Dysphagia: It doesn’t have to be hard to swallow.

What is dysphagia and how is it diagnosed and treated? Leading London-based consultant gastroenterologist, Dr Rami Sweis shares his expertise on the condition, discussing what causes it, how it is diagnosed, and how it can be treated.

What are the symptoms of dysphagia?  

Dysphagia is a medical term which incorporates a variety of symptoms occurring from the throat or anywhere down the oesophagus (food pipe). There can be a variety of symptoms which include choking, problems with initiating swallowing, food sticking or issues with food progressing down the oesophagus slowly. It can also be described as a holding up of food, pain, discomfort or even of food coming back up. Dysphagia almost always requires investigation with endoscopy in the first instance in order to exclude conditions that need to be treated in a more rapid fashion. 

What are the causes of dysphagia?  

There are a variety of causes that can lead to these symptoms. First and foremost, one needs to exclude the sinister conditions, such as cancer, growth or blockage, and to do this endoscopy is required. However, in the majority of cases, the cause is not something sinister, but still a camera is the first step so that pictures and biopsies can be taken to look under the microscope.  

Endoscopy is a painless procedure whereby a camera is passed from the mouth to the stomach. It normally takes no more than 7 minutes and can be performed either with a numbing throat spray or with sedation whereby patients are comfortable and asleep. Patients do not need to ‘swallow’ the camera, the endoscopist does all the work while the patient just lays on their side comfortably for a few minutes. 

Once endoscopy is done, and if no obvious problems have been identified, the next step is to perform tests to investigate both the function and structure of the oesophagus. These tests include: 

1. High resolution manometry
2. Barium swallow

High resolution manometry: This is important to understand how the oesophagus works whilst eating and drinking. A very thin, floppy tube with pressure sensors is passed from the nose to the stomach. Patients are then asked to swallow water and then food (e.g., rice or they are asked to bring food that they know causes symptoms). This is a 20-minute test and is normally well tolerated and not very uncomfortable. The tube is removed as soon as the test is complete. The patient often can watch the trace as it is produced and take part in the analysis as the images are very easy to understand as the trace appears spontaneously as one swallows.   

If there also are symptoms of reflux, impedance-pH monitoring can be performed. This normally follows manometry whereby an even thinner tube is passed in the same way, but this tube has pH sensors that measure acid and non-acid reflux. This tube stays in place for 24 hours so that all reflux is recorded onto a receiver, which is a small box that the patient carries on the shoulder or belt. 24 hours later, the recorder returned and the tube is easily removed. Again, this is normally well tolerated and painless. 

Barium swallow: This test requires the patient to swallow a liquid that can be picked up on x-ray. This helps determine the structure and shape of the oesophagus. There are different types of barium swallow. Sometimes the doctor might ask for one even if a barium study has already been done at your local hospital. This normally will be a different type of barium study in order to look for aspects of the oesophagus not picked up by the standard test.  

What conditions might lead to dysphagia and how do these tests help to diagnose them?  

Each test looks at a different aspect of the oesophagus as there is no ‘one test’ that looks at everything. The most common conditions to look for with tests are: 

1. Worrying features like a cancer are assessed with endoscopy. Biopsies will be taken and other tests such as a CT scan might be requested. The doctor will always explain everything, including the next steps immediately after the endoscopy if anything like this is found.  
2. Endoscopy also helps exclude other conditions which can only be identified by looking, taking photos and taking small biopsies. These include inflammation of the oesophagus that can range from mild redness to severe ulceration, therefore describing varying degrees of reflux. Hiatus hernia can be measured which can also be associated with reflux. Narrowing in the oesophagus can be seen which can be the consequence of reflux disease or other conditions such as eosinophilic oesophagitis, a condition that is similar to having asthma in the oesophagus that is due to an allergy to a particular type of food.
3. Movement disorders of the oesophagus can lead to varying degrees of dysphagia but are very difficult to measure without high resolution manometry. This is performed whilst the patient is asked to drink and eat to reproduce symptoms. Conditions that lead to this include spasms, hypercontractions, loss of contractions or a non-relaxing valve between the oesophagus and stomach, also known as achalasia. Each of these conditions requires a different type of treatment but needs to be diagnosed appropriately and often it is only manometry that can differentiate between one condition and the other.  

