Ljudem s hujšim GERB se lahko hrana vrne iz želodca v požiralnik ali usta, zlasti če dejavnosti povečajo pritisk v trebuhu, na primer s kašljanjem in upogibanjem.
Simptomi disfagije, povezani s požiranjem
Najpogostejši simptom disfagije pri požiranju je občutek, da se zaužita hrana zatika, bodisi v spodnjem delu vratu ali v prsnem košu.
Pri nevroloških težavah lahko pride do težav pri požiranju, ker se hrana ne more potisniti z jezikom v grlo.
Starejši posamezniki z zobno protezo morda ne prežvečijo dobro hrane in zato pogoltnejo velike kose trdne hrane, ki se zataknejo.
Disfagija je medicinski izraz za simptom težav pri požiranju, ki izhaja iz latinske in grške besede, ki pomeni težave pri prehranjevanju.
Požiranje je zapleteno dejanje.
Glede na njegovo kompleksnost ni čudno, da je bilo požiranje, ki se začne s krčenjem zgornjega žrela, "avtomatizirano", kar pomeni, da za požiranje, ko se začne požiranje, ni treba razmišljati. Požiranje nadzirajo avtomatski refleksi, ki vključujejo živce v žrelu in požiralniku ter center za požiranje v možganih, ki je z žrelom in požiralnikom povezan z živci. (Refleks je mehanizem, ki se uporablja za nadzor številnih organov. Refleksi zahtevajo, da živci znotraj organa, kot je požiralnik, zaznajo, kaj se dogaja v tem organu, in pošljejo informacije drugim živcem v steni organa ali zunaj organa. Informacija se obdeluje v teh drugih živcih in se določijo ustrezni odzivi na razmere v organu. Nato še drugi živci pošiljajo sporočila iz procesnih živcev nazaj v organ, da nadzorujejo delovanje organa, na primer krčenje mišice organa. Pri požiranju pride do obdelave refleksov predvsem v živcih v steni žrela in požiralnika ter možganih.)
Kompleksnost požiranja pojasnjuje tudi, zakaj obstaja toliko vzrokov za disfagijo. Težave se lahko pojavijo pri:
Težave so lahko znotraj žrela ali požiralnika, na primer s fizično zožitvijo žrela ali požiralnika. Disfagija je lahko tudi posledica bolezni mišic ali živcev, ki nadzorujejo mišice žrela in požiralnika, ali poškodbe centra za požiranje v možganih. Nazadnje, žrelo in zgornja tretjina požiralnika vsebujeta mišico, ki je enaka mišicam, ki jih uporabljamo prostovoljno (kot so mišice rok), imenovane skeletne mišice. Spodnji dve tretjini požiralnika je sestavljena iz druge vrste mišic, znane kot gladke mišice. Tako lahko bolezni, ki prizadenejo predvsem skeletne mišice ali gladke mišice v telesu, prizadenejo žrelo in požiralnik, kar dodaja dodatne možnosti vzrokom za disfagijo.
Obstajata dva simptoma, ki se pogosto obravnavata kot težave s požiranjem (disfagija), ki pa verjetno nista. Ti simptomi so odinofagija in globusni občutek.
Odinofagija pomeni boleče požiranje. Včasih posameznikom ni lahko ločiti med odinofagijo in disfagijo. Na primer, hrana, ki se zatakne v požiralnik, je pogosto boleča. Je to disfagija ali odinofagija ali oboje? Tehnično gre za disfagijo, vendar jo posamezniki lahko opišejo kot boleče požiranje (tj. odinofagija). Poleg tega lahko bolniki z gastroezofagealno refluksno boleznijo (GERB) opišejo disfagijo, kadar je v resnici odinofagija. Bolečina, ki jo občutijo po zaužitju, mine, ko se vnetje GERB zdravi in izgine in je verjetno posledica bolečine, ki jo povzroča hrana, ki prehaja skozi vnetni del požiralnika.
Odinofagija se lahko pojavi tudi pri drugih stanjih, povezanih z vnetjem požiralnika, na primer pri virusnih in glivičnih okužbah. Pomembno je razlikovati med disfagijo in odinofagijo, ker so vzroki za vsako od njih lahko precej različni.
