Can Acid Reflux Make It Hard To Swallow?

Most people know that there is a lower esophageal sphincter (LES), which connects the esophagus to the stomach … and that acid reflux occurs when the LES doesn’t work as an effective barrier, opening when it shouldn’t. However, there is also an upper esophageal sphincter (UES) just behind the larynx that connects the pharynx (throat) to the upper esophagus. The UES is the last defense, last barrier against Respiratory Reflux. 

Using manometry, we found that the two most common causes of dysphagia (difficulty swallowing) were reflux-related malfunction of the UES and/or weak or interrupted esophageal peristalsis—the top-to-bottom contractions of esophageal muscles that move food through the esophagus. (FYI: Manometry measures the pressure and timing of esophageal and esophageal valve events, i.e., opening and closing of the valves, as well as peristalsis.)

Comments: (1) There is dysphagia, and there is dysphagia. People with dysphagia from the two causes presented here can still eat; severe dysphagia with weight loss is a different matter. (2) If you have dysphagia and its cause is not obviously reflux, you should see a physician, and I recommend an otolaryngologist (ear, nose, and throat physician). (3) Nest, after examination by a physician, a “barium swallow esophagram upright (standing) and supine (lying down)” is a noninvasive test that is usually diagnostic.  (4) Painful swallowing (odynophagia) is a red flag symptom; a physician should promptly investigate it as it is sometimes caused by throat cancer. 

 What Is UES Dyssynchrony?  

The most common cause of dysphagia is dyssynchrony of the UES. What is dyssynchrony? It’s improperly synchronized activation of the UES. With respiratory Reflux, the UES may inappropriately close during the middle of swallows. People with this problem usually point at their throats to show where the problem is.

People with dysphagia from UES dyssynchrony often have a companion symptom, Globus, a sensation of a lump in the throat. And this is a different symptom from just sticky throat mucus. If a person has dysphagia as their primary symptom, they usually have globus, but people with globus as the primary symptom may or may not have dysphagia.

Good outcomes: When we get follow-up manometry after effective antireflux treatment, with resolution of the dysphagia and/or globus symptoms, UES and esophageal functions always return to normal.

What Is Esophageal Dysmotility?

Respiratory reflux can also cause esophageal dysmotility (“lazy esophagus”), in which normal peristalsis — the top-to-bottom contractions of esophageal muscles that move food from the throat to the stomach — is interrupted.

Dysmotility explains why patients with this say that food does not go down all the way and seems to get stuck in the middle of the esophagus. People with this usually chew their food well and keep a glass of water ready because drinking water will usually move the stuck food into the stomach. 

Many physicians mistakenly think that esophageal dysmotility is a cause of acid reflux, and they often prescribe prokinetic agents, drugs that supposedly improve esophageal dysmotility. Unfortunately, those drugs have a seriously bad side-effect profile. However, the crucial error is that the dysmotility results from reflux, and not the other way around. Effective antireflux treatment will resolve this type of dysphagia. 

Of note, I have seen two patients who initially presented for evaluation and treatment of reflux and who had complete aperistalsis, that is, no movement of the esophagus with swallowing … it was a “dead tube.” In both cases, esophageal function returned to normal, flat normal, after reflux treatment. 

What is Achalasia?

Achalasia is a rare autoimmune disease that causes progressive dysmotility by attacking the nerves that drive the esophageal muscles. In addition, the LES usually doesn’t relax properly, so people with this can develop a huge dilated esophagus that can lead to pneumonia if the material backs up into the lungs at night. 

Achalasia is often (wrongly) confused with dysmotility from acid reflux. Many physicians falsely believe that dysmotility associated with reflux should be treated with a prokinetic agent again to improve esophageal function as if the diagnosis was achalasia. 

The key point is that reflux is the cause of most cases of dysphagia, and that achalasia is a rare diagnosis. Always treat the reflux first! 

What Are Esophageal Rings and Strictures?

If a person has long-standing esophageal reflux (many years), they can get circumferential scarring within the esophagus, and such narrowing can cause dysphagia. If the scar is thin, it is called an esophageal ring, and if it is thick, it is called an esophageal stricture. A barium swallow esophagram or endoscopy can diagnose rings and strictures.

Rings and strictures can entrap food, especially poorly-chewed food. In most cases, these narrow areas require endoscopic dilation (stretching open). In addition, people with rings and strictures need aggressive, long-term antireflux treatment; otherwise, they will grow back. 

Comments: (1) Esophageal rings are sometimes called Schatzki’s rings. (2)  More severe and less common causes of dysphagia include scleroderma, esophageal cancer, stroke, and neurological diseases, such as Lou Gehrig’s Disease (ALS). All of those diagnoses have other symptoms that usually make the diagnosis.

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