Approach To Dysphagia - Standard Treatment Guidelines
Dysphagia is an important symptom of esophageal or pharyngeal disorder. It usually indicates the presence of an underlying disease process and, therefore, requires prompt evaluation.
The Ministry of Health and Family Welfare has issued the Standard Treatment Guidelines Gastroenterological Diseases for Approach To Dysphagia. Following are the major recommendations :
Case definition
Dysphagia is defined as difficulty or inability to transfer food from the oral cavity to the stomach.
Incidence of Dysphagia
Dysphagia has been shown to be present in 20% of patients seen at primary care level and 15% of elderly patients in the community. Many of the elderly patients do not seek medical advice. Incidence data from India are lacking.
Differential Diagnosis
Dysphagia is sub classified into two types depending on the location of the lesion. Inability or difficulty in transferring food from oral cavity to upper esophagus is referred to as oropharyngeal dysphagia. Inability or difficulty in transferring food from upper esophageal region to stomach is
termed asesophageal dysphagia.
A careful history is vital in identifying the type and underlying cause of dysphagia. Difficulty in initiating a swallow suggests oropharyngeal dysphagia. This may be accompanied by sensation of food getting stuck above suprasternal notch, choking sensation, nasal regurgitation of food, aspiration, dysarthria and dysphonia. When swallow is initiated but a few seconds later the patient feels food is getting stuck in esophagus (below suprasternal notch), esophageal dysphagia is likely. Dysphagia may occur due to structural lesions in the pathway of food bolus transit (Mechanical dysphagia) or neuromuscular dysfunction (Motor dysphagia). Difficulty in swallowing liquids and solids from the onset of dysphagia suggests motor dysphagia while difficulty in swallowing solids alone at the onset of illness indicates mechanical dysphagia. A short duration of progressive symptoms with significant weight loss is suggestive of malignancy. Presence of pain during swallowing (odynophagia) may occur in infective lesions (Candida, CMV, etc,) or acute ulcerating lesions (pill esophagitis). History of gastroesophageal reflux symptoms, systemic illness (Stroke, Parkinson’s disease, myasthenia gravis, muscular dystrophy, scleroderma, AIDS, etc.), drug/corrosive ingestion, exposure to radiation and surgeries in past may provide further clues to the diagnosis. Clinical examination for thyromegaly, cervical lymph nodes, oral cavity lesions and central nervous system function may be helpful. Hence, a careful history usually enables a physician to narrow down the list of differentials. Table 1 shows the differential diagnosis of dysphagia.
Table 1: Differential diagnosis in a patient with dysphagia
| Oropharyngeal | Esophageal |
Mechanical
| Mechanical
|
Motor
| Motor
|
Prevention and Counselling
As dysphagia is a symptom resulting from various disease entities rather than a single disease, preventive measures are feasible in only certain situations. Diseases resulting from specific inciting agents may be prevented if awareness is improved among the general population.
1. Esophageal cancers have been associated with alcohol consumption, obesity and smoking and counselling about avoiding these risk factors might be useful.
2. Appropriate labelling of corrosive substances and keeping them away from the reach of children may prevent corrosive injuries of esophagus.
3. Swallowing pills in upright position with plenty of fluid may prevent pill esophagitis.
4. Prompt therapy of gastroesophageal reflux disease with proton pump inhibitors may heal esophageal ulcers and prevent development of peptic stricture.
5. Adequate chewing of food reduces the chance of food bolus impaction.
6. Counselling patients that dysphagia is an alarm symptom which requires prompt medical attention may help in early diagnosis and management of malignancy of esophagus.
Optimal diagnostic criteria, Investigations, Treatment and Referral Criteria
Situation 1: At Secondary Hospital/Non-Metro situation
Clinical diagnosis:
Dysphagia is a symptom and hence a history of difficulty/inability to initiate or complete a swallow is sufficient to confirm its presence. Further probing about the duration, nature (solids alone or for both solids and liquids), course (progressive or intermittent) of the symptom as well as associated symptoms (see section on differential diagnosis) helps to reduce the number of possible etiologies and plan appropriate focussed investigations.
Investigations:
- Prior to investigations for oropharyngeal/esophageal lesions, systemic illnesses causing dysphagia (stroke, Parkinson’s disease, Myasthenia gravis, etc.) should be considered and appropriately evaluated.
