Approach to Dysphagia With Dr. Claire Beveridge

Podcast Transcript

Dr. Brateanu: 

Welcome to the Medicine Grand Rounders Podcast, a platform dedicated to exploring key topics in internal medicine. Highly relevant to the medical community. This podcast is made possible through the generous support of a grant from the Cleveland Clinic Education Institute. However, the views and opinions expressed here are those of the speakers and do not necessarily reflect the official position of the Cleveland Clinic. Each episode brings together world class experts and distinguished physicians from Cleveland Clinic to share their knowledge, experience and perspectives on issues that impact healthcare professionals and patient care. Our discussions aim to promote learning, advance professional development and inspire meaningful conversations with the medical community. Today's episode is hosted by Dr. Nitu Kataria, Internal Medicine Physician at the Cleveland Clinic, and me, Dr. Andrei Brateanu also in Internal Medicine. We invite you to join us as we delve into today's thought-provoking topic.

Hussam Kawas:

Hello, my name is Hussam Kawas. I'm one of the internal medicine residents at the Cleveland Clinic, and our topic today is dysphagia for the internist. I have the pleasure of introducing our clinical expert today, Dr. Claire Beveridge, who is an esophageal specialist here and leads the eosinophilic esophagitis (EoE) clinic. Hello, Dr. Beveridge.

Dr. Beveridge:

Hi, thank you so much for having me!

Hussam Kawas:

Thank you for being here. 

So, to start off, you know, dysphagia is something that internists encounter frequently, both in the clinic and in the hospital. Before we dive into a case, could you define dysphagia for us and explain why it's such an important symptom for internists to recognize?

Dr. Beveridge:

Absolutely. So dysphagia is an issue with swallowing, and how I describe it to patients is when you swallow food or liquid, it's something that gets stuck or slowly moves down, and it can definitely be an issue for patients in terms of quality of life, can sometimes lead to food impactions, having to go to the emergency department, rare cases of perforations related to it, or aspiration.

Hussam Kawas:

Thank you, and to help frame our discussion, let's walk through a fictional case. So, we have a 28-year-old man presenting to the clinic with intermittent difficulty swallowing solid foods for about one year. He describes the sensation of food getting stuck in his chest, particularly when eating meats and bread. On two occasions, he's had to drink large amounts of water to help food pass, and once he nearly went to the emergency department for a food impaction. He denies difficulty initiating his swallow and has no coughing or choking with meals. Liquids go without difficulty. He has no weight loss. Past medical history is notable for asthma and seasonal allergies. He has been treated intermittently with proton pump inhibitors for presumed GERD with minimal improvements. He has never had a upper endoscopy. So, Dr. Beveridge, as a specialist seeing this case, how are you thinking about this presentation?

Dr. Beveridge:

It's a really great question. So, when I hear that it's more of an issue with solid foods going down, I'm thinking more about a structural issue with the esophagus. If there is more of an issue with liquids going down, you would think more motility. And you were also saying that there was no issue with initiation of the swallow or coughing. So therefore, I don't think it's so much oropharyngeal where there could be concern for aspiration, but more of esophageal dysphagia since it's being felt more in the chest. In terms of the things that it could be, I mean, common things being common, you can always think about acid reflux being part of the cause. But there are a lot of buzzwords here that you're using in terms of it being a young patient who has other atopic conditions, kind of the classic foods of steak and bread, potentially needing to go to the emergency department. And so all of that is kind of hinting towards eosinophilic esophagitis for me.

Hussam Kawas:

And at this point, what would be the appropriate next diagnostic step?

