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Understanding & Managing Swallowing Disorders

Online Health Chat with Scott Gabbard, MD and Siva Raja, MD, PhD

Thursday, April 3, 2014

Description

Affecting more than 15 million Americans, swallowing and esophageal disorders can range in severity and be chronic concerns that plague daily life. However, disorders such as esophagitis, gastroesophageal reflux disease (GERD), Barrett’s esophagus and achalasia often can be treated successfully before long-term damage occurs.

The esophagus is a tubular neuro-muscular organ that carries what we eat or drink from the throat into the stomach. This process requires a healthy esophagus which can be affected in many different ways. The esophagus can be damaged from acid reflux, infections, medications, radiation, benign or malignant tumors, surgical procedures, neuromuscular diseases and many other causes. The most common symptoms arising from the esophagus are swallowing difficulties (dysphagia) and painful swallowing among other conditions.

Fortunately, in many cases swallowing disorders are temporary issues that can be managed with over-the-counter medicines and lifestyle changes. But for other patients, swallowing disorders are chronic concerns and can lead to more serious conditions. Many patients require occupational or physical therapy to learn exercises and swallowing techniques to improve their conditions. Medications, esophageal dilation and surgery are reserved for patients who need further treatment to overcome swallowing disorders.


About the Speaker

Scott Gabbard, MD is a board-certified gastroenterologist in the Department of Gastroenterology and Hepatology in Cleveland Clinic’s Digestive Disease Institute. He sees patients in Cleveland Clinic’s Center for Swallowing and Esophageal Disorders. Dr. Gabbard completed his fellowship in advanced esophageal and motility and a fellowship in gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center, in Lebanon, NH. He completed his resident in internal medicine at University of North Carolina Hospitals in Chapel Hill, NC. Dr. Gabbard graduated from medical school at Case Western Reserve University School of Medicine, in Cleveland, Oh.

Siva Raja, MD, PhD is a board-certified thoracic surgeon in the Department of Thoracic and Cardiovascular Surgery in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic. His specialty interests include lung and esophageal cancer.

Dr. Raja completed his fellowship in cardiothoracic surgery at Cleveland Clinic following the completion of his residency in general surgery at Brigham & Women’s Hospital, in Boston. Dr. Raja earned his medical degree and a doctorate in molecular and cellular pathology from the University of Pittsburgh School of Medicine, in Pittsburgh.

During medical school, Dr. Raja completed one-year research fellowships in thoracic surgery at the University of Pittsburgh Medical Center and with the National Institute for Diabetes, Digestive and Kidney Diseases at Vanderbilt University, in Nashville, Tenn.

Dr. Raja sees patients at Cleveland Clinic main campus and at Medina Hospital.


Let’s Chat About Understanding and Managing Swallowing Disorders

Moderator: Welcome to our “Understanding and Managing Swallowing Disorders” online health chat with Scott Gabbard, MD and Siva Raja, MD, PhD. We are very excited to have them here today! Let's begin with the first question!


Diagnosis of Swallowing Difficulty

barbl708: I am a former smoker of 20 years, and quit in 2001. Although I stopped smoking many years ago, I just recently noticed that when I find myself eating certain foods, like French fries and meats, it is almost like the chewed food pauses and I need something to drink to remind myself to start swallowing. Does this sound like a swallowing disorder? I have been under stress (undergoing a divorce and being a caregiver) over the last few years and wondered how or why this is happening. I am normally very healthy. I am 51 years old with no surgeries and active, but had one anxiety attack July 2013 that was followed by a panic attack. The only medications that I am on include Singulair® (montelukast) and 10 mg Lexapro® (escitalopram) per day since anxiety attack last year. Do you have any advice?

Scott_Gabbard,_MD: This does sound like a swallowing disorder. I would recommend an upper endoscopy for further evaluation. One increasingly common cause of difficulty swallowing is a condition called eosinophilic esophagitis. This is a condition in the esophagus that can be related to food allergies.

MikeF: Occasionally I experience difficulty swallowing, in that I feel the item is "stuck" in the upper portion of the throat. I drink water and eat something in an attempt to get it moving. Sometimes the item moves very, very slowly from the back of my mouth into my throat causing me to extend my neck in an attempt to move it. What can be causing this and is it something I should be concerned with?