Globusni občutek se nanaša na občutek, da je v grlu cmok. Bulica je lahko prisotna nenehno ali le pri zaužitju. Vzroki za občutek globusa so različni in pogosto ne najdemo nobenega vzroka. Globusni občutek so različno pripisali nenormalnemu delovanju živcev ali mišic žrela in GERB. Občutek krogle običajno jasno opišejo posamezniki in redko povzroči zmedo s pravo disfagijo.
Kot smo že omenili, obstaja veliko vzrokov za disfagijo. Zaradi udobja lahko vzroke za disfagijo razvrstimo v dve skupini;
Vzroke lahko tudi različno razvrstimo v več skupin.
Pri nevroloških težavah lahko pride do težav pri požiranju, ker bolus ne more potisniti z jezikom v grlo. Starejši posamezniki z zobno protezo morda ne prežvečijo dobro hrane in zato pogoltnejo velike kose trdne hrane, ki se zataknejo. (Kljub temu se to običajno zgodi, ko pride do dodatne težave v žrelu ali požiralniku, kot je striktura.)
Najpogostejši simptom disfagije pri požiranju pa je občutek, da se zaužita hrana zatika, bodisi v spodnjem delu vratu ali v prsnem košu. Če se hrana zatakne v grlu, lahko pride do kašljanja ali zadušitve z izkašljevanjem pogoltne hrane. Če hrana vstopi v grlo, se izzove močnejši kašelj in zadušitev. Če mehko nebo ne deluje in ne zapira pravilno nosnih poti, lahko hrana – zlasti tekočina – vrne v nos pri pogoltnu. Včasih se lahko hrana takoj po zaužitju vrne v usta.
Hrana, ki se drži v požiralniku, lahko tam ostane dlje časa. To lahko povzroči občutek, da se prsi napolnijo, ko zaužije več hrane, zaradi česar mora posameznik prenehati jesti in morda piti tekočino, da bi poskušal hrano sprati. Nezmožnost uživanja večjih količin hrane lahko povzroči izgubo teže. Poleg tega lahko hrana, ki ostane v požiralniku, vrne iz požiralnika ponoči, medtem ko posameznik spi, in posameznika lahko zbudi kašelj ali zadušitev sredi noči, ki ga izzove hrana, ki zavre. Če hrana vstopi v grlo, sapnik in/ali pljuča, lahko izzove epizode astme in celo povzroči okužbo pljuč in aspiracijsko pljučnico. Ponavljajoča se pljučnica lahko povzroči resne, trajne in progresivne poškodbe pljuč. Občasno se posamezniki ne zbudijo iz spanja zaradi vrele hrane, ampak se zjutraj prebudijo in najdejo zavrnjeno hrano na blazini.
Posamezniki, ki zadržujejo hrano v požiralniku, se lahko pritožujejo zaradi simptomov, podobnih zgagi (GERB). Njihovi simptomi so lahko res posledica GERB, vendar so bolj verjetni zaradi zadržane hrane in se ne odzivajo dobro na zdravljenje GERB.
Pri spastičnih motnjah gibljivosti lahko posamezniki razvijejo epizode bolečine v prsih, ki so lahko tako hude, da posnemajo srčni napad in povzročijo, da gredo na urgenco. Vzrok za bolečino pri spastičnih motnjah požiralnika ni jasen, čeprav je vodilna teorija, da je posledica krča mišic požiralnika.
Odinofagija in globusni občutek. O občasnih težavah pri razlikovanju disfagije od odinofagije smo že razpravljali, pa tudi o razliki med disfagijo in občutkom krogle.
Traheoezofagealna fistula. Ena motnja, ki jo lahko zamenjamo z disfagijo, je traheoezofagealna fistula. Traheoezofagealna fistula je odprta komunikacija med požiralnikom in sapnikom, ki se pogosto razvije zaradi raka na požiralniku, vendar se lahko pojavi tudi kot prirojena (prirojena) prirojena napaka. Zaužita hrana lahko izzove kašelj, ki posnema kašelj zaradi motenj v delovanju mišic žrela, ki omogočajo vstop hrane v grlo; v primeru fistule pa je kašelj posledica prehoda hrane iz požiralnika skozi fistulo v sapnik.
Ruminacijski sindrom. Sindrom prežvekanja je sindrom, pri katerem se hrana brez napora vrne nazaj v usta po končanem obroku. Običajno se pojavi pri mlajših ženskah in bi ga verjetno lahko zamenjali z disfagijo. Vendar po zaužitju ni občutka sprijemanja hrane.
