Dysphagia pathophysiology
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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
Anatomically, swallowing can be divided into three phases:[1][2][3][4]
- Oral preparatory phase
- Oral voluntary phase
- Pharyngeal phase
- Esophageal phase
(a)Oral preparatory phase:
- This phase involves mastication and formation of a bolus in the oral cavity.
(b)Oral voluntary phase:
- It is characterized by propelling the bolus into the pharyngeal phase.
- It is controlled by the corticobulbar tracts and cranial nerves V(trigemenal),VII(facial)and XII(hypoglossal).
(c)Pharyngeal phase:
- This phase is a reflex mechanism.
- It is controlled by the cranial nerves V(trigemenal),X(vagus)XI(accessory) and, XII(hypoglossal).
(d)Esophageal phase:
- The esophagus is a part of the gastrointestinal tract which is responsible of moving the food from the mouth to the rectum.[5]
- The esophagus has anti-reflux barrier which prevents the return of the acidic contentof the stomach back to the esophagus. The anti-reflux barrier consists of the lower esophageal sphincter (LES) and the related part of the diaphragm.
- The lower esophageal sphincter is contracting smooth muscle at the end of the esophagus responsible for the food passage to the stomach. LES has high pressure tone which helps keeping it a strong barrier between the esophagus and the stomach.
Pathogenesis of Dysphagia
The pathogenesis of dysphagia can be explained on the basis of etiology. It can be
- Physiological
- Pathological
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Effect of aging on swallowing mechanism
Physiological dysphagia
Normal aging results in following changes in the swallowing mechanism:[6][7][8][9][10]
- Reduced lingual movement
- Delayed onset of the pharyngeal swallow
- Delayed upper esophageal sphincter manometric relaxation during swallowing
- Diminished pharyngolaryngeal sensory discrimination
- Cerebral atrophy
- Decreased nerve function
- Decline in muscle mass
Pathological dysphagia
Pathological dysphagia can occur as a result of the following mechansims.
1.Luminal Stenosis
Esophageal lumen can be narrowed by the following factors:[11][12][13][14]
- Stricture
- Inflammation
- Web
- Malignancy
2.Non-obstructing gastro-esophageal disease
Many patients that describe dysphagia will have normal investigations including UGE and high-resolution manometry (HRM), suggesting that a dysfunction of the somatosensory as opposed to neuromuscular apparatus might be present[15]
3.Primary motility disorder
The pathophysiological process in primary motility disorder is:[16][17][18][19]
- An imbalance between inhibitory and excitatory neurons of the myenteric plexus at the distal oesophageal sphincter.
- There is a decrement in inhibitory innervation (nitrous oxide, or vasoactive intestinal peptide) leading to aperistalsis. [20]
- Failure of relaxation of the lower oesophageal sphincter during swallowing.[21]
4.Rheumatological conditions
The underlying pathophysiological mechanism of dysphagia in rheumatological conditions is as follows:[22][23]
- The smooth muscle of the mid and lower oesophagus is replaced by fibrous tissue secondary to the underlying autoimmune pathology leading to incompetence of the lower oesophageal sphincter (LOS) and subsequently to GORD and dysphagia.
Examples:
- CREST syndrome[24]
- Sjogren’s syndrome[25]
- Systemic lupus erythematosus (SLE)
- Mixed connective tissue disease (MCTD)
- Rheumatoid arthritis
5.Medication induced
A group of several medications can contribute to dysphagia by the following mechanism:[26][27][28][29]
- They decrease the strength of lower oesophageal sphincter relaxation.
- Reduction in lubrication by reduced saliva and impairment secondary peristalsis.
- Compromise the airway patency and hence leading to the risk of aspiration. Finally, medications that have a local or systemic immunosuppressant effect can predispose to infective oesophagitis[60]. * Suppress the local and systemic immunity and predispose to infections.
