The Relationship Between Dysphagia and Eosinophilic Esophagitis

Trouble Swallowing Food

What is Dysphagia?

Dysphagia is the medical term used to refer to difficulty swallowing. Dysphagia includes difficulty beginning a swallow (known as oropharyngeal dysphagia) and the feeling of food being stuck in the neck or chest (called esophageal dysphagia). When a patient has been evaluated for dysphagia, it's necessary for the doctor to confirm which sort of dysphagia you may have, oropharyngeal or esophageal, as distinct tests are used for each type. Dysphagia has to be separated from odynophagia, which can be described as pain during swallowing. This may arise from infection or inflammation in the gut. Dysphagia also has to be distinguished from globus sensation (commonly known as having a "lump in your throat"). This is a continuous sense of something being stuck in the back of the throat, which doesn't typically make swallowing difficult. By comparison, dysphagia is a symptom which only occurs when trying to swallow. Globus can occasionally be observed in acid reflux disease, but more frequently, it's due to greater sensitivity in the esophagus or throat.

Dysphagia is a common symptom of individuals who have Eosinophilic Esophagitis.

What causes Dysphagia?

Two common types of dysphagia exist -- oropharyngeal and esophageal dysphagia -- there are considered the two broad groups of causes for dysphagia. Within each broad group, there are two subgroups of causes: neuromuscular (between the muscle or nerve), and structural, in which the esophagus is narrowed or compromised. EoE sufferers typically have the latter (narrowing of the esophagus).

Oropharyngeal dysphagia: Neuromuscular causes are more common than structural causes of this sort of dysphagia. This is because the nerves controlling the muscles of the mouth, back of the throat (pharynx) and the upper end of the thoracic (upper esophageal sphincter) have direct connections with the mind through cranial nerves, and may consequently be damaged in disorders involving the brain or cranial nerves.

Esophageal dysphagia: In this type of dysphagia, structural causes are a lot more common than disorders involving nerves or muscles. Therefore, narrowing in the esophagus from discoloration due to acid reflux disease, inflammation of the lining of the esophagus (normally from acid reflux disease but sometimes from diseases), tumors inside the gut, and compression of the esophagus from growths in the chest or sometimes an enlarged heart can cause dysphagia. Moreover, a special sort of inflammation brought on by a form of blood cell called eosinophils may lead to dysphagia; this problem is known as eosinophilic esophagitis.

The esophageal muscle may be weak and at times not able to create sufficient pressure during contraction. In extreme conditions, the muscle creates no force and is not able to squeeze -- this can be called scleroderma esophagus (although scleroderma isn't often the cause), and may be associated with dysphagia. Another disease of the nerves and muscles is achalasia; a condition where the muscle at the base end of the esophagus can't relax during swallowing due to abnormal nerve control. The muscle in the body of the esophagus also doesn't squeeze normally in achalasia and becomes stretched and weak. If the nerves are abnormal to a lesser degree, spasm of the esophagus can result, which could also cause dysphagia.

What are the symptoms of Dysphagia?

By definition, dysphagia is the feeling that food or fluids don't pass normally in the mouth into the stomach. Symptoms may vary depending upon the location of the abnormality causing dysphagia. After the patient has oropharyngeal dysphagia from a neuromuscular cause, muscles involved with chewing and in pushing food into the back of the throat may also be involved. Generally speaking, dysphagia happening within one second of attempting to swallow is because of oropharyngeal dysphagia. The muscles that protect the nose and the voice box (larynx) during swallowing may be faulty in their function, causing the individual to have food and beverage come out through the nose or enter the airway through the larynx (voice box) while attempting to swallow (known as 'aspiration'). Food entering the larynx can cause choking, coughing, or even result in a kind of pneumonia called aspiration pneumonia. There might be a change in the individual's voice (husky voice or hoarse voice) due to the involvement of nerves that control the vocal cords. The trouble swallowing is typically felt in the area of the back of the throat.

