DYSPHAGIA AND ITS HOMEOPATHIC MANAGEMENT
Department Of Practice of Medicine.
Father Muller Homoeopathic Medical College and Hospital
Deralakatte, Mangaluru 575018
Dysphagia Treatment – Dysphagia is the sensation of food being obstructed in the food passage anywhere from the mouth to the stomach. This article reviews knowledge about, Swallow mechanism, Swallowing phases, Functional grades, Types, causes, Diagnosis and its general and Homeopathic management.
Dysphagia, pharynx, larynx, esophagus, miasm.
OD = oropharyngeal dysphagia, EO = esopharyngeal dysphagia
“Dysphagia” a Greek word. “Phagia” mean ‘to eat’, and ‘dys’ means ‘with difficulty’ so in dysphagia, eating become unjoyful. So by definition, dysphagia is nothing but the sensation of food being obstructed in the food passage anywhere from the mouth to the stomach.
Basic anatomy and physiology of upper UGT
The act of swallowing requires the passage for food and drink from the mouth into the stomach. From mouth to hypo pharynx covers 1/3rd of passage while 2/3rd is covered by the oesophagus. The swallowing centre in the brain stem is located in the floor of 4th ventricle and adjacent region of medulla; from here it is connected to cerebral cortex, vomiting centre, and respiratory centre. All these areas work in coordinated manner to provide voluntary as well as involuntary control of swallowing. An adult swallows approximately 580 times/ daily and the act goes on unconsciously.
There are two phases in the process of swallowing.
1. Oropharyngeal Phase
2. Oesophageal Phase
1. OROPHARYNGEAL PHASE (Voluntary phase)
This phase starts by the entry of food bolus from the mouth to the proximal end of oesophagus. It has 6 phases – 1. Elevation of tongue 2. Posterior movement of tongue 3. Elevation of soft palate 4. Elevation of hyoid 5. Elevation of larynx 6. Tilting of epiglottis.
2. ESOPHAGEAL PHASE (Involuntary phase)
Food bolus is propelled through the oesophagus by the involuntary wave of contraction mediated by the enteric nervous system. Pressure gradient speeds the movement of food from the hypo pharynx into the oesophagus when the cricopharyngeal muscles relaxes. The primary peristaltic contraction which is initiated by the swallowing, moves down the oesophagus at the rate of 2-4cm/sec and reaches the distal oesophagus about 9sec. The duration varies from 8-20 sec.
Types and aetiology of dysphagia:
It has been classified broadly into two types on the basis of site 1.Oropharyngeal. (High dysphagia) 2. Oesophageal (Low dysphagia)
It is the difficulty in emptying material from the oropharynx into the oesophagus. It results from abnormal function proximal to the oesophagus. Patient complain of difficulty in initiating swallowing, nasal regurgitation and tracheal aspiration followed by coughing.
1. Neuromuscular Disease
Ø Parkinson’s Ds
Ø Multiple sclerosis
Ø Bulbar poliomyelitis
Ø Brain stem tumour
Ø Wilsons disease
Ø Peripheral neuropathies
c) Motor endplate
Ø Myasthenia gravis
Ø Muscular dystrophy
Ø Metabolic myopathy (glycogen storage disease, lipid storage disease)
2. Mechanical /obstructive lesions
Ø Oral ulcers (mouth, throat, oesophagus)
Ø Abscess (peri-tonsillar, pharyngeal, retropharyngeal)
c) Plummer-Vinson syndrome
d) Extrinsic compression
Ø Thyromegaly / Hashimotos thyroiditis
Ø Cervical osteophytes
e) Disorders of the upper oesophageal sphincter
i. Incomplete relaxation
Ø Cricopharyngeal achalasia
Ø Occulopharyngeal muscular dystrophy
ii. Inadequate opening
Ø Cricopharyngeal bar
Ø Zenker diverticulum
iii. Delayed relaxation
Ø Familial dysotonomia
It is the difficulty in passing the food down the oesophagus. Here the patient complaints of feeling of food getting stuck several seconds after swallowing and will point towards the suprasternal notch or behind the sternum.
1) Neuromuscular / Motility disorders
a) Most common
Ø Diffuse oesophageal sphincter
Ø Motility disorders secondary to
• Collagen disorders
• Chagas disease
2) Mechanical /obstructive
Ø Dysphagia is due to mucosal oedema /benign tumours
Ø Gastro oesophageal reflux disease (GERD)
Ø Infectious esophagitis- HIV, H. pylori, Herpes, Candidiasis.
