Trouble Swallowing? It Could Be Dysphagia

Podcast Transcript

Dr. Scott Steele:

Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, president of main campus and colorectal surgeon here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to welcome Dr. Fady Asslo, who's a gastrologist at Cleveland Clinic, Florida. And today we're going to talk a little bit about dysphagia, which is a swallowing disorder. And so, Fady, thanks so much for joining us on Butts & Guts.

Dr. Fady Asslo:

I'm glad to be here. Thank you for having me.

Dr. Scott Steele:

So for those of you who aren't familiar with Dr. Asslo, Dr. Asslo, why don't you give us a little bit of your background, where you're from, where'd you train, and how did it come to the point that you're at Cleveland Clinic, Florida?

Dr. Fady Asslo:

Scott, I'm an international graduate. I came from Middle East originally. I started my training in New Jersey, working in Seton Hall University Community Hospital in St. Michael, serving a lot of underprivileged folks, learning a lot, working with excellent doctors. I did my training residency, chief resident over there. Then I joined a fellowship program with Seton Hall University as well, New Jersey. I was there for three years and then I moved to New England. I was in Maine for almost eight years practicing. Then I joined my practice in Vermont before moving South of Florida just a few months ago. Happy to be here.

Dr. Scott Steele:

Well, we're glad to have you. And what a regional distribution in weather between Upper Maine and Vermont this time of year and Florida. So our listeners might not realize how complex the swallowing process is. So let's just begin there. Take us through the swallowing process, something we take for granted all the time. How do we normally swallow? And maybe if you will, what could maybe go wrong at each one of these steps?

Dr. Fady Asslo:

It's something I really like to read and talk about esophageal disorders, but starting with the normal process, swallowing for the most part basically consists with three stages. The first phase basically we call the oral is where things happen inside the mouth. It's mostly driven by our chewing process, basically trying to chew the food and break it down using our tongue to move the food backward. We call the bolus. And from there, this is mostly under our control, but from there, once it hits the second phase called the pharyngeal phase, it becomes really involuntary. This is where we have at least 25 groups of muscle working in coordination, which requires a really intact nervous system that comes from the brain, especially the brainstem that help sync the process here.

And once we finish the pharyngeal, which is our throat phase, it goes to our feeding pipe called the esophageal phase. And it really happens frequently throughout the day. We basically swallow on average up to 600 times a day. It really takes a second for us or so for the food to go through our mouth and reaching our throat. And from there, it takes another 10, 15 minutes to finalize the chewing and food finally reaching the stomach. So it's a quick, it really requires high order of coordination between the muscles and things can go wrong in any of those stages and we end up having symptoms. We have to be careful.

Dr. Scott Steele:

That's pretty amazing. 600 times a day. So now that we have a better understanding of what goes into that swallowing process, as I set off the lead, we're going to talk a little bit about dysphagia. So can you give our listeners a high-level overview about the swallowing disorder, dysphagia? What does it feel like for somebody who has it and how common is it?

Dr. Fady Asslo:

So dysphagia is basically it's a disorder of the swallowing process. It could happen in any of those phases. When it comes to gastroenterology, we mostly focus on the esophagus disorder, but really dysphagia can involve also oral neurological disorders. Sensation of food basically getting stuck, not going in the right direction where food sometimes can get stuck in the chest, upper or lower part of the chest. Also, sometimes dysphagia can be due to throat or oral disorder where people start to cough as soon as they start eating, because we're basically aspirating on food particles. We can have regurgitation, meaning food going in the wrong direction. Instead of going into a feeding pipe, it comes up through our nose. It can actually aspirate on food. It can goes in our airways.

So coughing, choking on food, sometimes emergency where it feels like food getting impacted, folks end up in the ER with food impactions sitting in their feeding pipe are required. So symptoms can be mild to severe. Symptoms can be acute. One incident happens and no warning symptoms before or after and symptoms can be progressive. So it's going to depend on the condition we're dealing with here.

Dr. Scott Steele:

So one of the things that we talk about is functional dysphasia as well as dysphagia. How are those two different? And do we know what causes functional dysphagia?

