Dysphagia is a pathological condition in which the act of swallowing is disrupted. It is manifested by difficulty swallowing solid food, liquids, saliva, their ingestion into the respiratory organs, increased saliva formation, pain behind the sternum, hoarseness of voice, sore throat. It is diagnosed by pharyngoscopy, esophageal radiography, esophagogastroscopy, pH-metry, esophageal manometry. Treatment involves the appointment of etiopathogenetic therapy of a disease complicated by dysphagia. If a disorder occurs against the background of severe organic changes in the pharynx, esophagus, and adjacent organs, surgical interventions are performed.
ICD 10
R13 Dysphagia
Meaning
Dysphagia is a secondary pathological process and develops against the background of other diseases. Swallowing disorders are detected in all age groups, but the incidence increases with age. According to the results of observations, the prevalence of pathology is 11% in the general population and reaches 13% in patients over 65 years of age.
At a young age, dysphagia often complicates the course of injuries, malignant neoplasia of the head and neck. In elderly patients, the leading causes of impaired swallowing are disorders of cerebral circulation, neurodegenerative diseases. The relevance of timely diagnosis of dysphagic syndrome is due to a significant deterioration in the quality of life of patients and a high risk of mortality in the event of complications.
Causes of dysphagia
Specialists in the field of modern gastroenterology separately consider etiological factors leading to the development of oropharyngeal (“high”) and esophageal (“lower”) swallowing disorders, although some of them are detected in both types of pathology. The passage of a food lump through the pharynx and the proximal part of the esophagus is disrupted by such reasons as:
- Mechanical obstruction. Violation of the oropharyngeal phase of swallowing can be caused by inflammatory processes (pharyngeal abscess, tonsillitis), thyroid hyperplasia, enlarged lymph nodes, hypopharyngeal diverticulum, cervical osteophytes, muscle fibrosis, cricoid-pharyngeal adhesions. Narrowing of the upper digestive tract is also observed in malignant neoplasia of the oral cavity, pharynx, larynx, the consequences of their surgical treatment and radiation therapy.
- Neuromuscular disorders. Oropharyngeal dysphagia develops in the acute phase of cerebral stroke in 42-67% of patients, its severity directly correlates with the severity of cerebral circulatory disorders. In half of patients with parkinsonism, clinical symptoms of impaired oropharyngeal swallowing are observed, in another 45% of patients, latent signs of the disorder are detected instrumentally. Dysphagia is complicated by multiple sclerosis, amyotrophic lateral sclerosis, pseudoparalytic myasthenia gravis.
Esophageal swallowing disorders are often caused by esophageal pathology, chronic diseases of the gastrointestinal tract, mediastinum. Acute forms of dysphagia occur with allergic Quincke’s edema, sudden obstruction of the esophageal body and gastroesophageal transition by foreign bodies. Normal passage of solid and liquid food through the esophagus into the stomach may interfere:
- Narrowing of the esophagus. The lumen of the organ decreases with eosinophilic pharyngitis, malignant tumors of the esophagus, stomach cancer with a lesion of the cardiac department, complicated course of gastroesophageal reflux disease. Cicatricial stenosis develops after radiotherapy of thoracic oncological diseases, chemical burns with caustic compounds, potassium chloride, salicylates, and some other drugs. Signs of dysphagia are noted when the lumen of the organ is narrowed less than 12 mm.
- Compression of the esophagus from the outside. The passage of food is hindered by volumetric formations that exert pressure on the esophageal wall. Esophageal dysphagia is often found in tumors (lung cancer, bronchial tubes, thymoma), enlargement of mediastinal lymph nodes, retrosternal goiter, infectious diseases (tuberculosis, histoplasmosis), paraesophageal hernia. Swallowing difficulties are detected in cardiopathology — mitral valve defects, vascular compression.
- Disorders of the contractile activity of the esophagus. Esophageal swallowing disorders complicate achalasia, diffuse esophageal spasm, corkscrew-like deformity of the organ. Pathological changes in motor skills are noted in patients with systemic scleroderma, Chagas disease, diabetes mellitus. Disorders of esophageal muscle contractions that interfere with the swallowing process occur when taking nitrates, estrogens, methylxanthines, calcium channel blockers.
