DIFFICULTY SWALLOWING: SYMPTOMS, DIAGNOSIS, AND RELIEF TIPS

Dysphagia and Dyspepsia

Dysphagia refers to difficulty in swallowing, which can occur at any stage of the swallowing process, from the mouth to the esophagus. It can manifest as a sensation of food getting stuck in the throat or chest, pain while swallowing (odynophagia), or an inability to swallow altogether. Dyspepsia, on the other hand, is a term used to describe discomfort or pain in the upper abdomen, often associated with bloating, nausea, and indigestion. While dysphagia is primarily related to swallowing mechanics, dyspepsia pertains more to gastrointestinal function.

Causes of Dysphagia

1. Strictures: Esophageal strictures are narrowings of the esophagus that can result from chronic gastroesophageal reflux disease (GERD), inflammation, or scarring from previous injuries or surgeries. These strictures can impede the passage of food.
2. Malignancy: Tumors in the esophagus can cause obstruction and lead to dysphagia. Both benign and malignant growths may compress or invade surrounding tissues, making it difficult for food to pass through.
3. Achalasia: This is a condition where the lower esophageal sphincter fails to relax properly during swallowing, leading to difficulty in moving food into the stomach. It is characterized by increased pressure at the lower esophagus and may also involve dilation of the esophagus above this point.
4. Neurological Causes: Various neurological conditions can affect swallowing by impairing muscle coordination and strength. Conditions such as stroke, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, multiple sclerosis (MS), and cerebral palsy can all contribute to dysphagia.

Red Flag Signs and Assessment of Dysphagia

‘Red flag signs’ are symptoms that indicate a potentially serious underlying condition requiring urgent investigation. In dysphagia, these may include:

• Unintentional weight loss
• Persistent vomiting
• Blood in vomit or stool
• Severe pain on swallowing
• New-onset dysphagia in individuals over 50 years old

The assessment of dysphagia typically involves several diagnostic tools:

1. Blood Tests: These tests help identify underlying conditions such as anemia (which could suggest malignancy) or infections that might contribute to symptoms.
2. Endoscopy: An upper endoscopy allows direct visualization of the esophagus and stomach lining. It helps identify structural abnormalities like tumors or strictures and enables biopsy if necessary.
3. Contrast Studies: A barium swallow study involves ingesting a contrast material that coats the esophagus while X-rays are taken. This method helps visualize functional aspects of swallowing and identifies areas where obstruction occurs.

Presentation and Risk Factors for Oesophageal Cancer

Oesophageal cancer often presents with progressive dysphagia as one of its earliest symptoms due to tumor growth obstructing the esophagus. Other common presentations include:

• Weight loss
• Chest pain
• Chronic cough
• Hoarseness
• Regurgitation

Risk factors for developing oesophageal cancer include:

1. Age: The risk increases significantly after age 50.
2. Gender: Males are more likely than females to develop oesophageal cancer.
3. Tobacco Use: Smoking is a major risk factor.
4. Alcohol Consumption: Heavy drinking increases risk.
5. Gastroesophageal Reflux Disease (GERD): Chronic GERD can lead to Barrett’s esophagus, which increases cancer risk.
6. Obesity: Higher body mass index (BMI) has been associated with increased risk.
7. Dietary Factors: Low intake of fruits and vegetables may contribute.

In summary, understanding dysphagia involves recognizing its causes—ranging from structural issues like strictures and malignancies to neurological disorders—and being aware of red flag signs that necessitate further investigation through blood tests, endoscopy, and contrast studies for proper diagnosis and management.

Medical and Surgical Treatments of Oesophageal Cancer Including Palliative Care

Oesophageal cancer is a serious condition that requires a multifaceted approach to treatment, which can be categorized into medical, surgical, and palliative care options.