- For structural oropharyngeal dysphagia, a nasopharyngeal endoscopy is appropriate. Specimen from lesions should be obtained for histopathology and/or microbiological evaluation. For motor oropharyngeal dysphagia, video-fluo roscopic swallowing study is the best modality.
- In patients with structural esophageal dysphagia, upper gastrointestinal endoscopy is appropriate as it enables better characterisation of lesion and collection of specimen for histopathology and/or microbiological evaluation.In suspected esophageal motility disorder, barium swallow study may be the appropriate initial test. For further characterisation of the motility disorder, patient may be referred to a higher center for esophageal manometry.
Treatment:
Oropharyngeal dysphagia:
1. Treatment of neuromuscular causes is difficult but in conditions like myasthenia gravis and Parkinson’s disease medical therapy may be useful.
2. Adequate nutrition is crucial. Thick fluids or soft solids are better tolerated.
3. If risk of aspiration is high, feeding through nasogastric tube may be considered or surgical gastrostomy/jejunostomy may be performed for feeding.
4. For infective lesions, antibiotics may be used.
5. Malignant lesions require a multidisciplinary approach at a higher center.
Esophageal dysphagia:
1. Both structural and motor lesions require therapeutic endoscopic procedures or surgery and, hence, are better managed at a higher center.
2. Calcium channel blockers provide some relief in achalasia cardia or diffuse esophageal spasm.
3. Proton pump inhibitors may be given for peptic strictures.
4. Soft foods should be recommended in case of esophageal webs and rings.
Standard Operating Procedure
Out Patient: Patients without systemic illness and with adequate hydration and good sensorium can be managed as outpatients.
In Patient: Patients with severe systemic illness, dehydration and impaired level of consciousness should be managed as inpatients.
Day Care: Patients with dehydration can be managed on a day care basis and discharged after proper hydration and intervention if they can subsequently adequately nourish themselves at home.
Referral criteria:
1. Oropharyngeal dysphagia: Non-availability of video fluoroscopy or gastrointestinal endoscopy facilities or for management of malignant lesions.
2. Esophageal dysphagia: For further evaluation and management after barium swallow study
3. Patients with systemic illnesses requiring specialised care
Situation 2: At super speciality facility in Metro Location where higher-end technology is available
Clinical diagnosis:
Dysphagia is a symptom and hence a history of difficulty/inability to initiate or complete a swallow is sufficient to confirm its presence. Further probing about the duration, nature (solids alone or for both solids and liquids), course (progressive or intermittent) of the symptom as well as associated symptoms (see section on differential diagnosis) helps to reduce the number of possible etiologies and plan appropriate focussed investigations.
Investigations:
1. Prior to investigations for oropharyngeal/esophageal lesions, systemic illnesses causing dysphagia (stroke, Parkinson’s disease, Myasthenia gravis, etc.) should be considered and appropriately evaluated. Consultation with a neurologist and imaging of brain as well as electrophysiological study of nerve/muscles may be warranted.
2. Structural oropharyngeal dysphagia:
(i) Consultation with an ENT specialist for nasopharyngeal endoscopy is appropriate. Specimen from lesions should be obtained for histopathology and/or microbiological evaluation.
(ii) If no lesion is found, a computed tomography of the lower head and neck region would be required.
3. Motor oropharyngeal dysphagia:
(i) Video-fluoroscopic swallowing study is the best modality.
(ii) Manometric study may be undertaken to assess for upper esophageal sphincter dysfunction and cricopharyngeal achalasia.
4. Structural esophageal dysphagia:
(i) Upper gastrointestinal endoscopy is appropriate as it enables better characterisation of lesion and collection of specimen for histopathology and/or microbiological evaluation.
(ii) If a peptic stricture is suspected, a 24 hour esophageal ph study would confirm the presence of gastroesophageal reflux.
(iii) If the esophageal mucosa is normal during endoscopy, extrinsic compressive lesions should be suspected and computed tomography of mediastinum or endoscopic ultrasonography from esophagus is required to locate these lesions.
5. Esophageal motility disorder:
(i) Barium swallow study may be the appropriate initial test.
(ii) For further characterisation of the motility disorder, esophageal manometry should be performed.
Figure 1 shows the approach to a patient with dysphagia.
