Dysphagia pathophysiology: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
=== Physiology of normal swallowing === | === Physiology of normal swallowing === | ||
Anatomically, swallowing can be divided into three phases:<ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><ref name="pmid24772045">{{cite journal| author=Aslam M, Vaezi MF| title=Dysphagia in the elderly. | journal=Gastroenterol Hepatol (N Y) | year= 2013 | volume= 9 | issue= 12 | pages= 784-95 | pmid=24772045 | doi= | pmc=3999993 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24772045 }} </ref><ref name="pmid21915488">{{cite journal| author=Cassiani RA, Santos CM, Parreira LC, Dantas RO| title=The relationship between the oral and pharyngeal phases of swallowing. | journal=Clinics (Sao Paulo) | year= 2011 | volume= 66 | issue= 8 | pages= 1385-8 | pmid=21915488 | doi= | pmc=3161216 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21915488 }} </ref> | Anatomically, swallowing can be divided into three phases:<ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><ref name="pmid24772045">{{cite journal| author=Aslam M, Vaezi MF| title=Dysphagia in the elderly. | journal=Gastroenterol Hepatol (N Y) | year= 2013 | volume= 9 | issue= 12 | pages= 784-95 | pmid=24772045 | doi= | pmc=3999993 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24772045 }} </ref><ref name="pmid21915488">{{cite journal| author=Cassiani RA, Santos CM, Parreira LC, Dantas RO| title=The relationship between the oral and pharyngeal phases of swallowing. | journal=Clinics (Sao Paulo) | year= 2011 | volume= 66 | issue= 8 | pages= 1385-8 | pmid=21915488 | doi= | pmc=3161216 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21915488 }} </ref><ref name="pmid2333995">{{cite journal| author=Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur JG et al.| title=Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing. | journal=Am J Physiol | year= 1990 | volume= 258 | issue= 5 Pt 1 | pages= G675-81 | pmid=2333995 | doi=10.1152/ajpgi.1990.258.5.G675 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2333995 }} </ref> | ||
* Oral preparatory phase | * Oral preparatory phase | ||
* Oral voluntary phase | * Oral voluntary phase | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Propulsive failure can result from dysfunction of the central nervous system control mechanisms, intrinsic musculature, or peripheral nerves. Structural abnormalities may result from surgery, neoplasm, caustic injury, or congenital anomalies.
Pathophysiology
Physiology of normal swallowing
Anatomically, swallowing can be divided into three phases:[1][2][3][4]
- Oral preparatory phase
- Oral voluntary phase
- Pharyngeal phase
- Esophageal phase
(a)Oral preparatory phase:
- This phase involves mastication and formation of a bolus in the oral cavity.
(b)Oral voluntary phase:
- It is characterized by propelling the bolus into the pharyngeal phase.
- It is controlled by the corticobulbar tracts and cranial nerves V(trigemenal),VII(facial)and XII(hypoglossal).
(c)Pharyngeal phase:
- This phase is a reflex
- It is controlled by the cranial nerves V(trigemenal),X(vagus)XI(accessory) and, XII(hypoglossal).
(d)Esophageal phase:
- The esophagus is a part of the gastrointestinal tract which is responsible of moving the food from the mouth to the rectum.[5]
- The esophagus has anti-reflux barrier which prevents the return of the acidic contentof the stomach back to the esophagus. The anti-reflux barrier consists of the lower esophageal sphincter (LES) and the related part of the diaphragm.
- The lower esophageal sphincter is contracting smooth muscle at the end of the esophagus responsible for the food passage to the stomach. LES has high pressure tone which helps keeping it a strong barrier between the esophagus and the stomach.
Pathogenesis of Dysphagia
The pathogenesis of dysphagia can be explained on the basis of etiology. There are a number of causes of different types of dysphagia of which the most common is stroke among the elderly.
Effect of aging on swallowing mechanism
Normal aging results in following changes in the swallowing mechanism:[6][7][8]
- Reduced lingual movement
- Delayed onset of the pharyngeal swallow
- Delayed upper esophageal sphincter manometric relaxation during swallowing
- Diminished pharyngolaryngeal sensory discrimination
- Cerebral atrophy
- Deterioration in nerve function
- Region-dependent decline in muscle mass
The following table elaborates the mechanism, genetic association, gross pathology features and microscopic findings of each cause.
