Why am I struggling to swallow solid food?
Q ABOUT four years ago, I noticed I couldn’t swallow pills very easily. Then one day I ate some chicken and my throat seemed to be so blocked I couldn’t even swallow water. I now have to avoid anything which cannot be chewed to the consistency of mashed potato — my diet is almost totally liquid smoothies.
Tests have revealed nothing. One doctor said it might be bad posture. Another that my circulation system might be putting pressure on my oesophagus. The problem is slowly progressing. How will this develop in the future? I am 80. David Curry, Bacup, Lancashire. A It Is reassuring that the investigations you have undergone have excluded a sinister cause such as a tumour obstructing the oesophagus, but it is still a significant problem, given the increasing restrictions on what you can swallow.
Difficulty swallowing is called dysphagia. there are several types, including oral dysphagia, which affects the mouth. What you describe is oesophageal dysphagia, when there is a sense of food having got stuck for a moment or two after swallowing when it reaches the oesophagus, or gullet.
typically this is investigated with a barium swallow, which involves drinking a suspension of barium sulphate while X-rays are taken. Barium is a metal so shows up on the image, helping outline the passage from the throat to the stomach.
An endoscopy, when a small camera is passed down the oesophagus allowing a visual inspection, will also have been carried out to exclude any potential obstruction not revealed by the X-rays.
these tests will have ruled out the possibility that the problem is a stricture (a narrowing of the oesophagus) which may be related to acid reflux, for instance.
Acid reflux can scar the oesophagus, and this scar tissue tends to contract, leading to narrowing. this is more common in older patients.
the tests will have also ruled out an oesophageal web, a fold of the lining of the oesophagus linked to iron deficiency; although the exact mechanism remains unexplained.
that means we must consider whether a structure outside of the oesophagus is exerting pressure and causing these symptoms.
this could be the result of an abnormality in blood vessels, for instance, such as the subclavian artery in the neck, which may cause symptoms in later years most probably as the tissues, especially the arteries, become more rigid with ageing.
Or it could be an enlarged left atrium (one of the upper chambers of the heart) which again may put pressure on the oesophagus.
It has also been suggested that your posture might be related. If this is the case then you would also notice a change in your posture. this could be linked to cervical osteoarthritis (arthritis in the neck), which can trigger the formation of new bone — known as cervical osteophytes — as part of the body’s repair mechanism. the osteophytes can cause dysphagia by pushing the upper part of the oesophagus forwards.
Finally, it is important to consider achalasia, a rare disorder affecting the muscular contraction that moves food along the oesophagus to the stomach.
With achalasia, the sphincter (or valve) at the bottom of the oesophagus also stops relaxing when the patient swallows. this tends to progressively impair the swallowing of both solids and liquids — so not exactly the symptom you describe.
I’d suggest the next step is a Ct scan of your chest to reveal the state of your cervical spine and which may also identify any abnormality of your blood vessels. My advice would be to discuss this with your GP.
Q SIX years ago I had a heart attack and a pacemaker was fitted. Then four years ago I had a blood clot in my right lung and so take warfarin every day. I’ve been told I could be considered for a new drug known as PCSK9, given by self-injection, as I have very high cholesterol (with a reading of 9.1).
Over the past 15 years I have tried many statins but ended up with bad joints and muscle aches; they also interfered with my liver function. I’ve been told that my
high cholesterol was probably hereditary. Do you think I should give PCSK9 a try? Yvonne Steele, Bournemouth. A YOU have had quite a dramatic time: a heart attack, a blood clot and familial hypercholesterolaemia, a heriditary form of high cholesterol.
studies have confirmed that ‘bad’ or low density lipoprotein (LDL) cholesterol plays a key role in the furring up of the arteries not only in the heart but also in the brain and in the legs.
so reducing your elevated cholesterol level must be a priority. A number of LDL-lowering drugs, including statins, ezetimibe, and PCsK9 inhibitors have been proven to reduce future cardiovascular events such as heart attacks.
the injection you have been offered — which contains the drug alirocumab — works by inhibiting an enzyme called PCsK9 (proprotein convertase subtilisin kexin 9), found in the liver, which raises LDL cholesterol levels.
Alirocumab has been found to reduce LDL by over 50 per cent.
the drug is well-tolerated: trials have evaluated it for some years and serious adverse effects are uncommon. In particular, the muscle problems you experienced with statins do not occur. Nor (in contrast to the statins) is there a threat to your liver.
Finally, I have not detected any conflict between this and the warfarin that you need for the prevention of any future blood clots.
Given your risk factors, I think a PCsK9 inhibitor gives you the best chance of reducing your risk or further illness, so I’d go ahead and take it.