Deglutition disorders

Dysphagia is related to the impairment of food passage from the mouth to the stomach. Globus pharyngis implies the frequent and often painful sensation of a lump in the throat that usually does not interfere with swallowing and may even be relieved by food intake. The diagnosis is based upon a careful history, clinical examination, endoscopy, dynamic imaging (videofluoroscopy, cinematography, videosonography) and electrophysiologic procedures (including pharyngoesophageal manometry, electromyography and pH determinations). Structural lesions of the cervical spine such as diffuse idiopathic skeletal hyperostosis are rare causes of dysphagia. Dysphagia following anterior cervical fusion as well as globus and dysphonia due to dysfunction of the vertebral joints are more likely. Symptoms with swallowing fluids indicate a neurogenic origin. Dyscoordinated swallowing, nasal reflux, dysphonia or general weakness may also occur. Chronic aspiration with respiratory compromize is the main consequence in a variety of neurological disorders as well as in cases of postsurgical dysphagia. Relaxation of the upper esophageal sphincter indicates coordinated muscle movement between the pharynx and esophagus. Dysfunction of the pharyngoesophageal segment may lead to cricopharyngeal achalasia. A dyskinetic sphincter commonly represents an extrapharyngeal cause: i.e., disease associated with gastroesophageal reflux. Disorders of the esophageal phase of deglutition can produce retrosternal pain, heartburn, regurgitation and vomiting, as well as laryngeal and respiratory signs. Esophageal motility disorders include lower achalasia, tumors, peptic strictures, inflammatory diseases, drug-induced ulcers, rings and webs. Motility disorders present with aperistaltic, spontaneous contractions, diffuse esophagospasm, or a hypermotile esophagus. Gastroesophageal reflux with esophagitis must always be excluded, especially in patients with a globus sensation. The multiple features of the appearance of the symptoms of dysphagia and globus makes multidisciplinary approach necessary in order to establish a diagnosis and begin effective treatment.     

Clinical and electrophysiological evaluation of dysphagia in myasthenia gravis

OBJECTIVE: To evaluate dysphagia at the oropharyngeal stage of swallowing and to determine the pathophysiological mechanisms of dysphagia in patients with myasthenia gravis. METHODS: Fifteen patients with myasthenia gravis with dysphagia and 10 patients without dysphagia were investigated by a combined electrophysiological and mechanical method described previously. Laryngeal movements were detected by a piezoelectric transducer and the related submental EMG (SM-EMG) and sometimes the EMG of cricopharyngeal muscle of the upper esophageal sphincter (CP-EMG) were recorded during dry or wet swallowing. The results of these electrophysiological variables were compared with those of normal age matched control subjects. RESULTS: In patients with myasthenia gravis with dysphagia, it was found that the time necessary for the larynx to remain in its superior position during swallowing and swallowing variability in successive swallows increased significantly compared with normal subjects and with patients with myasthenia gravis without dysphagia. The total duration of SM-EMG activity was also prolonged in both groups but more severely in the dysphagic patients. Electromyographic activity of the CP sphincter was found to be normal in the dysphagic patients investigated. All the patients with myasthenia gravis with dysphagia had pathological dysphagia limits (<20 ml water) whereas other patients except two, were within normal limits. CONCLUSIONS: Because the electrophysiological variables related to oropharyngeal swallowing were prolonged even in patients with myasthenia gravis without dysphagia, it is concluded that the submental and laryngeal elevators are involved subclinically in myasthenia gravis and, because of compensating mechanisms, the patient may not be dysphagic. As the CP-EMG behaviour was found to be normal, a coordination disorder between normal CP sphincter muscle and the affected striated muscles of the laryngeal elevators may be one of the reasons for dysphagia in myasthenia gravis. This method also made it possible to investigate the myasthenic involvement in the laryngeal elevators that cannot be evaluated by other electrophysiological methods in myasthenia gravis.     

