Twitter debate: controversies in dysphagia

Introduction

The final #FGDebate of 2021 discussed controversies in investigating and managing dysphagia. The debate generated over 200 000 impressions with over 70 participants and broadly covered topics of food bolus impaction, eosinophilic oesophagitis (EoE) and oesophageal strictures and briefly touched on dysphagia in scleroderma. In this article, we will expand on the key discussion points from the debate.

Management of food bolus impaction

In our first case, a young man had a turkey bone stuck in his throat. Although he was able to speak, he was struggling to swallow his saliva. We asked our #FGDebate participants whether this patient should first try a fizzy drink, glucagon or head to the emergency department for further assessment. While the majority advised the patient to go to the hospital (80%), others recommended a fizzy drink or glucagon, which led to the discussion of investigations and management of patients with a food bolus obstruction.

Food bolus impactions tend to occur in the oesophagus, with the most common causes being meat pieces or bones in the Western world and fish bones in Asia. The sharp edges of meat bones have a greater chance of perforation than soft food obstructed in the oesophagus. Thus, it is important to arrange either a CT scan or at least a chest X-ray prior to undertaking an oesophago-gastro-duodenoscopy (OGD).¹ Ideally, endoscopic assessment should be undertaken within 12–24 hours following impaction to reduce the risk of complications, which include perforation, retropharyngeal abscess and/or fistula formation. Endoscopic assessment should be carried out more urgently, however, if the patient is unable to swallow their saliva. While a trial of glucagon or fizzy drinks is still commonly practised in the emergency department setting, there is limited evidence to support their use and the potential risks of aspiration and/or perforation secondary to nausea and vomiting may outweigh any benefits.² Similarly, there is little evidence to recommend the use of hyoscine butylbromide (Buscopan) in the management of oesophageal food bolus obstruction.³

When attempting endoscopic extraction, an overtube is recommended, particularly for sharp bones. Pushing blindly into the stomach is not routinely advised as the distal oesophageal anatomy beyond the food bolus is often not visible and is contraindicated if there is a stent already in place, due to the risk of perforation and stent migration.⁴ However, gentle pushing on the central part of the food bolus with air insufflation can be attempted safely, for soft food bolus obstruction, especially if there is space seen between the food bolus and the wall of the oesophagus. If there is resistance, breaking a large bolus into smaller pieces can be achieved by using different types of grasping forceps, polypectomy snares, retrieval nets or baskets before attempting extraction or pushing the food into the stomach.¹

Eosinophilic oesophagitis

As the #FGDebate continued, the discussion progressed from managing food bolus obstructions to investigating and treating the underlying pathology, which can be found in over 75% of cases. Peptic strictures are the most common cause (>50%), followed by EoE in almost 40% of cases.^{1 5} EoE is the most common cause of food bolus obstruction in patients under the age of 50 years. While typical endoscopic features of EoE include the presence of white exudates, longitudinal and vertical furrows, oesophageal rings and trachealisation of the oesophagus, oesophageal oedema and mucosal friability (crepe paper oesophagus), approximately 10% of patients have either very subtle findings or a completely normal oesophagus.^{6 7} To increase the diagnostic sensitivity of EoE, at least six biopsies should be taken from at least two different locations in the oesophagus, typically from the distal and proximal halves of the oesophagus.⁸

There are several treatment options to consider in EoE. Proton pump inhibitors (PPIs) have been shown to be effective in achieving remission in approximately 30%–50% of patients after an 8-week course and is more efficacious when given two times per day.^{9 10} Topical steroids in the form of orodispersible budesonide 1 mg two times per day have been shown to be effective in inducing remission and also in maintenance of this remission over a 12-month period.^{11 12} Further studies are needed to investigate its effect in maintaining remission beyond a year. Elimination diets can have a role in the management of EoE but only in the setting of an experienced dietitian supervising the dietary restriction and should include histological assessment to confirm improvement.^{8 13} If left untreated, EoE can result in persistent symptoms and inflammation, leading to oesophageal remodelling, stricture formation and functional abnormalities of dysmotility.⁸

Oesophageal strictures

Our next #FGDebate case had an elderly woman suffering from weight loss and odynophagia, with her OGD showing severe oesophagitis and an oesophageal stricture. We asked our audience whether her symptoms and OGD findings were characteristic of benign or malignant strictures with a mixed response, leading us to delve into distinguishing stricture features, investigations and management.