With esophageal dysphagia, food might be consumed normally but might get trapped in the chest or neck. This is the most common feeling of dysphagia in individuals with EoE. Symptoms of acid reflux disease-like heartburn may also be present because reflux is the most frequent cause of narrowing of the esophagus resulting in dysphagia. Despite the fact that the abnormality might be at the bottom end of the esophagus, the feeling of food being trapped may be sensed higher up in the torso or even at the neck area. Rarely, food might actually block the esophagus (food impaction, which in most EoE individuals means throwing the food back up in order to remove the impaction) -- this will cause a complete inability to consume, including fluids, and generally requires urgent endoscopy to remove the food bolus. Achalasia, a state where the esophagus fails to relax and allow food to pass, may be tricky to diagnose because symptoms progress slowly. Patients with esophageal spasm may have chest pain too.

How to treat Dysphagia?

For the most part, the treatment of dysphagia is based upon the cause. Treatment often involves making a change in the foods consumed or the consequences of food. The modified barium swallow may identify foods of certain consistencies which can be consumed better than others. The test can also identify neck and head positions that facilitate swallowing. Balloons may be passed through the endoscope and bloated to extend the narrowing, or dilators (long plastic or rubber cylinders of various sizes) may be passed through the mouth, occasionally over a guide wire. Since narrowing is usually linked to acid reflux disease, treatment with an acid-reducing representative is usually suggested.

Patients with eosinophilic esophagitis are treated with acid lowering agents or steroid preparations sprayed into the back of the throat and swallowed. Dilation can also be effective but should be carried out with caution to prevent tears; dilation is usually performed if steroid preparations don't improve dysphagia in eosinophilic esophagitis. After the narrowing is from inoperable cancer, wire or metallic stents (thin expandable tubes) can be placed during endoscopy to maintain the lumen of the esophagus open letting food and liquid to pass through. Patients with achalasia improve when the muscle at the base end of the esophagus is interrupted, either with a huge balloon (pneumatic dilation) or through an operation where the muscle is cut (myotomy). From time to time, botulinum toxin (BOTOX®) may be injected into the muscle at the base end of the esophagus to make it unwind, but this treatment simply leads to short-term progress in achalasia.

What can you expect from Treatment?

This depends upon the cause of dysphagia. Dysphagia from strictures (narrowings) from the esophagus can improve nicely with extending of the esophagus, but repeat endoscopic sessions for extending may be necessary from time to time. Dysphagia from acid reflux disease, esophageal infections, and eosinophilic esophagitis may resolve completely with medications. Dysphagia from achalasia enhances with either surgery or forceful dilation of the lower end of the esophagus, but the esophagus remains dilated. When the reason for dysphagia can't be treated, alternative choices include placing a wire or metal stent to keep the esophagus open, particularly when the narrowing is because of cancer.

With both kinds of dysphagia, if symptoms are present over a long time period, patients may drop weight and become malnourished. Weight loss can be worse when the cause is cancer of the esophagus, or when there's a really tight narrowing or obstruction in the gut. Dehydration can happen if there is difficulty swallowing liquids. At times, if the esophageal blockage is almost complete, it may be bypassed to prevent some of those problems, by putting a tube into the stomach for feeding (percutaneous gastrostomy tube). This is also occasionally performed in oropharyngeal dysphagia once the danger of fluids and food entering the lungs and causing pneumonia is high.

Keeping it simple

If you made it this far, you may be a bit confused on what to do next if you experience Dysphagia. Seeing a doctor get properly diagnosed is always the best first step. In most cases, food sensitivities are the culprit and causing inflammation of the esophagus, which is causing the esophagus to narrow and food impaction to take place. In order to determine if you are eating food that are causing food sensitivities, you can do the following:

  1. Take an at home, inexpensive, yet thorough food sensitivity test through Everlywell.
  2. Based on the results, you eliminate foods that are triggers for inflammation.
  3. You can look at different medications to treat inflammation or take the natural approach with supplements.

Dysphagia sucks. Take these simple steps to decrease the occurrences and improve your day to day life. 

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