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Specific Clinical Issues: Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities
Specific Clinical Risk Factors:
GI Problems in People with Developmental Disabilities
James G. Willcox, MD



Dysphagia, esophageal disorders & GE reflux
OPENING COMMENTS:
Dont confuse usual with normal
Dont ignore the signs that a problem exists (I told ya and I told ya)
Its important to be proactive (anticipate)
Kitchen to bathroom

DYSPHAGIA
difficulty swallowing (difficulty in passage of food, solid or liquid, from the
mouth to the stomach)
inability to handle oral secretions
inability to safely take medications orally

ESOPHAGEAL DISORDERS:
anatomical problems (hiatal hernia, esophageal stricture, esophageal web,
esophageal diverticulum, esophageal ring, tumors)
inflammation (esophagitis) due to GE reflux, medications (e.g., ASA, NSAIDs,
KCl, iron, vit C, TCN), chemicals (lye or acid)
infections
esophageal dysmotility - difficulty with movement of food, solid or liquid,
through the esophagus due to decreased or ineffectual peristalsis (e.g.,
presbyesophagus), diffuse spasm, achalasia
may involve retrograde movement of material from the esophagus to the pharynx
and result in aspiration

GE REFLUX
retrograde movement of gastric contents from the stomach into the esophagus and
higher, the latter possibly resulting in aspiration of contents into the trachea and
lungs
natural occurrence
symptomatic vs. asymptomatic
degree of esophageal damage varies (most severe Barretts)
effects on pharynx, larynx, and tracheobronchial system
antireflux barrier:
lower esophageal sphincter (LES)
esophageal clearance (gravity, peristalsis, salivation, anchoring of distal
esophagus in abdomen)
gastric reservoir (dilatation, increased intragastric pressure, delayed gastric
emptying, increased acid secretion)


Page 1 of 6 Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities
Those at special risk:
Individuals with cerebral palsy, Down Syndrome (especially as they age)

Individuals with facial malformations (e.g., cleft palate)
Individuals who have had strokes or problems resulting in paralysis of
muscles involved in swallowing
Individuals with Bells palsy
Individuals who have difficult to control seizure disorders
Individuals with Parkinsons Disease, neuromuscular disorders

Elderly

Individuals with skeletal deformities such as severe (kypho)scoliosis
Individuals with a collagen disease affecting the esophagus (scleroderma,
polymyositis)

Premature infants
Individuals who are marginally compromised and are put on new medications
that have adverse side effects (e.g., psychotropic drugs, anticholinergics,
anticonvulsant medications, medications for spasticity, any medication
causing lethargy, calcium channel blockers, theophylline)
Individuals who have (or have a history of) esophageal lesions or cancers
Recumbent positioning
Increased abdominal tone
Constipation
Individuals who steal food
Individuals who eat too fast

Clinical Implications:

Morbidity (illness)
Recurrent respiratory infections, changes in pulmonary status
Inadequate hydration, leading to problems with blood electrolytes, lethargy,
worsening constipation
Inadequate nutrition (malnutrition) leading to compromised health status
Inability to take medications properly (e.g., seizure control)
Esophageal changes (esophageal stricture, Barretts esophagus, esophageal
cancer)

Mortality (death)

Page 2 of 6 Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities
What triggers the need for an investigation?

Its helpful when the individual can communicate verbally or otherwise.

Sometimes the desire to please or fear can interfere.

Sometimes there is a delay in recognition of the problem.