Solid bolus swallowing in the radiologic evaluation of dysphagia

Patients with dysphagia, heartburn and chest pain are regularly referred for radiologic evaluation of swallowing. The liquid barium swallow has been of great value for the biphasic evaluation of the pharynx and esophagus. Though many patients complain of dysphagia specifically for solids, solid bolus swallow is usually not part of the evaluation. For the present study we therefore included the use of a solid bolus with a diameter of 13 mm and interviewed the patients carefully for any symptoms during this tablet swallow. Of 200 patients examined, the tablet passed through the esophagus without delay in 102. In the 98 patients with delayed passage, the solid bolus arrest occurred in the pharynx in 5 and in the esophagus in 93. Arrest in the esophagus was due to esophageal dysmotility in 48 patients. Twenty of these were symptomatic during the tablet swallow. A narrowing was the cause in 45, of whom 9 had symptoms. In 18 patients (9%) the solid bolus added key information to the radiologic evaluation. We therefore recommend that the solid bolus is included in the routine radiologic work-up of patients with dysphagia. Careful attention to symptoms during the tablet swallow is important.     

Pathological and genetic correlates of apoptosis in the progression of colorectal neoplasia

Recent data indicate that dysphagia may occur following unilateral cortical stroke; however, the elucidation of specific cytoarchitectonic sites that produce deglutition disorders remains unclear. In a previous study of unilateral cortical stroke patients with dysphagia, Daniels et al. proposed that the insula may be important in swallowing as it was the most common lesion site in the patients studied. Therefore, 4 unilateral stroke patients with discrete lesions of the insular cortex were studied to further facilitate understanding of the role of the insula in swallowing. Dysphagia, as confirmed by videofluoroscopy, was evident in 3 of the 4 patients; all had lesions that involved the anterior insula, whereas the only patient without dysphagia had a lesion restricted to the posterior insula. These data suggest that the anterior insula may be an important cortical substrate in swallowing. The anterior insula has connections to the primary and supplementary motor cortices, the ventroposterior medial nucleus of the thalamus, and to the nucleus tractus solitarius, all of which are important regions in the mediation of oropharyngeal swallowing. Therefore, discrete lesions of the anterior insula may disrupt these connections and, thereby, produce dysphagia.     

Diurnal variation of adrenocortical activity in chronic fatigue syndrome

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23-78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21-67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 +/- 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.     

Leiomyomata of the esophagus. An analysis of 838 cases

Review of the world literature to the end of 1971 has provided data on 838 cases of esophageal leiomyomata, including our own 19 surgically removed lesions. Although esophageal leiomyoma is the most common of the benign tumors of the esophagus, it is still rare compared with carcinoma. It occurs in more men than women, by a ratio of 1.9 to 1. Over 50% of the patients with leiomyoma of the esophagus are asymptomatic. Dysphagia and vague pain are the most frequent symptoms. Pyrosis is mentioned in the literature as present in 40% of the cases, but it is considered mainly as symptom of coexistent hiatal hernia. Diagnostic problems often arise, as the smooth muscle tumors may mimic mediastinal neoplasms, cysts, or even aneurysms, or complicate coexisting hiatal hernia and esophageal diverticulum. Operative management by transthoracic enucleation is the procedure of choice, although resection of the esophagaus may be required in few cases. Postoperative morbidity is minimal and results are excellent.     

Ethical review of multi-centre research: a survey of local research ethics committees in the south Thames region

We reported a 63-year-old woman with myotonic dystrophy (MD), who had frequent swallowing disturbances and died from suffocation asphyxia. Her esophagus on CT image 30 minutes after taking semi-solid meal showed dietary remnants in the middle portion of esophagus with entire esophageal dilatation. At autopsy, there was marked atrophy in the striated muscles in the upper part and smooth muscles in the lower part of the esophagus. The site of dietary stagnation on CT image was identical to the atrophic smooth muscle layer seen at autopsy. We speculate that one of the causes of esophageal motor dysfunctions is smooth muscle atrophy. The dietary stagnation in the esophagus may increase a risk of the asphyxia. Therefore we need to keep patients at the straight position during and after dietary ingestion to prevent respiratory problems.     

