Dysphagia refers to a condition characterized by a disorder of the swallowing act and a difficult passage of the food lump through the esophagus, which most often occurs in patients suffering from diseases of the upper gastrointestinal tract, brain and central nervous system.
Dysphagia is often observed in elderly patients and in preterm infants. Accompanied by periodic or constant discomfort sensations when trying to swallow saliva, liquid or solid food, it can reach its extreme degree - aphagia, characterized by the absolute impossibility of swallowing.
Because dysphagia is a symptom of extremely dangerous diseases, the patient should be alerted and seek qualified medical care in case of even episodic manifestations. Careful diagnosis will help to establish the cause of this phenomenon and will give an opportunity to immediately begin treatment.
Symptoms of dysphagia of the esophagus and stomach
Clinical symptoms of dysphagia of the esophageal tube indicate abnormalities that occur when the food coma moves from the esophagus to the stomach. It is characteristic that at the moment of ingestion of food the patient does not experience the slightest discomfort.
Characteristic manifestations of dysphagia are presented:
- The disturbed progression of the food lump in the esophagus, arising in the area of the oropharynx( food masses are then thrown into the mouth or into the nasal cavity).
- Sensation of suffocation.
- Strong cough.
- Feeling of "choking" food.
- With hoarseness and hoarseness.
- Abundant salivation( salivation).
- The emergence of aspiration pneumonia, characterized by inflammation of the mucous membranes of the respiratory tract due to aspiration( leakage) of gastric juice, food and vomit.
- Either the total inability to swallow food, or the need to exert considerable effort to do so.
In the vast majority of cases( especially at the initial stages of the disease) the symptoms of dysphagia of the esophagus arise when eating solid food. After swallowing each sip with a large amount of water, the patient significantly alleviates the problem of swallowing a coma.
With the use of liquid food, as a rule, there are fewer problems, although in some types of pathology, as well as in the progression of the disease, difficulties even with the ingestion of water are observed.
By duration, dysphagia can be intermittent( paroxysmal) or permanent( rack).
The emergence of permanent dysphagia is characteristic of organic pathologies that provoke a persistent narrowing of the lumen of the esophageal tube, which causes problems with the passage of solid foods( fruits, pieces of meat, bread, etc.).Wash the food with water, the patient is relieved.
In some patients with esophageal cancer, dysphagia sometimes weakens and even disappears, creating the illusion of remission. Unfortunately, the cause of this short-term phenomenon is the ulceration and decay of a malignant tumor. Very soon, dysphagia again returns, acquiring the character of a leading clinical symptom and becoming even more painful and acute.
The cause of intermittent dysphagia is always esophagospasm( esophageal disease accompanied by spasms) due to dyskinesia of the esophageal tube and accompanying serious enough organic pathologies of the esophagus: tumors, diaphragmatic hernia, esophagitis.
Code of the disease according to ICD-10
In the international classification of diseases of the tenth version, dysphagia, referred to as "difficulty swallowing," is attributed to the XVIII class combining "Symptoms, signs and abnormalities detected during clinical and laboratory studies" under code R13.
In section R10-R19, pathologies relating to the abdominal cavity and digestive system are systematized.
The basic classification, taking into account the etiology of dysphagia, divides it into:
- Functional , which occurs in patients who do not have any anatomical prerequisites, but suffer from diseases of the nervous system, in which the process of neural regulation of the functioning of the esophagus is disturbed. Functional dysphagia is often called nervous( or neurotic), because its clinical manifestations-persistent violations of intestinal motility and difficulty swallowing-are observed only against the background of strong psychotraumatic situations. One of the varieties of psychogenic dysphagia is the emergence of a hysterical lump in the throat in patients suffering from neurogenic anorexia.
- True( or organic) , due to the presence of anatomical pathologies that make it difficult to swallow. More often these pathologies are represented by diseases of the esophagus( inflammations( esophagitis), ulcers, strictures, tumors, diaphragmatic hernias), as well as aneurysms, an increase in the thyroid gland and tumors of the chest.
Depending on the location of the problem area, dysphagia can be:
- Oropharyngeal( oropharyngeal), characterized by difficulty in passing food in the oropharynx. It is divided into:
- The upper dysphagia , which occurs in patients suffering from disorders of the nervous regulation of the oral cavity, pharynx and esophagus, as well as diseases of the thyroid gland, lymphatic system, spine and internal organs.