Signs & Symptoms:

Coughing, choking, cyanosis when eating or drinking

Crying, tearing, irritability while eating or drinking

Rales, stridor, wheezing, or congestion (gurgling) during or after eating or
drinking

Obvious difficulty chewing or swallowing

Obvious discomfort, pain, fear, or distress while eating or drinking (e.g., feeling
of food getting stuck)

Abnormal head/body positioning (especially backward arching at head/neck)

Food/meal refusal (sometimes related to unfamiliar staff)

Food spillage

Fatigue with eating

Recurrent emesis (may be behavioral but may be a symptom of GI discomfort or
of constipation)

Emesis during or after meals (including self-induced vomiting)

Vomiting of blood or coffee-ground material

Nasal reflux or regurgitation

Excessive salivation or mucus production, difficulty handling secretions

Rumination

Recurrent respiratory infections/aspiration pneumonias

Weight loss, chronic underweight status, or inadequate weight gain

Persistent or recurrent dehydration

Low grade fevers or spiking fevers of unknown cause

Unexplained anemia (iron deficiency anemia when there has been sufficient blood
loss or inadequate iron intake)

Chronic pharyngitis, laryngitis

Behavior problems around mealtime

Evidence of interstitial fibrosis on chest x-ray

Decreased serum protein, albumin, prealbumin levels

Evaluation:

History and Physical exam

Lab CBC, chemistries, stool for blood, emesis for blood, x-rays

Occupational or swallowing therapy assessment via history, exam, mealtime
evaluation, videofluoroscopy

History previous x-rays, pulmonary pathology)

Exam of oral structures, facial symmetry, muscle tone, dentition, tongue
movements, lip and jaw closure, method of processing food, drooling)

Videofluoroscopic assessment of:
-

pharyngeal structure, symmetry, delay, seepage, residue, timing and
swallow, aspiration or penetration)
Page 3 of 6 Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities
-

esophageal structure/abnormalities, motility/peristalsis
(primary/secondary/tertiary waves), lower esophageal esophageal
sphincter relaxation/patency, GE reflux, hiatal hernia
-

gastric structure, motility, emptying

Consultation with gastroenterologist who may elect to do:
-

esophageal manometry (pressure measurements)
-

esophagogastroduodenoscopy (looking into the esophagus, stomach, and
duodenum, taking biopsies, looking for H. pylori)
-

esophageal pH probe

Treatment:
General Treatment: Avoid constipation. If it is a problem, treat it (adequate hydration,
fiber, other dietary measures, medications, avoid medications that cause it or worsen it)

Treatment for Dysphagia & Esophageal Dysmotility:

Diet texture changes, thickening of liquids

Feeding techniques

Thermal stimulation

Physical management positioning

NG tube (short term when cause is self-limited or responsive to other treatment)

G-tube


























G-tubes
o

short-term or long-term
o

for supplemental use or total nutrition/hydration
o

types open surgical, PEG
o

indications: > 2months with an NG tube, documented aspiration or aspiration
pneumonia, protracted feeding times, failure of more conservative treatment,
esophageal obstruction or dysfunction (Note that GERD is not on this list)
o

risks post-op: wound infection, hemorrhage, malposition of tube, granulation
tissue, pressure necrosis of the abdominal or gastric wall, diarrhea,
pneumoperitoneum, gastrocolic or gastroenteric fistula, migration of the tube,
enlargement of the stoma, aspiration pneumonia
o

contraindications: gastric outlet obstruction, severe intractable gastroparesis,
noncompliance
o

benefits: convenient, easy to maintain and use, natural use of GI tract,
improved nutritional and hydration status, medication administration

G-tubes do not solve other GI problems such as GERD, aspiration of
oral secretions, gastroparesis.
Page 4 of 6 Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities

Treatment for GERD:
Positioning measures: Elevate head of bed
Remain
upright
after
meals/snacks
Avoiding predisposing factors: overeating, bedtime snacks, high fat foods, smoking,
alcohol, medications that make it worse, foods that make it worse (high-fat,
peppermint, chocolate, high acid content, caffeine), tight clothing over the
abdomen, posture that increase intraabdominal pressure
Medications:
- Antacids
- H2 blockers (H2 receptor antagonists)Tagamet, Zantac, Pepcid, Axid

side effects rare headache, lethargy, confusion, depression,
hallucinations, hepatitis, hematological to