Scott_Gabbard,_MD: There are multiple causes of difficulty swallowing, also known as dysphagia. I generally break these causes into three categories: mechanical blockage or abnormality, inflammation and dysmotility (disruption of the normal muscle function of the esophagus).We generally start the evaluation of dysphagia with either an upper endoscopy or a barium swallow. In your case we may start the evaluation with a barium swallow to rule out a pouch in the upper portion of the esophagus called a Zenker diverticulum. If we proceed to endoscopy, we look for narrow areas in the esophagus called strictures, these can often be dilated through the scope. We also take biopsies of the esophagus to rule out a condition called eosinophilic esophagitis. This is an allergic condition that can cause dysphagia. If the barium swallow and upper endoscopy are unremarkable, we will often perform a procedure called esophageal manometry. This is a procedure that evaluates the muscle function in the esophagus, to rule out achalasia or other motility disorder. At Cleveland Clinic, we use a special protocol for esophageal manometry. We perform over 1,000 manometries every year, and our staff is very experienced at performing and interpreting these studies!

Big Al: I am 78 years old with a sore throat, hoarseness, and difficulty swallowing. In February 2013, the ear, nose, and throat clinic did a barium swallow, but nothing was observed. In April 2013, my throat was still sore, and I had another type of barium swallow by a different clinic. I was told my throat is old and getting lazy. My throat does not always work right, and does not know the difference between solids and liquid. In September 2013, I went back to my family doctor with a sore throat and difficulty swallowing. In October 2013, I had an appointment with an ear, nose, and throat specialist, but nothing was found in my throat. I was shown pictures of my throat, and they were clear as far as I can tell. I was told there was no swelling and no obstructions. I was told the doctor would make an appointment for a throat checkup below esophagus, but as of now I have heard nothing about an appointment. Is it all my imagination or should I be inquiring further about an appointment?

Scott_Gabbard,_MD: It does sound like you could benefit from further investigation of your esophagus. In general, we would first review your barium esophagram and then consider performing an upper endoscopy to ensure that there is no mechanical obstruction or inflammation in your esophagus. If this was unremarkable, we could consider performing an esophageal manometry to further evaluate why your esophagus appeared “old and lazy” on the barium swallow. Some causes of the esophagus not working correctly can be treated, so it is important to investigate this further.

lulubell: I have suffered for over 30 years with a throat problem. My ENT (ear, nose and throat doctor) thought it was Zenker diverticulum, but after a barium swallow and a scope from a gastroenterologist, this diagnosis was not found. Food sticks in the back of my throat and the taste is horrible after so many days. After a while this food get bigger as I eat and causes me irritation. Sometime I am able to dislodge this by coughing or moving my tongue or neck in awkward movements. When it does come up it has a horrible smell just like my breath can have. My family teases me and says I have a hair ball. It feels uncomfortable when it gets larger. I don't know if my throat is deformed in some way. Is there something else that can be tested or done to end this nightmare for me?

Scott_Gabbard,_MD: Further evaluation for a motility condition should be considered. If all studies come back normal, it is probably not Zenker diverticulum.

gatorfrog: In October 2013, I had therapy to help me with my swallowing issues. It was electric stimulation while I was eating. It did help me out but now I am starting to have trouble again. I do the at-home exercises that they recommend. I have many health issues, including type 2 diabetes, fibromyalgia, myalgic encephalomyelitis (ME/CFS), and microvascular disease. I also have GERD (gastroesophageal reflux disease) and a hiatal hernia. I am wondering what causes these swallowing issues. My brother passed away a year ago from esophageal cancer, and I worry about that too. Are there other tests that I should be getting to find out why I am having trouble swallowing? Will it always be an issue, even after therapy?

Scott_Gabbard,_MD: As I had noted in a previous question, there are a few reasons for difficulty swallowing. Here at Cleveland Clinic, we use multiple tests to help diagnose and treat difficulty swallowing, including endoscopy, barium esophagram and esophageal manometry. We also use a modified barium swallow and our speech therapists to help with throat disorders. It sounds like you may benefit from further testing to help determine the cause of your difficulty swallowing. We would be more than happy to see you here at Cleveland Clinic!


Difficulty Swallowing with Thyroid Nodules

rthrboutdrs: I was diagnosed with thyroid nodules several years ago. I continue to have negative biopsies, but I do appear to have great difficulty swallowing—especially vitamins (thus I am very bad about my vitamin routine). Can this swallowing difficulty be related to the nodules? If so, can they alone be removed ? Many years ago my daughter who was 16 years old at the time was diagnosed with achalasia. She needed an esophageal "tube" to dilate her esophagus twice. Could this be a hereditary issue?

Scott_Gabbard,_MD: This question would be best answered by further testing with endoscopy, barium esophagram and esophageal manometry to ensure there is not a second disorder causing your symptoms.

