Latest / Medicine Matters: The Springer Medicine Podcast / Episode 23: Improving dysphagia outcomes

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Episode 23: Improving dysphagia outcomes · Medicine Matters: The Springer Medicine Podcast

• 0:05
  Speaker 0: Welcome to Medicine Matters, the Springer Medicine
• 0:08
  Speaker 2: Podcast.
• 0:11
  Speaker 0: I'm Dr Jane Gotzland.
• 0:14
  Speaker 0: In this episode, we'll be examining the latest clinical guidelines for the assessment and management of dysphagia.
• 0:21
  Speaker 0: With between ten and twenty percent of the population experiencing dysphagia at some point in their lives, it's an issue causing significant birds and on both population health and clinical resources.
• 0:34
  Speaker 0: considerable variability in diagnostic approaches and criteria, and in intervention efficacy and patient outcomes are confounding the problem.
• 0:43
  Speaker 0: This reality underscores the need for updated evidence-based recommendations to help clinicians navigate their care of individuals presenting with chronic dysphagia.
• 0:55
  Speaker 0: Fortunately, the UEG and ESNM recently published new guidelines that seek to address these challenges.
• 1:03
  Speaker 0: As always, the full transcript and links to all documents including the published guidelines discussed in this episode are available on our website www.springermedicine.com.
• 1:16
  Speaker 2: I'm Natalie Wood and I'm a Senior Clinical Content Manager with Springer Medicine.
• 1:20
  Speaker 2: Today I am excited to be speaking with Professor Eduardo Zavorino from the University of Peru about dysphagia, specifically the joint guidelines from United European Gastroenterology and the European Society for Neuro-Gastroenterology and Matility that were published in June this year.
• 1:38
  Speaker 2: Welcome and thank you for joining me.
• 1:40
  Speaker 1: Hello Rateli, thank you for the kind invitation and I'm happy to talk about this project which indeed was covered in the last three or four years.
• 1:50
  Speaker 1: so it was a huge project but luckily we came to an end and the publication of course.
• 1:58
  Speaker 2: Yes that must be very satisfying.
• 2:00
  Speaker 2: and to see the article out there.
• 2:02
  Speaker 2: Just before we sort of really dive into the guidelines.
• 2:06
  Speaker 2: I wondered if you could perhaps just start by telling us a little bit about what sparked your interest in esophageal disease and dysphagia in particular?
• 2:16
  Speaker 1: First of all, I'm an esophagologist, so I cover many, many aspects of gastroenterology, including of course the esophageal diseases.
• 2:26
  Speaker 1: from those, from gastroesophageal disease to motility disorder.
• 2:31
  Speaker 1: two years in offerings of arthritis and other main condition it the esophagus or the upper GI more in general.
• 2:39
  Speaker 1: This is part of my training when I was a fellow.
• 2:44
  Speaker 1: then was part of also my PhD although my PhD was covering also the immunomediated disease since I work with high BD and so on.
• 2:55
  Speaker 1: And then I was deeply involved in many, many guidelines for the subject diseases because we publish a lot as a group.
• 3:04
  Speaker 1: Also, when I moved from my original university, University of Genoa to University of Zurich to now University of Padua, and so we accumulated a lot of background and knowledge about the topics we covered in these guidelines and many others.
• 3:21
  Speaker 1: So that's the reason we took care about dysphagia, which is something that was completely lacking in the literature and of course thanks to the help of many many colleagues and the UAG.
• 3:35
  Speaker 2: Yes actually that leads us really nicely into my first question which was really to ask you what it was that had prompted the development of these guidelines and as you've sort of alluded to it was lacking.
• 3:49
  Speaker 2: So what was it you were really hoping for when you saw everyone was brought together to develop the guideline?
• 3:55
  Speaker 1: Yeah, you know, dysphagia is a symptom and maybe also a syndrome when it's based on functional complain, which is a little bit uncovered by current guidelines and also a little bit underestimated in terms of what to do in clinical practice, in terms of diagnosis and therapy from many, many colleagues working gastroenterology but also outside gastroenterology, internal medicine, YNT and so on.