Treatment:
Oropharyngeal dysphagia:
1. Treatment of neuromuscular causes is difficult but in conditions like myasthenia gravis and Parkinson’s disease medical therapy may be useful.
2. Adequate nutrition is crucial. Thick fluids or soft solids are better tolerated.
3. If risk of aspiration is high, feeding through nasogastric tube may be considered or percutaneous endoscopic gastrostomy may be performed. If percutaneous endoscopic gastrostomy is not feasible, surgical gastrostomy/jejunostomy may be performed for feeding.
4. For infective lesions, antibiotics may be used. For malignant lesions a multidisciplinary approach involving the surgeon, radiotherapist and oncologist is required.
Esophageal dysphagia: Treatment depends on the disease.
1. Achalasia Cardia:
a) For surgically low risk patients, graded pneumatic dilatation should be performed.
b) If two sessions of pneumatic dilatation does not provide adequate symptom relief, surgical (laparoscopic or open) myotomy of lower esophageal sphincter should be performed. Direct referral of patients for surgery is also an option.
c) For high risk surgical patients, botulinum toxin injection in the LES region may provide short term symptom relief.
2. Strictures (Corrosive, Radiation, Peptic and Anastomotic):
a) Endoscopic dilatation (bougie dilators) is the preferred initial treatment if feasible. Repeated dilatations may be required.
b) For long, tight strictures or those with frequent recurrence of symptoms after endoscopic dilatation, surgery may be considered. For short strictures dilatation using CRE (Controlled Radial Expansion) under endoscopic vision is effective. For Anastomotic strictures, dilatation using CRE balloons is beneficial.
c) Anti-reflux therapy with proton pump inhibitors reduces the need for further dilatation in peptic strictures.
3. Esophageal tumours:
a) Benign tumours causing dysphagia should be surgically resected.
b) If lesion is small and does not extend beyond submucosa (assessed using endoscopic ultrasonography), endoscopic mucosal resection/endoscopic submucosal dissection are less invasive options.
c) For operable malignant tumours, chemoradiation followed by surgery is the treatment of choice.
d) Most malignant lesions of esophagus are inoperable at diagnosis and hence palliation is the only option. Palliative options include – i) placement of a nasogastric feeding tube over a guide wire (placed during endoscopy), ii) esophageal stenting using self expandable metal stent (SEMS), iii) radiation therapy and iv) surgical gastrostomy/jejunostomy for feeding.
4. Esophageal webs and rings:
Esophageal webs and rings should be managed with endoscopic dilatation.
5. Other conditions:
a) Nitrates or calcium channel blockers can be used for diffuse esophageal spasm.
b)Systemic illness like scleroderma requires appropriate medical therapy.
Standard Operating Procedure
Out Patient: Patients without systemic illness and with adequate hydration and good sensorium can be managed as outpatients.
In Patient: Patients with severe systemic illness, dehydration and impaired level of consciousness should be managed as inpatients.
Day Care: Patients with dehydration can be managed on a day care basis and discharged after proper hydration and intervention if they can subsequently adequately nourish themselves at home.
Referral criteria:
While a super speciality center is expected to have all the diagnostic and therapeutic facilities, patients may be referred if required equipments/expertise are not available.
Who does what and timelines?
a. Doctor:
1. Within one hour of patient’s arrival at the hospital
Initial resuscitation if patient is sick, dehydrated, etc,.
History and clinical examination
Need for hospitalisation
After the patient is stabilised
Planning further diagnostic tests
Explaining the condition to patients and relatives and obtaining informed consent for procedures
Definitive treatment of the patient
Referral to other specialists in the same hospital or to other centers
b. Nurse:
1. On patient’s arrival at the hospital - Measure blood pressure, pulse rate, breathing rate and level of consciousness and inquire about the chief complaint. The doctor should be accordingly informed.
2. Obtain intravenous access, collect blood samples for investigations and carry out treatment orders for patients requiring emergency care.
3. Assist the doctor in performing procedures, surgery, etc.
c. Technician
1. Set up and maintenance of equipments required for emergency or elective care
2. Assist the doctor during endoscopic or surgical procedures
3. Keep a ready stock of instruments/accessories required for emergency or elective procedures
Guidelines by The Ministry of Health and Family Welfare :
Dr Ashok Chacko Department of Gastroenterology, Christian Medical College
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