- The average dysphagia observed in diseases of organs concentrated in the posterior mediastinum( heart, pleura, lymph nodes, blood vessels, connective tissues, nerve endings, etc.).
- Lower dysphagia, which can be caused by cysts and tumors of the diaphragm, as well as an increase in the liver and spleen.
2. Esophageal( esophageal).With this form of dysphagia, the source of pathology is concentrated in the area of the esophagus. This pathology is also divided into three forms:
- High esophageal dysphagia can result from spasmodic esophageal cavity, acute and chronic diseases of the mucous membranes of the mouth, pharynx and larynx, the presence of diverticula( protrusion) of the esophagus.
- The average esophageal dysphagia occurs in the presence of organic lesions of the esophagus( tumors, ulcers, diverticula, esophagitis, etc.) and functional neuromuscular disorders( diffuse spasm of the esophageal tube).
- Lower esophageal dysphagia can be caused by abnormalities in the functioning of the cardiac sphincter( dividing the esophagus and stomach), leading to the development of chalasia and achalasia of the esophagus. It can also provoke anatomical defects( diaphragmatic hernia, reflux esophagitis, ulcers, tumors) of the esophageal tube.
3. Cricopharyngeal, characterized by inconsistency of contractions of the circular fibers of the pharyngeal sphincter.
4. The large blood vessels( aortic branches) arising from the transmission of the esophageal tube lying close to it. A similar pathology is observed in patients with pathologies of these vessels.
Special forms include:
- Sydenopenic dysphagia I, having a number of synonymous names. Physicians refer to it as the syndrome of Kelly-Peterson, Rossolimo-Bekhterev or Plummer-Vinson. The cause of this pathology is the presence of iron deficiency anemia - a condition characterized by a violation of the production of hemoglobin due to an acute shortage of iron in the body. Sideropenic dysphagia manifests itself as the appearance of extremely unpleasant sensations in the esophagus, combined with a number of trophic lesions of the esophageal tube and stomach ailia, a pathology associated with a violation of the secretory function of this organ. Sideropenic dysphagia, manifested by the inability to swallow dry or solid food, is an extremely rare pathology that occurs in patients of middle or advanced age. Even more rare are cases of this pathology in adolescents.
- Paradoxical dysphagia is characterized by swallowing disorders, in which solid food enters the esophagus much more easily than liquid food. A patient suffering from this form of dysphagia can easily swallow large chunks, which can not be said about chewed food: swallowing causes significant problems.
- Lazorious dysphagia occurs as a result of squeezing the esophageal tube with an abnormal blood vessel. Most often this occurs in early childhood, but sometimes the pathology can manifest itself in adolescence: as the development of atherosclerotic changes in the problem vessel. To determine their presence for certain, it is necessary to conduct arteriography - a special test using a special dye and X-rays, which help to project a "map" of blood vessels onto the monitor screen. A little less informative is the diagnostic procedure for the radiopaque examination of the esophagus with the use of barium sulfate. In the overwhelming majority of cases, this form of pathology does not require special treatment. Restorative operations are performed only by certain patients.
There is a classification according to which dysphagia is divided into:
- Intra-esophagus , caused by organic pathology of the esophagus: burns, diverticula, scar strictures, benign lesions( leiomyomas), foreign bodies, Plummer-Vinson syndrome. Occurring more often in female patients, intraepithelial dysphagia is classified as a precancerous condition.
- Extra-esophagus , provoked by squeezing the esophageal tube with pathologically modified organs localized in the immediate vicinity of it. Dysphagia of this species occurs when:
- vascular pathologies( represented by an aneurysm of the aortic arch, compression of the esophagus by an abnormally deflected right subclavian artery crossing it from behind or in the front, coarctation of the aortic arch - congenital heart disease consisting of a segmented narrowing of its lumen);
- circular compression of the esophagus by large mediastinal tumors;
- mediastinitis( inflammation of the mediastinum), accompanied by a serious lesion and an increase in mediastinal lymph nodes;
- tumors of the thyroid and trachea;
- occurrence of osteophytes on the cervical vertebrae;
Reasons for the emergence of
In order for the process of moving a food coma from the oropharynx to the stomach to pass without problems, the muscles of the esophagus should be toned.
