This post was written by Reshi Kanuru, MD, PPG – Gastroenterology.
An older gentleman sat in the Emergency Department dry heaving and spitting into a bag to the point he couldn't even swallow water. He had been having mild symptoms for years when suddenly his food became lodged in his throat and he lost all ability to swallow.
Difficulty swallowing is a symptom that we too often incorrectly blame on getting older or dismiss as a minor issue. But trouble swallowing is a very serious symptom, even when the severity is mild, as difficulty swallowing can be a symptom of esophageal cancer.
Causes
Swallowing is a surprisingly complicated process that involves two main areas of our body: the oropharynx and the esophagus. The location where the difficulty swallowing occurs can help us identify the possible causes.
The oropharynx
The oropharynx is the area extending from the mouth to the back of the throat. In the oropharynx, the causes that can affect swallowing include poor teeth, ill-fitting dentures, dry mouth, post-nasal drip and even a stroke.
The esophagus
The esophagus is the tube that extends from the back of the throat to the stomach. When we think about difficulty swallowing, esophageal cancer is our greatest concern, but cancer is not the most common cause of difficulty swallowing. The most common esophageal cause for difficulty swallowing is esophagitis, which is when uncontrolled acid reflux causes inflammation in the esophagus. This inflammation in the esophagus makes the lining of the esophagus sticky and thus makes it difficult for food to pass.
Another very common cause is esophageal strictures. Strictures are areas of scar tissue that narrow the inside of the esophagus allowing food to become caught in these narrowed areas.
For some, trouble swallowing can even be related to allergies. In those with a history of allergies or asthma, who have trouble swallowing, we think of something called eosinophilic esophagitis. Eosinophilic esophagitis (EOE) is inflammation due to allergy cells, called eosinophils, that invade the esophagus due to exposure to certain food groups. Use of acid medications to decrease inflammation and diets that eliminate food groups like wheat, dairy, tree nuts, soy, seafood and eggs help treat this disease.
Another possible cause of trouble swallowing is motility disorders. Motility disorders are when the muscles of the esophagus do not work. Those with motility problems can have trouble swallowing solid food as well as simple things, like water.
Evaluation
For most who have difficulty swallowing, the first step is to undergo an upper endoscopy. An upper endoscopy is when you are sedated with medication so you do not feel any discomfort, and a flexible tube with a fiber optic camera is passed through the mouth into the esophagus, stomach, and beginning of the small bowel. During an upper endoscopy, the lining of the esophagus is visualized to look for things like inflammation and narrowing of the esophagus.
In addition, a physician can perform biopsies during the upper endoscopy to help diagnose various causes for trouble swallowing. If they identify an esophageal narrowing during the upper endoscopy, they can perform a dilation, where the esophagus is stretched, to make it easier to swallow. Based on the findings of the upper endoscopy your doctor may order further testing to look for alternative causes. Other tests include a barium esophagram, which is an x-ray test that can identify if the esophagus has any narrowings, and an esophageal manometry, which is a probe that measures if the muscles of the esophagus are functioning correctly.
When to seek evaluation
If you are having difficulty swallowing, even if it is as little as a couple of times a month, you should discuss your symptoms with your primary care physician and consider seeing a gastroenterologist for further evaluation.
At the Parkview Regional Medical Center, we have developed a specialized clinic called the Parkview Advanced GERD & Esophageal Services (PAGES) Clinic, where we focus on swallowing and heartburn-related issues. The PAGES clinic provides a multidisciplinary approach from Gastroenterology, Interventional Endoscopy and General Surgery to provide the best outcomes for every person who has difficulty swallowing or uncontrolled acid reflux.