1. Medical Treatments:
   • Chemotherapy: This is often used as a primary treatment for oesophageal cancer, especially in cases where the cancer is advanced or has metastasized. Common regimens include combinations of drugs such as cisplatin, fluorouracil (5-FU), and taxanes.
   • Radiation Therapy: This may be used in conjunction with chemotherapy (chemoradiation) or as a standalone treatment to shrink tumors before surgery or to relieve symptoms in advanced cases.
   • Targeted Therapy: Drugs like trastuzumab are used for HER2-positive oesophageal cancers. Other targeted therapies may focus on specific genetic mutations found in the tumor.
2. Surgical Treatments:
   • Esophagectomy: This is the surgical removal of part or all of the oesophagus and is typically performed when the cancer is localized. The extent of surgery depends on the tumor’s location and stage.
   • Endoscopic Mucosal Resection (EMR): For early-stage cancers confined to the mucosa, EMR can be performed to remove cancerous tissue without extensive surgery.
   • Palliative Surgery: In cases where curative surgery is not possible, procedures may be done to alleviate symptoms, such as placing stents to keep the oesophagus open.
3. Palliative Care:
   • Palliative care focuses on improving quality of life for patients with advanced disease. This includes pain management, nutritional support, psychological support, and symptom control through medications and interventions.

NICE Clinical Guidelines for Managing New-Onset Dyspepsia

The National Institute for Health and Care Excellence (NICE) provides guidelines for managing new-onset dyspepsia which include:

• Assessing patients based on their age and presenting symptoms.
• Offering testing for Helicobacter pylori infection if indicated.
• Considering endoscopy in patients over 55 years old with alarm symptoms (e.g., weight loss, difficulty swallowing).
• Providing proton pump inhibitors (PPIs) as initial treatment if H. pylori is not present or after eradication therapy.

Different Causes of Dyspepsia and Their Risk Factors

Dyspepsia can arise from various causes:

1. Functional Dyspepsia: Often idiopathic; risk factors include stress, anxiety, and dietary habits.
2. Gastroesophageal Reflux Disease (GERD): Associated with obesity, smoking, alcohol consumption, and certain medications.
3. Peptic Ulcer Disease: Caused by H. pylori infection or NSAID use; risk factors include smoking and excessive alcohol intake.
4. Gastritis: Can result from infections or irritants; risk factors include heavy alcohol use and chronic vomiting.

Different Causes of Gastro-Oesophageal Reflux Disease (GORD)

GORD occurs when stomach acid frequently flows back into the oesophagus due to:

1. Lower esophageal sphincter dysfunction
2. Hiatal hernia
3. Obesity
4. Pregnancy
5. Smoking
6. Certain foods (e.g., chocolate, caffeine) that relax the lower esophageal sphincter

Los Angeles Classification of GORD

The Los Angeles classification system categorizes GORD based on endoscopic findings:

• Grade A: One or more mucosal breaks <5 mm long that do not extend between the tops of two adjacent mucosal folds.
• Grade B: One or more mucosal breaks ≥5 mm long that do not extend between the tops of two adjacent mucosal folds.
• Grade C: One or more mucosal breaks that extend between the tops of two adjacent folds but involve less than 75% of the circumference.
• Grade D: Mucosal breaks that involve at least 75% of the circumference.

Conservative, Medical and Surgical Treatment of GORD

1. Conservative Treatment:
   • Lifestyle modifications such as weight loss, dietary changes (avoiding trigger foods), elevating head during sleep, and quitting smoking.
2. Medical Treatment:
   • Proton Pump Inhibitors (PPIs) are first-line therapy for reducing gastric acid production.
   • H2-receptor antagonists may also be used but are generally less effective than PPIs.
3. Surgical Treatment:
   • Fundoplication: A surgical procedure where the top part of the stomach is wrapped around the lower esophagus to prevent reflux.
   • LINX device implantation: A newer procedure involving a ring of magnetic beads placed around the lower esophagus to strengthen it against reflux.

In conclusion:

Oesophageal cancer treatments encompass medical therapies like chemotherapy and radiation; surgical options including esophagectomy; palliative care focusing on symptom relief; NICE guidelines emphasize assessment based on age/symptoms; dyspepsia causes range from functional issues to ulcers with various risk factors; GORD arises mainly from sphincter dysfunction/obesity; Los Angeles classification grades severity based on endoscopic findings; treatments involve lifestyle changes alongside PPIs/surgery when necessary.