• 4:23
  Speaker 1: So how we decided together with the European Society on Aerogastontology Motivity and UAG to develop a guidelines in order to cover the dysphagia complaint from every perspective and provide the same recommendation in order to do something for this patient for a symptom which is quite prevalent in clinical practice because between ten and twenty percent of the population complain of dysphagia during their lives.
• 4:54
  Speaker 1: So it's a prevalent symptom which requires many investigations or at least some knowledge in order
• 5:02
  Speaker 2: to manage
• 5:02
  Speaker 1: dysphagia in the correct way.
• 5:04
  Speaker 2: Yes absolutely and that was something I was going to ask.
• 5:08
  Speaker 2: actually in terms of the guideline obviously it's a huge article, I think it's like forty one statements that you've covered.
• 5:17
  Speaker 2: And it's broken down into sections.
• 5:18
  Speaker 2: And the first one is looking at the definition and epidemiology of dysphagia.
• 5:24
  Speaker 2: And you've alluded there to the prevalence being ten to sort of twenty percent.
• 5:29
  Speaker 2: What were the other major take home messages from that part of the guideline?
• 5:34
  Speaker 2: Do you think there's anything else that might surprise people?
• 5:39
  Speaker 1: I mean, during the research activity we did for the guidelines, we saw that There are not many studies working on investigating the epidemiology of this phase, which is quite interesting, and many of the data we have available come from different specialities, which is one important issue which led us to involve many other societies, not only gastroenterology, not only neurogastroenterology materials, but also the European Society of ENT.
• 6:11
  Speaker 1: The Ufge Society for Clinical Nutrition, Gastrointestinal and Dominar Radiology is following this order, which is probably one of the main society involved in the guidelines, and more in general, in the management of this patient.
• 6:25
  Speaker 1: So we discovered that indeed this is a symptom that may become a syndrome, but it's not only something that gastroenterology should take care of.
• 6:39
  Speaker 1: but also many other specialists who may encounter this symptom and manage this patient.
• 6:45
  Speaker 1: So this is a very important message which is this is a cross-sectional guidelines and it should be read and maybe implemented in the clinical practice by many of my colleagues, not only in gastroenterologists.
• 7:02
  Speaker 2: Yes, I completely take that point and obviously you've covered dysphagia as a whole, so that's the oropharyngeal dysphagia and the esophageal dysphagia and that was obviously a conscious decision.
• 7:13
  Speaker 2: I guess because patients arrive with the same symptom, they're having difficulties with swallowing.
• 7:20
  Speaker 2: Taking it back a little further, are you anticipating that these guidelines will also be useful to primary care physicians because they are people who will see the patients initially.
• 7:34
  Speaker 1: Fully agree with what you said, I mean the primary care physician are always the first physician who are in contact with this patient and can check initially a potential causes of dysphagia and then send the patient to the appropriate specialist.
• 7:52
  Speaker 1: This is particularly important also for them, but for everything I do, usually I try to involve the GPs because they are so important for a good management of the patient, independently from symptoms or location of the disease and so on.
• 8:10
  Speaker 1: And I hope that this collaboration will be forever and
• 8:14
  Speaker 2: ever.
• 8:15
  Speaker 2: So talking about that link between the primary care and then the referral.
• 8:20
  Speaker 2: I noted that one of the points was saying you know about the careful history taking is recommended and I guess that's where it starts with the primary care physicians because particularly in that first section of the guidelines it's pointing out all the different characteristics and then the second section when it goes into like the pathophysiology and comorbidities.
• 8:37
  Speaker 2: so is that how you imagine it that this first part in particular will be what helps get people to see the right specialist in the first place.
• 8:47
  Speaker 1: Yeah, yeah, there are many questionnaires or at least some stuff that can help a physician to identify the condition or at least to suggest the patient where to do.