Problems with the way the oesophagus is shaped can be seen with a barium swallow. A pocket can arise in the back of the throat known as a ‘diverticulum’ or spasms in the top of the oesophagus can lead to problems initiating a swallow such that food sticks at the back of the throat and upper oesophagus. Food can also come out of the mouth or there can be excessive throat clearing. On the other hand, an abnormal shape of the oesophagus further down can be the consequence of motility disorders that are not treated over a prolonged period of time. Again, each of these conditions requires a different type of treatment, so diagnosing the right one is crucial.  

What treatment options are available for dysphagia? 

Treatment depends on the type of disorder that is uncovered with tests in combination with what symptoms are the most troublesome. These include the following: 

1. Conditions like cancer are not common, but if found, a discussion with the cancer doctors will be required. Treatment options include chemotherapy, radiotherapy, surgery and many others, all depending on the type and stage of cancer found. What is important however is that the earlier this is diagnosed the better the outcome will be following treatment. If there is rapid dysphagia and other new symptoms such as regurgitation and/or unexplained weight loss, please seek medical attention soon.  
2. Inflammation that is due to reflux are treated with anti-reflux therapies. These could include tablets to stop acid from forming in the stomach, antacids to neutralise existing acid or anti-reflux procedures (like anti-reflux surgery or trans-oral incisionless fundoplication) to stop acid from coming up.  
3. Narrowings in the oesophagus can be due to no particular cause, or can be the consequence of reflux or other conditions such as eosinophilic oesophagitis. Treatment will often be a combination of medication and/or dilatation of the narrowing with a balloon placed through the camera. The balloon is blown up for a few seconds then taken down to recreate the opening. The same can be applied for spasm of the back of the throat.  
4. Botox can be used to treat spasms in the oesophagus. Other treatments can also be used as anti-spasm medications. These include medicines similar to the ones used to treat high blood pressure (e.g., calcium channel blockers or nitrates) or even Viagra.  
5. Conditions such as achalasia, whereby there is loss of movement in the oesophagus and a non-relaxing valve between the oesophagus and stomach (known as the lower oesophageal sphincter) can be treated with either Botox, balloon stretch of the sphincter, or cutting the non-relaxing muscle with surgery (Heller myotomy) or per-oral endoscopic myotomy (POEM). In this case the doctor will go through the risks and benefits of each procedure in details before a decision is made.  
6. There are many other, often rarer conditions that can be treated in a variety of ways, sometimes combining different treatments. On the other hand, sometimes there is no abnormality identified, in which case reassurance and/or medications that suppress sensitivity might be the best options.  

What should someone do if they are experiencing swallowing problems?   

It’s important to understand that the severity of symptoms does not always equal the severity of the disorder. Sometimes even the most severe pain can be the consequence of a hypersensitive oesophagus, whilst in others with very few symptoms there can be an advanced disorder of movement of the oesophagus. Speaking to the doctor and describing symptoms in detail and answering the questions asked is a crucial first step for the doctor to decide if there are simple treatments to consider such as a tablet and if there are tests to arrange before treatments are offered. The history along with the results of appropriate tests are what are required to determine which treatments are most appropriate.  

If there are swallowing problems, first and foremost, you need to see a doctor, preferably one with an upper GI interest in order to determine what should be done. The next steps should always be decided together so that you are reassured and convinced that you are receiving the best tests and treatments. Not everything can be treated but important conditions need to be excluded and your doctor should take the time to explain this to you and answer all your questions in detail.  

If you are experiencing difficulties swallowing and would like to book a consultation with Dr Rami Sweis, you can book on directly by visiting his Top Doctor’s profile.