Dr. Beveridge:

Yeah, really good question. Personally, what I would do is an upper endoscopy, and I would want to do it off of any sort of medication, so no proton pump inhibitors or anything like that, because if you initiate any of those medications, it could partially treat the underlying condition, and then you kind of lose that diagnostic ability of the endoscopy. So I would want to do upper endoscopy, where I take a careful look at the esophagus, look for the classic endoscopic findings that we see with eosinophilic esophagitis. Those are called the ERAFs, which stands for edema, rings, exudates, furrows, and stricture, and I would take a lot of biopsies. It's a patchy condition for eosinophilic esophagitis, so you do have to make sure that you take a lot of biopsies throughout the esophagus, and I would also take a careful look for any signs of acid reflux. So any esophagitis at the end of the esophagus, the GE junction, and of note, you can have both. You can have eosinophilic esophagitis and acid reflux, or you could have one or the other. A lot of patients who have acid reflux though won't have esophagitis, so if you don't see the esophagitis, it doesn't mean that they don't have it, but if you see it, it is very helpful and can be diagnostic for it.

Hussam Kawas:

That's very helpful. Thank you. I think one thing we typically struggle with is that question about keeping the proton pump inhibitors on or, you know, taking them off. GI are usually pretty helpful about answering these questions. But I think in this case, it's very, you know, nicely how you touched upon it and how it's actually one of the treatments for eosinophilic esophagitis.

Dr. Beveridge:

Exactly. And then one other thing that I'll add is, you know, a lot of people will be asking, you know, should I get an esophagram done or anything like that? And esophagram is not a wrong answer and would be totally fine to get in addition but wouldn't prevent me from getting an upper endoscopy. It can sometimes give us a roadmap in terms of what's happening. And if someone is having particularly like a lot of difficulty with their swallowing, sometimes it can help tell us how narrowed things may be. And that can help us know, you know, can I just do a normal stretching dilation if there's a narrowing or do I need a potentially use fluoroscopic guided dilation? Personally, if I were to see this patient clinic, I would just start with the upper endoscopy, but not wrong to get an esophagram in addition.

Hussam Kawas:

And once the diagnosis is confirmed, what are the main treatment options that you typically use for patients with eosinophilic esophagitis?

Dr. Beveridge: 

Absolutely. This is very much a shared decision-making with the patient. There's no one right answer. I joke with my patients that the only wrong answer is to do nothing. So, in terms of treatment options, I tell them that I think about it in two buckets. We have the diet elimination approach and the medication approach. It's an allergic condition of the esophagus that can be triggered by either food or environmental allergens. And so, if we take away the six major food triggers for EOE, then sometimes we can get patients under control for their EOE. So those would be dairy, wheat, seafood and shellfish, tree nuts and peanuts, soy and eggs. Now that only works about 80% of the time for patients because they may have an environmental trigger instead, or they could have both. And if you have both, no amount of diet elimination is going to control the environmental trigger. If things are controlled, then you can start reintroducing food groups one to two food group at a time every four to six weeks with repeated biopsies. And if the biopsies show that the eosinophils are still controlled, great. That is not a trigger.   But if it shows a spike in the eosinophils, then you know, okay, that is a food trigger for you. Most patients have one to three food triggers. The two most common are dairy and wheat. Now it is a very intense diet to do in terms of how restrictive it can be for a patient and how many endoscopies are required. So, it is not for everyone. I know personally, if I were to have EOE, I would not pick the diet elimination approach. And I tell that to patients, but a lot of patients really want to do it, which is great. And then I think getting a dietician involved is very helpful. There's a dietician here who I work very closely with, and he's the one and only who I send to in terms of my elimination diet patients. And then I kind of schedule them for serial upper endoscopies with biopsies. So that's the diet elimination approach.

Then there's the medication approach, right? Typically start with proton pump inhibitors first. It works about 50% of the time. We are not using it because of acid reflux, which is what it's most commonly used for. We're using it because it can directly act upon Eotaxin-3, which is part of the inflammatory pathway for EOE. There's a theoretical benefit that if we control the reflux, that we are helping protect the epithelial barrier better to not allow for those environmental or food triggers to get through the tight junction. But that's more of a theory. That's typically my first line. And then after that, I discuss with them either doing a swallowed steroid, which is a topical corticosteroid. We do have a new FDA approved medication for that now, but we can also jerry rig our asthma medications, which is what we had been doing for years and years. And then that works about 70% of the time with an increased risk of having oral or esophageal candida. So, you kind of have to counsel them on how to take it similarly to how you would counsel your patients with asthma or COPD with their steroid inhalers.

