Introduction
In Gut Matters we discuss 4 problems that older adults often meet. These are:
- (1) Dysphagia (difficulty swallowing);
- (2) Dyspepsia (Indigestion) and gastric pain;
- (3) Constipation; and
- (4) Fatty liver and liver cirrhosis.
Dysphagia (Difficulty Swallowing)
The feature image depicts a nice food court with eating stalls . Unfortunately, as we get older, dysphagia or difficulty swallowing can get in our way of our enjoying our food, glorious food — either acutely as in the case of a stroke, or less acutely as in failure of oro-pharyngeal muscles in the upper esophagus. Dysphagia can also be due to spasm of esophageal muscles, obstruction from within, in the wall, or outside the esophagus. Let us first define what is dysphagia and then classify the 4 types of dysphagia by location.
Definition of dysphagia
Dysphagia refers to difficulty in moving liquid, food, or saliva from the mouth down the esophagus (gullet) and on to the stomach. There are four locations where this can occur.[1] See Figure 1.
Causes of Dysphagia
Common causes at the 4 locations are:
- 1-Oropharyngeal dysphagia. Muscle causes: Throat muscle swallowing loss of function due to age, stroke, Parkinson’s disease, myasthenia gravis. Obstruction: Oropharygngeal cancer.
- 2-Esophageal dysphagia. Muscle causes: Diffuse muscle spasm, scleroderma. Obstruction: Esophageal cancer, stricture of esophagus from prolonged gastro-esophageal reflux.
- 3-Esophagogastric dysphagia. Muscle causes: Failure of the lower esophageal sphincter to relax. Obstruction: Gastric cancer, stricture.
- 4-Paraesophageal dysphagia. Nerve cause: Achalasia, Obstruction: Compression on the esophagus from outside by surrounding structures e.g., thyroid gland, cervical spine disease. In achalasia. damage to nerves in the esophagus results in paralysis and dilation of the lower end of the esophagus over a period of time, eventually not being able to propel food into the stomach and food collects in the dilated esophagus.
Investigations
Based on the description of swallowing difficulty, various tests may be ordered to evaluate the problem (Mayo Clinic, 2022).[2] These include:
- 1-Xays with barium contrast (Barium X-rays). These provide information on the changes of the esophagus, and also blockages in the esophagus.
- 2-Dynamic swallowing study. Barium coated foods of different consistencies are swallowed to provide images of these foods as they move down the throat and along the passage down the esophagus.
- 3-Visual examination of the esophagus (endoscopy). An endoscope (a thin flexible instrument is passed down the throat into the esophagus so that the interior of the esophagus lining can be seen and biopsies can be taken. Inflammation of the esophagus, narrowing, or tumor can be visualised.
- 4-Fiber-optic endoscopic evaluation of swallowing (FEES). A special camera mounted in a lighted endoscope is used to examine the swallowing processes when the patient is asked to swallow.
- 5-Esophageal muscle test (manometry). In this assessment, a small tube is inserted into the esophagus and connected to a pressure recording device to measure esophageal muscle contractions as the patient swallows.
- 6-CT scan and MRI scan. These provide detailed images of cross-sectional images of bones. organs and soft tissues for detailed study of abnormalities.
Treatment
Treatment of dysphagia depends on the underlying cause that is found.
Oro-pharyngeal dysphagia. Thickening of all drinks and soups helps the patient swallow without choking due to food going into the airways and even down the lungs. The amount of thickener needed to create a consistency where the patient can drink without choking can be read from the label of a thickener agent like Thick and Easy, Thixer, or other brands.
Figure 4 shows the instructions to thicken water, beverages, and soups taken from Thick & Easy — one of the preparations of commercially available thickeners.
Take home messages
1-Dysphagia or difficulty swallowing can be the result of either loss of muscle function, spasm of muscle of the esophagus, or narrowing of the esophagus by cancer in the esophagus, narrowing or stricture of the walls of the esophagus, and compression of the esophagus from outside from surrounding structures like the thyroid gland, enlarged heart chambers, or lymph nodes outside the esophagus.
2-There is a need to attend to such problems earlier by seeing a family doctor. Some causes like oro-pharyngeal dysphasia can be treated with thickening of water, beverages, and soups with commercial thickeners. Tumours, or strictures will need the expertise of a surgeon.
Acknowledgments
Grateful thanks are due to the following:
- 1-Simon Kareman. Thanks for the Unsplash feature image of the food court.
- 2-The publishers of Clinical Methods for the picture on the esophagus and locations where dysphagia may occur.
- 3-Thick & Easy. Thickener mixing chart on the tin label.
References
- 1-Douglas Wolf. Chapter 82. Dysphagia. in: Walker HK, Hall WD, Hurst JW editors. Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edition. Boston: Butterworths; 1990. https://pubmed.ncbi.nlm.nih.gov/21250045/
- 2-Editors. Dysphagia: Symptoms and causes. Mayo Clinic, 2022. https://www.mayoclinic.org/diseases-conditions/dysphagia/symptoms-causes/syc-20372028
- 3-Editors. Dysphagia: Diagnosis and treatment. Mayo Clinic, 2022. https://www.mayoclinic.org/diseases-conditions/dysphagia/diagnosis-treatment/drc-20372033
- 4-Thick & Easy. Thickener mixing chart. Label accessed 2022 Sep 13.
Dr LG Goh
Dr GOH Lee Gan is a retired Associate Professor in the Department of Family Medicine, National University Health System. He has an interest in learning and teaching how we can age well everyday (AWE).