A whole complex of pathogenic factors can prevent this natural process.
It is known that in a large number of patients, the cause of dysphagia is the functional inconsistency of the neuromuscular apparatus of the esophagus, which is responsible for the movement of food masses along it.
This condition can occur due to fault:
- spasmodic esophageal tube;
- trauma to the head or spine;
- systemic scleroderma - an inflammatory lesion of small blood vessels that makes the esophagus tissues excessively hard;
- a number of serious diseases: Parkinson's disease, multiple sclerosis, achalasia cardia( neurogenic disease of the cardiac valve, as a result of which it partially or completely loses its ability to relax when swallowed food), post-poliomyelitis syndrome, muscular dystrophy;
- diseases of the immune system that provoke the onset of tumor or inflammatory processes;
- dermatomyositis - a serious progressive disease of connective tissue, smooth and skeletal muscles, leading to a significant disruption of their motor functions;
- polymyositis - a systemic autoimmune disease that causes the onset of the inflammatory process in skeletal muscles by infiltration( penetration into the tissue and accumulation in them) of lymphocytes;
- of systemic lupus erythematosus is an inflammatory disease accompanied by damage to the capillary apparatus of the kidneys and small dermal vessels, leading to changes in the skin, musculoskeletal system and internal organs.
No less common cause of dysphagia is the esophageal tube blockage resulting from:
- Bundling of esophageal structures that are congenital or acquired.
- Benign or malignant tumors of the esophagus.
- Gastroesophageal reflux, due to the weakness of the cardiac valve, due to which there is a throwing of digestive juice and stomach contents into the esophagus. Inevitably formed and scarring ulcers lead to a significant narrowing of the lumen of the esophageal tube and to a deterioration in its elasticity.
- Congenital or acquired esophageal diverticulosis.
- Esophagitis is an inflammatory disease of the mucous membranes of the esophagus that occurs when infectious diseases and allergic reactions of the body. Sometimes the cause of esophagitis can be irritation, provoked by a pill that is stuck in the folds of the esophagus.
- Pressurization of the esophageal tube by tumor or other neoplasms of nearby internal organs( eg, pathologically enlarged lymph nodes or bone spur on the vertebra).
- Natural aging of the body, leading to a loss of tonus of virtually all muscles( including the muscular apparatus of the esophageal tube).This factor is the most common cause of dysphagia in elderly patients.
Many pathologies of the oropharynx, presented by:
- , can provoke the emergence of dysphagia. Benign and malignant growths.
- Otkom Kvinke - a severe allergic reaction to animal hair, pollen, food, leading to extensive swelling of the pharynx and larynx.
- A paralysis of the pharyngeal muscles that developed as a result of cerebral circulation, triggered by brain tumors, atherosclerosis( a disease accompanied by deposition of lipid metabolism products on the walls of blood vessels), traumas of the cervical spine or brain.
The degree of dysphagia is associated with a violation of the passage of the esophageal tube:
- With the first degree of , there are periodic difficulties with swallowing solid food and minor pain as the food coma progresses.
- The second grade is characterized by the problem-free passage of exclusively semi-liquid food.
- With the third degree of dysphagia, the patient can swallow only liquid food.
- The fourth degree is marked by the appearance of aphagia - the total inability of the swallowing act( including water and saliva).
- The beginning of the diagnosis is a thorough analysis of complaints, during which the doctor asks the patient to describe the clinical manifestations of the disease in as much detail as possible, asks questions about the nature of the food and about the products, the use of which leads to the appearance of dysphagia. Even at the first visit of the patient, the specialist should establish in which part of the esophageal tube the pathology is localized. He will ask if there is pain when swallowing, what the duration of the attack, whether it is accompanied by heartburn and cough and how much the patient has decreased body weight. At this stage, it is often possible to identify signs of diseases of the gastrointestinal tract and neuromuscular structures.
- Analyzing the life history of , the specialist first of all will pay attention to the transferred diseases of the gastrointestinal tract( represented by gastritis, esophagitis, burn of the esophageal tube), and also the presence of operations.
- Important information can be obtained from an analysis of the family history of , which contains information about diseases carried by close relatives of the patient.
