[Dysphagia] Remember the esophagus

[eripley at yahoo.com (Irene Campbell-Taylor)]

If you thicken foods and fluids, please remember this:
    Normal adult swallowing of liquid and viscous material: scintigraphic data on bolus transit and oropharyngeal residues. Hamlet S; Choi J; Zormeier M; Shamsa F; Stachler R; Muz J; Jones L Dysphagia 1996 Winter;11(1):41-7    
  Scintigraphic data are provided for 20 normal control subjects, 39-65 years of age. Each subject swallowed 10 cc of water and 10 cc of a more viscous material (1,100 centipoise) consisting of apple juice thickened with Thick-It, a commercial food thickener. The test substances were combined with 2.5 mCi Tc-99m sulfur colloid. Scintigraphic data were acquired in dynamic mode for 10 sec at 25 frames/sec as the subject swallowed. Time-activity (TA) data were used to compute transit times, percentage residues in the mouth and pharynx, percent ingested, and a derived swallow efficiency score. The liquid was ingested in a single swallow by all subjects, and 9 cc was actually transferred to the esophagus. In contrast, for the viscous material, 11/20 subjects performed a second clearing swallow within the 10-sec interval. On the first swallow with the viscous substance, an average of 7 cc was transferred to the esophagus. Scintigraphy offers an excellent technique for determining natural
 and preferred volumes for swallowing a variety of bolus consistencies, since it can quantify the volume of each swallow or partial swallow. In this group of subjects the oral discharge time was shorter with the viscous material than with the water, but the pharyngeal transit times were not significantly different for the two bolus consistencies. Numerical efficiency scores were lower for the viscous material, indicating that such a measure is bolus dependent.
   
  It would appear that, by thickening substances, one places on the dysphagia patient the demand to swallow more often - not, I would suggest, desirable.And the transfer into the esophagus is not as efficient - and these were normals.
   And:
  Unexplained dysphagia: viscous swallow-induced esophageal dysmotility. Meshkinpour H; Eckerling G. Dysphagia 1996 Spring;11(2):125-8      
  Dysphagia is a manifestation of several clinical conditions of diverse origin. In spite of the variation in these disease entities in terms of their etiology, clinical presentation, natural history, and treatment, the mechanism of this clinical complaint is not always clear. We studied a group of patients with dysphagia for solids in whom no anatomic or motor abnormalities were encountered on standard studies. The group consisted of 37 patients, 25 women and 12 men, who were complaining of dysphagia of 6 months or longer duration and they did not demonstrate structural or motor abnormalities on barium esophagogram, esophagoscopy, and standard esophageal manometry. A group of 24 age-matched patients, 14 women and 10 men, with noncardiac chest pain served as the patient control. Esophageal contractile activities were studied after 10 wet swallows (5 ml of water) and 10 viscous swallows (5 cubic cm of marshmallow). Resting lower esophageal sphincter pressure and its relaxation
 response to swallows, amplitude of peristaltic activities, rate of dysphagia provoked during the study, and the frequency of abnormal esophageal contractions were evaluated. Six abnormal esophageal contractile activities-failed peristalsis, dropout, repetitive, simultaneous, spontaneous contractions, and aperistalsis-were utilized to generate an esophageal peristaltic dysfunction index. The mean LESP was 8.1 +/- 4.7 in the dysphagia group and 16.1 +/- 4.3 in the chest pain group. The mean amplitude of peristaltic contractions was 47.1 +/- 16.1 and 89.0 +/- 27.0 mmHg after wet swallows for dysphagia and chest pain groups, respectively. These values were 58.2 +/- 12.4 and 92.4 +/- 22.1 for viscous swallows. Swallowing provoked dysphagia in 89% of the dysphagia group after viscous swallows and 9% after wet swallows. In contrast, only 11% and 3% of control group complained of dysphagia during the study. This group of patients probably represent a cohort of patients with a nonspecific
 esophageal motor disorder in whom both clinical symptom and their esophageal motor counterpart can only be elicited in response to viscous swallows. We strongly believe in addition of viscous swallows in evaluating dysphagic patients in whom symptoms remain unexplained in light of standard studies.
   
  Since the mouth, oropharynx and esophagus form a single functional unit with effects both backward and forward, one forgets this at one's peril.



Dr I Campbell-Taylor
Clinical Neuroscientist
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