Dysphagia

Abstract

Introduction Dysphagia is a clinical symptom, which patients report as difficulty in swallowing. Dysphagia is a clinical sign when we prove an impaired swallowing. Dysphagia can be caused by the narrowing of the gastrointestinal tract due to mechanical obstacles or failures of those structures in the nervous system and the muscles that are involved in swallowing. From dysphagia we must distinguish other similar clinical conditions. Clinical manifestation The exact medical history allows distinction between oropharyngeal and esophageal dysphagia. Medical history helps us to distinguish between structural and functional disorders. With an accurate medical history and clinical examination we can find the underlying pathology that caused dysphagia. Then the patient can be directed to the appropriate specialist. Neurological diseases like stroke, usually cause dysphagia in the early stages of the swallowing process -oropharyngeal dysphagia. In further investigations we usually use endoscopy, barium swallowing and esophageal manometry . Dysphagia after stroke is quite common. In the acute phase of stroke dysphagia symptoms are presented in 30 to 50% of the patients. Within 6 months, the incidence of dysphagia lowers to approximately 10%. Stroke in the area of the brainstem is less common than in other affected areas of the brain. Those who survive the brainstem stroke have a very good prognosis for physical activity. The affected patients are particularly prone to dehydration and malnutrition but also have an increased risk of aspiration pneumonia. Usually, the recurrent episodes of aspiration pneumonia are fatal rather than the first aspiration pneumonia. In most of the stroke patients swallowing already returns to normal during the first week. Moreover, dysphagia is associated with sarcopenia after an acute stroke. Evaluation and treatment Early detection of dysphagia with an appropriate nutritional support have significant impact on the prognosis and are therefore of utmost clinical importance for the patients after stroke . Dysphagia is associated with an extended hospitalization and increased mortality. It is necessary to use additional tests for an unexplained dysphagia in order to confirm the diagnosis and to assess the risk of aspiration. The prospective study in stroke patients, where the bedside tests for dysphagia and video fluorography were used, confirmed that dysphagia is independently associated with the respiratory infection. The predictive value of video fluorography is increased by using sensory testing methods, laringopharyngeal with a flexible nasopharyngoscopy. If the specific treatment is not an option, stroke related dysphagia is managed in a non-specific manner. We have to realize that the most important consequences of oropharyngeal dysphagia are dehydration, malnutrition, aspiration pneumonia, and sudden death. The objectives of nonspecific treatments are primarily the reduced aspiration and improved swallowing, so as to enable optimal nutritional status and hydration. Treatment should be adjusted individually, according to the functional and structural abnormalities. A common measure for dysphagia is a diet modification. In the cases of impaired oral intake we feed via nasogastric tube feeding or through a gastrostomy to achieve a satisfactory nutrient intake. Transiently we can use parenteral preparations. When administering drugs to the patients with dysphagia, we must realize that we choose between the benefits and risks for the patient; therefore, the treatment should be regularly updated. All temporary or permanent discontinuations of medications should be documented with the arguments for such decisions. Keywords: dysphagia, elderly