- Physical examination of the patient will necessarily consist of examining the oral cavity and palpation of the cervical lymph nodes.
The laboratory research unit consists of:
- Clinical and biochemical blood tests.
- Performing a coprogram( analysis of stool).In patients with dysphagia, it usually reveals the presence of poorly digested food particles and coarse plant fibers, as well as an increased fat content.
A patient who first consulted a gastroenterologist about dysphagia should go through them in the following order:
- Primary-screening-diagnostic technique is irrigoscopy( X-ray examination with the introduction of radiopaque substance - barium suspension).Before starting the procedure, the patient is asked to take a sip at first a liquid, then a thick suspension of barium sulfate, after which he takes a horizontal position. With the help of an irrigoscopy, a specialist can detect the presence of a pathological narrowing of the esophageal tube or a blockage of its lumen, which makes it impossible for the food coma to move normally.
- The main diagnostic procedure of a gastroenterological examination appointed by a doctor is fibrogastroduodenoscopy( FGDS) - an endoscopic procedure that gives an opportunity to assess the condition of the mucous membranes of the upper gastrointestinal tract and to identify the disease. Having found out an ulcer or a tumor, the endoscopist will perform a biopsy, taking samples of the problem tissues for subsequent histological examination. If there are signs of esophagitis, he will take a sample of the contents of the esophageal tube to perform bacteriological sowing, designed to identify the causative agent of pathology.
- Esophagometometry( or esophagomanometry) is a technique for detecting diseases of the esophagus and adjacent organs, which consists in recording changes in pressure in its cavity by means of an electromanometer. This procedure, which is mandatory for all patients, makes it possible to identify the existence and nature of disorders of the esophageal motility, and also to measure the pressure in the area adjacent to the cardiac valve in order to exclude the possibility of achalasia of the cardia.
- Intra-esophageal pH-metry is the most significant diagnostic technique for the detection of reflux esophagitis, carried out with a pH-metric probe having one or more pH sensors. In addition to measuring the acidity level, the total frequency and duration of episodes of reflux esophagitis are calculated during the study.
- Esophageal scintigraphy is a radioisotope technique for studying the contractility of the esophageal tube - it is used to assess the condition of the esophagus motor function and the tone of the cardia( lower esophageal sphincter).The study uses a radioactive isotope of technetium. With the normal functioning of the esophagus, 90% of the ingested food( meaning its maximum volume) labeled with the isotope must move from the esophagus to the stomach in ten seconds. The increase in the time required for the evacuation of food masses suggests a decrease in the peristaltic activity of the esophageal walls, which is characteristic of systemic scleroderma.
- Endosonography( or endoscopic sound) of the esophagus is a combined ultrasound procedure that involves the introduction of an ultrasound sensor into the cavity of the esophageal tube( this manipulation is performed during esophagoscopy).With the help of this procedure, an endoscopist can assess the condition of regional lymph nodes, all layers of the esophageal wall and adjoining mediastinal organs, and also detect esophageal tube tumors( especially those localized in the submucosa layer).The information obtained is necessary to address the need for prompt treatment.
- Laryngoscopy is used for visual inspection of the posterior wall of the larynx - a procedure requiring the use of a special mirror or special apparatus - a laryngoscope.
- The method of ultrasound examination of the abdominal cavity is used to determine the state of the stomach, gallbladder and bile ducts, kidneys, pancreas and intestines, as their damage can cause dysphagia.
- If no reason to prevent the passage of a coma on his way from the esophagus to the stomach was not revealed, the patient is referred to the procedures of encephalography and magnetic resonance imaging of the brain. With their help, diseases of the nervous system can be detected.
Differential diagnosis requires a careful analysis of the patient's complaints, together with a detailed analysis of anamnesis of life and family history:
- Information on the existence of long-lasting heartburn, preceding the emergence of dysphagia, most likely indicates peptic stricture of the esophagus.
- The presence of short-lived transient dysphagia can be a consequence of the inflammatory process. Its combination with loneliness( painful swallowing) gives grounds for assumptions about the presence of herpetic or candidal esophagitis arising in patients undergoing immunosuppressive( aimed at suppressing unwanted immune reactions of the body) therapy or in cancer patients.
- Recurrent single-phagia may be triggered by a diffuse spasm of the esophagus.