Pathogenesis
There are two key mechanisms of dysphagia development — obstructive and dysregulatory, which can be combined in some pathological conditions. In obstructive swallowing disorders, the passage of food is disrupted due to the existence of a mechanical obstacle – inflammatory, granulomatous processes, scarring, volumetric formations protruding into the lumen of the digestive organs or compressing them from the outside. In some cases, the situation is aggravated by pain syndrome, especially pronounced with inflammation.
The pathogenesis of dysregulatory dysphagia is based on innervation disorders due to damage to the swallowing center of the medulla oblongata, the enteral nervous system, pathological changes at the level of the esophageal muscular layer. As a result of the contraction of the muscles of the soft palate, the pharynx becomes discoordinated, the esophageal peristaltic reflex is disrupted, which leads to a change in the process of natural passage of food.
Classification
The existing systematization of clinical forms of dysphagia takes into account both the anatomical level of swallowing disorders and the degree of their severity. This approach facilitates the identification of the root cause of disorders, allows you to evaluate the prognosis and develop optimal patient management tactics. Gastroenterologists distinguish the following types of disease:
Anatomical level: oropharyngeal (oropharyngeal) and esophageal dysphagia. In the first case, the formation of a food lump is disrupted, its movement in the direction of the throat, the initial swallowing movements. In the second case, the passage of products through the esophagus and their entry into the stomach becomes difficult.
By severity: there are 4 degrees of dysphagia. At grade I, the patient experiences difficulties with swallowing solid foods, at grade II, only liquid food is swallowed. Patients with dysphagia of the III degree have impaired swallowing of not only solid food, but liquids, saliva. At the IV degree, it becomes impossible to swallow any food.
Symptoms of dysphagia
At the initial stage of the disease, patients usually complain of difficulty swallowing solid food, accompanied by discomfort in the pharynx and esophagus. There may also be painful sensations along the esophagus, increased salivation, a feeling of bursting behind the sternum. Characteristic symptoms of the disease are hoarseness of the voice, a feeling of lack of air, dry cough, sore throat. The progression of dysphagia leads to violations of the ingestion of liquid food, its entry into the respiratory organs of the patient. Sometimes the disease is accompanied by heartburn. With a prolonged course, there is a deterioration in the general condition of the patient, a significant loss of body weight due to lack of food.
Complications
With dysphagia, esophagitis is often observed, which, with a chronic course, increases the risk of metaplasia of the epithelium of the esophageal mucosa with the development of a tumor. The constant throwing of food particles into the respiratory tract causes aspiration pneumonia, characterized by a severe course and resistance to therapy. A constant deficiency of nutrients causes a sharp weight loss of the patient up to cachexia, which is accompanied by dystrophic changes in internal organs. When the trachea is compressed by esophageal tumors, acute respiratory failure (asphyxia) is observed, threatening the patient’s life and requiring emergency measures.
Diagnostics
Detection of swallowing disorders is usually not difficult due to the typical clinical picture of the pathological condition. However, the key task of diagnostic search in dysphagia is the diagnosis of diseases that could cause the disorder. The examination of the patient is carried out comprehensively and includes the following methods:
- Examination of the pharynx. Pharyngoscopy reveals the causes of oropharyngeal dysphagia: tonsillitis, glossitis, neoplasms, foreign bodies. The method is supplemented by indirect laryngoscopy, which allows to diagnose the pathology of the epiglottis.
- Esophagography. Radiography of the esophagus with oral administration of a contrast agent reveals disorders of the involuntary phase of swallowing and changes in esophageal motility characteristic of dysphagia. Radiologically, it is also possible to determine the presence of diverticula.
- Esophagogastroscopy. With EGD, the esophageal mucosa and gastric cardia are well visualized, which helps to detect macroscopic changes in the epithelium that cause dysphagia. At the same time, a tissue biopsy is performed for histological examination.
- Determination of the hydrogen index. Daily pH-metry is the most accurate study for the diagnosis of reflux esophagitis in order to confirm the organic nature of dysphagia. Additionally, esophageal manometry can be performed to detect disorders of the lower gastroesophageal sphincter.
