Dysphagia in patients with Chagas' disease and Zenker's diverticulum

Descrevemos dois pacientes, um do sexo feminino e outro do sexo masculino, ambos com 64 anos, que apresentavam a associação entre divertículo de Zenker e esofagopatia provocada por doença de Chagas. Um dos pacientes iniciou com disfagia esofágica há cinco anos, que depois se associou a disfagia orofaríngea há nove meses. O outro paciente tinha disfagia orofaríngea há oito meses. Ambos tinham antecedentes de doença de Chagas. Os dois pacientes tinham alterações do exame clínico da deglutição, ou seja, dificuldade de ingestão de líquidos e pastosos. A ingestão era lenta e havia resíduos em cavidade oral, sem tosse após a deglutição. O diagnóstico foi feito por exame sorológico e estudo radiológico de faringe e esôfago, complementados por exame endoscópico. Os resultados dos exames radiológicos de faringe e esôfago mostraram, em um paciente, o divertículo faringo-esofágico (Zenker), trânsito lento (duração superior a dez segundos) do meio de contraste pelo esôfago e, no outro, o divertículo de Zenker e trânsito pelo esôfago com duração normal (duração inferior a dez segundos) com presença de contrações terciárias. O tratamento foi realizado com diverticulectomia, miotomia do cricofaringeo e miotomia da transição gastroesofágica em um paciente e miotomia do cricofaríngeo no outro. Concluímos que é possível haver a associação de duas causas de disfagia no mesmo paciente, a orofaríngea, consequente a divertículo de Zenker, e a esofágica, consequente à doença de Chagas. O pleno conhecimento da relação causa-efeito destas duas condições necessita novos estudos.It is described the cases of two patients, one female and one male, both 64 years old, who had Zenker's diverticulum associated to chagasic esophagopathy. One of them had esophageal dysphagia for five years, later associated with oropharyngeal dysphagia (for nine months). The other patient had oropharyngeal dysphagia for eight months. Both had lived in endemic areas for Chagas' disease, and had positive serologic tests for the disease. In the clinical evaluation, both patients had slow ingestion of liquids and paste bolus, and residues in oral cavity, without coughing after deglutition. Diagnosis was made by serologic test and radiologic examination of pharynx and esophagus, as well as a careful endoscopic examination. Radiologic results showed, in one of the subjects, pharyngo-esophageal diverticulum (Zenker), and slow barium bolus transit (more than ten seconds to cross the esophageal body), and, in the other patient, Zenker's diverticulum and normal esophageal transit duration (less than ten seconds), with presence of tertiary contractions. Treatment consisted of diverticulectomy, cricopharyngeal myotomy, and cardiomyotomy of the lower esophageal sphincter for one patient, and cricopharyngeal myotomy for the other one. It is concluded that it is possible to have association of two causes of dysphagia in the same patient: the oropharyngeal, due to Zenker's diverticulum, and the esophageal, due to Chagas' disease. The knowledge of cause-effect relationship between these conditions needs further investigations

Clinical evaluation of swallowing in Chagas disease

OBJETIVO: Avaliar clinicamente a deglutição orofaríngea de pacientes portadores da doença de Chagas com disfagia e comparar os achados da anamnese entre os doentes chagásicos de acordo com o grau do megaesôfago. MÉTODOS: Utilizando protocolo de avaliação, estudamos a deglutição de 21 pacientes com doença de Chagas e comprometimento do esôfago diagnosticado por sorologia e exame radiológico do esôfago, e de 18 sujeitos sadios assintomáticos pareados por idade e gênero. Nos dois grupos foi realizada anamnese contendo questões relacionadas à queixa de disfagia. Após este procedimento, foi realizada avaliação clínica da deglutição, sem introdução de dieta via oral e com dieta via oral nas consistências líquida e pastosa, abrangendo aspectos estruturais e funcionais. Os resultados foram analisados estatisticamente. Este é um estudo experimental e transversal. RESULTADOS: Maior proporção de pacientes chagásicos apresentou deglutições múltiplas e elevação laríngea reduzida na deglutição das consistências líquida e pastosa, em relação aos sujeitos sadios. Os pacientes com aumento do diâmetro do esôfago referiram mais frequentemente queixa de perda de peso quando comparados aos pacientes sem aumento do diâmetro do esôfago. CONCLUSÃO: Os pacientes chagásicos podem apresentar alterações na deglutição orofaringeana e pacientes com maior comprometimento do esôfago apresentam maior perda de peso do que os pacientes com menor comprometimento.PURPOSE: To clinically evaluate oropharyngeal swallowing in dysphagic patients with Chagas disease, and to compare anamnesis data among chagasic subjects according to the degree of megaesophagus. METHODS: An evaluation protocol was used to assess the swallowing of 21 patients with Chagas disease and involvement of the esophagus, diagnosed through serology and radiologic evaluation of the esophagus, and 18 asymptomatic healthy subjects paired by age and gender. Both groups answered an anamnesis that addressed questions related to dysphagia complaint. After this procedure, it was carried out a clinical evaluation of swallowing, involving both structural and functional aspects, with and without the introduction of oral feeding with liquid and pasty consistencies. The results were statistically analyzed. This is an experimental and transversal study. RESULTS: A larger number of chagasic patients presented multiple swallows and reduced laryngeal elevation during deglutition of food with pasty and liquid consistencies, when compared to healthy subjects. Patients with increased esophageal diameter reported weight loss more frequently, when compared to patients with normal esophageal diameter. CONCLUSION: Chagasic patients might present oropharyngeal swallowing alterations, and patients with more significant esophageal involvement present more weight loss than patients with less esophageal involvement

