoliation of the skin takes place); the Plummer-Vinson syndrome; patients with esophageal cancer, as a rule, smoke.
Dysphagia is progressive. It is quite possible surgical resection (more than 5-year survival - a rarity); as a palliative operation - intubation with a special tube (for example, Celestin).
[9], [10], [11], [12], [13], [14], [15], [16]
Benign esophageal stricture
Causes: gastroesophageal reflux, ingestion of corrosive substances, the presence of foreign bodies in the esophagus, trauma. Treatment: dilatation of the esophagus (endoscopic or buzhami under anesthesia).
Akhalasia
At the same time there is a violation of peristalsis of the esophagus with insufficient relaxation of the lower esophageal sphincter. The patient is able to swallow both liquid and dense food, but very slowly. If the barium is ingested, the radiologist sees the early filling of the "tape" of the esophagus, but its expansion occurs with a delay. Such patients may have bad breath, as well as repeated pulmonary infections due to inhalation of pathogenic microbes. After miomectomy, up to 75% of patients are cured. Some help is provided by the pneumatic dilatation of the esophagus.
[20], [21], [22], [23], [24], [25]
Plummer-Viysoa Syndrome
This atrophy of the mucosa and the growth of a special connective tissue in the esophagus against the background of iron deficiency anemia, it also occurs with postcricoid (located behind the cricoid cartilage) carcinoma.
Oropharyngeal dysphagia
Oropharyngeal dysphagia is a difficult progression of food from the oropharynx into the esophagus; is due to a violation of the function proximal to the esophagus.
Most often this occurs in patients with neurological disorders or muscle disorders that affect the striated muscles. Neurological disorders include Parkinson's disease, stroke, multiple sclerosis, amyotrophic lateral sclerosis (Charcot's disease), bulbar poliomyelitis, pseudobulbar paralysis and other CNS lesions. Muscular disorders include dermatomyositis, myasthenia gravis, and muscular dystrophy.
Symptoms of dysphagia include initially difficult swallowing, nasal regurgitation and aspiration into the trachea accompanied by a cough. The diagnosis is established by direct observation of the patient and by video recording of fluoroscopy of the throat of barium. Treatment of dysphagia is directed to the main cause.
Esophageal dysphagia
Esophageal dysphagia is a difficult passage of food through the esophagus. It is the result of either mechanical obstruction or motor impairment.
The causes of mechanical obturation include internal lesions of the esophagus, such as peptic stricture, esophageal cancer and the lower esophageal membrane. Mechanical obstruction can be a consequence of external pathological processes that cause compression of the esophagus and include: increased left atrium, aortic aneurysm, vascular changes such as aberrant subclavian artery (mysterious dysphagia), retrosternal goitre, cervical bone exostosis and swelling of the chest cavity, most often lung cancer . Rarely, the esophagus is affected by lymphoma, leiomyosarcoma or metastatic cancer. The reception of a corrosive substance often leads to a pronounced narrowing.
Disorders of motility are the cause of dysphagia in the violation of the smooth muscle tissue of the esophagus (ie, violation of the peristalsis of the esophagus and the function of the esophageal sphincter). Motor disorders include aphasia and diffuse spasm of the esophagus. Systemic scleroderma can be the cause of motor disorders.
Motor disorders cause dysphagia when taking solid and liquid foods; mechanical obstruction causes dysphagia when taking only solid food. Patients have the greatest difficulty in eating meat and bread; however, some patients can not take any solid food. Patients who complain of dysphagia in the lower esophagus usually correctly note the location of the cause, and with complaints of dysphagia in the upper esophagus - often vague.
Dysphagia can be intermittent (eg, lower esophageal sphincter dysfunction, lower esophageal ring or diffuse spasm of the esophagus), rapidly progressing for several weeks or months (eg, esophageal cancer) or progressing over several years (eg, peptic stricture) . Patients in whom dysphagia is caused by peptic stricture usually have a history of gastroesophageal reflux disease.
Dysphagia when taking liquid or solid food helps differentiate motor disorders from obstruction. X-ray studies with a barium throat (with a hard bread ball mixed with barium, usually in the form of a capsule or tablet) should be performed. If the study reveals obstruction, endoscopy (and possibly a biopsy) is shown to exclude malignancy. If the study with barium is negative or there is a suspicion of motor disorders, esophageal motility studies should be performed. Treatment of dysphagia is aimed at eliminating the cause.
[26], [27], [28], [29], [30], [31], [32],
Cricopharyngeal discoordination
With cricopharyngeal discoordination, there is an inconsistent reduction in the cryopharyngeal muscle (upper esophageal sphincter). This violation can cause a zenker's diverticulum; repeated aspiration of diverticulum contents can lead to chronic lung disease. The cause can be eliminated by an operation consisting in dissection of the cryopharyngeal muscle.
[33], [34], [35], [36], [37], [38], [39]
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 leaving the left side of the aortic arch, doubling the aortic arch or right-sided arch of the aorta with the left arterial ligament. Dysphagia can appear in childhood or later as a result of atherosclerotic changes in the aberrant vessel. X-ray examination with a barium throat reveals an external compression, but for the final diagnosis arteriography is necessary. Most often, no special treatment is required, but sometimes there is a need for surgical correction.
How is dysphagia diagnosed?
"Key to diagnosis", obtained from an anamnesis
If the patient is able to drink fluids as easily and quickly as usual (except in cases where dense food is on the mucous membrane of the esophagus), this indicates strictures, and if not, assume violations of the motor function of the esophagus (achalasia, neurological cases ). If the patient is difficult to do the actual swallowing movements, it is necessary to suspect bulbar paralysis. If dysphagia is permanent or very painful, strictures due to malignant neoplasm can not be ruled out. If during the reception of fluid from the patient's throat gurgling sounds are heard, and on the neck appears protrusion, then one should think about the presence of a "pharyngeal pocket" (food from it can regurgitate, throw back into the upper part of the pharynx).
The pathology of the pharynx is not difficult for differential diagnosis. The diagnostic task is to determine the nature of dysphagia - functional or organic.
Functional dysphagia is characterized by episodic or transitory occurrence and is provoked by irritating food, often liquid, cold, hot, acute, acidic, etc. At the same time, dense food does not cause esophagus spasm attacks. The severity of manifestations does not change over time. The time of occurrence does not depend on the stage of passage of food through the esophagus.
Dysphagia caused by organic pathology is characterized by slow development, with gradual weighting. It is provoked by the passage of dense food, the difficulty of the passage of liquids is noted in far-reaching cases of stenosis. Siping food with water brings relief. Vomiting is noted already in far-reaching cases; The level of lesion can be determined by the time of occurrence, the pain behind the sternum after ingestion of food: in the cervical region - after 1-1.6 c; in the thoracic - after 5-6 s; in the cardiac - in 7-8 c. Sharp pains are characteristic for ulcerative esophagitis, reflux-esophagitis, diverticulitis, - foreign bodies, rarely are with cancer.
Dysphagia of organic nature, even very weakly expressed, should be alarming for cancer, since it is the earliest and, perhaps, the only of the early manifestations. A compulsory study complex should include PHEGS and contrast fluoroscopy of the esophagus. In case of detection of organic pathology, additional investigations are performed by thoracic surgeons or, if there are specialists in the field, specialists of the centers of esophageal and mediastinal surgery.
Examination of patients
Complete clinical analysis of blood, determination of ESR, fluoroscopy with a sip of barium; endoscopy with biopsy; study the contractility of the esophagus (while the patient must swallow a catheter with a special sensor).