Difficulty Swallowing (Dysphagia)

Knowing the oesophagus

The gullet (oesophagus) is part of the gut (gastrointestinal tract). When we eat, food goes down the oesophagus into the stomach.

The upper section of oesophagus lies behind the windpipe (trachea). The lower section lies between the heart and the spine.

There are layers of muscle in the wall of the oesophagus. These contract to push food down into the stomach. The inner lining of the oesophagus (the oesophageal mucosa and submucosa) is made up of layers of various types of cells and some tiny glands that make mucus. The mucus helps the food to pass through smoothly.

There is a thickened circular band of muscle (a sphincter at the junction between the oesophagus and stomach. This relaxes to allow food down, but normally tightens up and stops food and acid leaking back up (refluxing) into the oesophagus. In effect, the sphincter acts like a valve.

Understanding dysphagia

The medical term for difficulty in swallowing is dysphagia. This symptom is usually due to a problem of the gullet (oesophagus). Less commonly, a problem at the back of the mouth, or something pressing on the oesophagus, can cause this symptom. A range of different causes of dysphagia are discussed below.

Dysphagia varies in terms of severity. When mild, it can mean a feeling of food just taking longer to pass through the oesophagus and it can be painless. Liquids may well cause no problem. When severe, it can mean both solids and liquids not passing down the oesophagus at all and may cause one to vomit back (regurgitate) food and drink. When moderate, it can be somewhere in between these extremes.

Symptoms that may occur at the same time as dysphagia are regurgitation of food, being sick (vomiting), coughing, choking and pain on swallowing (odynophagia). But none of these other symptoms may occur if the dysphagia is mild.

However, any degree of dysphagia should be investigated.

Dysphagia is a symptom that always needs to be explained and diagnosed correctly. For example, the first symptom of cancer of the oesophagus (oesophageal cancer) is often mild, painless dysphagia that then gradually becomes worse over time. So, this often needs to be ruled out or confirmed as the cause of the problem as soon as possible. As a general rule, the earlier a serious problem is diagnosed, the better the chance that treatment may improve the outlook (prognosis).

Triggers of dysphagia

There are many possible factors that trigger off Dysphagia. Below is a brief overview of the more common and important causes:

Stricture caused by severe oesophagitis

Oesophagitis means inflammation of the lining of the gullet (oesophagus). Acid reflux occurs when some acid leaks up (refluxes) into the oesophagus from the stomach. Most cases of oesophagitis are due to acid reflux. The inside lining of the lower oesophagus is irritated to cause inflammation. Gastro-oesophageal reflux disease (GORD) is a general term which describes the range of situations – acid reflux, with or without oesophagitis and symptoms. A complication of severe long-standing oesophagitis is scarring and narrowing (a stricture) of the lower oesophagus. Oesophagitis due to acid reflux is common, but a stricture causing difficulty swallowing (dysphagia) is an uncommon complication of this problem.

Cancer of the oesophagus

Though cancer of oesophagus (Oesophageal cancer) is uncommon, most cases occur in people over the age of 55. Younger people are seldom affected. Those diagnosed at an early stage have the best chance of a cure. Dysphagia is often the first symptom and is caused by the cancer growing and narrowing the passage in the oesophagus.

Other causes of Strictures

Although oesophagitis and cancer are the most common causes of oesophageal narrowing (strictures) there are various other causes – for example, following surgery or radiotherapy to the oesophagus. Various medicines can irritate the oesophagus and cause a stricture. Drinking bleach or other chemicals can cause damage, scarring and strictures.

Oesophageal webs and rings

These are abnormal non-cancerous overgrowths (extensions) of normal oesophageal tissue. They are uncommon. Their cause is not clear although oesophageal webs sometimes develop in people who have iron-deficiency anaemia. Webs and rings may not cause any symptoms but they sometimes cause dysphagia.

Achalasia

Achalasia is a condition that affects both the muscles and the nerves that control the muscles of the oesophagus. Achalasia typically first affects the nerves that cause the sphincter between the oesophagus and stomach to relax. There is difficulty in pushing food down as muscles do not contract properly . In addition, the sphincter does not relax properly so food cannot pass through into your stomach easily. This makes it difficult for one to swallow food properly. It mainly affects adults aged between 20-40 years. In most cases, no underlying cause can be found and the reason why the nerves and muscles in the oesophagus do not work so well is not clear.

