Dysphagia

Swallowing difficulties (dysphagia) may be attributable to a number of causes. Anyone experiencing swallowing difficulty should see their doctor to have it checked out straight away.

They may be caused by diseases which cause malfunctions in the brain such as Parkinson's, Multiple Sclerosis or Motor Neurone Disease, muscle dysfunction caused by stroke, achalasia whereby the Lower Oesophageal Sphincter doesn't relax sufficiently or stricture or narrowing of the oesophagus which may be due to a tumour.

Swallowing difficulties are usually diagnosed or investigated by a Barium meal or swallow which entails drinking a mildly radioactive liquid and having its progress checked by means of an X-ray scanner. 

Self help

The swallowing process may be assisted by cutting food up small, eating small mouthfulls, chewing well and remaining upright whilst the food bolus traverses the oesophagus. Drinking carbonated water can also assist the swallowing process.

If food remains lodged in the oesophagus for more than about 10 minutes, medical assistance needs to be sought.

Stricture

Strictures are narrowing of the oesophagus which may be due to many factors. Mostly they are benign and may be due to oesophageal scarring from oesophagitis, a hiatus hernia or dysfunctional lower oesophageal sphincter (achalasia) as described below.

In some cases, strictures can be caused by tumour.

Strictures may be treated by dilation described below or in some cases a stent may be used to hold the oeosphagus open.

See also Schatzki ring.

Achalasia

Achalasia (or cardiospasm) is a comparatively rare condition whereby the Lower Oesophageal Sphincter may not open properly for food to move into the stomach. We do not know why this develops in some people. It is probably due to damage to nerves in the wall of the oesophagus perhaps caused by a virus in early life.

The various treatment options for achalasia include the following.

Drugs may be prescribed which can relax the muscles. They are usually allowed to dissolve under the tongue half an hour before eating. They relax the pressure on the lower oesophageal sphincter temporarily but are not a long term solution.

Botox (Botulinum toxin) injections delivered endoscopically into the musculature provides sphincter relaxation lasting a few months or up to a year.

Dilation of the oesophago-gastric junction to stretch the opening may be achieved using a mercury filled bougie (a rubber cylinder) that is inserted blindly to the base of the oesophagus or an endoscopically guided balloon that is then inflated at the optimum point. Whereas stents to keep dilations open are often recommended following dilations elsewhere in the body, they are not recommended at the LOS.

Myotomy is surgery usually performed laparoscopically (ie keyhole surgery) to cut the muscle fibres that fail to retract. This provides a permanent solution but may have complications.

PerOral Endoscopic Myotomy (POEM) is a new technique that is currently being evaluated whereby the surgical procedure is conducted via and endoscope.

In October 2024, the American Gastronetrology Association provided comprehensive review of POEM with best practice advice here.

Complications of any treatment for achalasia include promotion of acid reflux because of the need to keep the LOS relaxed. Frequently fundoplication is offered at the same time as myotomy. [See chapter on fundoplication.]

The UK charity Achalasia Action, provides information and support and produces some excellent resources for patients with the condition.

Dilation

During the procedure, a balloon is positioned in the oesophagus by a special endoscope and inflated to stretch the stricture.

Read more about the procedure here.

A patient's experience of the procedure may be read here.

In 2024, Gastroenterology and Endoscopy News published a feature on the Management of Achalasia in 2 parts.

Part 1: Diagnosis concluded, "Achalasia is a complex esophageal motility disorder that has a significant impact on patients’ well-being and healthcare resources. Its etiology involves the inflammatory degeneration of inhibitory neurons within the esophageal wall, contributing to its subtle and progressive nature. While endoscopy is crucial for excluding secondary causes, [High Resolution Manometry] stands out as the definitive diagnostic tool for primary achalasia."

Part 2: Treatment comparing treatments said, "There are 3 definitive treatments for achalasia: pneumatic dilation, POEM [Per Oral Endoscopic Myotomy], and LHM [Laparoscopic Heller Myotomy]. The choice between these options can be influenced by the patient’s subtype of achalasia. Meta-analyses have indicated that for type II achalasia, there were no significant differences in outcomes between pneumatic dilation, POEM, and LHM. Network meta-analyses have suggested further that for all achalasia subtypes, both POEM and LHM are equally effective and superior to pneumatic dilation."

Cricopharyngeal Achalasia (CP Achalasia)

Also referred to as Cricopharyngeal dysfunction.

This is a rare condition where the cricopharyngeus muscle that constututes the upper oesophageal sphincter fails to relax properly leading to difficulty in swallowing. Unlike other forms of achalasia that affect the lower esophageal sphincter, this condition specifically involves the cricopharyngeus muscle located at the top of the esophagus. 

Symptoms

Diagnosis

It is usually diagnosed by Barium Swallow or endoscopy

Causes

Conditions like stroke, Parkinson’s disease, or motor neuron disease can disrupt the normal relaxation of the cricopharyngeus muscle but in many cases, the cause is unknown.

Treatment

A 2020 paper in Otolarygology looked at Management and Associated Outcomes but concluded, "Small sample sizes and heterogeneity of causes and treatments of CP achalasia, as well as short duration of follow-up, make it challenging to assess the superiority of one treatment over another."

Page updated 17 November 2024