OT: A Tough Problem To Swallow - Dysphagia

A Tough Problem to Swallow: Dysphagia

David A. Johnson, MD

Introduction

Hello, I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School. Welcome back to another session of GI Common Concerns -- Computer Consult.

Today I wanted to chat with you briefly about patients with dysphagia. Dysphagia is something that you'll see commonly. I wanted to give you some pearls and reflections from 30 years of experience in dealing with patients [with dysphagia].

What Is Dysphagia?

Let's first define dysphagia. Then I want to give you some things that I guarantee you that, at the end of this discussion, you'll say I didn't know that -- so stay tuned.

Let's start with dysphagia. Dysphagia means problem swallowing, as opposed to odynophagia, which is painful swallowing.

The first question I always ask when a patient says he or she has a problem swallowing is to determine if it occurs with solids or liquids, because this takes us down a whole different step of diagnoses and potential approaches depending on if we have solid food dysphagia as opposed to liquid food dysphagia or mixed solid and liquid food dysphagia.

I want to know if it is intermittent or if it is persistent. I want to know if it is progressive, because this could indicate a more structural cause going over the course of time. I want to know if it is associated with heartburn because heartburn certainly makes an issue of reflux type strictures. I want to know what medications the patient is taking or if there are any recent changes in the patient's medications. You might think about pill-induced esophagitis, not uncommon at all as it relates to nonsteroidal exposures, bisphosphonates, quinidine and quinine types of products, in particular, as it relates to other antibiotics, for example, doxycycline. Nonetheless, these are associated with a pill-induced esophagitis risk.

There may be something that is the new kid on the block. I would consider if there are atopic features. We'll come back to this in a second when we talk about eosinophilic esophagitis.

Patient Scenarios and Clinical Evaluations

Let's start with 3 patient scenarios.

First, there is a 24-year-old patient who comes to your office with episodic solid food dysphagia, with potentially a good history for food bolus obstruction.

Second, there is a 65-year-old patient who comes to your office with solid food dysphagia, and it's been evident over the last year. This is a 65-year-old woman who was most recently started on bisphosphonates for osteoporosis potential [because of] osteopenia on her DEXA scan.

The third patient has had solid and liquid food dysphagia, which has been evident over the past 5 or 6 years in retrospect. It's been somewhat progressive but not necessarily so. It's been a problem for this patient. This patient is, again, relatively youthful, around 45 years old.

So you've got several different patient scenarios.
Patient 1

Let's take the first patient, the 24-year-old patient with episodic solid food dysphagia. In this case, it's very easy to consider Schatzki's ring. This is a very common diagnosis in patients with episodic food dysphagia, and, in particular, it is associated 100% of the time with hiatal hernia. The absence of reflux symptoms is pretty typical. This patient may present with food bolus obstruction.

This requires an endoscopic evaluation. Anybody with solid food dysphagia warrants an endoscopy, but nonetheless this is potentially treatable and curable with a balloon dilation of the Schatzki's ring.

The fly in the ointment here has been that we've seen an increased association with reflux, so we really have to investigate whether this patient has heartburn, and if so, I would put the patient on a proton pump inhibitor and keep the patient on it indefinitely.

Now the new kid on the block is eosinophilic esophagitis, [and should be considered in a patient with] a history of food bolus obstruction. In fact, if I'm called to the emergency department with a younger adult, male in particular, who has food bolus obstruction in the absence of heartburn, I sure as heck think about eosinophilic esophagitis. This is a localized eosinophilic infiltrate in the esophagus. We think it's related to food-related allergies in a lot of cases. It is an entity that has previously been relegated only to children, pediatric patients, not an uncommon diagnosis, but now it is increasingly being recognized in adults.

So think about eosinophilic esophagitis; your gastroenterologist will need to help you here. These patients should all be referred for food allergy testing. There is not an infrequent association with food allergies that they could potentially be treated with. Sometimes we have to use an inhaled and swallowed steroid, but most frequently we're able to dilate them. I keep them all on a proton pump inhibitor. Again, counsel the patients about avoiding potentials for dysphagia. We'll talk [more] about that in just a second.