Dr. Fady Asslo:

Sure. I mean, function dysphagia is a little bit tricky. It requires further workup. Basically, it's a sensation of food getting stuck, not going from the mouth all the way to the stomach. But with negative workup, meaning you do the imaging, you do the endoscopy, you do evaluation and everything comes back within normal limit. But nonetheless, patient's still experiencing the symptoms. We have certain criteria called the Rome IV criteria we'll look at. And basically after we rule out other medical reasons, we can call it functional dysphagia.

Dr. Scott Steele:

What are the common symptoms associated with dysphagia? You mentioned a little bit of them, maybe a lump in the throat or maybe some pain, but overall, what is the definition of dysphagia?

Dr. Fady Asslo:

Dysphagia, basically it's impaired process where basically food causing a problem instead of being a source of nutrient, now all of a sudden it's a burden where it can cause discomfort, pain. Sometimes aspiration spreads a risk for infections in our lungs and sometimes emergency actually can cause complete shutdown of our feeding pipe and cause severe chest pain as well.

Dr. Scott Steele:

You mentioned in the past about maybe some different causes, but can you kind of dig into this a little further? And are there ways to reduce your risk in developing dysphasia?

Dr. Fady Asslo:

Yes, 100%. So commonly it's going to depend on where you look. If you look at a general population, common reason will be acid reflux disorder-related. Something with time acid reflux, if it's not under control, it will cause narrowing of the feeding pipe. Something called strictures, peptic strictures. And the best way to treat those is basically you want to treat that underlying acid reflux. So dietary and lifestyle changes, fasting two, three hours before bedtime, gradual weight loss, avoiding food that can trigger symptoms, taking certain medication that can suppress the acidity, the acid reflux for a short period of time. And also, there's also room for endoscopic procedures where we do endoscopy. We'll take a look and do a complete evaluation of the treating pipe and dilation of the system. We use a balloon or special dilators and bougies to help with those can open up esophagus.

Other reason for dysphagia, it's going to depend. Sometimes in the acute setting, folks who unfortunately have strokes, they may have impaired swallowing process and that can be anywhere between 30%, and some of the studies suggesting even higher percentage of folks admitted to the hospital with stroke, they can end up with dysphasia. A lot of them improve before discharge, so this also needs to be taken care of. Further work, it can be done with other reason for dysphagia. We have sometimes spasm disorders. We can talk about, we can have food allergy-driven dysphagia, certain conditions called eosinophilic subjects. So it depends on the age group, it depends on the setting. Normally for the most part, it's acid reflux-driven, but a lot of symptoms, a lot of conditions can also, we can talk about those can cause dysphagia as well.

Dr. Scott Steele:

So one of the things we like to do here on Butts & Guts is give our potential patients a walkthrough maybe what they may be experiencing when they perceive to have or do have different disorders. So how is dysphagia diagnosed and what tests are involved to confirm it isn't something else or just another swallowing disorder?

Dr. Fady Asslo:

Basically dysphagia, the patient will have subjective symptoms. So it's always complaint that the patient comes to see us work. Basically, it feels different when they feel like food taking its time to reach the stomach. There's some resistance. Also, many times food getting launched, it just causes pain and discomfort when it goes down. And you really have to ask the patient to clarify for how long those symptoms have been going on. What other symptoms associated with dysphagia? Is there any red flags? Red flags, these are concerning symptoms that may be more concerning conditions causing dysphagia, such as tumors, malignancies. So for instance, someone who has progressive symptoms when you used to have trouble swallowing solid food and now is able to tolerate less and less of food and eventually they're having hard time with the beverages as well and the water intake, let's call progressive dysphasia.

And if we look at other symptoms such as weight loss, family history, that's certainly concerning and need further workup here without further delay. Other patient may experience what we call intermittent dysphagia, meaning they have episodes where they experience food getting large, but in between they're doing fine. This could be due to a common and benign and narrowing in certain locations in the feeding pipe, commonly known as Schatzki ring, which has to do with the underlying hiatal hernias and acid reflux, and previously known as the steakhouse syndrome. People who eat steaks or any similar food like a dry chewy big bites without chewing well, they may end up with symptoms and that may require dilations.

