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[DYSPHAGIA] Interesting case
When you say he "pushed" the bolus back, I'm assuming
it's with his tongue -
right?
Although the GI series was described as normal (it
usually is even when GER
is chronic) he's showing pretty classic signs and
symptoms of GER plus
possible esophageal spasm, perhaps intermittent
achalasia etc. etc. The
"bread, meat" sticking is so common a sign of
gastroesophageal dysmotility
as to be almost diagnostic in and of itself. His
description of his throat
"locking" is a pretty good account of laryngospasm
cause by inhalation of
aerosolized gastric juice. Triadofilopoulos has
published the best
description to date of the back and forth relationship
of oropharyngeal and
esophageal dysphagia viz. if you have one you very
likely will have the
other.
I had a similar patient recently whose most alarming
symptom was
laryngospasm. I sent him to his GP who told him (and I
swear this is true)
that he "choked" because his epiglottis had been
covered in saliva. Now,
could I make that up? It's just an example of the
reluctance to recognize
that a) 7/10 adults in North America have GER and/or
GERD and that
b)adenocanrcinoma of the esophagus is the fastest
growing incident cancer in
Nothern Europe and North America, believed to be due
to the high incidence
of GER in the adult population and the esophagus'
being constantly bathed in
acid.
One need not have heartburn or any other similar sign
to have GERD and most
doesn't show up on standard GI series.
If I were he, I'd find another gastroenterologist.
By the way, the fellow with the "saliva covered
epiglottis" self medicated
with Gaviscon and symptoms disappeared.
Irene.
--- "Quinn, Darin" <QuinnD@rvh.on.ca> wrote:
> I had an interesting outpatient case yesterday in
> our clinic and I'm stumped
> as to where to go next:
>
> Healthy 32 year old male with a two year history of
> dysphagia with solids
> (mostly hard or chewy, eg. bread, pizza, apples) but
> never liquids. He
> described the problem as follows: on a daily basis
> while eating, he chews
> something, pushes it to the back of the mouth and
> into the throat, but then
> nothing happens and he has to bring it back up with
> forceful gagging and/or
> coughing. Once this happens, he stops eating and
> then later on, everything
> works fine again. There is no apparent pattern to
> the sudden dysphagia as
> far as time of day, type of food, stress level, etc.
> though he said that it
> seems to happen more often toward the end of a meal
> when he is almost full
> (but other times it happens on the first bite). The
> dysphagia has been
> stable over its two year history and he could not
> think of anything
> significant that occurred at the time it started.
> He did appear quite
> anxious when describing the problem and said
> (understansably) that it is
> very worrisome to him. I asked him briefly about
> stress but he said that
> this can happen even when he's having a great day
> and feels perfectly
> relaxed.
>
> Another other possibly related complaint was of a
> couple of sudden instances
> (approx. 3 in the last two years) of his 'throat
> locking up' for up to 1
> minute. During these episodes, he feels he cannot
> get any air in or out and
> then everything returns to normal once the 'spasm'
> passes. These did not
> coincide with eating and also showed no particular
> pattern.
>
> No significant medical history was noted and he is
> not on any medication. He
> quit smoking one year ago. His weight is healthy
> and stable and he has not
> had pneumonia. He denied any symtpoms of heartburn,
> dysphonia, and does not
> experience globus. ENT examination was normal, as
> was upper GI series. He
> reported no family history of dysphagia. There are
> no known food allergies.
>
> On examination, oral motor assessment was normal.
> VFSS was also normal with
> all consistencies, in both views in terms of timing,
> coordination, and
> oral/pharyngeal clearance. No overt anatomical
> abnormality was noted.
>
> Any ideas?
>
> Thanks in advance,
>
> Darin
>
>
> Darin Quinn, MSc.
> Speech-Language Pathologist
> The Royal Victoria Hospital of Barrie
> 201 Georgian Drive
> Barrie, Ontario L4M 6M2
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