Assessment of Swallowing Ability Scale for oral and oropharyngeal cancer patients

The Swallowing Ability Scale (SAS) has been recently reported by us. This scale is a new method to assess dysphagia after therapy for oral and oropharyngeal cancer. The preliminary results on 23 patients showed that the scale was reliable and sensitive to functional differences across a broad spectrum of oropharyngeal dysphagia after therapy. This paper confirmed the above facts in 73 oral and oropharyngeal cancer patients who were treated in two hospitals between 1995 and 1996. As stated in the previous paper, SAS consists of a 2-step questionnaire: the MTF score and the Dysphagia score. The MTF score is a simple and practical assessment tool consisting of three subscales: 1) Method of intake, 2) Time of intake, and 3) Food. The Dysphagia score is a relevant assessment tool for defining patients' anatomic or physiologic swallowing disorders. In 40 patients with wide resection of the tongue, the Dysphagia score (p < 0.05) and the MTF score (p < 0.01) were significantly decreased. And we found a correlation between the MTF score and the Dysphagia score (r = 0.78, p < 0.001) in 73 patients. The usefulness of the SAS will be further studied for the assessment of rehabilitation to improve postoperative dysphagia.     

Aberrant methylation of p16INK4a and deletion of p15INK4b are frequent events in human esophageal cancer in Linxian, China

Esophageal transit scintigraphy seems to be a valid methodology to assess impaired esophageal motility in early stages of disease. The purpose of this study was to discriminate patients with primary Raynaud's phenomenon (RP) and patients with systemic sclerosis (SSc) from healthy subjects by esophageal scintigraphy with a semisolid meal. METHODS: We studied 32 patients with primary RP, 18 with SSc and 13 healthy subjects. Dysphagia, acid regurgitation and heartburn were scored. After an overnight fast, all subjects underwent esophageal scintigraphy, using a semisolid orally ingested bolus (10 mL apple puree) labeled with 99mTc-sulfur colloid. Esophageal transit and emptying time and integral value were evaluated with the subjects in the upright (sitting) and supine positions. Transit time was defined as the time from the entry of 50% of radioactivity into the upper esophagus until the clearance of 50% of the bolus from the whole esophagus. Emptying time was defined as the time from the entry of 50% of radioactivity into the upper esophagus, until the clearance of 100% of the bolus from the whole esophagus. Integral value was defined as the total counts under the time-activity curve normalized to the maximum. RESULTS: Esophageal transit and emptying time and integral value, evaluated in both positions, were significantly higher in patients with SSc than in healthy subjects and than in patients with RP. Moreover, patients with RP had all three parameters, assessed in supine position, significantly longer compared to healthy subjects. Clinical scores regarding dysphagia, acid regurgitation and heartburn were not significantly different between patients with RP and SSc. CONCLUSION: Esophageal transit and emptying time and integral value appear to be able to discriminate patients with primary RP from patients with SSc and patients with RP from healthy subjects, suggesting an early mild esophageal dysfunction in RP.     

Fresh osteochondral allografts: a 6-10-year review

OBJECTIVE: To analyze the use of self-expanding metal coated esophageal stents a palliative therapy of malignant dysphagia. METHOD: We performed a one year prospective study placing 12 stents in 10 patients with malignant dysphagia. RESULTS: The insertion mean time was lower than 25 min, and most of our patients (70%) reported a good tolerance. Dysphagia score improved immediately and it lasted until death with no occlusions. Complications appeared early, 17% at the time of placement, with one patient having a life-threatening complication. The probability for these patients not to develop any complications after the three first weeks will be about 60%. CONCLUSIONS: Self-expanding metal coated esophageal stents provide a fast and lasting relief in malignant dysphagia, with a good tolerance.     

Esophageal disease in patients with AIDS: diagnosis and treatment

Patients with HIV infection often present with symptoms suggesting esophageal disease: these include odynophagia (pain with swallowing), dysphagia (difficulty in swallowing), and retrosternal chest pain. Esophageal symptoms rank second only to diarrhea in frequency of gastrointestinal complaints among patients with AIDS. Also, esophageal opportunistic infections have been associated with a poor outcome, the mean survival after diagnosis being less than 6 months in one study. Such short survival may be explained by the underlying immunosuppression, as well as a decrease in nutritional intake due to difficulty swallowing.     