Siva_Raja,_MD,_PhD: Regards to the thyroid nodules, the thyroid can be removed partially or completely based on the size of the nodules and the risk of presence of cancer. This is specifically addressed either by an ENT (ear, nose and throat) surgeon or endocrine surgeon. Achalasia is generally not considered a hereditary condition. Although in rare situations we have seen it in more than one family member.


Gastroesophageal Reflux Disease (GERD)

John77: I have celiac disease and GERD. Are they related?

Scott_Gabbard,_MD: They are not directly related to the best of my knowledge, but celiac disease can affect many intestinal processes. It is most important to follow the celiac diet, but also to follow a GERD-“friendly” diet.

Portugal4/4: If I eat a big meal at night, I get reflux when I lay down. I don’t have heartburn during the day, and this does not happen most days. I don’t want to take medicine every day. Is there anything that I can do to help with my reflux at night?

Scott_Gabbard,_MD: Reflux at night is an important issue. Studies have shown that using an incline wedge pillow can reduce reflux events at night. Last year, a study demonstrated that using a specialized support system that keeps patients on their left side reduced reflux more than just using the incline pillow alone. We are actually studying the use of this system here at Cleveland Clinic and are actively recruiting patients to participate. We would be happy to discuss this study with you in our clinic!

MartinE: I have chest pain, burning and shortness of breath, but it always starts with difficulty swallowing—usually when I am in bed at night. Could this be GERD (gastroesophageal reflux disease)?

Scott_Gabbard,_MD: Reflux at night is an important issue. Studies have shown that using an incline wedge pillow can reduce reflux events at night. Last year, a study demonstrated that using a specialized support system that keeps patients on their left side reduced reflux more than just using the incline pillow alone. We are actually studying the use of this system here at Cleveland Clinic and are actively recruiting patients to participate. We would be happy to discuss this study with you in our clinic!

swish: Where do you get the wedge pillow you refer to?

Scott_Gabbard,_MD: The system is available for purchase and has been approved by the FDA - the website is www.medcline.com. So far, our results have been very promising.

PattyPA: I have had GERD for the past 15 years. I take omeprazole although it does not seem to help. I keep my head elevated at night, eats small meals and avoid spicy foods. I eat a few hours before bed and try to exercise every day. Every night I wake up in the middle of the night with a very sore throat and every morning with hoarseness. I have been going to a gastroenterologist and I am not sure I have found any answers. Can you help?

Scott_Gabbard,_MD: As discussed before, we are actively researching patients with reflux at night. If lifestyle changes such as this do not help, I would consider further pH testing. If you have definitive reflux at night, you may benefit from surgery. Patients with a BMI (body mass index) over 35 often get greater benefit from a gastric bypass than a typical reflux surgery. We would be more than happy to see you in our clinic.

SMDTS: I have been taking 20 to 40 mg omeprazole for years to manage GERD. I still occasionally have spasms which result in coughing up fluid. An endoscopy a couple years ago did not reveal any problems. Is there a danger in staying on medication for years? Do I need to investigate further with a specialist?

Scott_Gabbard,_MD: In general, we feel that PPIs such as omeprazole are safe for long-term use (omeprazole has been on the market for 25 years). However, there are some small risks of using these medications long term. These medications may slightly increase the risk of developing osteoporosis, but recent studies have been controversial. One recent study from Canada found that patients who used these medications did not have accelerated bone loss over a 10 year span. There may be a slightly increased risk of developing pneumonia or c. difficile colitis in patients on these medications. These medications may increase the risk of vitamin B12 or magnesium deficiency. I always try to get my patients on the lowest effective dose of these medications. I do check vitamin B12 and magnesium levels every few years in my patients on chronic PPI therapy. For the second question, I would recommend further evaluation with a physician who specializes in the treatment of swallowing disorders, to ensure that there is no other issue affecting the motility (muscle function) of your esophagus.

derekl: I have been treated for GERD with PPIs for the past 15 or so years. I recently switched to Dexilant® (dexlansoprazole) from Prevacid® (lansoprazole). I'm also on methotrexate for sarcoidosis. I have been told that taking the two medications together could lead to problems. Should I be concerned? Also, have there been any non-medicine advancements to control GERD?

Scott_Gabbard,_MD: Medications such as Dexilant® can increase the levels of methotrexate in your blood. The physician who prescribes methotrexate will need to monitor this therapy closely to ensure that your immune system is not overly suppressed. There are a few nonpharmacologic treatments for GERD available. Weight loss in patients who are overweight can help reduce reflux and may help to strengthen the lower esophageal sphincter. Eating smaller, low-fat meals may help with reflux. Sleeping with an incline wedge pillow has been shown to reduce reflux at night. There are also new surgical options for the treatment of GERD such as the Linx® procedure. This is a string of magnetized titanium beads that is surgically placed around the lower esophageal sphincter to help reduce reflux. This is a relatively new surgery. Short-term results are quite promising, but long-term results are not yet available.


