Joseph R. Anticaglia MD
Medical Advisory Board
Dysphagia (dys difficulty — phagia eating) is the medical term used to describe difficulty swallowing. Something prevents the comfortable passage of food or liquids from the mouth to the stomach.
At times, we have all eaten too quickly, not chewed our food properly and experienced trouble swallowing. Ordinarily, this is nothing to worry about.
Worsening or persistent dysphagia is another matter. They are causes of concern in any age group. In the elderly, it can lead to dehydration, respiratory infections and malnutrition. In the younger age group without previous difficulty swallowing, it’s a physician’s red flag to rule out cancer.
Swallowing
Swallowing can be divided into the following phases:
- Phase 1 Oral (mouth)
- Phase 2 Pharyngeal (back of mouth)
- Phase 3 Esophageal Phase (food pipe)
Oral Phase: The oral (buccal) phase is mostly voluntary. Briefly, solid foods are mixed with saliva, chewed into a bolus and pushed back into the pharynx. Liquids are, according to some, “vacuumed” into the mouth and propelled into the pharynx.
Dysfunction in this phase can be due to anatomic changes (trauma, radiation therapy, post- surgery trauma, infections or cancer). It can also be caused by muscle weakness due to Myasthenia gravis or neurologic disorders such as Parkinson’s disease. Vascular lesions, e.g. stroke, can also disrupt the normal passage of food into the stomach.
Pharyngeal Phase: The pharyngeal phase of swallowing is involuntary. Food and liquid stimulate sensitive receptors in the base of the tongue and back of mouth. This causes a reflex reaction moving food toward the esophagus and stomach. The disorders of Phase 1 can also disrupt the normal functioning of the pharynx.
Esophageal Phase: This phase of swallowing is also involuntary. The musculature of the esophagus contracts and successive waves of contraction (peristaltic waves) push the food into the stomach.
Esophagus
The esophagus is a muscular tube approximately 10 inches in length depending on the size of the individual. It extends from the pharynx to the stomach. It takes about1 to 2 seconds for liquids to pass through the esophagus, 4-5 seconds for semisolids (cooked cereals) to move through the esophagus and approximately 7 to 8 seconds for solids (rolls, biscuits, bagels) to reach the stomach. It has a somewhat inverted “S” shape.
One can classify dysphagia into oropharyngeal and esophageal causes of dysphagia The present discussion will emphasize the esophageal reasons for dysphagia.
Esophagus in red (pharynx to stomach)
Three (3) Questions
- Do you have heartburn?
- Complication of reflux disease?
- Esophagitis
- Barrett’s Esophagus
- Is the dysphagia intermittent, progressive or persistent?
- Intermittent
- Esophageal rings
- Shatzski’s ring
- Progressive
- Strictures
- Carcinoma
- Intermittent
- What type of foods causes symptoms?
- Primarily Solids?
- Strictures
- Rings
- Carcinoma
- Both solids and liquids?
- Achalasia
- Motility disorders
- Scleroderma
- Primarily Solids?
Andrew is a 32 year hair stylist with a history of childhood allergies, sinusitis and asthma. He anticipated enjoying a pre-theater dinner and show but was taken to the emergency room in the middle of dinner after pieces of chicken “got stuck in my throat”. He was unable to swallow liquids and had difficulty swallowing his own saliva. He had chest pain and was drooling.
Health and Human Services A bolus of chicken in the esophagus.
Esophagus after the removal of chicken.
Notice the multiple rings in the esophagus
Eosinophilic Esophagitis EoE
When people have allergies, there is an increase in the number of eosinophils — white blood cells which make up part of the immune system. They can infiltrate, invade the esophagus changing the architecture of the esophagus. EoE is very often the reason why people get food stuck in the esophagus and need to go to the emergency room. The multiple rings in the esophagus impede the passage of food entering the stomach.
Michael is a 51 chef who has been troubled with reflux disease for at least 20 years. He complains of heartburn, indigestion, coughing and at times hoarseness. He takes a variety of medications for this problem. He knows what foods to avoid but as he puts it, “Life gets in the way.”
Massachusetts General Hospital
Barrett’s Esophagus (dark color)
Barrett’s Esophagus is due to the backflow of gastric juice into the esophagus. Over time, the normal tissues of the esophagus is replaced with pre-cancerous tissue that eventually can become an especially troublesome form of cancer, adenocarcinoma. Reflux disease is not as benign as many people think it is
Bobby is a 62 year old iron worker who has smoked a corn cob pipe since he was a teenager. On occasion, he smokes a corn cob pipe and cigars. He inhales both of them. The 3 months prior to seeing his doctor, he complained of progressive difficulty swallowing solid foods and more recently, difficulty swallowing liquids. During that time period, he lost about 11 pounds.
NIH, NCBI
Malignant stricture of the esophagus
The above X-ray image of a stricture or narrowing of the esophagus was caused by carcinoma of the esophageal. This stricture blocked the passage of food and liquids
into the stomach. The inside of the esophagus initially became inflamed, ulcerated, scar tissue formed and that lead to the eventual narrowing of the esophagus.
Dysphagia is not uncommon in acute care hospitals and is quite frequent in chronic care facilities. It’s a symptom that should not be ignored. Hopefully, three questions may encourage you to seek care sooner than later.
References:
Delton, Evan S MD MPH; Eosinophilic Esophagitis; Gastroenterol Clin North Am. available in PubMed Central-PMC; 2014Mar Gastroenterol Clin North Am. 2013 Mar; 42(1): 133-153. 1.
R. Lyer; R. DuBrow; Imaging of Esophageal Cancer; Cancer Imaging 2004; 4(2): 125-132. Published online 2004 Sep 9.
This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.