Dysphagia (Difficulty Swallowing)

What Is Dysphagia?

[dropcap]D[/dropcap]ysphagia is a functional upper digestive disorder characterized by difficulty in swallowing or food getting stuck and swallowing that takes longer than 10 seconds to complete.

Q: What determines the symptoms?

A: Symptoms depend on the location of the affected area of the esophagus. Problems with the upper esophagus are most readily described by the sufferer as causing difficulty swallowing. Problems with the lower esophagus tend to be described as food getting stuck on the way down.

Dysphagia is a major symptom of disorders that interfere with transport of swallowed food and liquids through the esophagus.

Dysphagia is the most common symptom of esophageal cancer, gastroesophageal reflux disease (GERD) and Plummer-Vinson syndrome.

• Discomfort from GERD is accompanied by heartburn from normally acidic gastric contents entering the normally alkaline esophagus.
• Discomfort from Plummer-Vinson syndrome is not painful.
• Discomfort from cancer progresses to very painful.

What Is Dysphagia In Celiac Disease and/or Gluten Sensitivity?

• Dysphagia is an atypical symptom of celiac disease.
• Esophageal motor abnormalities, which are atypical symptoms of celiac disease, cause slow or uncoordination propulsion of swallowed food and/or liquids that cause dysphagia.
• Motility problems often vary in discomfort and can be relieved in part by straightening the back or sitting with chest pulled up. However, these postures do not benefit if the problem is mechanical such as mucosal webs caused by iron deficiency in Plummer-Vinson syndrome, a tumor, or a stricture.
• Magnesium deficiency impairs peristalsis of the esophagus.

How Prevalent Is Dysphagia In Celiac Disease and/or Gluten Sensitivity?

Dysphagia is common in untreated patients with celiac disease.¹

Plummer-Vinson syndrome in celiac disease is a cause of dysphagia. A prospective study investigating the association of cervical esophageal web causing dysphagia with celiac disease found 23.8% patients with cervical esophageal web fulfilled criteria for diagnosis of celiac disease. All five had evidence of iron deficiency. Patients with celiac disease were advised of a gluten-free diet. All five celiac disease patients were free of dysphagia without recurrence after a mean follow up of 10 months (range: 3 to 16 months).²

What Are The Symptoms Of Dysphagia In Celiac Disease and/or Gluten Sensitivity?

Dysphagia is marked by these symptoms:

• Difficulty or inability to swallow.
• Gagging upon swallowing.
• Coughing at night.
• Chest pain over area of esophagus that is affected.
• Protein and calorie malnutrition develops.

How Does Dysphagia In Celiac Disease and/or Gluten Sensitivity Develop?

• Dysphagia results from the effects of gluten and malabsorption causing magnesium deficiency which impairs coordinated motility (movement).
• Other causes in celiac disease include GERD and mucosal web formation stemming from iron deficiency (Plummer-Vinson syndrome).
• Candida albicans is a cause of dysphagia. This organism takes advantage of unhealthy mucosal tissues. It is unique among oral pathogens in its ability to invade cornified layers of stratified squamous epithelium of the esophagus, as well as, the mouth, tongue, and gut. Stratified squamous epithelium is the tough surface cells that ordinarily protect underlying tissues from damage or invasion by microbes.
• Dysphagia also results from esophageal cancer, a complication of celiac disease.
• Glycogenic acanthosis is a possible cause of dysphagia if the plaques are large and/or cluster together. Normally, the plaques are spread apart.

Does Dysphagia Respond To Gluten-Free Diet?

Yes. Gluten free diet significantly decreases the rate of celiac disease-related dysphagia.³

6 Steps To Improve Dysphagia Caused By Celiac Disease:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both dysphagia and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁴
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁵
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁵
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁵.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁵
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁵
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁶[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, phytochemicals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources include tuna, salmon, cod, and others. Plant sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 for examples such as ginger.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely: 

[box type=”shadow” ]Certain prescription drugs deplete magnesium and iron which are causes of dysphagia. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

FEMALE HORMONES  disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Magnesium.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Magnesium.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
• Loop Diuretics (Lasix®, Bumex,®) deplete Magnesium.

ANTIVIRAL AGENTS

• Foscanet depletes Magnesium.

ANTIBIOTICS  disrupt intestinal permeability.

• Tetracyclines deplete Magnesium.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Iron.

ANTI-INFLAMMATORIES  disrupt intestinal permeability.

• Aspirin and Salicylates deplete Iron.
• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Magnesium.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Iron, Magnesium.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Iron, Magnesium.
• Alka Seltzer®, Baking Soda deplete Magnesium.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multi-vitamin/mineral supplement once a day giving 100% (not thousands).
• Ferrous fumarate as prescribed by doctor based on blood studies to determine iron needs. Do not take with other supplements because of interactions.
• Chelated magnesium to obtain 100% or as prescribed by your doctor.

Always check with your doctor when taking supplements to avoid interactions with medications.