• 8:58
  Speaker 1: The main point is always asking the right question to the patient.
• 9:03
  Speaker 1: Usually you have the right answer.
• 9:06
  Speaker 1: So this patient is a symptom which is as mentioned before a little bit underestimated.
• 9:13
  Speaker 1: because many patients believe that having a little bit of dysphagia in a week is something normal depending on how they chew, when they swallow, how much they drink.
• 9:25
  Speaker 1: So there are many, many reasons why they underestimated the condition.
• 9:30
  Speaker 1: And also, you know, there are some behaviors which patients usually build up for reducing the burden of the symptoms like divided the food in many, many small pieces, drinking a lot or try to avoid some foods with complex texture like meat, apple and so on.
• 9:52
  Speaker 1: And all this behavior may hit them in many, many conditions for oropharyngeal or esophageal dysphagia from inflammatory disorder like using ophiric esophagitis to more complex disorder like acalasia and so on.
• 10:05
  Speaker 1: So the duty of the physician and in particular the primary care physician should be to evaluate this and of course by investigating the symptoms and go a little bit in depth in order to understand how much is impacting the quality of life of the patient and indeed as the potential to be a symptom of the true diseases.
• 10:31
  Speaker 2: If we move on from talking about the definition and the epidemiology and I did note that you put forward a definition and that perhaps that was sort of a little lacking so hopefully that will be a really good start as well for people.
• 10:44
  Speaker 2: but then the pathophysiology and related conditions, were there any standout points from that section that you think it's worth highlighting?
• 10:56
  Speaker 1: I probably should understand one point, did the dysphagia guideline cover all the conditions which may cause dysphagia apart from those who have been already covered by other guidelines, so we did not go into details regarding the ecalasia.
• 11:15
  Speaker 1: and the eosinophilis of agitis.
• 11:17
  Speaker 1: This is important because if people want to find something regarding those two conditions, they will not find them in the guidelines because they are already covered elsewhere.
• 11:26
  Speaker 1: So we try to stress the other potential conditions associated with dysphagia, including the neurological, neuromuscular, rheumatological, endocrinological, infectious, genital, structural, mechanical, and oncological, you know.
• 11:44
  Speaker 1: many, many, many potential conditions which could not be covered by one guidelines.
• 11:49
  Speaker 1: We mentioned about that, but we also stressed that we had to know that dysphagia may be secondary to one of these potential pathologies and so patient and also physician have to think about them before moving forward with the diagnosis and the therapeutic approach.
• 12:13
  Speaker 2: Yeah, I noticed it's a long list and some of the conditions overlap, don't they, between whether they're more likely to be a cause of esophageal or a pharyngeal.
• 12:22
  Speaker 2: I noticed there was overlap, for example, like diabetes and so that isn't always helpful either, is it?
• 12:29
  Speaker 1: Yeah, yeah, yeah, of course, of course.
• 12:32
  Speaker 1: And also neurological, which are very, very important.
• 12:35
  Speaker 1: And at the start of this guidelines, it's important, of course, distinguish between Orphanageal and Esophageal, as you already mentioned correctly, because this may lead to different diagnostic approach, different therapeutic approach, but also different specialists that need to be consulted in order to obtain the right pathway for diagnosis and therapy.
• 12:59
  Speaker 1: So that's another important point.
• 13:02
  Speaker 2: Yeah.
• 13:03
  Speaker 2: I mean, it gives a real sense of the undertaking with these guidelines.
• 13:07
  Speaker 2: So once a person has been referred and they're on that diagnostic pathway, and I did see there are some really nice figures in the guideline to really help lay out the diagnostic approach and the therapeutic approach for both esophageal and oropharyngeal dysphagia.
• 13:23
  Speaker 2: I'm sure they'll be much appreciated and well used.
• 13:26
  Speaker 2: Once they're on that diagnostic pathway, what are the main recommendations?
