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Diagnosing dysphagia.

Difficulty in Swallowing Can Be a Matter of Changing Eating Habits or Cause for Serious Concern

At the age of 35, Susan tells her physician that she occasionally has problems swallowing solid food. It has been a problem for years, she says.

"It feels like pieces of food are getting stuck in my throat. It doesn't hurt, but it's really uncomfortable," she complains.

John, who's 65, also complains of trouble swallowing. In his case, it happens when he drinks and when he eats and it has become worse in recent months.

"It started about three months ago while I was eating a piece of steak. It's now so bad that I can't swallow anything unless I cut it into little pieces and chew it thoroughly."

Both of these patients are experiencing dysphagia. However, each person's history may lead to an entirely different diagnosis, ranging from a mechanical obstruction in the esophagus to a muscle disorder or cancer.

Dysphagia is a medical condition in which food does not move smoothly into the stomach. Those afflicted report the feeling of food getting "stuck" in the throat or behind the breast bone.

Physicians agree that dysphagia is usually caused by some form of organic lesion in the esophagus.

Taking a complete patient history is the best way to make a correct diagnosis. A physician who asks the right questions will soon discover with which kind of lesion he or she is dealing.

The type of food that causes the problem is very telling in diagnosis. A person who has difficulty swallowing only solids almost always has a mechanical obstruction. Someone who cannot swallow solids or liquids without difficulty is likely to suffer from a motility or neuromuscular problem, which would involve the neural supply or the smooth muscles of the esophagus.

A liquids-only difficulty probably indicates a lesion in the canal between the mouth and the esophagus (the oropharynx) or a (severe) dysmotility problem.

Whether the dysphagia happens only occasionally or becomes progressively worse is just as important. Someone who experiences difficulty swallowing solids only occasionally, perhaps once a year, probably has a Schatzki ring, that is, a narrowing of the lower part of the esophagus.

Someone whose dysphagia has become so severe that the person is unable to swallow any kind of solid food could have cancer, although a stricture -- an abnormal narrowing of the esophagus -- is probably more common. Unfortunately, strictures tend to be among the more difficult causes to diagnose.

The aforementioned diagnoses are the three most common mechanical lesions known to cause dysphagia -- peptic stricture, cancer, and the Schatzki mucosal ring.

Older patients are probably more likely to have cancer of the esophagus, especially if they have a history of heavy alcohol use and a smoking habit.

Patients with strictures also tend to be older, often having a long history of heartburn or antacid use.

Intermittent difficulty in swallowing both food and liquid suggests an esophageal spasm. Those cases that get progressively worse could signal the failure of an esophageal ring of muscle to relax (achalasia) or the deposit of connective tissue in the esophageal wall (scleroderma).

Other questions a physician might ask include:

When did the difficulty first appear?

Is the patient's appetite normal?

Are the meals eaten slowly or quickly?

How long after swallowing do symptoms develop?

Does the patient have heartburn?

Information on medications taken and past operations is also relevant for a diagnosis.

Answers to these queries can help the physician locate the site of the obstruction and determine whether a lesion might be malignant.

Severe injuries, cancer, excessive vomiting, birth defects, and nasogastric or tracheotomy tubes can all cause strictures. Certain agents, such as nonsteroidal anti-inflammatory drugs, ferrous sulfate, ascorbic acid, salicylates, doxycycline, and tetracycline, cause painful swallowing or inflammation of the esophagus.

Two other drugs -- quinidine gluconate or sulfate and potassium chloride -- can cause narrowing of the esophagus (esophageal stenosis). Clues to drug-induced disease are a history of cardiac disease or strictures located near the heart or lower esophagus.

The best first test for patients with dysphagia is a standard liquid barium swallow. This can confirm a suspected diagnosis by showing whether the lesion is a mechanical obstruction or a neuromuscular disorder.

If the swallow test is negative, the patient should swallow a barium tablet. The tablet will "hang up" on a ring, or stricture.

A swallow may also be followed by an endoscopic examination if a physician still has reason to suspect a mechanical obstruction. Passing an endoscope down into the stomach allows the physician to inspect visually the esophagus. Motility studies are helpful in identifying strictures, spasms, achalasia, and scleroderma. Biopsy or cytology can affirm a diagnosis.

Therapies can range from simply learning to chew one's food better, eating soft foods, or surgery, depending on the severity of the particular case.
COPYRIGHT 1992 Vegetus Publications
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Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Author:Cascio, Lynne
Publication:Nutrition Health Review
Date:Jun 22, 1992
Words:800
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