Dysphagia pathophysiology

Jump to: navigation, search

Dysphagia Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Dysphagia from other Conditions

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

Barium Swallow

Endoscopy

CT

MRI

Echocardiography and Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Dysphagia pathophysiology On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Dysphagia pathophysiology

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Dysphagia pathophysiology

CDC on Dysphagia pathophysiology

Dysphagia pathophysiology in the news

Blogs on Dysphagia pathophysiology

Directions to Hospitals Treating Dysphagia

Risk calculators and risk factors for Dysphagia pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Propulsive failure can result from dysfunction of the central nervous system control mechanisms, intrinsic musculature, or peripheral nerves. Structural abnormalities may result from surgery, neoplasm, caustic injury, or congenital anomalies.

Pathophysiology

Physiology of normal swallowing

Normal physiology of swallowing can be discussed under three phases:[1][2][3][4]

Oral phase

  • Preparatory phase:
  • Voluntary phase:
    • Voluntary phase is characterized by propelling the bolus into the pharyngeal phase.
    • Voluntary phase is controlled by

Pharyngeal phase:

  • Pharyngeal phase is a reflex mechanism and is controlled by the cranial nerves V, X, XI, and XII.

Esophageal phase:

GERD.png

Pathogenesis of physiological dysphagia

Physiological dysphagia occurs as a result of normal aging. Normal aging results in certain changes that affect the swallowing mechanism which include:[6][7][8][9][10]

Pathogenesis of pathological dysphagia

Pathological dysphagia can occur as a result of the following mechanisms.

1. Luminal Stenosis
2. Non-obstructing gastro-esophageal disease
  • Majority of the patients that present with dysphagia will have normal investigation findings.
  • Normal findings suggests a somato-sensory dysfunction rather than neuro-muscular cause of dysphagia.[15]
  • Non-obstructive causes of dysphagia include:
    • Motility disorders of esophagus
    • Rheumatological conditions
    • Medication induced dysphagia
    • Neurological disorders
Motility disorders of esophagus
Rheumatological conditions
  • The smooth muscle of the mid and lower esophagus is replaced by fibrous tissue secondary to the underlying autoimmune pathology leading to incompetence of the lower esophageal sphincter (LES) and subsequently to GERD and dysphagia.[22][23]
Medication induced
Neurological disorders
  • Neurological disorders predominanlty affect the oropharyngeal phase. However, pharyngeal phase of swallowing can also be involved in cases of stroke affecting the basal ganglia and the cortex, as it affects the ability to initiate the swallow and decrement in bolus transit between pharynx and esophagus.[31][32][33]
  • Neurological deficits can cause weakness of the oral musculature and tongue movements resulting in failure to form a intact food bolus and decreased sensitivity of the pharyngeal receptors, subsequent to neurological compromise leading to dysphagia.
  • The central, autonomic or peripheral nervous system is affected by several neurological diseases such as:

Genetics

The following genes can be involved in the development of dysphagia subsequent to different pathologies:

  • CTC1
  • DKC1 
  • NHP2
  • NOP10
  • RTEL1
  • TERC
  • WRAP53

Mutations in the following genes can cause esophageal cancer:

  • Chromosomal losses (4q, 5q, 9p, and 18q)
  • Chromosomal gains (8q, 17q, and 20q)
  • Gene amplifications (7, 8, and 17q)
  • PT53 genes and P16 genes 
  • Variants in ADH and/or ALDH2 genes

Associated Conditions

Common conditions associated with dysphagia include:

Gross Morphology

The gross morphology of dysphagia depends on the underlying pathologic condition. Following are the gross morphologic features of some important causes of dysphagia:

Zenkers diverticulum:

  • Diverticulum or a sac is seen in the esophagus

Esophageal stricture:

Esophageal cancer:

Squamous cell carcinoma or adenocarcinoma of the esophagus may appear as:

  • Polypoid lesion 

Achalasia:

Diffuse esophageal spasm(DES):

Gross thickening of muscularis propria layer and lower esophageal sphincter (LES) due to hyperplasia are characteristic findings of DES.