Gastroezofagealna refluksna bolezen (GERB). Pri ljudeh s hujšim GERB se lahko hrana vrne iz želodca v požiralnik ali usta, zlasti kadar dejavnosti povečajo pritisk v trebuhu, na primer s kašljanjem in upogibanjem. Regurgitacija se lahko pojavi tudi ponoči, ko osebe z GERB spijo, kot pri tistih z motnjami požiranja, pri katerih se hrana nabira v požiralniku.
Srčne bolezni. Motnje spastične gibljivosti, ki povzročajo disfagijo, so lahko povezane s spontano bolečino v prsnem košu, to je bolečino v prsnem košu, ki ni povezana s požiranjem. Kljub prisotnosti disfagije je treba spontano bolečino v prsnem košu vedno domnevati, da je posledica bolezni srca, dokler ni izključena srčna bolezen kot vzrok bolečine v prsih. Zato je pomembno, da skrbno testirate za srčno bolezen, preden požiralnik obravnavate kot vzrok bolečine v prsnem košu, ko se bolnik z disfagijo pritožuje nad epizodami spontane bolečine v prsnem košu.
Zgodovina posameznika z disfagijo pogosto daje pomembne namige o osnovnem vzroku disfagije.
Narava simptomov ali simptomov zagotavlja najpomembnejše namige o vzroku disfagije. Požiranje, ki ga je težko začeti ali ki vodi do regurgitacije nosu, kašlja ali zadušitve, je najverjetneje posledica težav v ustih ali žrelu. Požiranje, ki povzroči občutek, da se hrana zatika v prsnem košu (požiralniku), je najverjetneje posledica težave s požiralnikom.
Disfagija, ki hitro napreduje v tednih ali nekaj mesecih, kaže na maligni tumor. Disfagija samo za trdno hrano kaže na fizično oviro pri prehodu hrane, medtem ko je disfagija tako pri trdni kot tekoči hrani bolj verjetno posledica bolezni gladkih mišic požiralnika. Občasne simptome pogosteje povzročajo bolezni gladkih mišic kot obstrukcija požiralnika, saj je disfunkcija mišic pogosto občasna.
Namige dajejo tudi že obstoječe bolezni. Tisti z boleznimi skeletnih mišic (na primer polimiozitis), možganov (najpogosteje možganska kap) ali živčnega sistema imajo večjo verjetnost, da bodo imeli disfagijo na podlagi disfunkcije mišic in živcev orofaringeusa. Ljudje s kolagenskimi žilnimi boleznimi, na primer sklerodermo, imajo pogosteje težave z mišicami požiralnika, zlasti z neučinkovito peristaltiko.
Bolniki z anamnezo GERB imajo večjo verjetnost, da imajo strikture požiralnika kot vzrok za njihovo disfagijo, čeprav ima približno 20 % bolnikov s strikturami minimalne ali nič simptomov GERB pred pojavom disfagije. Menijo, da je refluks, ki se pojavi ponoči, bolj škodljiv za požiralnik. Obstaja tudi večje tveganje za raka požiralnika pri posameznikih z dolgotrajno GERB.
Izguba teže je lahko znak hude disfagije ali malignega tumorja. Ljudje pogosteje kot hujšanje opisujejo spremembo svojega prehranjevalnega vzorca – manjši ugrizi, dodatno žvečenje –, ki podaljšuje obroke, tako da so zadnji za mizo, ki konča jesti. Ta zadnji vzorec, če je prisoten dalj časa, kaže na nemaligni, relativno stabilen ali počasi napredujoč vzrok za disfagijo. Epizode bolečine v prsnem košu, ki niso posledica bolezni srca, kažejo na mišične bolezni požiralnika. Rojstvo in prebivanje v Srednji ali Južni Ameriki je povezano s Chagasovo boleznijo.
Fizični pregled ima omejeno vrednost pri predlaganju vzrokov za disfagijo. Nenormalnosti nevrološkega pregleda kažejo na nevrološke ali mišične bolezni. Z opazovanjem posameznega požiranja lahko ugotovimo, ali so težave pri požiranju, kar je znak nevrološke bolezni. Tumorji v vratu kažejo na možnost stiskanja žrela. Sapnik, ki ga ni mogoče premikati z ene strani na drugo z roko, kaže na tumor nižje v prsnem košu, ki je zajel sapnik in morda požiralnik. Opazovanje atrofije (zmanjšana velikost) ali fasikulacije jezika (fino tresenje) kaže tudi na bolezni živčnega sistema ali skeletnih mišic.
