Trouble swallowing can point to a number of possibilities
My 94-year-old father has been having trouble swallowing lately. He tries to expel any food by inducing himself to vomit, but it is very difficult. We looked up his esophagus symptoms, but there doesn’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.
DEAR DR. ROACH:
“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 (possibly above the esophagus, in the larynx or pharynx), or there are problems in the upper stomach that lead to the person noting problems with swallowing
ANSWER:
hile esophageal cancer is certainly a possibility, there are many others, including strictures, webs and rings. If your father would’ve 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 very extensive, and the muscular contraction needs to be well- coordinated in order for the esophagus to do its job properly. In older adults, the muscular contractions in the esophagus slow down, causing swallowing symptoms in many people.
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 a high suspicion for a neurological cause.
A recent column on an older woman getting a colonoscopy prompted many readers to ask about alternative colon- can
DR. ROACH WRITES:
cer 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, in order 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 obviously very easy to.do and aren’t quite as sensitive at finding polyps and cancer as a colonoscopy. But they are a very reasonable choice for someone who doesn’t really want to do a colonoscopy.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell. edu or send mail to 628 Virginia Dr., Orlando, FL 32803.