Storage Note for Supplements: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet  – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies:

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives are plant sources that tone muscle and improve peristalsis, and thus aid in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort. Puree any foods that cannot be thoroughly chewed. Cook meats well or make them into soups and stews for ease of digestion.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets stimulate and improve digestion and are easily digested.
• Cabbage stimulates and improves digestion and is also a liver decongestant.
• Lettuce stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa. Drink as tea or use in cooking.
• Chamomile (as a tea) also promotes healing and help relieve nervous tension. Drink as a tea.
• Parsley relieves colic, gas and indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is a soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Dysphagia In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet.” This study investigating gastrointestinal esophageal reflux disease (GERD) symptoms in 133 adult celiac patients at diagnosis and 70 healthy controls found that GERD symptoms are common in classically symptomatic untreated celiac disease (CD) patients. The gluten free diet (GFD) is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population.

Fifty-three patients completed questionnaires every 3 months during the first year and more than 4 years after diagnosis. GERD symptoms were evaluated using a subdimension of the Gastrointestinal Symptoms Rating Scale for heartburn and regurgitation domains.

RESULTS: At diagnosis, celiac patients had a significantly higher reflux symptom mean score than healthy controls. At baseline, 30.1% of celiac patients had moderate to severe GERD (score >3) compared with 5.7% of controls. Moderate to severe symptoms were significantly associated with the classical clinical presentation of celiac disease (35.0%) compared with atypical/silent cases (15.2%). A rapid improvement was evidenced at 3 months after initial treatment with a GFD with reflux scores comparable to healthy controls from this time point onward.⁷

“Cervical esophageal web and celiac disease.” This prospective study investigating the association of cervical esophageal web with celiac disease found that there is association between cervical esophageal web and celiac disease. All adult patients with cervical esophageal web and iron deficiency need screening for celiac disease even in the absence of chronic diarrhea.

Subjects included were consecutive patients with symptomatic cervical esophageal web diagnosed over a period of 4.5 years. Tissue transglutaminase antibody was measured in serum of each patient. Patients with elevated tissue transglutaminase antibody titer were subjected to esophagogastroduodenoscopy and biopsies were obtained from the descending duodenum to look for histological changes of celiac disease. Esophageal web was treated with bougie dilatation. Celiac disease was diagnosed on the basis of elevated tissue transglutaminase antibody and suggestive duodenal histology.

RESULTS: Twenty one patients were diagnosed to have cervical esophageal web. Eighteen (85.7%) had evidence of iron deficiency. Five (23.8%) patients with cervical esophageal web fulfilled criteria for diagnosis of celiac disease. All five had evidence of iron deficiency. None of these patients gave a history of chronic diarrhea. All patients were treated with bougie dilatation. Patients with celiac disease were advised of a gluten-free diet. All five celiac disease patients are free of dysphagia without recurrence after a mean follow up of 10 months (range: 3 to 16 months).⁸

“Glycogenic acanthosis of the esophagus: radiographic and pathologic features.” Diagnostic features of glycogenic acanthosis of the esophagus on air-contrast radiography, endoscopy, and histopathologic studies in 10 selected cases are presented. Glycogenic acanthosis of the esophagus is a common benign entity, characterized by multifocal plaques of hyperplastic squamous epithelium with abundant intracellular glycogen deposits.

At esophagoscopy or on autopsy specimens the lesions appear as slightly raised grey-white plaques which are usually 2-10 mm in diameter and may be confluent. They cause a finely nodular or cobblestone mucosal pattern demonstrable on double-contrast views of the well-distended esophagus. The findings are not associated with mucosal ulcerations, luminal narrowing, or mobility disturbance, although some patients may have coexistent hiatal hernia and gastroesophageal reflux.⁹

Sources:

1. Usai P, Usai Satta P, Lai M, et al. Autonomic dysfunction and upper digestive functional disorders in untreated adult coeliac disease. European Journal of Clinical Investigation. Dec 1997;27(12):1009-15. [↩]
2. Sinha SK, Nain CK, Udawat HP, Prasad KK, Das R, Nagi B, Singh K. Cervical esophageal web and celiac disease. J Gastroenterol Hepatol. 2008 Jul;23(7 Pt 1):1149-52. doi: 10.1111/j.1440-1746.2008.05452.x. Epub 2008 Jun 28. [↩]
3. Cuomo A, Romano M, Rocco A, Budillon G, Del Vecchio Blanco C, Nardone G. Reflux oesophagitis in adult coeliac disease: beneficial effect of a gluten free diet. Gut. Apr 2003;52(4):514-7. [↩]
4. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
5. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩]
6. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩]
7. Nachman F, Vázquez H, González A, Andrenacci P, Compagni L, Reyes H, Sugai E, Moreno ML, Smecuol E, Hwang HJ, Sánchez IP, Mauriño E, Bai JC. Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet. Clin Gastroenterol Hepatol. 2011 Mar;9(3):214-9. doi: 10.1016/j.cgh.2010.06.017. [↩]
8. Sinha SK, Nain CK, Udawat HP, Prasad KK, Das R, Nagi B, Singh K. Cervical esophageal web and celiac disease. J Gastroenterol Hepatol. 2008 Jul;23(7 Pt 1):1149-52. doi: 10.1111/j.1440-1746.2008.05452.x. [↩]
9. Ghahremani GG, Rushovich AM. Glycogenic acanthosis of the esophagus: radiographic and pathologic features. Gastrointest Radiol. 1984;9(2):93-8. [↩]