Other neurological problems

There are many other muscle and nerve disorders (neurological diseases) that can affect the nerves and muscles in the oesophagus to cause dysphagia. For example, certain types of stroke, oesophageal spasm, syringomyelia or bulbar palsy, myasthenia gravis, multiple scelrosis, motor neurone disease, dermatomyositis, myotonic dystrophy, Parkinson’s disease, Chagas’ disease. However, in general, in these situations dysphagia would not be the first symptom to develop and various other symptoms would usually also be present.

External pressure on the oesophagus

Pressure from structures next to the oesophagus can sometimes affect the function of the oesophagus to cause dysphagia. For example, cancer of the thyroid, lung or spine, or a large aortic aneurysm may press on the oesophagus. Again, other symptoms would normally have developed before the dysphagia.

Pharyngeal pouch

A pharyngeal pouch is an uncommon condition where a dead end pouch (diverticulum) forms coming off the lowest part of the throat (the lower pharynx). Most occur in people over the age of 70. It may not cause any symptoms but can cause symptoms such as dysphagia, a sense of a lump in the neck, food regurgitation, cough and bad breath.

Additional Elements

These include various rare conditions that cause inflammation or reduced function of the oesophagus; infections of the oesophagus or throat; cancer of the stomach or throat; swallowing large objects that get stuck (more common in children).

Globus sensation

Globus sensation is the term used when a person has the feeling of a lump in the back of their throat when actually there is no lump present when the throat is examined. This is not a true cause of dysphagia but is mentioned here for completeness

Some people with this condition may have a feeling or perception of difficulty swallowing. However, in this condition there is no true dysphagia, as one can eat and drink normally. Many people with globus sensation notice the symptoms most when they are swallowing their saliva.

Handling dysphagia

One must see a doctor promptly. It is very important to get a correct diagnosis as soon as possible.

Suggested Investigations

It depends on the possible causes of the difficulty swallowing (dysphagia), which may be determined by a doctor talking to you (your history) and an examination. Two of the most common tests done when someone has dysphagia are endoscopy and barium swallow.

Endoscopy

This is a test where an operator (a doctor or nurse) looks into the upper part of your gut (the upper gastrointestinal tract). An endoscope is a thin, flexible telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the oesophagus and down towards the stomach and duodenum. The tip of the endoscope contains a light and a tiny video camera so the operator can see inside your gullet (oesophagus), stomach and duodenum. The endoscope also has a side channel down which various instruments can pass. These can be manipulated by the operator. For example, the operator may take a small sample (biopsy) from the inside lining of the oesophagus by using a thin grabbing instrument which is passed down a side channel.

Barium swallow

This is a test that helps to look for problems in the oesophagus. The oesophagus and other parts of the gut do not show up very well on ordinary X-ray pictures. However, if one drinks a white liquid that contains a chemical called barium sulphate, the outline of the upper parts of the gut (oesophagus, stomach and small intestines) shows up clearly on X-ray pictures. This is because X-rays do not pass through barium.

Some more investigations

The following tests may be considered:

Oesophageal manometry – this is a test where a pressure-sensitive tube is passed via one’s nose or mouth into the oesophagus to measure the pressure of the muscle contractions in the oesophagus.

Videofluoroscopy – this is a bit like a barium swallow. Different drinks and foods are mixed with barium and you are asked to do various things like swallow, move your head, etc after drinking or eating the mixture. X-ray pictures are taken and your swallowing can be examined.

pH monitoring – during this test, a thin tube is passed through your nose or mouth and into your oesophagus. A monitor that is attached to the tube can measure the pH (acid level) in your oesophagus.

Remediation for dysphagia

The treatment depends on the cause. A speech and language therapy assessment can be very useful, especially when treating patients who have had strokes.​

CONCLUSION

There are various causes of difficulty swallowing or dysphagia as it is termed. One must see the doctor as soon as possible if one develops dysphagia. This is because a serious condition such as cancer of the gullet (oesophagus) can be the cause. As a general rule, the earlier a serious problem is diagnosed, the better the chance that treatment may improve the outlook (prognosis).