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.     

Esophageal rings, webs, and diverticula

Rings, webs, and diverticula are among the most common anatomic anomalies of the esophagus. Although these structural lesions are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation, and aspiration. This article discusses the epidemiology, pathogenesis, diagnosis, and therapy of esophageal rings, webs, and diverticula with emphasis on the clinical, diagnostic, and therapeutic strategies involved in caring for patients with these conditions.     

Persistent dysphagia after laser uvulopalatoplasty: a videoradiographic study of pharyngeal function

In a follow-up study of 79 patients two years after laser uvulopalatoplasty 21 (27%) reported persistent postoperative dysphagia, with aspiration symptoms in 22%. None of the patients had suffered from recurrent pneumonia. A total of 4% of the patients regretted the treatment because of their dysphagia problems. The objective of this study was to examine oral and pharyngeal function videoradiographically during swallowing in the patients with persistent dysphagia, to determine whether the subjective symptoms of dysphagia correlated with objective signs of pharyngeal dysfunction. Pharyngeal function during swallowing was deviant in 76% of the dysphagic patients. In 52% of the dysphagic patients premature leakage of bolus down to different levels of the pharynx, from the tongue base to sinus piriformis, was observed before the swallowing reflex was elicited. In the dysphagic patients substantial bolus retention was observed on the epiglottis or in the valleculae alter the propagation wave had passed (43%) as well as epiglottal dysmotility (24%). Of the dysphagic patients, 10% could not avoid aspiration during the examination. These findings could explain the symptoms reported by the patients.     

Esophageal manometry in the opossum

The opossum esophagus is commonly used as an animal model of the human esophagus. We used esophageal manometry in normal animals to provide basal data about normal esophageal motor functions in vivo in this species. At rest, separate and distinct high pressure zones can be recorded at the level of the lower esophageal sphincter, diaphragmatic hiatus, aortic arch, and upper esophageal sphincter. Each zone demonstrates a characteristic pattern of pressures in the radii of the coronal section and a characteristic response to swallowing. The hiatal and aortic zones can be mistaken for the esophageal sphincters. Pressures in the sphincters fall with swallowing. Peristalsis is not bolus-dependent and occurs with 98% of swallows. Pressures generated by peristalsis are greater in the middle of the esophagus than at the ends. Values for resting lower esophageal sphincter pressure and the characteristics of peristalsis were reproducible between different studies in the same animals.     

Study of adenovirus production in serum-free 293SF suspension culture by GFP-expression monitoring

BACKGROUND: Recently, investigators have reported the use of endoscopic myotomy in the treatment of esophageal achalasia. As with the open operation, considerable disagreement exists regarding the appropriate length of the myotomy and the need for a concomitant antireflux procedure. METHODS: Patients presenting with symptomatic achalasia between 1993 and 1997 were included in this prospective study. Preoperative studies included barium upper gastrointestinal study, endoscopy, and esophageal manometry. Laparoscopic myotomy was completed in all 20 patients; 18 had concomitant Toupet fundoplication. RESULTS: Operative times ranged from 95 to 345 minutes (mean 216). Blood loss ranged from 50 to 300 cc (mean 100 cc). There were 7 minor complications (5 mucosal injuries repaired laparoscopically, 1 bile leak and 1 splenic capsular tear). Nine patients began a liquid diet on the first day postoperatively; 19 were tolerating liquids by postoperative day 3. Hospital stay ranged from 2 to 20 days (mean 5). Eighteen patients had complete relief of dysphagia, with less than one reflux episode per month. One individual continues to have mild persistent solid food dysphagia. Another patient initially did well but subsequently developed mild recurrent dysphagia and reflux. One patient required laparoscopic take-down of the wrap because of recurrent dysphagia and now has no problems swallowing, but does complain of mild reflux. Two other patients also have mild reflux, 1 of whom did not undergo fundoplication. CONCLUSIONS: Laparoscopic Heller myotomy can be performed safely with excellent results in patients with achalasia. Adding a partial fundoplication appears to help control postoperative symptoms of reflux. This procedure should be considered the procedure of choice in patients with symptomatic esophageal achalasia.     

