Dysphagia (Trouble Swallowing)
Difficulty swallowing, medically known as dysphagia, is a common and often distressing symptom that can significantly impact a person’s quality of life. For patients in Singapore, it is a crucial symptom that warrants prompt evaluation by a gastroenterologist.
What is Dysphagia?
Dysphagia is the medical term for difficulty swallowing. While it may seem like a simple mechanical problem, dysphagia can be a sign of a wide range of underlying conditions, from benign motility disorders to serious conditions like oesophageal cancer. It is a symptom, not a disease itself, and can be categorised into two main types:
Oropharyngeal Dysphagia: Difficulty initiating a swallow. This often feels like food is getting stuck in the throat and is typically caused by problems with the nerves or muscles in the mouth or pharynx.
Oesophageal Dysphagia: The sensation of food getting stuck in the chest after a swallow has been initiated. This is usually due to an issue with the oesophagus (the food pipe). Timely diagnosis and management by a dysphagia specialist, such as a gastroenterologist, are essential to prevent complications like aspiration pneumonia, malnutrition, and dehydration.
What Causes Dysphagia?
The causes of dysphagia are varied and can be broadly classified as structural (a physical blockage) or functional (a problem with the muscles or nerves).
1. Oesophageal Dysphagia (Commonly seen in gastroenterology practice):
Structural Causes:
- Peptic Stricture: Narrowing of the oesophagus due to chronic inflammation from Gastroesophageal Reflux Disease (GERD).
- Oesophageal Cancer: A malignant tumour in the oesophagus that obstructs the passage of food. This is a critical cause to rule out.
- Eosinophilic Oesophagitis (EoE): A chronic immune-mediated inflammatory disease where a high concentration of eosinophils (a type of white blood cell) builds up in the oesophagus, causing strictures and rings.
- Oesophageal Rings and Webs: Thin, benign membranes of tissue that narrow the oesophagus. Schatzki’s ring is a common example.
- Extrinsic Compression: Pressure on the oesophagus from surrounding structures, such as an enlarged thyroid or a mass in the chest.
Functional (Motility) Disorders:
- Achalasia: A rare disorder where the lower oesophageal sphincter fails to relax, and the oesophagus lacks proper muscle contractions, making it difficult for food and liquids to pass into the stomach.
- Diffuse Oesophageal Spasm: Uncoordinated and forceful contractions of the oesophageal muscles.
- Scleroderma and other Connective Tissue Disorders: These can cause the oesophageal muscles to weaken, leading to ineffective movement.
2. Oropharyngeal Dysphagia:
Neurological Conditions:
- Stroke: The most common cause of oropharyngeal dysphagia.
- Parkinson’s Disease: Progressive loss of muscle control.
- Dementia: Cognitive decline affecting the swallowing process.
- Motor Neuron Disease (e.g., ALS): Degeneration of motor neurons that control swallowing muscles.
- Muscular Conditions:
- Myasthenia Gravis: An autoimmune disease causing muscle weakness.
Structural Issues:
- Pharyngeal Pouch (Zenker’s Diverticulum): A small pouch that forms in the throat, which can collect food and cause a feeling of a lump.
- Post-Radiation Strictures: Scar tissue formation after radiotherapy for head and neck cancers.
How is Dysphagia Diagnosed?
A thorough clinical history and physical examination are the first steps in diagnosing dysphagia. The gastroenterologist will inquire about the nature of the swallowing difficulty (solids vs. liquids), its onset, and any associated symptoms. The primary investigations used in a gastroenterology clinic are:
- Oesophagogastroduodenoscopy (OGD) / Upper Endoscopy: This is a crucial first-line test. A flexible endoscope with a camera is passed down the oesophagus to directly visualise the lining. It can detect structural abnormalities like tumours, strictures, or rings. Biopsies can be taken to test for conditions like EoE or cancer.
- Barium Swallow Study: An X-ray procedure where the patient swallows a barium-based liquid. This coats the oesophagus and allows the doctor to visualise the swallowing process and identify structural issues or motility problems that may not be apparent on endoscopy.
- High-Resolution Oesophageal Manometry: This is the gold-standard test for evaluating oesophageal motility. A thin tube is passed through the nose into the oesophagus to measure the strength and coordination of muscle contractions and the function of the oesophageal sphincters. It is essential for diagnosing conditions like achalasia and oesophageal spasm.
- Ambulatory pH Monitoring: Measures acid reflux into the oesophagus and is useful when reflux is suspected as the underlying cause.
When to Consult a Gastroenterologist
Dysphagia can affect nutrition, safety, and quality of life – but it’s manageable with the right diagnosis and support. If you or a loved one is experiencing trouble swallowing, don’t wait. A timely evaluation can make a big difference in recovery and comfort.
An experienced gastroenterologist can accurately diagnose your condition, rule out other serious issues, and develop a personalised management plan to help you find relief and prevent complications.
When to See a Doctor
Seek an urgent consultation with a gastroenterologist if you experience:
- Progressive Dysphagia: The swallowing difficulty is worsening over a short period.
- Unexplained Weight Loss: Significant weight loss without intentional dieting.
- Odynophagia: Pain with swallowing, which may suggest inflammation or a lesion.
- Haematemesis: Vomiting of blood.
- Vomiting and Regurgitation: Particularly of undigested food.
- Hoarseness or a Voice Change: This can be a sign of nerve damage or a tumour affecting the vocal cords.
- History of Smoking or Heavy Alcohol Use: These are significant risk factors for oesophageal cancer.
Ignoring these symptoms can lead to delayed diagnosis of a potentially life-threatening condition. Early intervention is key to achieving the best possible outcome.
Treatment Options
Treatment for dysphagia is tailored to the underlying cause. A multi-disciplinary approach involving gastroenterologists, speech therapists, and dieticians is often most effective.
Medical Management:
- Proton Pump Inhibitors (PPIs): For dysphagia caused by GERD or peptic strictures.
- Corticosteroids: For managing the inflammation in Eosinophilic Oesophagitis (EoE).
- Botox Injections: Can be used to relax the lower oesophageal sphincter in cases of achalasia.
Endoscopic and Surgical Intervention:
- Endoscopic Dilation: A balloon or dilator is used during endoscopy to stretch and widen a narrowed oesophagus due to strictures or rings.
- Per-Oral Endoscopic Myotomy (POEM): A minimally invasive endoscopic procedure for achalasia, where the muscles of the lower oesophageal sphincter are cut to allow food to pass.
- Stenting: In cases of advanced oesophageal cancer, a stent can be placed to keep the oesophagus open and allow the patient to eat.
- Feeding Tubes (e.g., PEG Tube): For patients with severe, chronic dysphagia, a feeding tube may be necessary to ensure adequate nutrition and hydration.
Swallowing Therapy and Diet Modification:
- Speech and Language Therapists (SLTs): Play a vital role in teaching swallowing exercises and techniques to improve muscle strength and coordination.
- Diet Modifications: Changing food texture (e.g., to soft, puréed, or thickened liquids) can make swallowing safer and easier.