The characteristic symptom of strictures is dysphagia to solids more than liquids. The formation of oesophageal strictures can occur for a wide variety of reasons, including long-standing inflammation and ulceration (peptic oesophagitis and corrosive oesophagitis), EoE, postoperative/chemoradiation therapy or postendoscopic resection (>75% circumferential endoscopic resection).¹⁴ While 70%–80% of oesophageal strictures are benign, resulting from long-standing gastro-oesophageal reflux disease, it can often be endoscopically difficult to distinguish between benign and malignant strictures.¹⁵ Thus, it is always recommended to perform biopsy on strictures in the first instance to obtain a definitive diagnosis to help guide further management. Barium swallow can also be useful to evaluate the location, length, diameter and number of strictures, as well to determine the presence of associated pathology such as an oesophageal diverticulum or a hiatus hernia.

Benign strictures can be simple or complex. Simple strictures, secondary to Schatzki’s rings, oesophageal webs and peptic strictures, are generally less than 2 cm in length, concentric and straight and allow the passage of a normal-diameter endoscope. They respond well to PPI therapy, reducing the need and frequency for stricture dilatation. Complex strictures, commonly seen secondary to postradiation or ingestion of caustic substances, are usually longer, angulated, irregular or have a severely narrowed diameter. Simple strictures respond well to dilatation treatment, while complex strictures have a tendency to be refractory or to recur despite dilatation, with increased risks of perforation.¹⁴

Further investigations including evaluating for oesophageal motility disorders

Our last case had a male patient complaining of worsening dysphagia, with skin thickening and joint pain, which brings us to our final topic of oesophageal motility disorders.

After excluding structural causes and EoE at OGD, patients with persistent symptoms should be considered for oesophageal motility evaluation. The mainstay of oesophageal motility investigations is barium swallow, and the gold standard investigation is oesophageal high-resolution manometry. Oesophageal motility disorders are defined according to the Chicago Classification into two broad categories based on manometry findings: disorders of oesophageal body peristalsis and disorders of oesophageal outflow obstruction, including achalasia.¹⁶ In the aftermath of the COVID-19 pandemic and recovery of motility laboratories, a triage tool developed by the Association of Gastrointestinal Physiologists has been shown to be able to prioritise patients with major oesophageal motility diagnoses and can expedite their diagnoses.¹⁷ Oesophageal motility disorders can either be primary or secondary disorders, for example, due to connective tissue diseases such as systemic sclerosis. While there are a number of possible causes of dysphagia in systemic sclerosis (table 1), oesophageal involvement, resulting in dysphagia, is a common presentation in systemic sclerosis, affecting over 90% of patients, and may be the first manifestation of the disease. Treatment options will be targeted at the cause of dysphagia.¹⁸

Table 1.

Causes, disease process and management options for dysphagia commonly seen in patients with scleroderma

Causes of dysphagia	Disease process	Management
Xerostomia	Dry mouth Salivary glands unable to produce saliva needed for food lubrication and mastication	Drinking water frequently Using artificial saliva
Microstomia	Abnormal small oral orifice Sclerofibrosis of perioral tissue and malfunctioning of temporomandibular joint	Exercises/massages to help stretch the mouth
Myositis	Pharyngeal dysphagia secondary to muscle impairment and inflammation of striated skeletal muscles necessary for the swallowing process	Immunomodulation
Oesophageal dysmotility	Absent peristalsis and reduced tone of the lower oesophageal sphincter can limit clearance of food, resulting in reflux	Smaller bites, chewing more, drinking water with food
Gastro-oesophageal reflux disease		Proton pump inhibitors Dietary and lifestyle modifications
Candida oesophagitis	Impaired host–defence system	Antifungal therapy
Gastroparesis	Fibrotic infiltration resulting in subsequent dysfunction of autonomic nerves, smooth muscle and enteric neurons The increased volume of gastric contents results in stomach distension and decreased lower oesophageal sphincter pressure, causing regurgitation of contents into the oesophagus.	Prokinetic agents Small, frequent meals Increased fibre intake

Conclusion

Dysphagia is an interesting phenomenon because it can present as a slow, insidious process but can also present as a medical emergency. The causes of dysphagia are numerous and can arise concomitantly with many other medical conditions. Consequently, managing these patients can be quite complex, but it is vital to understand when urgent treatment is needed. It is, therefore, important to keep up to date on the guidance in investigating and treating these patients appropriately. We are grateful for everyone who contributed their time and expertise for this debate and encourage all of you to participate in our future debates.

Ethics statements

Patient consent for publication

Not applicable.