Laryngopharyngeal Reflux (LPR)

LouisKY: I was diagnosed with laryngopharyngeal reflux. Is this the same as gastroesophageal reflux disease (GERD)? Do I follow the same diet?

Scott_Gabbard,_MD: This is a controversial topic. But, there may be a relation with GERD and people often use it synonymously with GERD. Unfortunately, the success rate of antireflux surgery for patients with LPR (Laryngopharyngeal Reflux) are not as high as for patients with GERD that is responsive to PPIs. Our approach at Cleveland Clinic would be to first prove objective evidence of reflux disease and also evaluate for other motility disorders of the esophagus.

millafib: While watching a television show on silent reflux, I realized I had all the symptoms, including occasional sore throat and loss of voice. I went to my ENT (ear, nose and throat) doctor and he diagnosed laryngopharyngeal reflux. He suggested using Zantac® (ranitidine) tablets, diet change, raising bed, etc. My symptoms have improved, but I can tell I still have reflux—especially with certain foods. Should I see a gastroenterologist to get things checked out lower down the pipe or just manage it and call if things get worse?

Scott_Gabbard,_MD: If your symptoms are continuing I would suggest specialized ph testing. If you can tell you still have reflux, it is not "silent."


Esophageal Spasm

AWilson60: I often choke on fluid and it is painful. It is often carbonated drinks, but not always. I have to either spit out the fluid or wait until the pain, pressure and inability to swallow subsides. This has occurred one to two times per day for the last several years. Often it happens on the first swallow of a drink. What are your thoughts on this?

Scott_Gabbard,_MD: Often, patients with chest pain when swallowing carbonated or cold beverages have a condition called esophageal spasm. As mentioned, we actually have a special protocol during esophageal manometry to try to “provoke” spasm in the esophagus. Medications that relax the smooth muscle of the esophagus can help with the symptoms of chest pain or difficulty swallowing. Some of these medications are specific blood pressure medications, so we like to confirm the diagnosis of esophageal spasm before starting these medications. One interesting study from about 10 years ago demonstrated that a few drops of peppermint oil extract mixed in a small amount of water before meals can help with esophageal spasm. I will often recommend this to my patients who have been diagnosed with esophageal spasm.


Throat Paralysis

jc7: I have a cavernous malformation in the brain stem. It has bled two times that I know of. The latest deficit that I have from the stroke is paralysis on the left side of my throat making it very difficult to swallow. The only way that I can get solid food down is to chase it down with liquids, (I can swallow liquids with no problem), take some bites, and chew, chew, chew. It takes me 45 minutes to eat a meal and it is exhausting. The paralysis was discovered with a FEEs test (I’ve also had barium swallow tests). I’ve completed some occupational therapy, which has helped a little (more in just managing the situation, so I don’t panic if I choke). It was also recommended that I have my throat stretched. What are your thoughts on this and can you give any other treatment therapy that might work for me?

Siva_Raja,_MD,_PhD: There are not any good solutions for your condition. When the time comes that oral intake of food is difficult or results in pneumonia, you may consider a feeding tube. Given that the mechanism of your problem is not due to the narrowing of your esophagus, it is unlikely that dilating the esophagus would provide benefit.

Scott_Gabbard,_MD: Using a multi-disciplinary approach is often the best treatment of this condition. Our speech pathologists here are fantastic and often find esophageal problems in addition to throat problems. While every patient is different, it may be helpful to have a repeat evaluation with speech pathology after your therapy has been completed.

jc7: One of the barium swallow tests did show a narrowing of my upper esophagus. I believe this is why they think stretching the throat might help. I am really nervous about this as I don’t want to cause additional problems. What are the risks of having your throat stretched? I am 52 years old.

Scott_Gabbard,_MD: The risk of perforation from esophageal dilation is between 1 in 200 and 1 in 500 for non-achalasia strictures. This may be a reasonable approach given the findings on barium swallow. You should discuss the risk of perforation with your gastroenterologist.


Gastroparesis

Bunker: I am 40 years old and have diabetes. I have severe heartburn and vomiting that I have been told is due to acid reflux, made worse by a slow stomach from the diabetes. I have a little relief from Nexium® (esomeprazole magnesium) two times per day, but do much better with a medicine called Reglan® (metoclopramide). Unfortunately it causes me to get nervous and shake. My doctor wants to put me on a medicine that he says is readily available, but not approved by the FDA. Do you have any advice?