Changes in the clinical blood test for dysphagia are nonspecific and correspond to the underlying disease. Anemia, moderate leukocytosis, increased ESR can be determined. The biochemical analysis of the blood shows a decrease in the level of total protein, dysproteinemia, possibly an increase in the content of liver enzymes. To assess the state of the digestive tract, an ultrasound of the abdominal cavity is performed. In order to exclude the pathology of the nervous system, a comprehensive neurological examination is carried out, according to the indications, an MRI of the head, a CT scan of the brain, and an EEG are prescribed. To exclude possible pulmonological and cardiological pathology, chest x-ray, echocardiography, ECG are recommended.
Differential diagnosis of dysphagia syndrome is performed between diseases that can cause this pathological condition. The disease is differentiated with dysphagia, hysterical “lump in the throat” (globus pharyngeus), dyspnea, phagophobia. In addition to observation by a gastroenterologist, the patient may need consultations with an otorhinolaryngologist, thoracic surgeon, oncologist and other specialists.
Treatment of dysphagia
The etiology and course of the disorder have the greatest influence on the choice of medical tactics. The main therapeutic tasks are the restoration of swallowing, prevention of possible complications, first of all — aspiration in oropharyngeal dysphagia of neuromuscular genesis. Patients with acute forms of swallowing disorders, usually occurring with mechanical obstruction of the esophagus, are shown emergency assistance for the removal of a foreign body.
Correction of long-existing disorders involves complex etiopathogenetic treatment of pathology complicated by dysphagia. From pharmaceutical preparations , taking into account the causes of the disease , they are used:
- Means to improve neuroregulation. To restore swallowing, patients with Parkinsonism are prescribed dopamine agonists and precursors, central N-holinoblockers. Manifestations of dysphagia in myasthenia gravis decrease against the background of taking anticholinesterase agents. In case of cerebral strokes, intensive complex therapy with neuroreparants, neuroprotectors, membrane stabilizers is carried out.
- Calcium channel blockers. Reduce the concentration of calcium ions in muscle fibers, eliminating spastic conditions (diffuse esophageal spasm, achalasia) and improving the passage of food. If necessary, dysphagia therapy is supplemented with nitrates that have a relaxing effect, anticholinergic agents, phosphodiesterase inhibitors that affect neuromuscular regulation.
- Antisecretory drugs. Recommended for combination of dysphagia with GERD, eosinophilic esophagitis. Proton pump inhibitors are most often used, which reduce the secretion of hydrochloric acid and thus reduce irritation of the esophageal mucosa with gastric secretions. In the presence of eosinophilic esophagitis, aerosol forms of local steroid preparations are additionally used.
With a proven infectious genesis of the disease accompanied by dysphagia, antibacterial and antiviral therapy is indicated. Most patients require a correction of the diet — replacing solid foods with soft foods, a restrictive diet in the presence of hypersecretory disorders. In all cases of neurological pathology, rehabilitation is prescribed using techniques to improve oral swallowing.
In a number of patients, persistent dysphagic disorder can be eliminated only surgically. With neoplasia that compresses the esophagus, resection or removal of the affected organs is performed. According to the indications, the operation is supplemented with chemo and radiotherapy. With dysfunction of the upper esophageal sphincter, Cenker diverticula, cricopharyngeal myotomy is effective.
Augmentation, balloon dilation, esophageal stenting, endoscopic dissection of strictures allow to restore the esophageal lumen with its cicatricial narrowing, compression by adjacent organs. For the treatment of therapeutically resistant achalasia, an esophagocardiomyotomy is performed. With dysphagia associated with irreversible changes in the esophagus, esophagoplasty is performed.
Prognosis and prevention
The probability of a full recovery depends on the cause that led to the development of dysphagia. The prognosis is considered relatively favorable if the symptoms are caused by increased acidity of gastric juice and other conditions that respond well to drug therapy. Prevention of dysphagia includes timely treatment of diseases of the digestive tract (peptic ulcer, GERD), refusal to eat very hot, fried food, alcohol, cessation of smoking, careful supervision of children, excluding the ingestion of small objects and toys by the child.
Literature
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