Examples:
- Antipsychotic, e.g., olanzapine, clozapine[30]
- Tricyclic antidepressant, e.g., amitriptylin
- Anticholinergic,
- Opioids
- Iron supplements
- Potassium supplements
- NSAIDs
- Tetracyclines
- Macrolides
- Bisphosphonates
- Calcium channel blockers
- Nitrates
- Alcohol
- Theophylline
6.Neurological disorders
The pathology of neurogenic causes of dysphagia is as follows:[31][32][33]
- Predominanlty affect the oropharyngeal phase.
- There is 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.
- The central, autonomic or peripheral nervous system is affected by several neurological diseases such as:
- Parkinsons disease
- Myasthenia gravis
- Motor neuron disease
- Cerebrovascular accident
- Multiple sclerosis
- Dysphagia is commonly seen after 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.
The following table summarizes the mechanism, genetic association, gross pathology features and microscopic findings of common causes of dysphagia.
Cause of dysphagia | Type of food | Type of progression | Pathophysiological changes | Genetic association | Gross pathology features | Microscopic findings | |
---|---|---|---|---|---|---|---|
Oropharyngeal dysphagia | Soilds | Liquids | Intermittent/Progressive | ||||
•Zenker's diverticulum
•Webs |
Yes | No | Progressive | •Zenker's diverticulum(ZD):
|
Diverticulum or a sac is seen in the esophagus |
| |
•Webs | |||||||
•Neoplasm | Yes | Yes | Progressive | •Neoplasm | |||
Myogenic causes
•Myasthenia gravis •Connective tissue disorder •Myotonic dystrophy Neurogenic causes •ALS •Parkinsonism •Stroke |
Yes | Yes | Progressive | ||||
Esophageal dysphagia | |||||||
•Pill esophagitis
•Caustic injury •Chemotherapy |
Yes | No | |||||
•Strictures
•Esophageal Cancer |
Yes | No | Progressive | Esophageal stricture is the result of:[34][35]
|
The following genes can be involved:
|
On gross pathology, circumferential thickening of the lower esophageal wall are characteristic finding of esophageal stricture due to gastroesophageal reflux disease.[36]
|
On microscopic histopathological analysis, characteristic findings of esophageal stricture due to gastroesophageal reflux disease are:[40]
|
•Esophageal Cancer: |
Mutations in the following genes can cause esophageal cancer: |
Squamous cell carcinoma or adenocarcinoma of the esophagus may appear as:[42]
|
Nuclear atypia of malignancy:
| ||||
•Rings
•Webs |
Yes | No | Intermittent | Rings:
Webs: Multiple theories have been found:
|
|||
•Achalasia
•Diffuse esophageal spasm(DES) |
Yes | Yes | Intermittent | •Achalasia:
|
|
| |
•Diffuse esophageal spasm(DES):
|
There is a genetic association between DES and achalasia[47] | Gross thickening of muscularis propria layer and lower esophageal sphincter (LES) due to hyperplasia are characteristic findings of DES | There is degeneration of vagal fibres, inflammatory infiltration of myenteric plexus, and hyperplasia of smooth muscles are characteristic findings of DES | ||||
•Scleroderma | Yes | Yes | Progressive |
Gallery
Zenkers diverticulum
Esophageal cancer
Esophagitis
Esophageal stricture
References
- ↑ 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.
- ↑ Aslam M, Vaezi MF (2013). "Dysphagia in the elderly". Gastroenterol Hepatol (N Y). 9 (12): 784–95. PMC 3999993. PMID 24772045.
- ↑ 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.
- ↑ 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.
- ↑ Stein HJ, DeMeester TR (1992). "Outpatient physiologic testing and surgical management of foregut motility disorders". Curr Probl Surg. 29 (7): 413–555. PMID 1606845.
- ↑ Masoro EJ (1987). "Biology of aging. Current state of knowledge". Arch Intern Med. 147 (1): 166–9. PMID 3541821.