Investigation and Treatment of Helicobacter Pylori

Helicobacter pylori (H. pylori) is a gram-negative bacterium that colonizes the gastric epithelium and is associated with various gastrointestinal diseases, including peptic ulcers and gastric cancer. The investigation and treatment of H. pylori involve several steps:

1. Diagnosis:
   • Non-invasive tests:
     • Urea Breath Test (UBT): Patients ingest a urea solution labeled with a carbon isotope. If H. pylori is present, it metabolizes the urea, producing carbon dioxide that can be detected in the breath.
     • Serology: Blood tests can detect antibodies against H. pylori, but they may not distinguish between current and past infections.
     • Stool Antigen Test: This test detects H. pylori antigens in stool samples, indicating an active infection.
   • Invasive tests:
     • Endoscopy with Biopsy: An upper gastrointestinal endoscopy allows direct visualization of the stomach lining, where biopsies can be taken for histological examination or culture to confirm the presence of H. pylori.
2. Treatment:
   • The standard treatment regimen for H. pylori infection is known as “triple therapy,” which typically includes:
     • Two antibiotics (e.g., amoxicillin and clarithromycin) to eradicate the bacteria.
     • A proton pump inhibitor (PPI) (e.g., omeprazole) to reduce gastric acid secretion, enhancing antibiotic efficacy.
   • Treatment duration usually lasts 10-14 days.
   • In cases of antibiotic resistance or treatment failure, “quadruple therapy” may be employed, which includes bismuth subsalicylate along with two antibiotics and a PPI.

Aetiology, Pathogenesis, and Pathology of Barrett’s Oesophagus

1. Aetiology: Barrett’s oesophagus is primarily caused by chronic gastroesophageal reflux disease (GERD), where acidic gastric contents frequently flow back into the esophagus due to lower esophageal sphincter dysfunction. Other risk factors include obesity, smoking, and certain dietary habits.
2. Pathogenesis: The pathogenesis involves repeated exposure of the esophageal mucosa to acid and bile salts from the stomach, leading to injury and inflammation (oesophagitis). Over time, this chronic injury prompts a metaplastic change in the squamous cells lining the esophagus to columnar cells—a process known as intestinal metaplasia.
3. Pathology: Histologically, Barrett’s oesophagus is characterized by the presence of specialized intestinal metaplasia in the distal esophagus. This condition increases the risk for developing dysplasia (abnormal cell growth) and subsequently esophageal adenocarcinoma.

Management of Barrett’s Oesophagus and Its Complications

1. Surveillance: Patients diagnosed with Barrett’s oesophagus require regular endoscopic surveillance to monitor for dysplasia or cancer development. The frequency of surveillance depends on whether dysplasia is present—every 3-5 years for non-dysplastic Barrett’s; annually for low-grade dysplasia; every 6 months for high-grade dysplasia.
2. Treatment Options:
   • For patients with low-grade dysplasia or non-dysplastic Barrett’s oesophagus:
     • Lifestyle modifications (diet changes, weight loss).
     • PPIs may be prescribed to manage GERD symptoms.
   • For high-grade dysplasia:
     • Endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) may be performed to remove dysplastic tissue.
     • Radiofrequency ablation (RFA) can also be used to destroy abnormal cells while preserving normal tissue.
3. Complications: Complications include progression to esophageal adenocarcinoma if left untreated; therefore, timely intervention is crucial.

Hiatus Hernia

A hiatus hernia occurs when part of the stomach protrudes through the diaphragm into the thoracic cavity via an opening called the hiatus. There are two main types:

1. Sliding Hiatus Hernia: This is more common and occurs when both the stomach and gastroesophageal junction slide up into the chest cavity during activities like bending over or lying down.
2. Paraesophageal Hiatus Hernia: This type occurs when part of the stomach pushes through alongside the esophagus but does not affect its position relative to the diaphragm.

Symptoms may include heartburn, regurgitation, difficulty swallowing, or chest pain; however, many individuals remain asymptomatic.