Endoskopija. Endoskopija vključuje vstavitev dolge (en meter) fleksibilne cevi z lučjo in kamero na koncu skozi usta, žrelo, požiralnik in v želodec. Oblogo žrela in požiralnika je mogoče vizualno oceniti in pridobiti biopsije (majhne koščke tkiva) za pregled pod mikroskopom ali za bakterijske ali virusne kulture.
Endoskopija je odlično sredstvo za diagnosticiranje tumorjev, striktur in Schatzkijevih obročev ter okužb požiralnika. Prav tako je zelo dober za diagnosticiranje divertikulov srednjega in spodnjega požiralnika, slab pa za diagnosticiranje divertikulov v zgornjem požiralniku (Zenkerjev divertikulum).
Možno je opaziti nenormalnosti mišične kontrakcije požiralnika, vendar je manometrija požiralnika test, ki je veliko bolj primeren za oceno delovanja mišic požiralnika. Resistance passing the endoscope through the lower esophageal sphincter combined with a lack of esophageal contractions is a fairly reliable sign of achalasia or Chagas disease (due to the inability of the lower esophageal sphincter to relax), but it is important when there is resistance to exclude the presence of a stricture or cancer which also can cause resistance. Finally, there is a characteristic appearance of the esophageal lining when infiltrated with eosinophils that strongly suggests the presence of eosinophilic esophagitis.
X-rays. There are two different types of X-rays that can be done to diagnose the cause of dysphagia. The barium swallow or esophagram is the simplest type. For the barium swallow, mouthfuls of barium are swallowed, and X-ray films are taken of the esophagus at several points in time while the bolus of barium traverses the esophagus. The barium swallow is excellent for diagnosing moderate-to-severe external compression, tumors, and strictures of the esophagus. Occasionally, however, Schatzki's rings can be missed.
Another type of X-ray study that can be done to evaluate swallowing is the video esophagram or video swallow, sometimes called a video-fluoroscopic swallowing study. For the video swallow, instead of several static X-ray images of the bolus traversing the esophagus, a video X-ray is taken. The video study can be reviewed frame by frame and is able to show much more than the barium swallow. This usually is not important for diagnosing tumors or strictures, which are well seen on barium swallow, but it is more effective for suggesting problems with the contraction of the muscles of the esophagus and pharynx (though esophageal manometry, discussed later, is still better for studying contraction), milder external compression of the esophagus, and Schatzki's rings. The video study can be extended to include the pharynx where it is the best method for demonstrating osteophytes, cricopharyngeal bars, and Zenker's diverticuli. A modified barium swallow is a version of the test evaluating the oropharyngeal phases of swallowing. A speech pathologist is usually involved with the evaluation to determine subtle sequence and phase abnormalities.
The video swallow also is excellent for diagnosing penetration of barium (the equivalent of food) into the larynx and trachea due to neurological and muscular problems of the pharynx that may be causing coughing or choking after swallowing food.
Esophageal manometry. Esophageal manometry, also known as esophageal motility testing, is a means to evaluate the function of pharyngeal and esophageal muscles. For manometry, a thin, flexible catheter is passed through the nose and pharynx and into the esophagus. The catheter is able to sense pressure at multiple locations along its length in both the pharynx and the esophagus. When the pharyngeal and esophageal muscles contract, they generate a pressure on the catheter which is sensed, measured and recorded from each location. The magnitude of the pressure at each pressure-sensing location and the timing of the increases in pressure at each location in relation to other locations give an accurate picture of how the muscles of the pharynx and esophagus are contracting.
The value of manometry is in diagnosing and differentiating among diseases of the muscle or the nerves controlling the muscles that result in muscle dysfunction of the pharynx and esophagus. Thus, it is useful for diagnosing the swallowing dysfunction caused by diseases of the brain, skeletal muscle of the pharynx, and smooth muscle of the esophagus.
Esophageal impedence. Esophageal impedence testing utilizes catheters similar to those used for esophageal manometry. Impedence testing, however, senses the flow of the bolus through the esophagus. Thus, it is possible to determine how well the bolus is traversing the esophagus and correlate the movement with concomitantly recorded esophageal pressures determined by manometry. (It also can be used to sense reflux of stomach contents into the esophagus among patients with GERD.) Multiple sites along the length of the esophagus can be tested to assess the movement of the bolus and presence of reflux, including how high up it extends.