And then there's Dupilumab, also called ‘Dupixent’, which is a once-a-week biologic agent that they would give themselves at home. Some insurance companies cover it if they fail the PPI. Some insurance companies require that they also try the steroid first.

Hussam Kawas:

Thank you. That's very comprehensive and helpful. Now, circling back to our topic of dysphagia, you touched upon esophageal and oropharyngeal dysphagia already. I think it would be helpful if you could go over some of the most common causes that you see in each bucket and how you'd like to think about it.

Dr. Beveridge:

So, for oropharyngeal dysphagia, there can be a few different things for that. Could be vocal cord dysfunction, could be mass, could be aspiration, could be a neuromuscular issue. Kind of what can span both oropharyngeal to like esophageal a little bit will be the cricopharyngeal bar. You can kind of get both of those symptoms. The one to not miss for oropharyngeal dysphagia is lack of dentition. You may or may not be surprised at the number of consults I've gotten where once I talk with them, I realize that they are just not using their dentures when they eat and that is the reason for them having oropharyngeal dysphagia.

In terms of esophageal dysphagia, we have kind of structural, motility, inflammatory issues to think about. So, for structural, again, kind of that cricopharyngeal bar, you could have rings, webs, strictures. For inflammation, it could be eosinophilic esophagitis, lymphocytic esophagitis, a caustic injection, pill-induced esophagitis, viral esophagitis. GERD in and of itself can cause some inflammation and difficulty with swallowing. And then if you add on a peptic stricture to that, it'll definitely cause dysphagia. And then you have the motility issues. The biggest ones to think about would be achalasia, EGJ outflow obstruction. Some of the other ones can, hyper contractile esophagus can also cause some issues with swallowing.

Hussam Kawas:

And how do you like to think about the workup of both these buckets and how they differ?

Dr. Beveridge:

So, if I am worried about achalasia and kind of the things to think about with that would be difficulty with swallowing, regurgitation can sometimes sound like acid reflux, but that's not what's happening. Food and liquid is getting stuck at the distal esophagus and then they're just regurgitating it back up, chest discomfort with eating and weight loss. So, for that, I do like to get the esophagram because it's very helpful to know how widened the esophagus may be. If it's tortuous, are things draining okay or not? It helps give a lot more information in terms of surgical planning, but I would still do an upper endoscopy, and you do need to rule out malignancy as a cause, which would then be called pseudo-achalasia. If I'm thinking more EOE or GERD, I don't necessarily need the esophagram done. If there's any oropharyngeal components, then I definitely want to get that modified barium swallow done.

Hussam Kawas:

It's very helpful to think about. I think one thing that we see when we talk about oropharyngeal dysphagia is the involvement of SLP or the speech-language pathologists. Can we go over maybe how you think about the management of oropharyngeal dysphagia and the involvement of SLP in this process?

Dr. Beveridge:

Speech language pathology is very helpful when it comes to oropharyngeal dysphagia. I also often get our ear, nose and throat doctors involved because they manage more the oropharyngeal part as opposed to gastroenterology. And a lot of it depends on what they see, right? I mean, if there's something where they feel like speech therapy will be useful and kind of help with the risks for aspiration, then speech language pathology definitely has an amazing role. If it seems like it's more vocal cord paralysis or anything like that, then really making sure your ear, nose and throat doctors are involved because sometimes they can do, you know, injections or other modalities to kind of help decrease the risk of aspiration.

Hussam Kawas:

Something I'm pretty sure you've seen in your practice is the empiric use of proton pump inhibitors for dysphagia. I wanted to get your thoughts about that.