- The type of dysphagia often depends on the consistency of the food used. Difficulties arising from the ingestion of exceptionally solid food indicate the presence of organic dysphagia. To push a lump stuck in the narrowed part of the esophagus, it is enough for a patient to drink some quantity of some liquid. Discomfort in swallowing liquid food is caused by impaired motor function of the esophageal tube. With a pronounced narrowing of the lumen of the swallowing canal, the emergence of dysphagia is observed with the use of both solid and liquid food.
The complex of the main therapeutic measures is aimed at treating the pathology, which provoked the emergence of dysphagia.
After the examination, the patient is to be placed in a hospital, where he is under constant supervision of medical personnel.
The primary goal of this stage therapy is to restore the swallowing function.
Dysphagia is treated with drugs that correct for violations of the esophageal motility. This category includes:
- Prokinetics are drugs that stimulate the motility of the organs of the gastrointestinal tract.
- Spasmolytics are drugs that relieve pain caused by muscle spasm.
- Holinolytic( or anticholinergic) drugs that block receptors and the physiological effects of acetylcholine.
Antidepressants and psychotropic medications are used to relieve nervous tension in which the patient is constantly in the patient.
Drugs "Drotaverin", "No-Shpa", "Papaverin" will help cope with the muscular spasm that occurs when swallowing.
If the emergence of dysphagia was triggered by a bacterial infection, antibacterial and anti-inflammatory drugs are used.
Therapy of the syndrome after a stroke
In patients who have suffered a stroke, dysphagia is caused by paralysis or paresis of the muscles that provide the act of swallowing( for example, disruption of the hyoid and facial nerve occurs due to paralysis of the muscles of the pharynx and buccal muscles).
For the restoration of speech and swallowing during the rehabilitation period, complex treatment is applied, providing:
- Medical therapy, designed to improve metabolic and trophic processes in the structures of the brain.
- Specialized massage of the tongue( if there is a dysarthria).
- Classes with speech therapist-aphasiologist - doctor, engaged in speech restoration.
- Performing complexes of special articulatory gymnastics.
- Classes of logarithmics.
- Passage of physiotherapy procedures.
The development of a program of therapeutic measures to restore speech and swallowing in patients undergoing rehabilitation after a stroke is strictly individual.
Video on how to treat dysphagia after a stroke:
Observance of a chemically, mechanically and thermally sparing diet is an important part of dysphagia therapy. Nutrition of a patient suffering from dysphagia should obey the following principles:
- It should be divided: that is, the patient should eat a little, but often( at least five times a day).
- Eaten food should be wiped, warm and slightly salted. When preparing it, you must use olive oil or butter. The use of pork fat is categorically contraindicated.
- Patient is not allowed to eat dry and hastily. Any food should be chewed very carefully.
- In order to avoid regurgitation( esophageal vomiting), the patient should refrain from any( especially forward) slopes of the body within two hours after eating.
- The last meal should take place at least a couple of hours before departure at night.
The diet of a person suffering from dysphagia should be as follows:
- The best way to cook food is cooking, baking and steaming.
- Smoked, fatty, fried, salted, spicy and canned dishes are completely excluded from the daily diet. Under the same strict prohibition is the use of fast food, any carbonated and alcoholic beverages, products containing a large amount of coarse plant fiber, and strong coffee and tea.
- The diet should be mainly egg-milk-vegetable, containing porridge( semolina, oats, buckwheat, rice) and mucous soups.
- It is useful for the patient to take dairy and sour-milk products, meat( preferably white) and fish of lean sorts, boiled or steamed vegetables.
Folk remedies of
There are a lot of tools in the arsenal of folk healers that help to stop the manifestation of dysphagia:
- Preparing a medicinal harvest from the well-ground phytosaw material ( root of valerian( 30 g), hop cones( 25 g), lemon balm( 25 g), peppermint(25 g), rosemary( 20 g), St. John's wort( 20 g)), take a tablespoon of herbal mixture and pour a glass of steep boiling water. After a two-hour infusion and straining, the ready-made broth, which has a soothing effect, is taken to the ¼ cup three times a day before meals.