Scott_Gabbard,_MD: It sounds like you may have gastroparesis as a result of your diabetes, this is a condition in which the stomach empties more slowly than it should. This can result in abdominal discomfort (called dyspepsia) and it can also result in reflux. The first step in treatment is to ensure that your blood glucose is tightly controlled. Studies have demonstrated that high blood sugars (in the 400s) can paralyze the stomach of patients without diabetes. The next step is to stick to a gastroparesis diet, which consists of small, lower fat meals. Reglan® is in a class of medications called prokinetics, these help to speed the emptying of the stomach. Unfortunately, Reglan® commonly causes anxiety and restlessness. Reglan® can also rarely cause a very serious movement disorder called tardive dyskinesia. For this reason, the FDA has placed a “black box” warning with the use of Reglan®. Your gastroenterologist may have been speaking about domperidone, which is another prokinetic medication. Domperidone does not cross into the brain, thus it does not cause movement disorders. The main adverse reaction that we worry about with domperidone is heart arrhythmia, so patients require an EKG before and after starting domperidone. Unfortunately, the FDA has not approved domperidone in the United States. Domperidone is commonly obtained from other countries with a prescription. In fact, it is available over-the-counter in countries like New Zealand. Here at Cleveland Clinic, we are actively obtaining an Investigational New Drug application from the FDA, so that we can prescribe domperidone from our pharmacy. We are in the final stages of approval for this medication. I want to also give a plug for our brand new Gastroparesis Clinic. This is a monthly multidisciplinary clinic of gastroenterologists and minimally invasive surgeons, all aimed at treating gastroparesis. Thus far, I have heard very promising things about this clinic.

Bunker: My doctor also mentioned having bariatric surgery because I am significantly overweight. I know it could also help my reflux, but would this be risky with my slow stomach?

Siva_Raja,_MD,_PhD: Actually, some bariatric surgeries have been shown to help with gastric paresis. The sleeve gastrectomy (a type of bariatric surgery) is not associated with decreased reflux, and should be avoided with patients with esophageal reflux. Gastric bypass may be your best option, but this should be done after a consultation at a high volume center.


Barrett’s Esophagus

DonnaL: My husband had an endoscopy three years ago and it showed Barrett’s esophagus. He had another endoscopy the next year and it was gone. The doctor said maybe it was due to the prior biopsy removing it. This month it is showing Barrett’s esophagus again with no dysplasia. Is the advice to have an endoscopy every three years too long to wait? Is there anything he can do to stop the Barrett’s esophagus from progressing or to make it better?

Scott_Gabbard,_MD: Barrett’s esophagus is a result of chronic acid reflux disease. In this condition the cells that make up the lining of the esophagus change and become more like stomach lining cells. This transformation is called intestinal metaplasia. Barrett’s esophagus does not cause any symptoms. However, we care about Barrett’s esophagus because it can rarely progress to esophageal cancer. The risk of this changing to cancer is related to how much Barrett’s is present. Some people with very bad reflux have a large amount of their esophagus lining affected by Barrett’s esophagus. We call any segment longer than 3 cm “long-segment Barrett’s esophagus.” Overall, the risk of Barrett’s esophagus progressing to cancer is somewhere around 1 in 400 per year, but we think that patients with long-segment Barrett’s esophagus are at higher risk than those with short-segment Barrett’s esophagus. The recommendations are for patients with Barrett’s esophagus to undergo upper endoscopy with many biopsies of the Barrett’s esophagus every three to five years. When we perform biopsies of the segment of Barrett’s esophagus, we are looking for microscopic changes called dysplasia, patients with high-grade dysplasia are at much higher risk of progressing to cancer, roughly seven percent per year. Because of this, we will often perform a procedure called ablation, this attempts to change the Barrett’s esophagus back to normal esophagus tissue. Ablation is an involved process, it often involves multiple endoscopies over the span of a year.

Busy bee: I have been diagnosed with Barrett's esophagus. My brother died from esophageal cancer two years ago. I have been taking omeprazole for some years now due to gastroesophageal reflux disease (GERD) and now the Barrett's esophagus. Would taking Nexium® (esomeprazole magnesium) be better at healing my esophagus than the omeprazole? Since my brother died from esophageal cancer, will I be more prone to cancer since I already have Barrett's esophagus? Is there anything else I can do or eat that would keep the Barrett's esophagus from getting worse or being there at all?