Microscopic Pathology

Esophagitis

H&E stain of esophagus biopsy showing eosinophilic esophagitis, manifested by an infiltration of eosinophils in the lamina propria


Esophageal stricture

Esophageal stricture <"https://commons.wikimedia.org/wiki/File%3ATinci%C3%B3n_hematoxilina-eosina.jpg"> via Wikimedia Commons</ref>


Esophageal stricture due to GERD, via wikipedia.org[34]


References

  1. Cook, Ian J.; Kahrilas, Peter J. (1999). "AGA technical review on management of oropharyngeal dysphagia". Gastroenterology. 116 (2): 455–478. doi:10.1016/S0016-5085(99)70144-7. ISSN 0016-5085.
  2. Aslam M, Vaezi MF (2013). "Dysphagia in the elderly". Gastroenterol Hepatol (N Y). 9 (12): 784–95. PMC 3999993. PMID 24772045.
  3. Cassiani RA, Santos CM, Parreira LC, Dantas RO (2011). "The relationship between the oral and pharyngeal phases of swallowing". Clinics (Sao Paulo). 66 (8): 1385–8. PMC 3161216. PMID 21915488.
  4. Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur JG; et al. (1990). "Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing". Am J Physiol. 258 (5 Pt 1): G675–81. doi:10.1152/ajpgi.1990.258.5.G675. PMID 2333995.
  5. Stein HJ, DeMeester TR (1992). "Outpatient physiologic testing and surgical management of foregut motility disorders". Curr Probl Surg. 29 (7): 413–555. PMID 1606845.
  6. Masoro EJ (1987). "Biology of aging. Current state of knowledge". Arch Intern Med. 147 (1): 166–9. PMID 3541821.
  7. Carucci LR, Turner MA (2015). "Dysphagia revisited: common and unusual causes". Radiographics. 35 (1): 105–22. doi:10.1148/rg.351130150. PMID 25590391.
  8. Cook IJ, Weltman MD, Wallace K, Shaw DW, McKay E, Smart RC; et al. (1994). "Influence of aging on oral-pharyngeal bolus transit and clearance during swallowing: scintigraphic study". Am J Physiol. 266 (6 Pt 1): G972–7. doi:10.1152/ajpgi.1994.266.6.G972. PMID 8023945.
  9. Shaw DW, Cook IJ, Gabb M, Holloway RH, Simula ME, Panagopoulos V; et al. (1995). "Influence of normal aging on oral-pharyngeal and upper esophageal sphincter function during swallowing". Am J Physiol. 268 (3 Pt 1): G389–96. doi:10.1152/ajpgi.1995.268.3.G389. PMID 7900799.
  10. Easterling, Caryn S.; Robbins, Elizabeth (2008). "Dementia and Dysphagia". Geriatric Nursing. 29 (4): 275–285. doi:10.1016/j.gerinurse.2007.10.015. ISSN 0197-4572.
  11. Starmer HM, Riley LH, Hillel AT, Akst LM, Best SR, Gourin CG (2014). "Dysphagia, short-term outcomes, and cost of care after anterior cervical disc surgery". Dysphagia. 29 (1): 68–77. doi:10.1007/s00455-013-9482-9. PMID 23943072.
  12. Inayat F, Hussain Q, Shafique K (2017). "Dysphagia Caused by Extrinsic Esophageal Compression From Mediastinal Lymphadenopathy in Patients With Sarcoidosis". Clin Gastroenterol Hepatol. 15 (7): e119–e120. doi:10.1016/j.cgh.2016.11.010. PMID 27840183.
  13. Oda K, Iwakiri R, Hara M, Watanabe K, Danjo A, Shimoda R; et al. (2005). "Dysphagia associated with gastroesophageal reflux disease is improved by proton pump inhibitor". Dig Dis Sci. 50 (10): 1921–6. doi:10.1007/s10620-005-2962-5. PMID 16187198.
  14. Roman S, Kahrilas PJ (2014). "The diagnosis and management of hiatus hernia". BMJ. 349: g6154. doi:10.1136/bmj.g6154. PMID 25341679.
  15. Philpott H, Nandurkar S, Royce SG, Thien F, Gibson PR (2014). "Risk factors for eosinophilic esophagitis". Clin Exp Allergy. 44 (8): 1012–9. doi:10.1111/cea.12363. PMID 24990069.
  16. Xiao Y, Kahrilas PJ, Nicodème F, Lin Z, Roman S, Pandolfino JE (2014). "Lack of correlation between HRM metrics and symptoms during the manometric protocol". Am J Gastroenterol. 109 (4): 521–6. doi:10.1038/ajg.2014.13. PMC 4120962. PMID 24513804.