• 13:32
  Speaker 1: I mean, of course, we did two different algorithms for the two different kinds of dysphagia.
• 13:38
  Speaker 1: One important point is that there are more investigations than only endoscopy.
• 13:45
  Speaker 1: Because in clinical practice, we see many, many patients who complain of orpharyngeal and esophageal dysphagia and the only test.
• 13:53
  Speaker 1: They underwent two endoscopy, maybe many, many times.
• 13:58
  Speaker 1: I see patients who... had a seven or eight upper endoscopy and never did a swallow, a bottom swallow or a manometry or ENT investigation with a fibroscope, which is, I mean, irrelevant.
• 14:15
  Speaker 1: because we need also when a test is negative to go for that, to understand the reason why the symptom is present.
• 14:24
  Speaker 1: And so we don't have to limit ourselves to what is available in my center or in your center.
• 14:31
  Speaker 1: We need to be informed that there are many, many tests which may explain the symptomatology and we should go further and use them.
• 14:40
  Speaker 1: Of course, this means losing a bit of time, involving many, many colleagues because, as mentioned before, speech therapist, specialist for the Apple's Vagios Finter, neurologists and so on.
• 14:55
  Speaker 1: but this is done for a good reason which is the resolution of the symptomatology and the improvement of the quality of life of our patients.
• 15:05
  Speaker 1: So please do that.
• 15:10
  Speaker 2: And there's obviously in the guidelines.
• 15:11
  Speaker 2: there's lots of different levels of evidence for all the different recommendations and some of the recommendations are stronger than others.
• 15:18
  Speaker 2: but all of the statements were approved and so are you hoping that Over time, perhaps those recommendations for where the level of evidence might have not been so strong that you will be able to sort of strengthen that as time goes, or do you think new things will emerge?
• 15:36
  Speaker 1: Yeah, that's an important point.
• 15:38
  Speaker 1: Now the guidelines are usually done with the grade system, which provide the evidence according to the presence of randomized control trial or a metanase or randomized control trial of prospective studies.
• 15:51
  Speaker 1: for dysphagia and more in general many other conditions which have no drugs or are mainly based on diagnosis evidence.
• 16:04
  Speaker 1: From retrospective studies or course studies.
• 16:07
  Speaker 1: of course the evidence cannot be as high as for a randomized control trial trying to see the efficacy and the safety of a new drug or a new biologic and so on.
• 16:18
  Speaker 1: So we try to apply the gray system but it was evident from the beginning that it was not possible.
• 16:24
  Speaker 1: So we applied in hand a modified grade system which gave us the need of calling this recommendation and not through guidelines.
• 16:37
  Speaker 1: And of course the evidence for each statement is quite low.
• 16:42
  Speaker 1: But this is current practice.
• 16:44
  Speaker 1: This is what we do in clinical practice from every country in the world.
• 16:51
  Speaker 1: we have many many representatives from many physicians from many countries in Europe.
• 16:57
  Speaker 1: so this is done in Italy, in France, in UK, in Romania, in Germany.
• 17:04
  Speaker 1: so it can be generalized everywhere.
• 17:08
  Speaker 1: and of course the evidence is low now.
• 17:10
  Speaker 1: probably in the future I'm not expecting it will be higher but this is something that is more empirical than evidence-based.
• 17:18
  Speaker 1: so
• 17:20
  Speaker 2: I was going to ask, I suppose, in terms of diagnosis and all of the technological advances there have been, I mean starting with endoscopy and then we've progressed and we've got menometry now and we've got endoflip and all of that kind of thing.
• 17:34
  Speaker 2: How do you see that fitting into sort of a routine workup for something like esophageal dysphagia?
• 17:40
  Speaker 2: they're still sort of, you know, highly specialized tests and how they're accessed and getting patients to have those tests.
• 17:47
  Speaker 2: How easy is that to implement?
• 17:51
  Speaker 1: Yeah, this is a very good question.
• 17:53
  Speaker 1: Indeed, more in-depth we go and more complex, hard tests and difficulties in terms of availability of these tests.