Scott_Gabbard,_MD: There is no data definitively showing that one PPI (proton pump inhibitor) medication is better than another at preventing progression of Barrett's esophagus. I would ensure that your acid reflux is well controlled on the medicine and consider pH testing. I would consider surveillance endoscopy in shorter intervals for someone who has a family history of esophageal cancer. You may also consider discussing ablative therapies with your gastroenterologist given your family history. We often perform ablation for patients with dysplasia. However, ablation can also be considered in someone with Barrett’s esophageal with a family history of esophageal cancer.


Primary Progressive Aphasia (PPA)

lfletcher3: In March 2013, I was diagnosed with primary progressive aphasia (PPA) by Jinny Tavee, MD at Cleveland Clinic. I want to learn about this new dementia issue . In a video from Mayo Clinic the doctor said that PPA itself will not kill patients, but at some time, we will not be swallowing in about two years and then we will die. I want to get my throat working and help my muscles stay strong. I've started with singing therapy, and eat lots of fresh vegetables. I don't know that it will help me. If you have good information that would help PPA patients, I will do everything that you want me to do.

Scott_Gabbard,_MD: We feel that diseases, such as primary progressive aphasia and other progressive neurologic disorders, benefit from a multidisciplinary approach, which sounds like what you have been doing. It is important to have your neurologists and speech pathologists work together very closely. We are very lucky to have Dr. Tavee and the neuromuscular physicians at Cleveland Clinic. They do a wonderful job for our patients with these disorders.


Traction Diverticulum

DRNB: I have been diagnosed with traction diverticulum of the esophagus by endoscope. My symptoms are stomach pain and excess stomach gas with occasional pain and swallowing difficulties in the throat. Can you tell me about surgery for this condition. What does it entails? What is the recovery and quality of life? I am 78 years old and in otherwise good health.

Siva_Raja,_MD,_PhD: Traction diverticulum are often associated with prior exposure to tuberculosis (TB) bacteria. I would make sure that you do not have active TB. The treatment involves removal of the diverticulum, so the food does not get hung up in the diverticulum. Prior to surgery, a manometry evaluation from a swallowing center is necessary to determine any swallowing disorders that may have an effect on the treatment plan. The recovery is four to six weeks with excellent quality of life when performed for the right reasons by experienced personnel.


Multiple Throat Diagnoses

skh727: In 2003, I was diagnosed with diffuse scleroderma with a lot of internal organ involvement. In January, 2014, during an esophagogastroduodenoscopy (EGD or upper endoscopy), for gastric antral vascular ectasia (GAVE), I was diagnosed with Barrett's esophagus. During another EGD two months later, monolial esophagitis was found, and I was put on Mycostatin® (nystatin) for two weeks. I am concerned that this is going to keep happening. I am concerned that the next finding will be esophageal cancer. Is there anything I can do to prevent this?

Scott_Gabbard,_MD: Our approach at Cleveland Clinic is to treat monilial esophagitis with oral antifungal agent and not topical nystatin therapy. The risk of esophageal cancer in Barrett's esophagus is low, but does increase if reflux is not controlled. I would make sure that your fungal infection has been eradicated with the nystatin therapy. If not, you may need an oral anti-fungus agent like Diflucan® (fluconazole).


Testing: pH Testing and Esophageal Manometry

skh727: What does pH testing involve?

Scott_Gabbard,_MD: There are a few different types of ph tests. One type involves a thin string that goes through your nose into the esophagus and stays in place for 24 hours. Another type involves placement of a wireless capsule into your esophagus and measures the amount of acid in your esophagus for 48 hours. We do both tests here at Cleveland Clinic.

LorraineK: I have been experiencing gastroesophageal reflux disease (GERD) symptoms and difficulty swallowing since January. Treatment with PPIs (proton pump inhibitors) and various diagnostics testing have not found a cause. Can you talk about the esophageal manometry testing and whether it would be helpful in my case?

Scott_Gabbard,_MD: Esophageal manometry involves a thin tube placed into the nose and into the esophagus. You are not sedated for the procedure, but numbing medication is placed in your nose beforehand. The entire procedure takes about 15 minutes. I have had it done to myself and did not feel it was too bad. It is our best test to determine the function of the esophagus.


Medical Devices for Swallowing

meharrison: What swallowing treatments are available? I have heard of medical devices that help you swallow for a short period of time. Are there devices that can be used to help retrain muscles or assist in swallowing for 24 hours seven days a week?

Scott_Gabbard,_MD: Currently there is no device that helps with esophageal muscle function that I am aware of. There are studies abroad involving stimulators placed into the lower esophageal sphincter for treatment of gastroesophageal reflux disease (GERD). Initial results have been favorable, but long-term studies have yet to be published.


