Modified Mondays: When what goes down comes back up

In yet another episode of “How Esophageal Issues Can Look Like Suspected Oropharyngeal Dsyphagia”, we have a really interesting patient from our Michigan team this week. The patient had a recurrent diagnosis of aspiration pneumonia, and reported to our team that he “gets aspiration pneumonia every time” he is admitted to the hospital. He also mentioned a history of gastric bypass surgery that wasn’t noted in the patient’s medical history. Clinical swallow eval showed no overt s/s but suspicious for silent aspiration.

The first thing our team noticed when they turned on the fluoro was a whole lot of hardware in the cervical spine that wasn’t noted in the patient’s history. The records showed a prior surgical history in the thoracic and lumbar spine, but nothing for the cervical. The study started off as we always do, with thin liquid, and proceeded through our protocol. The patient had a perfectly normal and beautiful swallow, until solid foods were attempted. Our SLP then began to see reverse flow from the proximal esophagus up into the pharynx and eventually all the way up to the oral cavity. As you continue to watch, you will see the severity of the reverse flow increase significantly. Our team then turned the patient for the A-P view and an esophageal screen, but before they could see much detail, the patient began to then have some significant emesis.

After the patient recovered a bit, he told our SLP that he “can’t drink and eat at the same time” and if he does, he “will always throw up”. After seeing the study and combining that with the patient report, our SLP and physician recommended an urgent GI consult.

This case highlights the importance of not only instrumentation, but also really engaging in conversation with the patient. Medical records are not always complete, and patients don’t always think to tell us everything during the initial interactions. Ongoing dialogue about past symptoms, assessments, and surgeries can eventually reveal a much bigger picture of the dysphagia than expected. Clinically, this patient didn’t really have anything “jump out” at bedside, no real overt symptoms. Only because the facility SLP knew how often aspiration can be silent, and recognized that the history of recurrent pneumonia as well as the patient’s report that he had “some kind of swallow test before” could be cause to suspect oropharyngeal dysphagia that required instrumentation to fully assess were we able to make the correct referral for this patient.

Esophageal issues can often (I would ALMOST say “always”) look like oropharyngeal dysphagia, which is why, although we really didn’t need it for this patient, the A-P view with an esophageal sweep can be such an important part of a comprehensive swallow assessment. More on this in the coming few weeks!