• 18:04
  Speaker 1: And those will be available everywhere.
• 18:06
  Speaker 1: Then if we move further for high-resolution monometry and hand-of-flip with this device able to measure the distensibility of the esophagus and also this secondary peristalsis of the esophagus, this is quite more rare in every country, at least in Europe, which is a very common device in the US, but in Europe still has to be implemented in clinical practice.
• 18:36
  Speaker 1: That's another good point that when the diagnosis is going to be a little bit more complex, we should send the patient to a referral center, a high-specialized center for esophageal diseases.
• 18:51
  Speaker 1: This is not true only for a resolution monotony and end-of-lip, also for some tests regarding the use MRI or CT.
• 19:02
  Speaker 1: we need radiologists who are specialists in a swallowing disorder because you know everyone is more dedicated to an aspect of the different diseases, conditions may occur in clinical practice and so in some cases it is better to send this patient to a highly specialized center also because the treatment coming from the diagnostic approach usually is done in this center rather than in the general community or in the general gastroenterology center.
• 19:35
  Speaker 1: so we need to be aware of which is the best center close to our activity in order to send a patient there and to have the best for their condition.
• 19:48
  Speaker 2: Yeah I was going to ask a little bit about therapy but I think you've really touched on it there.
• 19:53
  Speaker 2: I guess as people work their way through the system and the diagnosis becomes more specialized, the treatment becomes more sort of involved, so it's probably not useful to talk about individual sort of interventions.
• 20:05
  Speaker 2: I did note that it was saying in terms of medical therapies can be quite limited if it's a motor function issue and stuff like that.
• 20:13
  Speaker 1: Yeah, yeah, yeah, medical therapy is quite limited, particularly when we are talking about mortality disorder of the esophagus.
• 20:21
  Speaker 1: including ineffective esophageal motility, hypercontractile disorder or EGJ at flow obstruction, but also for acalasia is much more implementable in using the philiaesophageitis because we have dragged quite effective in that field, like topical corticosteroid and now first biologic which has been developed and launched in the market.
• 20:49
  Speaker 1: Two years ago, We have some drugs for functional dysphagia, which is a condition diagnosed according to the ROM-IV criteria, which will be ROM-V next year in May, which can provide us many insights on how to define the condition to treat the condition with neuromodulators or behavioral therapy.
• 21:14
  Speaker 1: Of course, we have Jax when we have rheumatological disease, neurological disease, which may explain the symptomatology, but of course in this case we need doing the right technosis and then treat the conditional underlying the symptomatology.
• 21:35
  Speaker 1: For oropharyngeal dysphagia probably is much more complex.
• 21:41
  Speaker 1: Then for esophageal dysphagia, because for oral pharyngeal dysphagia, the number of treatment are less than for esophageal dysphagia.
• 21:53
  Speaker 1: In this case, most of the patients are treated according to the anatomical condition, functional condition or neurological disease behind the symptomatology.
• 22:04
  Speaker 1: And the treatment is usually done through different techniques.
• 22:10
  Speaker 1: able to improve the symptomatology like deep brain stimulation, peripheral magnetic stimulation, electrical stimulation, many, many treatment which have limited evidence of efficacy, but there are, there is the efficacy, so it's important that the right specialist is going to cover this aspect and is giving the right treatment for your patient.
• 22:37
  Speaker 2: So moving on slightly to say how have the guidelines been received?
• 22:43
  Speaker 2: Because obviously they were published a little bit earlier on in the year.
• 22:46
  Speaker 2: So I wondered how you feel they've been received by the community so far?
• 22:52
  Speaker 1: I mean, these cadres were presented in towards a big meeting like UEG, Wicca and the room was full.
• 23:01
  Speaker 1: So I believe that was quite appreciated and also was contacted by many many GPS not only specialists asking me or giving me good feedback regarding its usefulness.