Esophageal Dilation

linbow: I have to have my esophagus dilated at least once a year. However, it always feels like there is a grip around my throat. Why is that?

Scott_Gabbard,_MD: Often this symptom is due to nerve irritation and not persistent narrowing in the esophagus. Sometimes medications that decrease nerve sensitivity can help with this condition. I would consider discussing this further with your gastroenterologist.


Achalasia Treatment

JenniferL25: My husband has a history of radiation and achalasia. He had a Heller myotomy with a Dor fundoplication three months ago. He is still experiencing achalasia symptoms. The surgeon feels it is related to the tissue damage from prior radiation. Are there any other options for him?

Scott_Gabbard,_MD: Achalasia is a condition in which the bottom valve of the esophagus (the lower esophageal sphincter) does not open, and the muscle in the body of the esophagus does not squeeze correctly. Achalasia can result in various symptoms. The most common symptoms are difficulty swallowing (dysphagia) and chest pain. In general, our therapies are better at treating the dysphagia than they are with chest pain. At Cleveland Clinic, we perform a timed barium esophagram before and after surgery to document how successful the surgery was at opening the lower esophageal sphincter. Every patient is different, but we have considerable experience in seeing patients like your husband, who have continued symptoms of achalasia despite surgery. We use a multidisciplinary approach to achalasia that combines gastroenterologists, thoracic surgeons, minimally invasive surgeons and radiologists to help determine the next best approach for our patients. We all meet on a regular basis to discuss our most complicated patients and come up with a plan to help with their condition.

TomK: I have achalasia and my doctor wants to do surgery. I am wondering what other options there are for achalasia, such as natural herbs or other treatments. If I do need to proceed with surgery, what is the best approach? My doctor said there are minimal risks, but I am very nervous and want to make sure I make the best decision.

Scott_Gabbard,_MD: Currently, there is no medication that is FDA-approved to treat achalasia. While some medications may help with symptom relief, we generally feel that patients with achalasia need to undergo more definitive treatment of their disease to help prevent formation of “mega-esophagus.” In that condition the esophagus becomes very dilated and tortuous. The most important aspect of treatment of achalasia is that you get your care from a center with experience in treating the condition. At Cleveland Clinic, our surgeons routinely perform over 50 Heller myotomies per year for patients with achalasia. Our gastroenterologists perform many pneumatic dilations every year as well. Even though no medication is currently recommended for long-term care of achalasia, smooth muscle relaxers such as nitrates or sildenafil may help with symptoms. Botox® (botulinum toxin) injection into the lower esophageal sphincter (LES) offers about 75 percent short-term relief of symptoms, but over 50 percent of patients will need repeat injections after six months. It is low risk. Pneumatic dilation of the LES has a success rates of 75 to 90 percent in studies, but may require multiple dilations of increasing size (3.0 cm, then 3.5 cm, and then 4.0 cm). The perforation rate has been reported from 0.5 to 5 percent, but the overall rate is thought to be about .9 percent in experienced hands. The rate of gastroesophageal reflux disease (GERD) after dilation is 20 to 30 percent. Heller myotomy has a success rate of 85 to 95 percent. The rate of GERD after surgery is about 30 percent, but it can decrease to about 10 percent with Dor fundoplication. Peroral endoscopic myotomy has recently been performed at Cleveland Clinic. Short-term data from other facilities indicates around a 90 percent success rate. esophagectomy is reserved for patients with mega-esophagus. Symptom improvement is noted in around 80 percent of patients. There is greater morbidity than Heller myotomy.

swish: Our son is 20 years old. He was misdiagnosed with secondary adrenal insufficiency following an endoscopic endonasal approach (EEA) for a pituitary tumor. He was treated by a gastroenterologist as a child. He had two endoscopies and a barium swallow. These tests showed nothing and no additional testing was offered for four years even though his symptoms never improved. Our son now has osteopenia of his spine and osteoporosis of his hips. He cannot take typical medicine for gastroesophageal reflux disease (GERD). He is in his third period of vomiting in the morning, with severe nausea, spitting, stomach pain, halitosis, and weight loss. We arranged for an evaluation by an adult gastroenterologist. A barium esophagram showed dysmotility and immediate regurgitation. We are waiting for the results of another endoscopy and biopsies. This April he will undergo a manometry test. The doctor strongly suspects achalasia and believes he had it all along. Please advise on treatment options and any safe medications or lifestyle changes.

