Introduction

Dysphagia literally means ‘trouble swallowing’. It is not a condition in itself, but a symptom. There can be many causes varying from a muscular spasm or neurological cause, to oesophageal malignancy. As a result, any patient that presents with dysphagia needs to be thoroughly investigated for the possibility of malignancy.

Types of dysphagia can be divided due to where they occur, or what type they are e.g. obstruction or dysmotility.

Types of dysphagia

Pharyngeal / oesophageal

Causes
 

Oesophageal

Causes
  • Achalasia
  • Oesophageal spasm
  • Luminal obstruction (e.g. due to stricture, bolus, carcinoma or perhaps trauma damage)
 

External

Causes
  • Retrosternal goitre
  • Lung cancer
  • Pharyngeal diverticulum
  • Vascular abnormalities – e.g. abdominal aortic aneurism, enlarged heart.
  • Any type of mediastinal mass.
  • Diabetes – can cause motility disorders in upper GI tract. Most commonly causes delayed gastric emptying,
 
There is one further class of dysphagia we have yet to look at; this involves problems in the mouth. Ulcer, poor teeth and even something like tonsillitis can all affect swallowing, but these can usually be easily ruled out. Some patients might not be able to swallow because they can’t chew. If you cannot seal your lips (e.g. as a result of facial palsy) then it is very hard to swallow!

Symptoms associated with dysphagia

Key: Oropharyngeal symptoms in black, oesophageal in blue.
The associated symptoms help you decipher the cause of the dysphagia.
  • Chest pain due to oesophageal reflux
  • Pain on swallowing – odynophagia – associated with oesophagitis
  • Reflux of food or bile into the mouth – associated with severe GORD
  • Coughing and aspiration of food – due to laryngeal or bulbar nerve palsy
  • Palate incompetence – food goes into the nose when swallowing – associated with bulbar nerve palsy particularly after a cerebrovascular accident.
  • Loss of weight / anorexia – suggests upper GI malignancy
  • Hoarseness of voice – can be due to associated laryngeal malignancy, or as a result of laryngeal nerve palsy.

Diagnosis

The clinical history is the major factor in diagnosing. For example
  • Progressively worse dysphagia – suggests malignancy
  • Difficulty swallowing solids but not liquids – suggests muscular incoordination
  • Dysphagia with retrosternal pain and regurgitation – suggests stricture or carcinoma
  • Dysphagia with weight loss – suggests malignancy

Investigations

Often the diagnosis is purely clinical, but in cases where the diagnosis is particularly difficult, then investigations may be done. These might include:
  • Barium swallow – this gives very good views of the upper oesophagus, and thus will aid diagnosis of pharyngeal pouches and strictures, however often a negative result will be found, and this will require endoscopy. As a result, this test is rarely used, and endoscopy if the first investigation of choice.
  • Endoscopy – this is actually quite risky compared to say endoscopy for gastric purposes, because things like pharyngeal pouches and strictures increase the risk of perforation. Strictures are often visible, and these can be diagnosed as benign or malignant. It may also be possible to diagnose achalasia if the oesophagus appears dilated in the presence of food residue.
  • CT scan – this is rarely used as an investigation but may be regularly used to assess the level of malignancy.
  • Endoscopic ultrasound – this is very useful at measuring things to do with the oesophageal wall. It cannot be performed if there is a narrowing at the top of the oesophagus because this prevents the passage of the instrument.
  • 24Hr pH monitoring – this helps to see the amount of oesophagitis present and thus decided whether this may be a causing factor.
 

Pharyngeal Pouches

These are a major cause of dysphagia. A pouch occurs due to uncoordinated swallowing movements within the pharynx. These movements will cause a herniation through the cricopharyngeous muscle and lead to the formation of a pouch.
The patients are often elderly and symptomless, although common symptoms include a ‘gurgling’ noise coming from the pharynx after swallowing, and dysphagia.
A barium swallow will reveal the pouch and also show the uncoordinated swallowing.
Endoscopy is not advisable, as the endoscope can become stuck in the pouch and perforate it.
Surgery is recommended for those people with a pharyngeal pouch.
 

Achalasia

(aka cardiospasm)
This is a motility disorder of the oesophagus and has two main features:
  1. The oesophageal sphincter will not relax properly, and so food cannot pass into the stomach in the normal manner
  2. The peristaltic contractions of the oesophagus do no propagate properly, and so the oesophagus will gradually become more and more dilated.
It occurs most commonly in those aged 30-60, and has an incidence of 1 in 100 000.
The exact cause is not known, although there are abnormalities in nervous ganglia associated with the oesophagus. The nervous ganglia within the oesophagus and in the oesophageal sphincter will degrade.
The dysphagia it causes is intermittent, but gradually progressive in the long term.
It equally affects both liquids and solids and often causes aspiration.
It is generally painless, but about 10% if patients may feel pain during the early stage of the disease. These patients have what is known as vigorous achalasia.

Complications

As the disease progresses it may begin to cause pain and weight loss. It is strongly associated with oesophageal carcinoma, and many patients will also suffer from pulmonary complications as a result of aspiration.

Diagnosis

Chest X-ray
Barium swallow – this will produce a characteristic ‘bird’s beak’ appearance (see below)
Manometry – this is where the pressure within the oesophagus is measured.

 
Appearance of achalasia on barium swallow, showing constriction of the LOS
[Image from Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38, Farnoosh Farrokhi, Michael F. Vaezi. Reproduced in accordance with the Creative Commons Attribution 2.0 licence]

Treatment

This usually involves the removal of the sphincter at the bottom of the oesophagus.
Reflux disease is an almost inevitable complication.
Another option is to insert a balloon, which is then inflated, and basically rips the sphincter muscle.
Both types of treatment will have about a 90% success rate.
 

Scleroderma

This is a systemic auto immune connective tissue disorder. It causes hardening (sclerosis) of the skin and sometimes other organs. It also causes atrophy of muscles, and dilation of the oesophagus as well as general systemic relaxation of smooth muscle. On top of this, often oesophageal reflux exists which causes oesophageal strictures and thus complicates the issue.

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