• 23:17
  Speaker 1: Also the fact that this was a project led by me but also by Amir Mari from Israel who helped a lot in disseminating this guidelines is a point of strength because again Many societies around Europe or the world meaning that the widespread diffusion of the guidelines will be helpful and will be effective in order to provide the same evidence in order to treat this patient.
• 23:44
  Speaker 1: Of course, nothing is perfect and luckily because otherwise I would not have the possibility to improve and also this guideline can be improved.
• 23:55
  Speaker 1: but I believe that this is a very good starting point also for communicating between HASS gastroenterologists and radiologists and neurologists and ENT specialists, particularly those involved in swallowing disorder from Natalia Rommel, Perk, Avié and many many other specialists who would take care of patients with Orofaryngeal dysphagia.
• 24:23
  Speaker 1: I'm very enthusiastic about these guidelines and I hope they will go very,
• 24:28
  Speaker 2: very well.
• 24:29
  Speaker 2: I've taken up lots of your time and I really appreciate it.
• 24:32
  Speaker 2: I want to bring our conversation to a close and I appreciate this is really an unfair question given the size of the guidelines.
• 24:40
  Speaker 2: If you had to pick just one or two elements from the guidelines, what do you think is going to have the biggest impact?
• 24:50
  Speaker 2: What are you most excited about?
• 24:52
  Speaker 2: that you think is the biggest take-home messages from the guidelines that you would sort of really want to get out there.
• 24:58
  Speaker 1: We mentioned this a little bit at the beginning.
• 25:01
  Speaker 1: The interpretation of the symptomatology is the key to understand the underlying disease.
• 25:06
  Speaker 1: And I have to say that many colleagues usually tend to be a little bit fast when they do the history taking and when they investigate the symptomatology.
• 25:18
  Speaker 1: when you are able to distinguish between oropharyngeal and dysophagia, then you are already going in the right direction of the typhosis.
• 25:29
  Speaker 1: So I believe this is a very, very, very important message.
• 25:33
  Speaker 1: And also the interpretation of dysphagia, because dysphagia can be interpreted as a hardware, as chest pain.
• 25:41
  Speaker 1: There are many, many unfortunately misleading concepts regarding it.
• 25:46
  Speaker 1: So this is a really really an important point.
• 25:50
  Speaker 1: and the other important point as mentioned again before that we should not limit our approach to what we have the endoscopy.
• 26:00
  Speaker 1: We need to go further investigate more doing second level third level of examination and this will be impactful for the clinical practice
• 26:11
  Speaker 2: helpful
• 26:12
  Speaker 1: for our patient and in many many cases we will find the reason of the symptomatology and we will find the solution of the symptomatology.
• 26:23
  Speaker 1: maybe not completely abolishing the symptomatology because we have a limitation regarding treatment but at least improving the quality of life of our patient and providing them the right explanation of the symptoms which is in some way more important than giving the magic pill able to recover everyone and improve the quality of life of everyone.
• 26:49
  Speaker 1: So, these are the two main messages which I would like to give.
• 26:54
  Speaker 2: Oh, that's wonderful.
• 26:56
  Speaker 2: Thank you so much.
• 26:57
  Speaker 2: So, I mean, I know we've really just scratched the surface with our conversation and there's a lot more that we could discuss.
• 27:04
  Speaker 2: But for now, I would like to say a huge thank you to Professor Tabarino.
• 27:08
  Speaker 2: Thank you very much for your time and for sharing your expertise with us.
• 27:12
  Speaker 2: and for giving us your highlights from the new guidelines.
• 27:15
  Speaker 2: It's been an absolute pleasure to talk to you.
• 27:18
  Speaker 2: And for those of you who are listening and would like to read the guidelines in full, a link will be provided.
• 27:24
  Speaker 2: Thank you all for listening.
• 27:25
  Speaker 1: Thank you, Nathalie.
• 27:27
  Speaker 1: Thank you also for those who are
• 27:28
  Speaker 0: listening.
• 27:39
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• 27:46
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