- The decoction prepared from the root of the broad-leaved ( 15 g), the herb of ephedra and the motherwort taken for 20 g. Has an antispasmodic effect. Pour the crushed herbs with a liter of cold water and allow them to brew for four hours. After this, the container with infusion is put on the fire, brought to a boil and boiled for a short time on low heat for three minutes. Withdraw from the fire, the broth is cooled and filtered. Take until a complete cure for a couple of tablespoons a quarter of an hour before eating.
- For the treatment to be more successful, folk healers recommend ten minutes before meals to take the above-described antispasmodic broth , and soothing - either half an hour before meals or between meals.
- As an antispasmodic, tincture of belladonna ( belladonna) can be used. It is taken three times a day( at the first intake - 5, in the second - 10, in the third - 15 drops) for ten minutes before meals.
- Instead of water, you can use a decoction, prepared from a teaspoon of anis seeds , a tablespoon of lightly roasted flax seed, a tablespoon of natural honey and water( 600 ml).Put the mixture on a weak fire, bring it to a boil, then immediately filter. Drink exclusively in a warm form.
- You can make syrup and take it on a teaspoonful a couple of hours after each meal. For its preparation, take the dried leaves of plantain( 5 tablespoons) and, in a liter of water, boil for half an hour on low heat. Adding a teaspoon of chopped celery fruit and 300 g of honey, boil for another ten minutes. Filter after cooling.
- In the presence of permanent constipation regular enema from one liter of warm chamomile tea is recommended. It is prepared by brewing three tablespoons of dried chamomile flowers with a liter of boiling water. After a twenty-minute infusion, tea must be filtered. Perform an enema in the evening hours preceding the night rest.
Soothing and restorative action is provided by water procedures performed every other day:
- fifteen-minute coniferous baths( water temperature - 35 degrees);
- hot compresses applied to the chest and covering the body from the clavicles to the xiphoid process;
- moist wraps( the duration of the procedure is 50 minutes).
The same compress is applied to the spine( from the first cervical to the tenth thoracic vertebra).Closely wrapped the patient( suitable wool scarf or scarf), for an hour put him in a warm bed. Having removed the compress, for a quarter of an hour the body of the patient is well rubbed with a piece of woolen cloth or a hair brush.
Surgical treatment is used in case of burns of the esophageal tube and when tumors are detected. If a malignant formation was detected at the stage of metastasis, an operation consisting of stitching the tube into the stomach followed by removal to the outside( through the abdominal wall) is performed.
After the operation, the food will be injected into the patient's body through the implanted tube using a syringe. Such a patient will need special and constant care, as well as with the help of an experienced psychiatrist, who from time to time will adjust his psychological state.
Dysphagia can trigger the onset of:
- Esophagitis( inflammation of the mucous membranes of the esophageal tube).
- Aspiration pneumonia caused by the throwing of the contents of the oropharynx into the trachea and the lungs( through the nose).
- All kinds of breathing disorders( up to its complete cessation) due to swelling of the esophageal tube, which can strongly squeeze the trachea.
- Pneumosclerosis is a serious damage to lung tissue as a result of exposure to them of acidic gastric contents left in them at the time of the swallowing act violation.
- Abscesses of the lungs( abscesses, surrounded by a protective capsule) developing when the gastric contents are thrown into the airway lumen.
- Malignant, rapidly growing esophagus tumor and cardiac part of the stomach, resulting from a chronic emerging esophagitis.
- Severe dehydration of the body.
- Significant weight loss due to reduced intake of nutrients.
To prevent the emergence of dysphagia syndrome, it is necessary:
- To treat diseases that are capable of provoking a violation of the swallowing act in a timely manner.
- Monitor your diet by eating healthy foods( greens, vegetables, fruits) containing lots of vitamins and fiber and completely giving up too fatty, fried, sharp and salty foods.
- Avoid too hot food and drinks( to avoid burning the esophagus).
- Use caution when using fish, preventing sharp bones from escaping into the esophagus.
- Refuse to wear tight and tight clothes, tight corsets and belts.
- Timely and regular medical examinations aimed at identifying tumors, diseases of the gastrointestinal tract and digestive system.
- If an alarm is detected, the gastroenterologist should immediately be shown.
- Regularly engage in physical education( for strengthening and good muscle tone).
- Refuse from smoking and alcohol abuse.
- Closely monitor the small children, preventing them from swallowing tablets and small items that can injure the esophagus and internal organs.