Difficulty Swallowing
By gi health
Swallowing is just another example of how we don't appreciate our bodies until something
goes wrong. Normally, swallowing is a rapid and efficient action that requires less than two
seconds to complete and one that all of us take for granted. After all, we have been doing it
since birth and never had reason to give it a thought. We just expect our food to naturally
find its way to our stomach without falling into our lungs and cutting off our breathing.
Actually the process is quite complicated requiring coordination of a large number of
muscles in the mouth, throat, and esophagus, but usually all goes well and it can be taken
for granted.
It's Stuck
What a surprise it is then when an individual is sitting in a nice restaurant, perhaps in the
middle of a romantic meal or an important business luncheon, and suddenly a piece of meat
becomes lodged in their esophagus. It went down okay - but not all the way. It just hangs
there, right in the middle. It won't go down, nor can it be brought back up. Anxiety
develops as a sensation of pressure occurs in the chest and foamy saliva begins to back up.
Breathing is not impaired since there are two "pipes" - the foodpipe (esophagus) and the
windpipe (trachea) - and the latter is not affected. But, what a miserable, embarrassing,
and helpless feeling. Sometimes the blockage will resolve on its own with a great sense of
relief. But, usually after more than several hours of procrastination, these individuals seek
medical attention. You can find them several nights a week sitting in the ER with a paper
cup in hand to catch their saliva. This common problem is usually not resolved until an
emergency procedure is performed to remove the offending object. Relief is instant. The
next step is to find out why this has happened and how to prevent it from happening again.
What Tests are Needed?
Diagnosis is an important first step in treatment. Before the doctor can develop a treatment
plan, tests must be performed to determine what caused the problem. Testing will usually
begin with a medical history and physical exam. The doctor will want to know how often and
under what circumstances the problem occurs.
Most cases will require a "scope" test of the upper digestive system. Also known as a
gastroscopy or EGD exam, this simple test is quickly and painlessly performed using a mild
sedative. A thin, flexible, sterilized tube is passed through the mouth and down into the
esophagus and stomach. A tiny color video camera within this instrument allows the doctor
to directly examine the esophagus, stomach, and upper small intestine. When necessary,
photographs and biopsies can be obtained for later review. Occasionally, barium x-rays may
be requested to view the esophagus while swallowing.
Less commonly, the doctor may request an esophageal manometry study which measures
the strength and coordination of the esophageal contractions as well as the pressure of the
special "trapdoor valve" between the stomach and esophagus. By performing these tests
the doctor can most accurately determine exactly what is causing difficulty swallowing and
what treatment will be necessary.
Strictures and Rings
Most patients have trouble swallowing because their lower esophagus has become damaged
from the corrosive effects of chronic acid heartburn. This eventually leads to the build-up of
scar tissue and then a narrowing, or stricture, of the esophagus. Some patients have similar
symptoms due to the formation of a peculiar ring of scar tissue in the lower esophagus. The
cause of this so-called Schatzki's ring is not known. Both strictures and rings act like
roadblocks preventing the passage of food down into the stomach. These strictures and
rings are often associated with a hiatal hernia - a minor displacement of part of the stomach
through the diaphram and up into the chest. A hiatal hernia is a common condition and does
not cause difficulty swallowing by itself. But when associated with a stricture or ring,
symptoms may occur.
To prevent further swallowing problems, this roadblock must be opened using a technique
called esophageal dilatation which stretches the narrowed spot. A variety of devices are
available to help your doctor open up the passageway. These include simple dilators, or
bougies, that are flexible tapered rubber tubes that come in various diameters. Several
bougies of increasing size may be passed down the esophagus in one session to dilate the
stricture. This can be done with or without sedation. Most often, dilatation of a benign
stricture or ring can be accomplished at the same time as the gastroscopy scope exam.
Once the stricture is identified, a thin deflated balloon dilator can be passed through the
scope and positioned across the narrowed segment. This cigar-shaped balloon is then
inflated with water and held in place for several minutes. This repairs the stricture in much
the same way as an angioplasty corrects a blocked artery in the heart. The balloon dilator is
then removed and the scope withdrawn. However, if at the time of the scope examination,
the esophagus is very inflamed or ulcerated, the dilatation may have to be delayed until the
ulcers are healed.
What Are The Risks?
In most cases, dilatation of an esophageal stricture or ring is performed without problems.
However, in rare cases complications can occur. The most common complication is bleeding.
There is usually some minor bleeding with successful dilatation, but not enough to cause
problems or symptoms. Rarely, the bleeding may be persistent and require treatment. The
most serious complication is perforation of the esophagus. The wall of the esophagus is thin
and, despite your doctor's best efforts, a tear may occur during the dilatation. An operation
is usually required to correct this problem. Fortunately, this is quite uncommon.
What Else Could be Done?
Another choice is to do nothing and to just live with the stricture, limit your diet to soft
foods forever, and take your chances on having future choking spells. This is seldom
advised. On the other end of the spectrum, you could have open chest surgery to remove
the narrowed spot in your esophagus. This major surgery is usually reserved for only the
most severe cases. For most patients, dilatation seems to be a more reasonable "middle
ground."
Will the Problem Return?
It's hard to predict, but a large percentage of esophageal strictures eventually return as the
scar tissue gradually shrinks tighter and tighter. Many patients undergo periodic esophageal
dilatation to prevent further symptoms. The risk of recurrence can be reduced by preventing
acid reflux and aggressively treating any symptoms of heartburn. Most people do best if
they take prescription strength acid-reducing medications on a daily basis and pay attention
to chewing properly.
Cancer is Less Common
A small number of patients have difficulty swallowing because of a tumor, sometimes
cancerous, blocking the opening of their esophagus. This condition is obviously very
important and requires prompt evaluation and treatment. A combination of surgery,
chemotherapy, and radiation therapy is usually prescribed. Most cancers of the esophagus
arise in abnormal cells that develop in response to chronic poorly controlled heartburn.
Better control of the heartburn may prevent the cancer. If you have chronic heartburn, see
your doctor before cancer has a chance to develop.
Spastic Esophagus
Sometimes there is no blockage that can be treated with dilatation. The problem may
simply be a " disorganized," spastic, or weakened esophagus. This condition often affects
the elderly. In this instance, instructions may be given to modify the consistency of the
food, eat smaller and more frequent meals, use proper posture at the dinner table, take
smaller bites, chew more carefully, and to consume plenty of fluids at mealtime. Better
fitting dentures sometimes solves the problem.
Neurological Problems
Sometimes the problem is not digestive, but rather a neurological one, like a stroke or ministroke. About 30% of stroke patients will have dysphagia, or difficulty swallowing due to
damage to the part of the brain that controls swallowing. Here there is no narrowed
segment to dilate. Treatment is geared to support nutrition and other body functions until
swallowing ability returns. A special feeding tube called a PEG is often inserted.