Hard to swallow

Introduction The normal swallowing function is called dysphagia. The normal swallowing action includes four stages: the oropharynx, the esophageal sphincter, the esophagus itself, and the lower esophageal sphincter. When an obstacle occurs in one stage, it can cause difficulty in swallowing. That is, a symptom that is hindered by the food from the mouth to the stomach, which may be caused by functional or organic obstruction of the pharynx, esophagus or spray. The patient adheres, stops or feels choking around the pharynx, behind the sternum or after the xiphoid immediately after eating or within 8 to 10 seconds.

Cause

Classification of causes:

(i) Mouth, throat and throat diseases:

1, stomatitis, trauma.

2, pharyngeal and throat diseases: 1 abscess around the tonsils; 2 abscesses in the posterior pharyngeal wall; 3 throat, throat tuberculosis; 4 throat, throat diphtheria.

(2) Esophageal diseases:

1, esophagitis: 1 non-specific esophagitis; 2 digestive esophagitis, digestive esophageal ulcer soup.

2, esophageal cancer.

3. Benign tumors of the esophagus.

4, the esophagus "benign" narrow.

5, esophageal diverticulitis.

6, esophageal tuberculosis.

7, Barrett's esophagus.

8, esophageal hiatus hernia.

9, foreign bodies in the esophagus.

10, esophageal submucous abscess.

11, esophageal congenital diseases: 1 esophageal fistula; 2 congenital esophageal atresia; 3 congenital esophageal stricture; 4 congenital tube is too short; 5 congenital esophageal dilation.

12, esophageal compression: 1 mediastinal disease; 2 cardiovascular disease; 3 thyroid enlargement.

(3) Neurological, muscular diseases or dysfunction:

1, nerve, muscle organic disease: 1 central nervous system, cranial nerve disease; 2 muscle disease; 3 connective tissue disease; 4 systemic infection and poisoning.

2, nerve, muscle dysfunction: 1 sputum sputum; 2 iron deficiency dysphagia; 3 diffuse esophageal fistula; 4 mental achalasia.

mechanism

Normal swallowing movements include the oropharynx, the esophageal sphincter, the esophagus itself, and the lower esophageal sphincter. When an obstacle occurs in one of the stages, dysphagia can be caused.

1. Oropharynx stage: The initial stage of swallowing movement, the food passes through the oropharynx. Under normal circumstances, it only lasts for about one second, involving random movement of the oropharyngeal muscle. When there is a disease such as inflammation or trauma in the oropharynx, the patient may not swallow because of the pain. When the facial muscles (VII brain nerves). The lingual muscle (VII cranial nerve) and the pharyngeal muscle (IX, X cranial nerve) paralysis affect the swallowing movement, and the posterior cranial nerve (IX, X, VII) cranial nerve damage caused dysphagia in the medullary palsy.

2, the esophageal sphincter stage: after each swallowing action begins, the esophageal sphincter muscles relax, then esophageal peristalsis, the food group passed smoothly. When the vagus nerve and the swallowing nerve disorder are dominated by this part, the upper esophageal sphincter dysfunction may occur, and symptoms of dysphagia may occur.

3, the esophagus itself: the cause of dysphagia in the esophagus itself, mainly mechanical obstruction or occlusion in the esophagus, such as esophageal cancer, benign esophageal stricture; external pressure on the esophageal wall, such as intrathoracic goiter, aorta Tumors, etc.; esophageal motility weakened, esophageal peristalsis weakened, disappeared or abnormal, such as diffuse esophageal fistula, dermatomyositis, scleroderma. Can cause difficulty swallowing.

4, the lower esophageal sphincter stage: the main mechanism of dysphagia caused by lower esophageal sphincter is due to achalasia of the lower esophageal dysfunction, more common in the sputum sputum; also seen in the lower esophageal mechanical obstruction, such as lower esophageal cancer, cardia cancer, benign esophageal stricture.

an examination

Related inspection

Esophageal X-ray barium meal examination dinitrochlorobenzene (DNCB) electronic gastroscope cerebrospinal fluid copper esophagography

First, medical history

1, age: after birth or lactation, there are frequent anti-feeders, to consider congenital esophageal diseases, such as congenital esophageal stricture, congenital esophageal stenosis, etc.; children suddenly dysphagia, mostly due to esophageal foreign body; People with dysphagia are more likely to have esophageal cancer.

2, the history of pre-existing disease: patients with a history of long-term stomach disease or history of acid, burning, gastric juice or bile reflux should consider reflux esophagitis, esophageal peptic ulcer and dysplasia; all have esophagus, stomach surgery History, longer-term esophageal gastric tube history, accidental corrosive agents, etc., should consider esophagitis or benign stenosis. Patients with dysphagia and mood should consider sputum spasm or diffuse esophageal fistula, mental scapular achalasia.

3, and the relationship between diet: patients with mechanical obstruction caused by esophageal or esophageal extracavitary factors, can have symptoms of dysphagia, and as the degree of esophageal occlusion continues to increase, the diet will gradually become difficult From general food, soft food, semi-liquid food, and liquid food, there may be no water in the end. People with pharyngeal neuropathy may be more difficult to eat on a liquid diet than on a solid diet. Drinking water can cause nasal reflux or cough. Eat too cold, too hot, too fast or irritating things to induce dysphagia, more suggestive esophagitis or esophageal fistula.

