Dysphagia: An Overview of Swallowing Difficulties
Guest: Dr. Donald Castell – Gastroenterology & Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Donald Castell who is the Director of Esophageal Disorders Program at the Medical University of South Carolina. Dr. Castell, one of your areas of interest is in swallowing difficulties. What causes swallowing difficulties? There must be a number of causes.
Dr. Donald Castell: You are absolutely correct about that. Possible causes for difficulty with eating and swallowing is very broad. It starts with neurologic things. I mean, everybody knows that the stroke patient often has trouble swallowing. But, it could be more subtle things, such as Parkinson’s disease, Lou Gehrig’s disease, or whatever. It extends on down into the esophagus, which is of course my area of primary interest. Here, now, we are dealing with problems with the esophagus pushing the food into the stomach as it normally does, or with something that is obstructing the flow of food down the esophagus.
Dr. Linda Austin: What is the most common problem in the esophagus when there are swallowing difficulties?
Dr. Donald Castell: The most common problem would be something related to reflux disease, what we call GERD, or gastroesophageal reflux disease. Patients will reflux acid into their esophagus and develop some injury, and that will cause a little narrowing of the opening. We call that a stricture. That is the most common cause of esophageal dysphagia.
Dr. Linda Austin: How about the second most common cause?
Dr. Donald Castell: Well, the second most common cause is probably, it is hard to decide where you go from there, it is probably some kind of an innocent ring or web, and we see a fair amount of that in patients. They tell us that they have trouble swallowing only certain solid types of material. Liquids will flow fine on into the stomach. Usually what we find is that, inside their esophagus, there is a very thin narrowing, a web-type structure or complete ring around the inside portion of the esophagus. That can be very quickly eliminated with the endoscope.
Dr. Linda Austin: So, it is pretty easy to treat?
Dr. Donald Castell: Yes, usually.
Dr. Linda Austin: Any more worrisome causes?
Dr. Donald Castell: Well, indeed. One of the major messages that I would like people to take away from our talk is that you do not ignore dysphagia. That is what we call it, difficulty with eating, from the Greek. That is basically what it means. So, you do not ignore swallowing problems because there is a small chance that it could be a malignancy beginning, and the sooner you recognize that, the greater the possibility that it will be curable.
Dr. Linda Austin: What are the risk factors for those sorts of cancers?
Dr. Donald Castell: The risk factors that have been well shown over the years are smoking and heavy alcohol consumption. So, that alcoholic patient that likes to smoke with their drinks, which is a very common scenario, is at the greatest risk of all. Obviously, like many malignancies, as people get older, age is a factor. Those are really the major things, habits and age.
Dr. Linda Austin: How do you go about diagnosing which of those possibilities might be the cause?
Dr. Donald Castell: Usually we start with some kind of a barium x-ray study. We call it a barium swallow. That, done properly, will help you to differentiate whether the problem is actually high, like in the mouth or back of the throat, or further down, that is, in the esophagus. So, a good barium study really is the key entry evaluation, I believe, in these patients.
Dr. Linda Austin: And then what?
Dr. Donald Castell: Then, it depends on what you see. If you see something that looks like it could be obstructing then endoscopy is the preferred next step. The advantage of endoscopy is that you can also do a biopsy. So, right away, you can begin to rule in, or rule out, is there anything that might have a malignant potential?
So, the endoscope is very important. If, in fact, the esophagus looks to be fairly normal and nothing obstructing the flow of barium, you are probably going to do what we do in our laboratory, an esophageal motility study, and measure the pressures that are generated when we swallow.
Dr. Linda Austin: Dr. Castell, thank you so much.
Dr. Donald Castell: You are welcome.
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