Dr. Scott Steele:

So when should someone see a doctor about swallowing difficulties? And you mentioned some of the very red flag symptoms or warning signs, but are these ones that should not be ignored?

Dr. Fady Asslo:

Certainly the red flag should require urgent attention. For the most part, if folks experiencing dysphagia, they should always bring it up with the primary care doctor and some of them will require further evaluation. A lot of them, if the symptoms suggest of acid reflux disorder, you can certainly start with conservative measures with the acid reflux lifestyle, weight loss, fasting three hours before bedtime, taking certain medication. And if symptoms improve, it's always debatable whether they should go straight to endoscopy or not, especially if they had prior workup done in the past like previous endoscopy or previous X-rays were negative.

Younger folks who have underlying perhaps other allergic conditions such as asthma or skin eczema when they were younger, you start worrying about maybe it's a allergic condition, something called eosinophilic esophagitis that can cause dysphagia for sure, but also can cause chest pain, heartburn, acid reflux. So this will require also care. We have to go in, explore the esophagus with endoscopy and do biopsies, making sure it's not the case here.

Dr. Scott Steele:

So I know you talked about there's a lot of different potential underlying diagnoses here, but let's look at some of maybe the more common treatment options. Are there different treatment options out there to treat dysphagia, whether it be surgical or medical?

Dr. Fady Asslo:

Yes, it can vary. So the corner stone here is basically the treatment with the diet and lifestyle. Then we have the medication that focus on suppressing the acidity of the stomach and help controlling the acid reflux better. We have a certain medication we use for the spasm disorders. There's certain spasm disorders such as what we call jackhammer esophagus or diffuse esophageal spasm. We use certain medication to calm down the muscular layers in the feeding pipe such as calcium channel blocker. Also, we have Botox injection directly into the muscular layer of the feeding pipe for certain conditions, not for all conditions. Then from there, we can look into the traditional surgeries where they do surgery.

So again, there's certain spastic disorders, something called achalasia, we do a long cut in the muscular layer, something called myotomy, and the surgery called Heller's myotomy. This is for certain population or it's more concerning findings such as esophageal tumor, then we're looking into more invasive surgeries where they remove part of the feeding pipe and reconnect the stomach or the remnant of the stomach to the feeding pipe. Beyond that, you're looking into also dilations, different type of dilation. So I think it's really going to depend on what we're dealing with. Eventually, if it's what we call the oral or pharyngeal dysphagia, meaning it's not feeding pipe-related dysphasia, then the treatment is going to depend on the patient. If they're after acute stroke, they do speech therapy that helps strengthening some of those muscles to prevent or at least lower the risk of aspiration and slowly progress through the diet consistency from soft to eventually hopefully regular food, newer approaches, our main campus in the Cleveland Clinic, they're doing pharyngeal electrical stimulation where they help stimulate some of those pharyngeal muscles. There's some studies actually showing it helps improve the swallowing.

Eventually, for folks who are not improving, they cannot swallow safely, we have to look into supporting the nutritional needs here, but without putting the patient at risk for aspiration or at least minimizing the risk. So this is where a feeding tube option will be available here either directly in the stomach or in small bowel and other nutritional support that can come through the veins, something called TPN or PPN. This is not recommended on the long run. It comes with the pros and cons. We always recommend to use the GI tract first. As an alternative, we can use the circulation, but that's not recommended as a first line.

Dr. Scott Steele:

So are there any specific foods or drinks that are easier or harder to swallow? And what advice would you give to patients about eating safely?

Dr. Fady Asslo:

Well, in acute setting, if you feel like food is stuck in esophagus, all of a sudden you're not able to swallow, the most important thing here is to stop eating. Some folks, they insist on eating a couple more bites or drinking water perhaps to flush it down. Many times this will not work and actually make the situation worse. So give it sometime, stop eating. If the symptom's not resolving, obviously in the next 30 minutes, 60 minutes, I'll proceed to the ER for evaluation for food impaction. Now, this is the acute setting. Chronically speaking, you really have to make sure everything is done correctly. So if it's a matter of a chewing problem, make sure you take your time, you chew, take your time when you chew you're not in a hurry when you eat. Eating big bites that's drier in nature, not well chewed, will cause dysphagia. So make sure you're chewing well.

