Esophageal and Swallowing Disorders

(Dysphagia, esophageal diverticula, spasm, stricture, varices, and webs)

The esophagus, or gullet, is a muscular tube, approximately 10 inches long, that extends from the mouth to the stomach. It is sometimes called the food pipe to distinguish it from the nearby windpipe, or trachea. Valve mechanisms at both the upper and lower ends, as well as gravity and a wavelike muscular motion called peristalsis, keep food moving through the esophagus in the right direction.

Before it reaches the stomach, the esophagus passes through an opening in the diaphragm called the hiatus. Disorders of the esophagus may occur at any point along the way. Some involve the swallowing mechanism, which may be affected by a congenital malformation or injury to the head or neck, and interfere with the normal passage of food into the stomach. More commonly, the esophagus itself becomes diseased. Esophageal disorders or conditions that may lead to difficulty in swallowing include the following:

Diverticula, which are outpouches that form in the esophagus wall. Infections, which may spread from the mouth and upper throat or result from an overgrowth of fungi such as candidiasis in the esophagus.

Esophageal infections are most common among people taking antibiotics and those with weakened immune systems from immunosuppressive medications or such diseases as cancer and AIDS.

Spasms, or achalasia, in which the muscles controlling the esophageal sphincter contract abnormally.

Stricture, in which abnormal muscle or mucosal tissue, erosion, or tumors narrow the lower esophagus, interfering with the passage of food.

Tumors, whether benign or cancerous, which may develop anywhere along the length of the esophagus.

Ulcerations, which may result from a backflow of digestive acids from the stomach or the accidental swallowing of a caustic substance.

Varices, masses of varicosed veins in the esophagus that are often associated with liver cirrhosis.

Webs, bands of tissue in the esophagus that are sometimes present at birth or that may develop during middle age. usually in association with an iron-deficiency anemia called Plummer-Vinson syndrome.

In addition to difficulty in swallowing, symptoms pointing to an esophageal disorder include chest pain, a burning sensation in the chest and throat, bad breath, frequent choking, and spitting up of undigested food.

Diagnostic Studies and Procedures

A detailed medical history, a careful description of symptoms, and a physical examination tell a doctor a great deal about the nature of esophageal and swallowing disorders, but additional tests are usually needed. An infection necessitates laboratory cultures to identify the bacterium or fungus. Otherwise, tests usually start with an upper GI series -- X-rays taken after the patient swallows barium, an opaque substance that makes the esophagus visible on film.

Depending upon what the X-rays show, additional tests may include endoscopy (to look at the inside of the esophagus), a CT scan or MRI, ultrasonography, and manometry, which measures the pressures on the upper and lower esophageal sphincters. These tests not only make it possible to determine exactly how long it takes for food to travel from the mouth to the stomach, but they also allow doctors to watch the entire process on a screen.

If endoscopy reveals a tumor or other suspicious area, biopsy samples will be taken during the procedure.

Medical Treatments

Some disorders, such as small pouches (diverticula) in the upper esophagus, do not need medical treatment; more often, however, medication and/or surgery are necessary.

Drug Therapy. The choice of medication depends upon the underlying problem. Mild candidiasis will be treated with nystatin, an antifungal medication that is used as a mouthwash and then swallowed. If this fails to clear up the infection, a stronger antifungal medicine, such as amphotericin B, may be prescribed.

Impacted and inflamed esophageal outpouches will be treated with antibiotics, although it is usually essential to remove the foreign material first. This can be done during endoscopy.

Medications that will relax smooth muscles, such as the calcium-channel blocker nifedipine (Procardia), usually alleviate esophageal spasms.

Surgical Treatments. Extensive webs are generally removed surgically, as are large outpouches in the lower part of the esophagus that interfere with normal eating. Numerous esophageal ulcers or erosions may require removal of part of the esophagus. If a large segment or all of the esophagus must be removed, a section of intestine may be used as a graft to link the throat and stomach. This procedure will restore the ability to eat normally. Alternatively, a portion of stomach may be narrowed to form a tube, which will then be moved higher into the chest cavity to assume the function of the esophagus.

Severe strictures can be widened surgically; in other cases, a doctor may insert a rubber dilator into the esophagus to stretch the narrowed segment or break the stricture.

If medication does not control esophageal spasms, an operation called a myotomy can reduce muscular action.

Variceal sclerotherapy is used to treat esophageal varices that rupture and cause severe bleeding. In this procedure, a varicosed vein is injected with a sclerosing solution that stops the bleeding; the scar tissue that subsequently forms ultimately destroys the diseased vein, thereby preventing future episodes of esophageal bleeding.

Alternative Therapies

Alternative therapies are of the most value in treating those esophageal problems that are related to stress rather than a physical abnormality.

Nutrition Therapy. A person with a narrowed esophagus or swallowing problems may need a liquid diet. A nutrition therapist can help structure a balanced diet for someone unable to eat solid foods. Naturopaths advise patients who suffer from esophageal spasms to abstain from spicy foods as well as caffeine and alcohol.

Yoga and Meditation. These and other relaxation therapies that call for deep breathing can help overcome stress-related swallowing problems.

Self-Treatment

If you have difficulty swallowing, try eating your food at room temperature, rather than when it is very hot or cold. Chew your food well, and flush it down with fluids. You may need to switch to pureed or liquid foods. If you have dry mouth, use artificial saliva, and moisten food well before attempting to swallow it.

Do not smoke, and abstain from alcohol or use it in moderation. The combination of smoking and heavy alcohol consumption greatly increases the risk of esophageal cancer. Alcoholism can also lead to cirrhosis of the liver, which is the major cause of esophageal varices and bleeding.

Other Causes of Swallowing Problems

Strokes, myasthenia gravis and other neuromuscular disorders, and tongue, larynx, and throat cancers may create swallowing difficulties. Anxiety can aggravate the problem. Dry mouth, often caused by a medication or disease that reduces saliva production, also affects the swallowing mechanism.