  17. Enestvedt BK, Williams JL, Sonnenberg A (2011). "Epidemiology and practice patterns of achalasia in a large multi-centre database". Aliment Pharmacol Ther. 33 (11): 1209–14. doi:10.1111/j.1365-2036.2011.04655.x. PMC 3857989. PMID 21480936.
  18. Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC (1992). "Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh". Gut. 33 (8): 1011–5. PMC 1379432. PMID 1398223.
  19. Pandolfino JE, Gawron AJ (2015). "Achalasia: a systematic review". JAMA. 313 (18): 1841–52. doi:10.1001/jama.2015.2996. PMID 25965233.
  20. Gockel I, Lord RV, Bremner CG, Crookes PF, Hamrah P, DeMeester TR (2003). "The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction". J Gastrointest Surg. 7 (5): 692–700. PMID 12850684.
  21. Vaezi MF, Pandolfino JE, Vela MF (2013). "ACG clinical guideline: diagnosis and management of achalasia". Am J Gastroenterol. 108 (8): 1238–49, quiz 1250. doi:10.1038/ajg.2013.196. PMID 23877351.
  22. Bredenoord AJ (2015). "Minor Disorders of Esophageal Peristalsis: Highly Prevalent, Minimally Relevant?". Clin Gastroenterol Hepatol. 13 (8): 1424–5. doi:10.1016/j.cgh.2015.03.013. PMID 25796576.
  23. Anselmino M, Zaninotto G, Costantini M, Ostuni P, Ianniello A, Boccú C; et al. (1997). "Esophageal motor function in primary Sjögren's syndrome: correlation with dysphagia and xerostomia". Dig Dis Sci. 42 (1): 113–8. PMID 9009125.
  24. Carlson DA, Hinchcliff M, Pandolfino JE (2015). "Advances in the evaluation and management of esophageal disease of systemic sclerosis". Curr Rheumatol Rep. 17 (1): 475. doi:10.1007/s11926-014-0475-y. PMC 4343525. PMID 25475597.
  25. Tang DM, Pathikonda M, Harrison M, Fisher RS, Friedenberg FK, Parkman HP (2013). "Symptoms and esophageal motility based on phenotypic findings of scleroderma". Dis Esophagus. 26 (2): 197–203. doi:10.1111/j.1442-2050.2012.01349.x. PMID 22590983.
  26. Bonavina L, DeMeester TR, McChesney L, Schwizer W, Albertucci M, Bailey RT (1987). "Drug-induced esophageal strictures". Ann Surg. 206 (2): 173–83. PMC 1493104. PMID 3606243.
  27. Philpott-Howard JN, Wade JJ, Mufti GJ, Brammer KW, Ehninger G (1993). "Randomized comparison of oral fluconazole versus oral polyenes for the prevention of fungal infection in patients at risk of neutropenia. Multicentre Study Group". J Antimicrob Chemother. 31 (6): 973–84. PMID 8360134.
  28. Sagar R, Varghese ST, Balhara YP (2005). "Dysphagia due to olanzepine, an antipsychotic medication". Indian J Gastroenterol. 24 (1): 37–8. PMID 15778537.
  29. McCord GS, Clouse RE (1990). "Pill-induced esophageal strictures: clinical features and risk factors for development". Am J Med. 88 (5): 512–8. PMID 2186626.
  30. Kohen I, Lester P (2009). "Quetiapine-associated dysphagia". World J Biol Psychiatry. 10 (4 Pt 2): 623–5. doi:10.1080/15622970802176495. PMID 18615368.
  31. Takizawa C, Gemmell E, Kenworthy J, Speyer R (2016). "A Systematic Review of the Prevalence of Oropharyngeal Dysphagia in Stroke, Parkinson's Disease, Alzheimer's Disease, Head Injury, and Pneumonia". Dysphagia. 31 (3): 434–41. doi:10.1007/s00455-016-9695-9. PMID 26970760.
  32. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005). "Dysphagia after stroke: incidence, diagnosis, and pulmonary complications". Stroke. 36 (12): 2756–63. doi:10.1161/01.STR.0000190056.76543.eb. PMID 16269630.
  33. Martino R, Pron G, Diamant N (2000). "Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines". Dysphagia. 15 (1): 19–30. doi:10.1007/s004559910006. PMID 10594255.
  34. From en.wikipedia.org, Public Domain, <"https://commons.wikimedia.org/w/index.php?curid=1931423">



Linked-in.jpg