Interaction of alpha-interferon with chemotherapeutic agents: effects on cytotoxic drug metabolism and multiple drug resistance

Sj?gren's syndrome (SS) is an autoimmune exocrinopathy that primarily affects the salivary glands but can also involve almost any other part of the gut. The most distressing manifestation of SS is xerostomia secondary to destruction of the salivary glands. The lack of saliva also leads to difficulty with chewing and initial swallowing and an increased frequency of dental caries. Another major problem is dysphagia due to the lack of saliva as well as esophageal dysmotility and/or esophageal webs. Chronic atrophic gastritis probably accounts for the epigastric pain, nausea, and other dyspeptic symptoms seen in SS. Sj?gren's syndrome is also one of the most frequent extrahepatic diseases associated with primary biliary cirrhosis, suggesting that this entity may be a secondary form of SS. The degree to which SS affects the small and large bowel is unclear, whereas pancreatic involvement appears to lead to only subclinical exocrine insufficiency.     

Severe complications following a "barium swallow" investigation for dysphagia

OBJECTIVE: To highlight the risks of investigation of patients with swallowing disorders by "barium swallow", when the disorders may arise from dysfunction of the upper swallowing tract. CLINICAL FEATURES: An 81-year-old Italian woman presented to her local doctor with a history of dysphagia of five days' duration. A barium swallow resulted in aspiration of a large amount of barium into the right main bronchus, causing severe problems. After a period of intensive respiratory care including intubation and continuous positive airway pressure, she recovered sufficiently to be referred to a rehabilitation unit. She had mild hemiplegia but severe dysphagia, secondary to a brain stem infarct. INTERVENTION AND OUTCOME: Persisting severe dysphagia was confirmed, with extreme risk of aspiration. The patient underwent percutaneous endoscopic gastrostomy and was discharged to live independently, but requiring long-term gastrostomy feeding. CONCLUSION: When a patient presents with dysphagia, great care should be taken to exclude upper tract dysfunction with its attendant risk of aspiration, generally by referral to a centre or consultant with expertise in this area, before ordering or carrying out investigations appropriate to disorders of the lower tract.     

Reflux esophagitis: manometry and Ph measurement

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Proven indications for manometry are dysphagia of unknown origin and noncardiac chest pain; in reflux esophagitis manometry is used for measuring pressure of the lower esophageal sphincter and detecting motility disorders of the esophageal body, pH-metry is used as long-term pH-metry to quantify gastroesophageal reflux during day and night; furthermore long-term pH-metry is important in the classification of atypical esophagitis. Recording gastroesophageal reflux and esophageal motility may influence planning of therapy and predict prognosis. Before antireflux surgery manometry and pH-metry are useful in judging the clearance mechanisms of the esophagus. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools in the long-term therapy of reflux esophagitis.     

Esophageal leiomyomatosis

PURPOSE: To reassess the clinical and radiologic findings in patients with esophageal leiomyomatosis. MATERIALS AND METHODS: A search of the authors' radiologic archives revealed six cases of esophageal leiomyomatosis in a 22-year period. The clinical findings and radiologic images were reviewed retrospectively. RESULTS: The average age of the patients was 10.8 years (range, 6-18 years). Five patients presented with slowly progressive dysphagia. Barium studies revealed smooth, tapered narrowing of the distal esophagus in five patients and characteristic defects on the superomedial aspect of the gastric fundus abutting the cardia, presumably due to bulging of this thickened mass of muscle into the stomach, in four patients. In two patients, computed tomography (CT) revealed marked thickening of the distal esophageal wall. CONCLUSION: Esophageal leiomyomatosis can be suggested in a pediatric patient with long-standing dysphagia in whom smooth, tapered distal esophageal narrowing is seen at barium study and circumferential esophageal wall thickening is seen at CT.