Having trouble swallowing points to several possibilities

Dear Dr. Roach: My 94-year-old father has trouble swallowing. He tries to expel any food by inducing himself to vomit, but it is difficult. We looked up his symptoms, but there don’t seem to be many causes. He does have chronic lymphocytic leukemia (CLL); would this point to cancer or a blockage? Would a sonogram show the problem?

M.M.V. “Trouble swallowing” can range from a large number of possibilities. The largest categories of possibilities are mechanical obstruction and neurological dysfunction.

Mechanical obstruction means that there is something blocking the esophagus, or there are problems in the upper stomach.

While esophageal cancer is a possibility, there are many others, including strictures, webs and rings. If your father had radiation as part of the treatment against his CLL, this would point toward a stricture. In people with a mechanical blockage, swallowing problems usually occur only with solid foods and get worse over time.

The nerve supply to the esophagus is extensive, and the muscular contraction needs to be well-coordinated in order for the esophagus to do its job. In older adults, the muscular contractions in the esophagus slow down, often causing swallowing symptoms.

However, it’s worth considering more serious problems, such as achalasia — a neurological disease of the esophagus. It’s unusual for a person to be diagnosed with achalasia in their 90s; however, it has been reported. Neurological-based swallowing problems tend to be worse with liquids.

A sonogram usually isn’t the first diagnostic test. A look inside the esophagus with an endoscopy is commonly the first test, but a barium swallow can also be done to identify a cause behind a mechanical blockage. When there aren’t any blockages, a manometry test is done when there is suspicion for a neurological cause.

Dr. Roach Writes: A recent column on an older woman getting a colonoscopy prompted many readers to ask about alternative colon-cancer screening tests, such as CT colonography (“virtual colonoscopy”); fecal immunochemical testing (FIT); and multi-target DNA testing (such as Cologuard). Any of these are reasonable options; however, a positive test will require an urgent colonoscopy, and possibly a biopsy, to confirm the diagnosis.

I have had many patients do a CT colonography, but most weren’t happy with the preparation, which is the same as a colonoscopy, and the discomfort associated with the test. (Carbon dioxide gas is used to inflate the colon, just as it is in a colonoscopy, but in a CT colonography, the patient is not sedated.) However, the test is great at identifying cancer and precancerous polyps; although 12% of the time, the CT colonography will say that there is a problem when there isn’t one.

The stool-based tests look for cancer DNA and/or blood. They are easy to do and aren’t as sensitive at finding polyps and cancer as a colonoscopy. But they are a reasonable choice for someone who doesn’t want to do a colonoscopy.

Email questions to ToYourGood Health@med.cornell.edu