Scott_Gabbard,_MD: I am sorry to hear about your son. I do think that manometry will be very important to help rule out achalasia. See prior response regarding achalasia therapy.

Siva_Raja,_MD,_PhD: If achalasia is confirmed, your son should have a definitive treatment such as a Heller myotomy.


Heart Surgery after Esophagectomy

CharlaK: My husband had an esophagectomy 15 years ago and may need heart surgery in the near future. Can you tell me if that would be too risky or should he try to look into the new catheter surgeries?

Siva_Raja,_MD,_PhD: It is not an additional risk. However, the echo cardiogram (TEE [trans esophageal echocardiogram]) they would do during surgery may be difficult to do. They may need to do an on-table echocardiogram.


Esophageal Cancer Surgery

LauraR: My dad has esophageal cancer. They plan to remove his esophagus and part of his stomach, and then pull the remaining stomach up into his chest to be the tube for his foods. Can you talk about the success of this surgery and the recovery? I know he will not be able to eat food at first, but will there be a time when he will be back to eating?

Siva_Raja,_MD,_PhD: It is a successful surgery when performed in high volume centers with more than 15 to 20 esophagectomies performed per year. The rate of death is higher when performed in centers with low volumes. For example at Cleveland Clinic, our mortality after this surgery is one percent. The recovery is generally in the order to six to eight weeks. However, there can be minor complications that can be an issue for several months after surgery.

GeorgeH: My grandfather was just told he has a tumor in his esophagus. He is meeting with the doctor next week to go over the treatment plan. Will they do surgery and chemotherapy—what is the usual plan. Are there specific questions he should ask? Is this something that is a typical plan of care or do different surgeons and doctors treat the same way?

Siva_Raja,_MD,_PhD: For early stage cancer the treatment is surgery alone. For locally advanced cancer, it is radiation and chemotherapy followed by surgery. If the patient has widespread disease, is elderly (older than 80 years old) or has multiple medical problems, then chemotherapy would be the treatment of choice. The most important question to ask the surgeon is how many surgeries does he or she perform in a year. Outside of major cancer centers, the treatment can be variable and nonstandardized. It is best to receive your treatment at a center that is able to provide a multidisciplinary consultation.


MyConsult® Evaluation

zarnawabkhan: My daughter who lives in Pakistan suffers from hiatal hernia. She vomits after every meal or beverage for the last five months. We have visited doctors, but she is still not recovering. She underwent three barium swallows and four endoscopies. The doctor has advised an esophageal manometry, but have not had it done yet because there are few manometers in Pakistan. We checked on the locations of these machines elsewhere. Please advise us what we can do for her health. She has had CT scans of the chest and brain, and blood tests for every diagnosis. Only hiatal hernia is showing. Please help us by telling us what we can do for her further.

Siva_Raja,_MD,_PhD: Often we can get a very good sense of the disease process from the video barium esophagram. I would ensure that these were video esophagrams. We have an online MyConsult® service (www.clevelandclinic.org/myconsult.) If you have these tests and videos, you can send them in for consultation.


Closing

Moderator: I'm sorry to say that our time is now over. Thank you again, Dr. Gabbard and Dr. Raja, for taking the time to answer our questions.


For Appointments

To make an appointment with Scott Gabbard, MD, or any of the specialists in the Center for Swallowing and Esophageal Disorders or Digestive Disease Institute, please call 216.444.7000 or 800.223.2273, ext. 47000 (toll-free). You can also visit us online at www.clevelandclinic.org/digestive.

To make an appointment with Siva Raja, MD, PhD or any of our thoracic surgeons in the Miller Family Heart and Vascular Institute, please call 216.445.6860 or toll-free 866.289.6911. You can also visit us online at www.clevelandclinic.org/heart.


For More Information

On Swallowing and Esophageal Disorders
On Cleveland Clinic

The Center for Esophageal and Swallowing Disorders provides patients with a variety of esophageal problems with a comprehensive diagnostic evaluation to find the cause and give the appropriate treatment for the esophageal condition. Our staff work closely with other specialties in a multidisciplinary way to approach and solve the patient's problem. These include advanced endoscopists, thoracic and general surgeons, ENT physicians and speech pathologists, allergy-immunologists and pulmonologists as well as radiologists and pathologists.

The team also includes an American Board-certified gastroenterologist with special interest, expertise and experience in esophageal disorders. Staff also includes medical assistants and registered nurses who perform diagnostic procedures dedicated to diagnose esophageal disorders.

On Your Health

MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.


Contact Information

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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Reviewed: 05/14

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2014. The Cleveland Clinic Foundation. All rights reserved.