Ø Medication induced esophagitis (NSAIDs, Quinidine)
Ø Radiation treatment
Ø Caustic injury
b) Disorders of wall
Ø Oesophageal stricture
Ø Zenker diverticulum
Ø Epiphrenic diverticulum
c) Disease causing external compression
Ø Hiatus hernia
Ø Cervical osteophytes
Ø Mediastinal growth
Ø Vascular ring (dysphagia lusoria)
d) Luminal obstruction
Ø Foreign bodies
Ø Oesophageal webs
Ø Schatzki rings
Ø Carcinoma oesophagus
Functional Grades of Dysphagia
1. Complaints of dysphagia but still eating normally
2. Requires liquid with meals
3. Able to take semisolid, but unable to take any solid
4. Able to swallow liquids only.
5. Unable to swallow liquids
6. Unable to swallow saliva also.
Approach to a Patient of Dysphagia
1) Dysphagia is more for solids /more for both liquids and solids
a) Dysphagia is more for Solids
Mechanical lesion: It is mainly due to the narrowing of the lumen of the oesophagus due to some obstruction.
§ Cancerous growth,
b) Dysphagia is more for both liquids and solids
Neurological: It is due to mesenteric plexus, mesenteric plexus, and problem with the peristaltic movement of oesophagus.
2) Nature of the symptom
a. Dysphagia for solids
• Lower oesophageal B ring
• Carcinoma oesophagus
• Stricture of oesophagus
b. Dysphagia for both liquids & solids
• Diffuse oesophageal spasm
• Cork screw oesophagus
• Systemic sclerosis
3) Associated symptoms
• Heart burn –oesophageal stricture
• Weight loss
• Fatigue – suggestive of cancer
• Coughing – suggests pharyngeal dysphagia due to motor dysfunction
Ø Barium swallow
Ø Upper GI endoscopic study
Ø PH monitoring in the lower oesophagus
Ø Lateral X ray of neck on barium swallow
Some helpful findings in dysphagia
• Dysphagia immediately after food: pathology in the oral cavity /pharynx.
• Food regurgitated long after it was taken: oesophageal obstruction
• Painful dysphagia: infective/inflammatory disorders of oral cavity, muscle contraction above the level of obstruction to the oesophagus
• Painless dysphagia: tumour invasion causing denervation.
• Dysphagia with dusky erythematous rash: Dermatomycositis
• Dysphagia with Raynaud’s phenomenon: Systemic sclerosis
• Dysphagia with cough and dyspnoea: Pulmonary aspiration
According to the pathology and progress of the disease miasm can vary. It starts with psora, because it is functional in most of the cases. But when it comes with any obstruction, or growth, in conditions like systemic sclerosis, cancer etc. then it progress from psora to sycotic to syphilitic. So it has a trimiasmatic presentation.
Dysphagia general management
Ø Changing head position while eating
Ø Retraining the swallowing muscles
Ø Do strength and coordination exercises for tongue
Ø Patients with severe dysphagia and recurrent aspiration require gastrostomy tube.
§ Treatment is directed at the specific cause
§ If a stricture, ring or web is found, careful endoscopic dilatation is performed
§ In achalasia balloon dilatation of the LES
1) Dysphagia for solids/mechanical lesion
Constriction and contraction of oesophagus, great difficulty in swallowing solid food, painless sore throat, and offensive discharge. Contraction at cardiac orifice. Teeth and gums sore ulcerated, breath fetid, tongue feels burned. Can swallow liquid only, least solid food gags.
Can only swallow liquids. Spasm of oesophagus as soon as the food enters the oesophagus, causes gagging and chocking. Hungry but refuses food. Gastric weakness and malignancy . Enlarged mesenteric glands .pain in abdomen while swallowing food. Habitual colic, with hunger, but food is refused.
Regurgitation of food about an hour after eating. Painful contraction of stomach extending to oesophagus.
Sensation as if a plug and of a splinter in throat. Quinsy. Stitches in throat extending to the ear when swallowing.
• Merc. sol.
• Merc. cor
• Ferrum met
2) Dysphagia for both liquids and solids/neurological lesion
Throat sore, worse left side, swallowing liquids .feeling as if something was swollen which must be swallowed; worse swallowing saliva or liquids. Empty swallowing more painful than swallowing solids .throat pain aggravated by hot drinks. Liquids more painful than solids when swallowing.
Painful swallowing, throat feels burned raw, aggravated by empty swallowing.
Painful swallowing. Feeling of a lump in the throat. Better by eating something solid
Throat constricted; difficult deglutition, worse by liquids, sensation of a lump. Oesophagus dry, feels contracted. Spasm in throat. Dread of drinking.
Better by warmth. Empty swallowing more painful, sensation of a lump in the throat with constant necessity to swallow.
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