4, swallowing pain: swallowing inflammation, ulcers or traumatic swallowing pain when eating. Esophageal dysphagia is associated with pain and severity, and its distribution involves the posterior sternum, under the xiphoid, shoulder area, back, shoulders, neck and so on. If you eat an acidic diet, it will cause pain immediately, and it is more common with esophageal inflammation and ulcers. If you eat too cold or too hot diet induced pain, mostly diffuse esophageal fistula. In the non-swallowing period, there are also pains caused by extreme dilatation of the esophagus, and advanced esophageal cancer has mediastinal inflammation.

5, esophageal reflux: the inflow of food immediately reflux to the nasal cavity and cough, diagnosed as abnormal pharyngeal neuromuscular, long-term reflux after a meal, mostly due to the expansion of the proximal segment of the esophageal obstruction or the presence of sputum The reflux can be a food residue left over from the meal and has an acid odor. The amount of reflux in the sputum is often more, and it often occurs in the supine position at night, causing cough. Most of the esophageal cancer reflux is bloody mucus.

6, the disease stage and the course of disease development: patients with progressive dysphagia first consider esophageal cancer, and the course of disease is shorter, mostly 7-8 months. The course of the disease progressed slowly, mostly benign stenosis. The course of the disease is longer, and the symptoms of dysphagia are mild and recurrent. Most of them are patients with sputum.

7, hoarseness: dysphagia with hoarseness should consider the mediastinal invasion caused by esophageal cancer invading the recurrent laryngeal nerve; or due to aortic aneurysm, mediastinal tumor or mediastinal lymph node tuberculosis compression of the recurrent laryngeal nerve caused by hoarseness.

8, cough: dysphagia associated with cough should consider whether you have esophageal cancer, cardia cancer, sputum or esophageal diverticulum and other diseases; those with severe cough should consider pharyngeal neuromuscular disease or esophageal cancer patients with esophageal fistula .

Second, physical examination

Should pay attention to the general nutritional status, with or without skin disease or swollen lymph nodes, with oropharyngeal inflammation, ulcers or trauma, with or without tongue and soft palate. Can the patient hear the jet murmur in the xiphoid within 10 seconds after the patient takes a sip of water (the patient takes the seat, the stethoscope is placed on the left side of the xiphoid, and the patient can hear the jet murmur within 10 seconds after drinking a sip of water, There is no obstruction in the cardia, so the delay of the noise is not obvious or obvious, suggesting that the cardia has obstruction.

Third, laboratory inspection

Esophageal acid perfusion test (Bemstein), patients with sputum take a seat, through the nostril cannula about 30 ~ 35cm deep, drip into physiological saline, 100 ~ 125 drops / min, then switch to 0.1mol / L hydrochloric acid at the same drip rate, such as Post-sternal pain or heartburn, positive for the experiment, suggesting secondary esophageal fistula in reflux esophagitis.

Fourth, equipment inspection

1, X-ray examination: chest fluoroscopy or chest large piece can be seen with or without mediastinal enlargement, aortic aneurysm, left atrial enlargement or pericardial effusion. Esophageal barium meal examination can check the pharynx and esophageal length and the location of the spray site.

2, pull-net exfoliated cell examination: esophageal pull-net exfoliative cytology is an economical, simple, easy, safe and reliable method for diagnosing early esophageal cancer and esophageal cancer, which is most suitable for outpatient and esophageal cancer high incidence areas. For the anti-cancer screening, the positive diagnosis rate was as high as 87.8%~94.2%. Can be used as a means of inspection in a coarse screen.

3, esophagoscopy: patients with dysphagia using esophagoscopy, can directly observe the lesion location, extent, morphology, and color, and do exfoliative cytology brush examination and pathological histology bite examination. For example, esophageal cancer, smear cancer, sputum sputum, benign esophageal tumor, benign esophageal stricture, diffuse esophageal fistula, esophageal foreign body, esophageal hiatal hernia, esophageal tuberculosis, esophageal fungal infection are clearly differentiated.

4, esophageal pressure test: esophageal pressure test is very important to determine the movement function of the esophagus. It is very useful for some motor function diseases, such as polymyositis, dermatomyositis, visible 1/3 peristaltic wave disappearance in the esophagus, reduction of resting pressure on the esophageal sphincter, and non-creeping small contraction wave in the esophagus. The sphincters cannot relax; the diffuse esophageal fistula has esophageal strength and recurrent contraction waves, while the lower esophageal sphincter relaxes well.

Differential diagnosis

Dysphagia should be differentiated from the following symptoms:

1. Difficulty swallowing when lifting neck:

The early symptoms of esophageal compression type cervical spondylosis are characterized by difficulty in swallowing when the neck is raised and disappear when the neck is bent. Esophageal compression type cervical spondylosis, also known as dysphagia type cervical spondylosis, is relatively rare in clinical practice. It is because of its rareness that it is easily misdiagnosed or missed. Therefore, attention should be paid.

2. Swallowing disorders:

Swallowing is one of the most complex body reflexes and requires good coordination of oral, pharyngeal, larynx and esophageal functions. Dysphagia can lead to dehydration, malnutrition, aspiration pneumonia (recurring), and even suffocation and death. From the time of swallowing to the arrival of food at the door, it takes only a few seconds to go through the complex process described above. This indicates that dysphagia occurs when a link in the swallowing reflex arc of normal humans is damaged. Some patients with dysphagia may be killed by so-called aspiration pneumonia, which is caused by a swallowed food that often enters the trachea and causes a lung infection. Therefore, in the early stage of the disease, the swallowing activity is uncoordinated, and the coughing phenomenon often occurs when swallowing, so attention should be paid and the treatment should be checked early.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.