If you're missing some of the teeth, you probably should get that fixed. If using denture, make sure it's well-fed denture chewing well on food. And eventually, if we're not able to chew well, then this is where we have to really help our chewing process by eating softer food, but it's not going to become dry and cause lodging in a cleaning pipe. When it comes to pharyngeal phase, folks who have no underlying neurological disorders, for the most part, they're really not at risk for aspiration, but nonetheless, make sure you're not paying attention to chewing. So we can aspirate on food. For instance, we're basically trying to breathe deeply at the same time we're eating, so there's a risk here for aspiration. For the most part, take your time, be cautious about that when you eat, be sitting upright, have the gravity working for your own effect that helps to get the food down faster.

And then when it comes to esophagus, I think it's going to come down to what can I tolerate if you have hiatal hernias, large-size hiatal hernias, if you have strictures, narrowing in a feeding pipe, so make sure the food is softer in nature. Make sure you're chewing well. Make sure it's lubricated. We're drinking water on the side. It's moistened food. And get the underlying problem taken care of as well. So if you have underlying motility problems, you have strictures narrowing, large-size hiatal hernia, you probably should get those taken care of, repaired. Otherwise, you are at risk of acute emergencies, food impaction. Sometimes food impaction can cause severe damage to the lining of the feeding pipe and even more injury, complete injury to the lining, perforation perhaps.

Dr. Scott Steele:

You mentioned the pharyngeal muscular stimulation a little bit earlier, but is there any other new research technology treatment options that are on the horizon to deal with either other swallowing disorders or dysphagia?

Dr. Fady Asslo:

This is the new field now where we're trying to work more on the central swallowing because receptors. Our swallowed center is actually in the brainstem and this is where intensive speech therapy, physical therapy early on improve the recovery here and a lot of us sometimes we neglect, but it's very important to jump on it early on. It's a recovery process here. That's pharyngeal electrical stimulation is basically working on that field, basically trying to stimulate those muscles, send the signals back to the brain centers and activate that circuit. I think in the future we're still lacking a certain treatment for certain conditions, especially when the esophagus we have weaker contractions. For instance, people who have scleroderma, people who have a complete absence of muscular activity. I think this is where the challenge is because as we speak today, there's no available medication to help stimulate a muscular contraction of the esophagus. I think that's a field for us to look at. We're definitely lacking more options to offer the patient here.

Dr. Scott Steele:

So now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, what is your favorite sport?

Dr. Fady Asslo:

For me, definitely basketball and soccer.

Dr. Scott Steele:

What is your favorite dessert?

Dr. Fady Asslo:

That'll be the classic red velvet, cream cheese red velvet.

Dr. Scott Steele:

If you could get a superpower, what would that superpower be?

Dr. Fady Asslo:

Go back in time, for sure.

Dr. Scott Steele:

Speaking of going back in time, if you could go back in time and give yourself advice when you were just turning about the college age, what advice would you give yourself?

Dr. Fady Asslo:

I guess go back to the earlier endoscopic field, get involved in that. It's very interesting to look inside the body as a whole and explore the GI tract. That was definitely a field I'm interested in.

Dr. Scott Steele:

Fantastic. And so give us a final take-home message to our listeners regarding dysphagia.

Dr. Fady Asslo:

I think it is important to be aware of the red flags. You should be aware of and seek attention. You should be aware of the eating habits. A lot of us, we're not sitting properly. We're laying halfway back when we eat. We're not chewing well. Be aware of the lifestyle. It's important to prevent emergencies, aspiration. And I think talk to your doctor if you have underlying symptoms such as acid reflux before it progress into narrowing strictures and dysphagia. So you really want to go ahead of the problem, fix that problem, and prevent emergency in the future.

Dr. Scott Steele:

Fantastic advice. And so for more information in order to make an appointment in the Florida region, please visit clevelandclinicflorida.org/digestive. That's clevelandclinicflorida.org/digestive. And if you're closer to Ohio, please visit clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Asslo, thanks so much for joining us on Butts & Guts.

Dr. Fady Asslo:

Scott, thank you very much for having me.

Dr. Scott Steele:

That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.