| Cause of dysphagia | Type of food | Type of progression | Pathophysiological changes | Genetic association | Gross pathology features | Microscopic findings | |
|---|---|---|---|---|---|---|---|
| Oropharyngeal dysphagia | Soilds | Liquids | Intermittent/Progressive | ||||
| •Zenker's diverticulum
•Webs |
Yes | No | Progressive | •Zenker's diverticulum(ZD):
|
Diverticulum or a sac is seen in the esophagus |
| |
| •Webs | |||||||
| •Neoplasm | Yes | Yes | Progressive | •Neoplasm | |||
| Myogenic causes
•Myasthenia gravis •Connective tissue disorder •Myotonic dystrophy Neurogenic causes •ALS •Parkinsonism •Stroke |
Yes | Yes | Progressive | ||||
| Esophageal dysphagia | |||||||
| •Pill esophagitis
•Caustic injury •Chemotherapy |
Yes | No | |||||
| •Strictures
•Esophageal Cancer |
Yes | No | Progressive | Strictures: | The following genes can be involved:
|
||
| •Esophageal Cancer: |
Mutations in the following genes can cause esophageal cancer: |
||||||
| •Rings
•Webs |
Yes | No | Intermittent | Rings:
Webs: Multiple theories have been found:
|
|||
| •Achalasia
•Diffuse esophageal spasm(DES) |
Yes | Yes | Intermittent | •Achalasia: |
|
| |
•Diffuse esophageal spasm(DES):
|
There is a genetic association between DES and achalasia[12] | Gross thickening of muscularis propria layer and lower esophageal sphincter (LES) due to hyperplasia are characteristic findings of DES | There is degeneration of vagal fibres, inflammatory infiltration of myenteric plexus, and hyperplasia of smooth muscles are characteristic findings of DES | ||||
| •Scleroderma | Yes | Yes | Progressive | ||||
References
- ↑ Cook, Ian J.; Kahrilas, Peter J. (1999). "AGA technical review on management of oropharyngeal dysphagia". Gastroenterology. 116 (2): 455–478. doi:10.1016/S0016-5085(99)70144-7. ISSN 0016-5085.
- ↑ Aslam M, Vaezi MF (2013). "Dysphagia in the elderly". Gastroenterol Hepatol (N Y). 9 (12): 784–95. PMC 3999993. PMID 24772045.
- ↑ Cassiani RA, Santos CM, Parreira LC, Dantas RO (2011). "The relationship between the oral and pharyngeal phases of swallowing". Clinics (Sao Paulo). 66 (8): 1385–8. PMC 3161216. PMID 21915488.
- ↑ Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur JG; et al. (1990). "Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing". Am J Physiol. 258 (5 Pt 1): G675–81. doi:10.1152/ajpgi.1990.258.5.G675. PMID 2333995.
- ↑ Stein HJ, DeMeester TR (1992). "Outpatient physiologic testing and surgical management of foregut motility disorders". Curr Probl Surg. 29 (7): 413–555. PMID 1606845.
- ↑ Masoro EJ (1987). "Biology of aging. Current state of knowledge". Arch Intern Med. 147 (1): 166–9. PMID 3541821.
- ↑ Carucci LR, Turner MA (2015). "Dysphagia revisited: common and unusual causes". Radiographics. 35 (1): 105–22. doi:10.1148/rg.351130150. PMID 25590391.
- ↑ Cook IJ, Weltman MD, Wallace K, Shaw DW, McKay E, Smart RC; et al. (1994). "Influence of aging on oral-pharyngeal bolus transit and clearance during swallowing: scintigraphic study". Am J Physiol. 266 (6 Pt 1): G972–7. doi:10.1152/ajpgi.1994.266.6.G972. PMID 8023945.
- ↑ Paladini F, Cocco E, Cascino I, Belfiore F, Badiali D, Piretta L; et al. (2009). "Age-dependent association of idiopathic achalasia with vasoactive intestinal peptide receptor 1 gene". Neurogastroenterol Motil. 21 (6): 597–602. doi:10.1111/j.1365-2982.2009.01284.x. PMID 19309439.
- ↑ Alahdab YO, Eren F, Giral A, Gunduz F, Kedrah AE, Atug O; et al. (2012). "Preliminary evidence of an association between the functional c-kit rs6554199 polymorphism and achalasia in a Turkish population". Neurogastroenterol Motil. 24 (1): 27–30. doi:10.1111/j.1365-2982.2011.01793.x. PMID 21951831.
- ↑ de León AR, de la Serna JP, Santiago JL, Sevilla C, Fernández-Arquero M, de la Concha EG; et al. (2010). "Association between idiopathic achalasia and IL23R gene". Neurogastroenterol Motil. 22 (7): 734–8, e218. doi:10.1111/j.1365-2982.2010.01497.x. PMID 20367798.
- ↑ Frieling T, Berges W, Borchard F, Lübke HJ, Enck P, Wienbeck M (1988). "Family occurrence of achalasia and diffuse spasm of the oesophagus". Gut. 29 (11): 1595–602. PMC 1433819. PMID 3061886.