Patient 2

The second patient is the 65-year-old woman who comes in with a history of progressive dysphagia. She has had bisphosphonate.

The first thing I would worry about is [to] exclude cancer. Progressive dysphagia is a concern; solid food dysphagia tells you that this is most likely an anatomic stricture and narrowing, and this patient is going to warrant an endoscopy.

The tip here is that this patient has had medications that potentially predispose her to pill-induced esophagitis. Bisphosphonates, in particular, are alluded to potentially nonsteroidal agents. It's a very common cause of strictures in the esophagus, particularly when you get into older patients, [as] their motility may be down; they may be taking them while recumbent or may lie down after they take these medications.

Think about patients who are taking antiarrhythmic agents; quinidine is a very classic example here. In patients with a potential for left atrial enlargement with impingement on the esophagus, quinidine can potentially hang up in the distal esophagus and cause strictures. We've seen this a lot with doxycycline in patients who taking repetitive dosing for a number of reasons, mostly for acne in younger patients and for rosacea in older patients. We have seen this a number of times, so ask about the co-medications. Obviously if they've had some caustic exposure in the past, that needs to be registered. So this patient potentially would have a pill-induced esophagitis risk.

Patient 3

The third patient, a 45-year-old man, has solid and liquid food dysphagia. I always worry about a motility cause if I hear liquid food dysphagia because there are very few things that can do that. Recognize that the esophagus is pretty predictable. If you have an anatomic narrowing of under 13 mm, virtually everybody will get solid food dysphagia, but liquids seem to go pretty classically through even the tightest stricture, up until they really have total obstruction, which is what achalasia really is.

So I'm worried about achalasia. You can have a primary achalasia, meaning it's a primary motility disorder, or a secondary achalasia, in particular associated with cancers at the EG (esophagogastric) junction, the fundus of the stomach. There are rare cases of patients who have a neurohumoral effect on the lower esophagus with pancreatic cancer and some lymphomas. Nonetheless, the majority of these are a primary cancer at that site, so secondary achalasia always needs to be excluded. It comes back to my point of all patients with dysphagia warrant endoscopy.

So I'm worried about achalasia. You can have a primary achalasia, meaning it's a primary motility disorder, or a secondary achalasia, in particular associated with cancers at the EG (esophagogastric) junction, the fundus of the stomach. There are rare cases of patients who have a neurohumoral effect on the lower esophagus with pancreatic cancer and some lymphomas. Nonetheless, the majority of these are a primary cancer at that site, so secondary achalasia always needs to be excluded. It comes back to my point of all patients with dysphagia warrant endoscopy.

Diagnostic Workup for Dysphagia

Now how do you work up these patients?

Endoscopy, [as] I said, is really the key, so you should refer to a gastroenterologist early in the case.

Dysphagia is what we call an alarm symptom or sign. An alarm symptom is if the patient is having trouble swallowing; a sign is a patient who presents with a food bolus obstruction and that would clearly be a warrant of an urgent endoscopy, even if the patient passes the bolus.

If you do a barium study, be aware of the fact that you could miss a lot of structural lesions by just a simple barium study. So in my case, I always alert the radiologist that I'm looking particularly for structural lesions, so I will always do a study that involves an evaluation for structural cause. I ask them to give a 13-mm barium tablet. Remember the 13-mm rule is that the patients who will present with obstruction, they always have dysphagia of 13 mm or less.

Other Problems to Consider in Patients With Dysphagia

I'm always worried, too, about dysphagia where patients have trouble initiating swallowing. This patient population may be more your older patients.

Here I think about cervical spine disease because the cervical spine compressing on the esophagus may create spurs and may create a structural obstruction, and a barium tablet would really hang up in the cervical esophagus. Unfortunately, there's not a whole lot we can do here from a dilation standpoint. However, there is a way that you can help patients position the esophagus by having them flex their head forward [to] relieve the compression from the posterior spine and the anterior spurs on the esophagus, and it may be something that they can work with.

