DYSPHAGIA
Dysphagia
means difficult or painful swallowing.
In one
study, 12% of 797 cancer patients complained of dysphagia on
admission to a hospice, and 60% of the patients with dysphagia
responded to medical treatment.
Causes:
- Candidiasis
-
Carcinoma
(esophagus, oropharynx, stomach)
-
Mediastinal
nodes (breast, lymphoma)
-
Pharyngeal
damage (cancer plus radiotherapy)
-
Neuromuscular
(see Amyotrophic Lateral Sclerosis)
Note:
Benign peptic stricture is a possibility.
Recurrent
cancer of the pharynx (previously treated with radiotherapy)
can cause complete dysphagia without any obstruction
at post-mortem. This is due to muscular incoordination and
splinting of the pharynx, and can respond to high dose
steroids.
Assessment:
-
Observe
swallowing
-
Liquids or
solids?
- Painful?
-
Dribbling?
(total dysphagia?)
- Coughing
after liquids? (fistula?)
The most
important first step in managing dysphagia is to watch the
patient attempting to swallow - to assess both pain and degree
of difficulty. If the patient is managing to swallow saliva
(about 500cc per day) he should be able to sip fluids. A
patient with a fistula into the bronchus will cough up orange
sputum after a drink of orange juice.«
If
swallowing causes burning or discomfort, assume candidiasis is
present. (see Candidiasis)
Management
options:
-
Treat candidiasis (thrush)
-
Liquidize food
-
Consider drug routes
-
Palliative radiotherapy
-
Dilation
-
Esophageal tube
-
Laser
-
High dose steroids
-
Management of a fistula
-
Total dysphagia
Discussion:
1.
Candidiasis tends to cause pain when swallowing (worse with
hot drinks). Severe esophageal candidiasis can occur even with
no evidence of oral thrush. A systemic anti-fungal,
ketoconazole 200mg 2 times a day, should be used. Swallowing
improves within 24 to 48 hours.
2.
Liquidize food, or use liquid food supplements.
3. Drugs
may have to be soluble or given by suppository or continuous
subcutaneous infusion.
4.
Palliative radiotherapy can shrink mediastinal nodes.
Carcinoma of the esophagus has usually already been treated
with radical, maximal dose radiotherapy, and further treatment
is not possible.
5.
Endoscopic dilation of the tumor can bring temporary relief
(days to weeks), but there is a risk of perforation. Dilation
has a place in the initial management of moderate dysphagia
(for solids but not liquids) and can bring improvement.
Endoscopy takes 10 to 15 minutes and does not require x-ray
screening facilities. If dysphagia recurs quickly, other
methods must be used.
6.
Esophageal tubes are always worth considering in severe dysphagia. Tube insertion is possible in 90% of patients. They
are best inserted under general anesthesia and x-ray control,
although they may be inserted under sedation. The tumor must
first be dilated and this can cause a fatal perforation and
mediastinitis. (There is about a 10% mortality with this
procedure.)
Previous
radiotherapy does not preclude tube insertion.
Intubation
of tumors occurring in the lower third, or for recurrent tumor
at an anastomosis, can be difficult because the tumor may not
hold the tube in place.
The results
are good. 30% of patients have normal swallowing and 60% can
manage semisolids. The patient is unaware of the tube when it
is correctly positioned.
The patient
is advised to:
-
Chew food
well
-
Avoid large
boluses of meat
-
Take fizzy
drinks (club soda, tonic water) with and after meals
7.
Endoscopic laser treatment is becoming increasingly available.
In one series of 68 patients 98% had relief of symptoms, and
the results are as good as tube insertion. The treatment
involves endoscopy under sedation. The malignant stricture is
usually dilated first (with the usual risk of perforation)
before the laser can be used. The laser destroys all
intraluminal tumor. Treatment takes about 20 minutes, and may
have to be repeated after about 3 months. It cannot be used
for dysphagia due to extrinsic compression or due to
circumferential tumors.
(see Lasers)
8. High
dose steroids (dexamethasone 8mg to 12mg per day) can be very
effective in relieving dysphagia, sometimes for many weeks.
This can be effective whether the cause is carcinoma of the
esophagus, mediastinal nodes, post operative stricture or
pharyngeal induration due to oropharyngeal carcinomas. It is
presumed to work by reducing inflammatory edema. The
dexamethasone has to be given by injection (8mg IM per day
for the first few days) if dysphagia is severe, or soluble
prednisolone 30mg 3 times a day can be used. There is a risk
of causing hunger without improving swallowing, but this
rarely occurs and hunger pains can be reduced by a small dose
of morphine. (see Steroids)
9. If a
broncho-esophageal fistula develops, the patient complains of
coughing after fluids. The cough can sometimes be reduced by
taking semisolids (custard, jello) while at an angle of 45
degrees. The insertion of a tube can seal a fistula, and
should be considered in a patient with a relatively good
prognosis. In most patients aspiration pneumonia supervenes
after a few days, and should be treated symptomatically (with
morphine and scopolamine).
10.
Patients with total dysphagia can still enjoy the taste of
different drinks even though they have to spit them out. They
have to spit out saliva, and reducing saliva with an
anti-cholinergic drug can be helpful.
«
In total
dysphagia, nasogastric feeding, parenteral feeding and
gastrostomy can have a place in exceptional circumstances for
a very few patients, but are usually best avoided as they can
prolong a distressing death.
(see Nutrition)
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.