The relationship between the oral and pharyngeal phases of swallowing

OBJECTIVE: This study was designed to investigate a possible relationship between the duration of the oral and pharyngeal phases of swallowing. INTRODUCTION: The oral and pharyngeal phases of swallowing are independent from each other but may be related. METHODS: We used videofluoroscopy to evaluate 30 healthy volunteers between 29 and 77 years of age who swallowed 5- and 10-ml liquid and paste boluses in duplicate. The duration of the oral phase, pharyngeal transit, and pharyngeal clearance were measured. RESULTS: There were no differences in oral or pharyngeal transit times between the liquid and paste boluses or between the volumes of 5 and 10 ml (p>0.40). The pharyngeal clearance time for the paste bolus (0.48 ± 0.27 s) was longer than for the liquid bolus (0.38 ± 0.11 s, p = 0.03) with no difference between the volumes of 5 and 10 ml. There was no significant correlation between the oral transit time and the duration of pharyngeal transit for the liquid (5 ml, Spearman's coefficient p: -0.14; 10 ml, p: 0.18) or the paste (5 ml, p: 0.08; 10 ml, p: 0.10). The correlation between the oral transit time and the pharyngeal clearance time was not significant for the liquid bolus (5 ml, p: 0.31; 10 ml, p: 0.18), but it was significant for both the 5 ml (p: 0.71) and 10 ml (p: 0.64) paste boluses. DISCUSSION: The relationship between the oral and pharyngeal phases of swallowing can be affected by bolus consistency. CONCLUSION: There is a correlation between the duration of oral transit and the duration of pharyngeal clearance during the swallowing of paste boluses

Prevalence of non-obstructive dysphagia in patients with heartburn and regurgitation

OBJECTIVE: Heartburn and regurgitation are the most common gastroesophageal reflux symptoms, and dysphagia could be a possible symptom. This investigation aimed to evaluate the prevalence of non-obstructive dysphagia in patients with heartburn and regurgitation. METHODS: A total of 147 patients (age, 20-70 years; women, 72%) complaining of heartburn and regurgitation, without esophageal stricture, previous esophageal surgery, or other diseases, were evaluated. Twenty-seven patients had esophagitis. The Eating Assessment Tool (EAT-10) was employed to screen for dysphagia; EAT-10 is composed of 10 items, and the patients rate each item from 0 to 4 (0, no problems; 4, most severe symptom). Results of the 147 patients were compared with those of 417 healthy volunteers (women, 62%; control group) aged 20-68 years. RESULTS: In the control group, only two (0.5%) had an EAT-10 score X5, which was chosen as the threshold to define dysphagia. EAT-10 scores X5 were found in 71 (48.3%) patients and in 55% of the patients with esophagitis and 47% of the patients without esophagitis. This finding indicates a relatively higher prevalence of perceived dysphagia in patients with heartburn and regurgitation and in patients with esophagitis. We also found a positive correlation between EAT-10 scores and the severity of gastroesophageal reflux symptoms based on the Velanovich scale. CONCLUSION: In patients with heartburn and regurgitation symptoms, the prevalence of dysphagia was at least 48%, and has a positive correlation with the overall symptoms of gastroesophageal reflux

Gender Effect on Oral Volume Capacity

Studies have shown anatomical and functional differences between men and women with respect to the mouth, pharynx, upper esophageal sphincter, and esophagus. The aim of this investigation was to analyze the influence of gender, body mass index (BMI), age, and orofacial anthropometric measurements on the intraoral maximum volume capacity for liquid. The investigation included asymptomatic subjects, 56 females and 44 males, aged 19-53 years. The volunteers sucked water through a straw up to the maximum tolerated oral volume, which was greater in men (71.2 +/- A 15.0 ml) than in women (55.4 +/- A 13.4 ml). Age, BMI, height, and number of teeth had no influence on the intraoral tolerated volume. Anthropometric orofacial measurements were greater in men than in women. In individuals with height between 1.66 and 1.89 m, anthropometric orofacial measurements were greater in men than in women, and the tolerated intraoral volume was greater in men than in women. There was a positive correlation between orofacial measurements and intraoral maximum volume. In conclusion, men have the capacity to place a larger volume of water inside their mouth than women. This observation is associated with higher anthropometric orofacial measures, but not with age, number of teeth, height, or BMI

VIDEOFLUOROSCOPIC EVALUATION OF SWALLOWS IN ANOREXIA NERVOSA

ABSTRACT Background There are some studies in the literature about the feeding behavior and masticatory process in patients with feeding disorders; however, it is not very well known if there are alterations in oral-pharyngeal swallowing dynamics in subjects with anorexia nervosa. Objective To evaluate the oral and pharyngeal bolus transit in patients with anorexia nervosa. Methods The study was conducted with 8 individuals clinically diagnosed and in treatment for restricting-type anorexia nervosa (seven women and one man), and 14 healthy individuals with no digestive or neurological symptoms (10 women, 4 men). Swallows were evaluated by videofluoroscopy with three swallows of 5 mL liquid bolus and three swallows of 5 mL paste bolus consistency, given in a random sequence. The participants were asked after each swallow about the sensation of the bolus passage. Results In the analysis of oral-pharyngeal transit duration, the mean duration of pharyngeal transit with paste bolus in patients with anorexia was shorter than in healthy volunteers (P=0.02). In the duration of movement of the hyoid bone, longer movement was observed in anorexia than in healthy volunteers with liquid bolus (P=0.01). With liquid bolus, five (62.5%) patients and one (7.1%) control had sensation of the bolus passage (P<0.05). Conclusion There seems to be no important alterations of swallowing in subjects with anorexia nervosa, although the results suggest that pharyngeal transit has shorter duration than that seen in healthy volunteers and the hyoid movement duration is longer in patients than in healthy volunteers. Fast pharyngeal transit may be the cause of bolus transit perception in patients with anorexia nervosa