Patients with solid and liquid dysphagia, particularly when they initiate the swallow, may tell you that there is a problem in getting that swallow started. Sometimes they'll even have nasopharyngeal regurgitation; as they start to swallow, they may tell you that this comes back up into their nose. This worries me a lot about neurologic causes, in particular, bulbar paralysis, so I think about things that involve the bulbar area, things like amyotrophic lateral sclerosis. I've seen this present this way a couple of times, in patients obviously with strokes. Think about transfer dysphagia, initiating swallow, getting it into the esophagus to begin with, it may be a problem.

You may serve these patients well by changing the evaluation to also a swallowing evaluation and by involving your swallowing team. Changing the viscosity of the bolus that they swallow may help. Thin liquids tend to slip back very quickly, so thicker liquids tend to have a little bit more allowance for compensation when these patients go to swallow and allow them potentially to not have problems with aspiration. Involving the swallowing team is important. Getting a speech therapist or a swallowing rehab person involved is very much important. Again, getting them to flex their necks. Thicken their liquids; I use an agent called Thick-It®, which is helpful to thicken the viscosity of the liquids, and it may be somewhat helpful.

Clinical Pearls for Dysphagia

Now a couple of pearls that I want to leave you with.

When you take a history for dysphagia, it's very difficult sometimes to get the right answer unless you ask the right question. It's kind of like [with] kids, if you don't ask the right question, you don't get the right answer. So ask specific questions. If you ask patients if they have trouble swallowing and they say no, then ask about provocative agents. I am going to give you a couple of tips.

Ask about meat. Meat is very difficult for some patients who have problems with dysphagia. They may start to avoid meat. So meat is one thing to always ask about.

Doughy bread products are another. You'll find that some patients, as they start to get problems with certain food groups, tend to select themselves away from certain food groups. You'll find that patients will select away from doughy bread, and they may go to more toasted bread or crusty bread because it tends to crumble. Doughy bread tends to glob up, and it becomes a bolus obstruction. It's very difficult for patients to swallow these types of things.

Pasta is the same way; it may create that same functional obstruction because it tends to glob up. In particular this is an event with rice; [it can occur with] some of the pasta noodles in particular. You may find this with patients when they try and eat these things that they tell you, oh yes, that always catches on me.

Vegetables and fruits that are fresh and have skins on them are notorious for this. So it makes sense that a hard piece of carrot would catch up, but maybe it may not make as much sense that a potato skin might or a fruit with a skin on it. These are very difficult to chew up.

I always start with the concept that you need to cut [food] into small pieces, irrespective of what the food group is because we can't tear things like canines do. We don't have canine teeth. I counsel my patients with dysphagia, or when I ask them about their food groups, I tell them that I want them to be good cutters as much as good chewers.

Starting with a small bolus is important. Avoiding food groups that we just discussed is important, tough meats, doughy bread products, pasta, things that have skins on them, fresh fruits and vegetables that are hard. These are questions that you want to ask.

I always involve the family, in particular with older patients. Ask about these patients and what do they observe from the family members who assess them while they're eating. You may find that older patients may also tend to eat more slowly and push away from the meal a little bit more slowly. Ask these questions of the family and observers.

Conclusion

I'll leave you with some tips from evidence of dealing with dysphagia over the past 30 years. I want you to really be thoughtful when you think about these patients. Consider things like:

* Eosinophilic esophagitis as the new kid on the block, a new entity that warrants referral to allergy [and] the involvement of a gastroenterologist;
* Think about motility causes;
* Think about pill-induced causes;
* Take a good history;
* If you have a patient who has dysphagia and identifies food groups as a problem, you need to then counsel the patient to avoid these food groups until they're seen by the gastroenterologist and appropriately dilated; and
* Cut [food] carefully.

Hopefully these things will serve you well in your next dealing of a patient with dysphagia. I look forward to discussing another topic with you soon. I'm Dr. David Johnson; thanks for listening.

David A. Johnson, MD
Professor of Medicine, Chief of Gastroenterology, Eastern Virginia Medical School, Norfolk, Virginia