Esophageal acid testing. Esophageal acid testing is not a test that directly diagnoses diseases of the esophagus. Rather, it is a method for determining whether or not there is reflux of acid from the stomach into the esophagus, a cause of the most common esophageal problem leading to dysphagia, esophageal stricture. For acid testing, a thin catheter is inserted through the nose, down the throat, and into the esophagus. At the tip of the catheter and placed just above the junction of the esophagus with the stomach is an acid-sensing probe. The catheter coming out of the nose passes back over the ear and down to the waist where it is attached to a recorder. Each time acid refluxes (regurgitates) from the stomach and into the esophagus it hits the probe, and the reflux of acid is recorded by the recorder. At the end of a prolonged period, usually 24 hours, the catheter is removed and the information from the recorder is downloaded into a computer for analysis. Most people have a small amount of reflux of acid, but individuals with GERD have more. Thus, acid testing can determine if GERD is likely to be the cause of the esophageal problem such as a stricture, as well as if treatment of GERD is adequate by showing the amount of acid that refluxes during treatment is normal.
An alternative method of esophageal acid testing uses a small capsule containing an acid-sensing probe that is attached to the esophageal lining just above the junction of the esophagus with the stomach. The capsule wirelessly transmits the presence of episodes of acid regurgitation to a receiver carried on the chest. The capsule records for two or three days and later is shed into the esophagus and passes out of the body in the stool.
Other tests The diagnosis of muscular dystrophies and metabolic myopathies usually involves a combination of tests including blood tests that can suggest muscle injury, electromyograms to determine if nerves and muscles are working normally, biopsies of muscles, and genetic testing.
The treatment of dysphagia varies and depends on the cause of the dysphagia. One option for supporting patients either transiently or long-term until the cause of the dysphagia resolves is a feeding tube. The tube for feeding may be passed nasally into the stomach or through the abdominal wall into the stomach or small intestine. Once oral feeding resumes, the tube can be removed.
Treatment for obstruction of the pharynx or esophagus requires removal of the obstruction.
Tumors usually are removed surgically although occasionally they can be removed endoscopically, totally or partially. Radiation therapy and chemotherapy also may be used particularly for malignant tumors of the pharynx and its surrounding tissues. If malignant tumors of the esophagus cannot be easily removed or the tumor has spread and survival will be limited, swallowing can be improved by placing stents within the esophagus across the area of obstruction. Occasionally, obstructing tumors can be dilated the same way as strictures. (See below.)
Strictures and Schatzki's rings usually are treated with endoscopic dilation, a procedure in which the narrowed area is stretched either by a long, semi-rigid tube passed through the mouth or a balloon that is blown up inside the esophagus.
The most common infiltrating disease causing dysphagia is eosinophilic esophagitis which usually is successfully treated with swallowed corticosteroids. The role of food allergy as a cause of eosinophilic esophagitis is debated; however, there are reports of using elimination diets to identify specific foods that are associated with allergy. Elimination of these foods has been reported to prevent or reverse the infiltration of the esophagus with eosinophils, particularly in children.
Diverticuli of the pharynx and esophagus usually are treated surgically by excising them. Occasionally they can be treated endoscopically. Cricopharyngeal bars are treated surgically by cutting the thickened muscle. Osteophytes also can be removed surgically.
Congenital abnormalities of the esophagus usually are treated surgically soon after birth so that oral feeding can resume.
As previously discussed, strokes are the most common disease of the brain to cause dysphagia. Dysphagia usually is at its worst immediately after the stroke, and often the dysphagia improves with time and even may disappear. If it does not disappear, swallowing is evaluated, usually with a video swallowing study. The exact abnormality of function can be defined and different maneuvers can be performed to see if they can counter the effects of the dysfunction. For example, in some patients it is possible to prevent aspiration of food by turning the head to the side when swallowing or by drinking thickened liquids (since thin liquids is the food most likely to be aspirated).
Tumors of the brain, in some cases, can be removed surgically; however, it is unlikely that surgery will reverse the dysphagia. Parkinson's disease and multiple sclerosis can be treated with drugs and may be useful in patients with dysphagia.