- ↑ Carucci LR, Turner MA (2015). "Dysphagia revisited: common and unusual causes". Radiographics. 35 (1): 105–22. doi:10.1148/rg.351130150. PMID 25590391.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Roman S, Kahrilas PJ (2014). "The diagnosis and management of hiatus hernia". BMJ. 349: g6154. doi:10.1136/bmj.g6154. PMID 25341679.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Pandolfino JE, Gawron AJ (2015). "Achalasia: a systematic review". JAMA. 313 (18): 1841–52. doi:10.1001/jama.2015.2996. PMID 25965233.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Sagar R, Varghese ST, Balhara YP (2005). "Dysphagia due to olanzepine, an antipsychotic medication". Indian J Gastroenterol. 24 (1): 37–8. PMID 15778537.
- ↑ 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.
- ↑ Kohen I, Lester P (2009). "Quetiapine-associated dysphagia". World J Biol Psychiatry. 10 (4 Pt 2): 623–5. doi:10.1080/15622970802176495. PMID 18615368.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Holzheimer, R (2001). Surgical treatment : evidence-based and problem-oriented. München New York: Zuckschwerdt. ISBN 3-88603-714-2.
- ↑ Belevich VL, Ovchinnikov DV (2013). "[Treatment of benign esophageal stricture]". Vestn. Khir. Im. I. I. Grek. (in Russian). 172 (5): 111–4. PMID 24640761.
- ↑ Yamasaki, Yasushi; Ozawa, Soji; Oguma, Junya; Kazuno, Akihito; Ninomiya, Yamato (2016). "Long peptic strictures of the esophagus due to reflux esophagitis: a case report". Surgical Case Reports. 2 (1). doi:10.1186/s40792-016-0190-1. ISSN 2198-7793.
- ↑ Maejima, Ryuhei; Uno, Kaname; Iijima, Katsunori; Fujishima, Fumiyoshi; Noguchi, Tetsuya; Ara, Nobuyuki; Asano, Naoki; Koike, Tomoyuki; Imatani, Akira; Shimosegawa, Tooru (2016). "A Japanese case of lymphocytic esophagitis". Digestive Endoscopy. 28 (4): 476–480. doi:10.1111/den.12578. ISSN 0915-5635.
- ↑ Contini, Sandro (2013). "Caustic injury of the upper gastrointestinal tract: A comprehensive review". World Journal of Gastroenterology. 19 (25): 3918. doi:10.3748/wjg.v19.i25.3918. ISSN 1007-9327.
- ↑ Wilcox CM (2013). "Overview of infectious esophagitis". Gastroenterol Hepatol (N Y). 9 (8): 517–9. PMC 3980995. PMID 24719600.
- ↑ "Esophageal stricture - Libre Pathology".
- ↑
- ↑ Sugarbaker, David (2015). Adult chest surgery. New York: McGraw-Hill Education. ISBN 0071781897.
- ↑ "Squamous cell carcinoma of the esophagus".
- ↑ Paladini F, Cocco E, Cascino I, Belfiore F, Badiali D, Piretta L; et al. (2009). "Age-dependent association of idiopathic achalasia with vasoactive intestinal peptide receptor 1 gene". Neurogastroenterol Motil. 21 (6): 597–602. doi:10.1111/j.1365-2982.2009.01284.x. PMID 19309439.
- ↑ Alahdab YO, Eren F, Giral A, Gunduz F, Kedrah AE, Atug O; et al. (2012). "Preliminary evidence of an association between the functional c-kit rs6554199 polymorphism and achalasia in a Turkish population". Neurogastroenterol Motil. 24 (1): 27–30. doi:10.1111/j.1365-2982.2011.01793.x. PMID 21951831.
- ↑ de León AR, de la Serna JP, Santiago JL, Sevilla C, Fernández-Arquero M, de la Concha EG; et al. (2010). "Association between idiopathic achalasia and IL23R gene". Neurogastroenterol Motil. 22 (7): 734–8, e218. doi:10.1111/j.1365-2982.2010.01497.x. PMID 20367798.
- ↑ Frieling T, Berges W, Borchard F, Lübke HJ, Enck P, Wienbeck M (1988). "Family occurrence of achalasia and diffuse spasm of the oesophagus". Gut. 29 (11): 1595–602. PMC 1433819. PMID 3061886.
- ↑ From en.wikipedia.org, Public Domain, <"https://commons.wikimedia.org/w/index.php?curid=1931423">