Dr. Beveridge:

So, I personally do not like to do an empiric trial of PPI for dysphagia because when we hear dysphagia, not very common, but you always worry about could there be a malignancy going on? If it is acid reflux, then you want to know is there any esophagitis there? Is there any Barrett’s there? Because that does help risk stratify what happens to that patient in the future. So, any sort of dysphagia, they need an endoscopy and not just a PPI trial. If they're having more just kind of classic reflux symptoms without dysphagia, then that's the role of a PPI trial.

Hussam Kawas:

You know, as we start to wrap up, what are the key red flags that internists should recognize as indications for an urgent referral to GI?

Dr. Beveridge:

You know, weight loss is definitely concerning in terms of malignancy or achalasia, so that would definitely be an urgent referral. New onset acid reflux, I would want to see that patient, it wouldn't be as urgent. Any kind of concerns for aspiration also, those would be the main ones that I would think about. I mean, really, I love seeing all dysphagia patients, and I would like to see them regardless. Or, you know, another urgent thing would be, you know, food impactions that are happening. We would want to see those patients sooner rather than later. But I think in general, there's definitely a role for gastroenterology when it comes to dysphagia in terms of figuring out, you know, the timing of the upper endoscopy, if they also need any of the esophagram, modified barium swallows done. I'm always happy to see them.

Hussam Kawas:

Oh, we're lucky to have you, Dr. Beveridge. Before we wrap up, can you leave us with maybe three key takeaway points for any internal medicine physician listening to this regarding dysphagia as a whole?

Dr. Beveridge:

Regarding dysphagia as a whole, definitely want to do an upper endoscopy as that's one of the most important diagnostic tools that we have. When there is weight loss, regurgitation, really want to know if it's more, you know, achalasia, malignancies, pseudo-achalasia, and then kind of thinking about the difference between oropharyngeal dysphagia and esophageal dysphagia because who they would see in clinic and the workup of that is very different. 

And I think I'm beyond three at this point, but I think also how you talk with your patients about it is really important. So, when you ask them about difficulties with swallowing, I don't just say, do you have issues with swallowing? I mean, I'll start the conversation that way, but I like to clarify with them because some patients will not fully understand what that means where, you know, I had a patient literally just today who was clearly describing dysphagia related to their achalasia, but they said that their swallowing was fine, but when you probe more, you're like, yeah, you know, food was getting stuck in my chest and I had to regurgitate it back up. So, kind of describing to them what it means and having them go through the phases of swallowing. So, I do it very simply. I say: you put food in your mouth, any issues with chewing, any issues with getting it to the back of the mouth, any issues with that first initiation of the swallow, any issues with it going down your esophagus. Especially for the EOE patients where this has been likely happening for a very long time, they compensate really well for it. So, they don't even know what normal swallowing is. So, you have to ask, do you feel like you have to chew really carefully? Are you always the last one at the table? Do you always need something to drink when you chew, like eat your food and chew your food? Because if you just asked, do you have any issues with swallowing? they'll say no. But then when you ask these very specific questions, they'll be like, oh yeah, that's not normal. Or like issues with pills, but not food can be another kind of clue that maybe there's EOE or a cricopharyngeal bar going on. So, kind of delving into the details a little bit more.

Hussam Kawas: 

Those are excellent points. On behalf of the Medicine Grand Rounders team, I'd like to thank our guests, Dr. Claire Beveridge, for joining us today and sharing her expertise on dysphagia. This was a great discussion, and I think our listeners will come away with a clear and practical framework for approaching dysphagia in internal medicine.

Thank you, Dr. Beveridge!

Dr. Beveridge:

Thank you so much!

Dr. Kataria: 

To our listeners, thank you for joining us on this deep dive into this important topic. We hope you found this episode both educational and engaging. On behalf of the team, thank you to our special guests who joined us today. Thank you also to the Cleveland Clinic Education Institute for the educational support of this project. Until next time, please enjoy this and future podcasts from the Cleveland Clinic Medicine Grand Rounders.