Achalasia is treated like a stricture of the esophagus with dilation, usually with a balloon. A second option is surgical treatment in which the muscle of the lower esophageal sphincter is cut (a myotomy) in order to reduce the pressure and obstruction caused by the non-relaxing sphincter. Drugs that relax the sphincter usually have little or a transient effect and are useful only when achalasia is mild.
An option for individuals who are at high risk for surgery or balloon dilation is injection of botulinin toxin into the sphincter. The toxin paralyzes the muscle of the sphincter and causes the pressure within the sphincter to decrease. The effects of botulinin toxin are transient, however, and repeated injections usually are necessary. It is best to treat achalasia early before the obstruction causes the esophagus to enlarge (dilate) which can lead to additional problems such as food collecting above the sphincter with regurgitation and aspiration.
In other spastic motility disorders, several drugs may be tried, including anti-cholinergic medications, peppermint, nitroglycerin, and calcium channel blockers, but the effectiveness of these drugs is not clear and studies with them are nonexistent or limited.
For patients with severe and uncontrollable symptoms of pain and/or dysphagia, a surgical procedure called a long myotomy occasionally is performed. A long myotomy is similar to the surgical treatment for achalasia but the cut in the muscle is extended up along the body of the esophagus for a variable distance in an attempt to reduce pressures and obstruction to the bolus.
There is no treatment for ineffective peristalsis, and individuals must change their eating habits. Fortunately, ineffective peristalsis infrequently causes severe dysphagia by itself. When moderate or severe dysphagia is associated with ineffective peristalsis it is important to be certain that there is no additional obstruction of the esophagus, for example, by a stricture due to GERD, that is adding to the effects of reduced muscle function and making dysphagia worse than the ineffective peristalsis alone. Most causes of obstruction can be treated.
There are effective drug therapies for polymyositis and myasthenia gravis that should also improve associated dysphagia. Treatment of the muscular dystrophies is primarily directed at preventing deformities of the joints that commonly occur and lead to immobility, but there are no therapies that affect the dysphagia. Corticosteroids and drugs that suppress immunity sometimes are used to treat some of the muscular dystrophies, but their effectiveness has not been demonstrated.
There is no treatment for the metabolic myopathies other than changes in lifestyle and diet.
Diseases that reduce the production of saliva can be treated with artificial saliva or over-the-counter and prescription drugs that stimulate the production of saliva.
There is no treatment for Alzheimer's disease.
With the exception of dysphagia caused by stroke for which there can be marked improvement, dysphagia from other causes is stable or progressive, and the prognosis depends on the underlying cause, its tendency to progress, the availability of therapy, and the response to therapy.
Recent developments in the diagnostic arena are beginning to bring new insights into esophageal function, specifically, high resolution and 3D manometry, and endoscopic ultrasound.
High resolution and 3D manometry
High resolution and 3D manometry are extensions of standard manometry that utilize similar catheters. The difference is that the pressure-sensing locations on the catheters are very close together and ring the catheter. Recording of pressures from so many locations gives an extremely detailed picture of how esophageal muscle is contracting. The primary value of these diagnostic procedures is that they "integrate" the activities of the esophagus so that the overall pattern of swallowing can be recognized, which is particularly important in complex motility disorders. In addition, their added detail allows the recognition of subtle abnormalities and hopefully will be able to help define the clinical importance of subtle abnormalities of muscle contraction associated with lesser degrees of dysphagia.
Endoscopic ultrasonography has been available for many years but has recently been applied to the evaluation of esophageal muscle diseases. Ultrasound uses sound waves to penetrate tissues. The sound waves are reflected by the tissues and structures they encounter, and, when analyzed, the reflections give information about the tissues and structures from which they are reflected. In the esophagus, endoscopic ultrasonography has been used to determine the extent of penetration of tumors into the esophageal wall and the presence of metastases to adjacent lymph nodes. More recently, endoscopic ultrasonography has been used to obtain a detailed look at the muscles of the esophagus. What has been found is that in some disorders, particularly the spastic motility disorders, the muscle of the esophagus is thickened. Moreover, thickening of the muscle sometimes can be recognized only by ultrasonography even when spastic abnormalities are not seen with manometry. The exact role of endoscopic ultrasonography has not yet been determined but is an exciting area for future research.
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Crohnova bolezen se poslabša brez zdravljenja. Če se ne zdravi, se Crohnova bolezen razširi po celotnem črevesnem traktu, kar povzroči hude simptome in slabše možnosti zdravljenja. Rak debelega čreves
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