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

November 13, 2013


More than 15 million Americans have a swallowing disorder, or dysphagia. Swallowing disorders include esophagitis and achalasia. Swallowing disorders can be caused by medical problems involving the throat, esophagus or brain. Associated medical conditions that can cause swallowing disorders include gastroesophageal reflux disease (GERD), multiple sclerosis, stroke, cancer, and immune function disorders.

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 that plague daily life 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 Speakers

Scott Gabbard, MD is a board-certified gastroenterologist in the Department of Gastroenterology and Hepatology in Cleveland Clinic’s Digestive Disease and Surgery 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.

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 PhD in molecular and cellular pathology from the University of Pittsburgh School of Medicine, in Pittsburgh.

During his medical school career, 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, Nashville, Tenn.

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

Let’s Chat About Ask the Experts: Understanding and Managing Swallowing Disorders

Moderator: Welcome to our chat "Ask the Experts: Understanding and Managing GERD and other Swallowing Disorders" with Cleveland Clinic gastroenterologist Scott Gabbard, MD, and thoracic surgeon, Siva Raja, MD, PhD. Dr. Gabbard, would you like to start begin?

Scott_Gabbard,_MD: While I am not able to provide a specific consultation over this webchat, I will tell you about what we offer at Cleveland Clinic. Our Swallowing Center provides a multidisciplinary approach to patients with swallowing disorders. We have a team of gastroenterologists, thoracic surgeons, minimally invasive surgeons, dedicated motility nursing staff and radiologists all with a specific focus on swallowing disorders. We also work very closely with ENT surgeons, pathologists and speech pathologists. We use proprietary techniques during motility testing to help provoke symptoms. We would love to meet you in person to discuss how Cleveland Clinic Swallowing Center can help to diagnose and treat your disorder.

Diagnosis, Causes, Symptoms and Associated Medical Conditions

Bassgab: What is your approach to patients with typical reflux symptoms who are not responsive to standard medical treatment?

Siva_Raja,_MD,_PhD: In these situations, it is imperative to establish the diagnosis of reflux and the mechanism of reflux. The symptoms of gastro-esophageal reflux can be due to esophageal stasis (achalasia), esophageal motility disorder (esophageal spasms), incompetent lower esophageal valve (hiatal hernia) or poor gastric emptying. Therefore, it is important to establish the presence of acid reflux with an incompetent lower esophageal valve. The anti-reflux procedures that are performed today attempt to recreate a competent esophageal valve. When operations are performed for the wrong indication, symptoms are not resolved. After establishing the presence of acid reflux and eliminating the other causes of the patient's symptoms, a Nissen fundoplication is offered as a primary treatment. Any hiatal hernia that is encountered is also repaired at the same time.

Scott_Gabbard,_MD: Some studies have suggested that over 50 percent of patients with GERD (gastroesophageal reflux disease) symptoms who don't respond to PPI (proton pump inhibitor) actually have functional heartburn, which is a nerve disorder. In functional heartburn, the nerves of the esophagus are overly sensitive. Thus, the treatment for this disorder would be medications that decrease the sensitivity of the nerves, not treating the acid. The best way to determine if a patient has GERD or functional heartburn is to perform a pH test while the patient is not on any medications for reflux.

gatorfrog: I am 56 years old, and have fibromyalgia. I went through 15 sessions of swallowing therapy involving neuromuscular electrical stimulation. I also have exercises that I have to do at home. I just finished the treatment, and I am curious what you think of this kind of treatment. How does fibromyalgia affect swallowing, and what are chances of recurrence—especially given my age?

Scott_Gabbard,_MD: In general, fibromyalgia affects the sensory nerves of the skeletal muscles. A related condition would be functional dysphagia, in which the sensory nerves of the esophagus are affected in a similar manner. However, we would need to first exclude other causes of difficulty swallowing such as a mechanical blockage from a stricture or esophageal spasm. We generally use endoscopy or a barium esophagram to rule out a mechanical blockage and esophageal manometry to rule out a muscle disorder such as spasm. If all of these are unremarkable, we can use medications aimed at treating the nerve disorder. Some of these medications are similar to those used for fibromyalgia.

clara: I was just told I have Barrett's esophagus. I have been on 81 mg aspirin and Plavix® (clopidogrel bisulfate) since 2009. The cardiologist thinks aspirin may be the problem. I have completed a year of Plavix® for the last stent. The cardiologist said I could go off either one, but not both. I decided to go off aspirin to see if the esophagus condition would get better. I really do not have many symptoms—maybe a little heartburn sometimes. I had the endoscopy done at the same time they did the colonoscopy. I did not think I needed the endoscopy at the time, because the colonoscopy was what I needed. I would rather be off Plavix®, but I surely do not want cancer. I have eight stents, and have been on Plavix® and aspirin since 2009. The gastroenterologist did not tell me anything to do except take a PPI (proton pump inhibitor). I am on Forteo® (teriparatide), and I know that PPIs affect the bones. I have osteoporosis. I felt that he thought I could do what I wanted to do, but take another test next year. I do not have any directions on how to address the esophagus problem.

Scott_Gabbard,_MD: Let's first start by discussing what Barrett's esophagus is, then we can discuss treatment options. Barrett's esophagus is a condition in which the lining of the esophagus changes, and begins to look like stomach lining. The main risk factor for Barrett's esophagus is gastroesophageal reflux disease (GERD), though many patients with Barrett's esophagus only have mild reflux symptoms. Barrett's esophagus is actually fairly common in the U.S., some estimate that up to three million Americans have Barrett's esophagus. I am not aware of aspirin or Plavix® (clopidogrel bisulfate) causing Barrett's esophagus.

We care about Barrett's esophagus because it increases the risk of esophageal cancer. The risk of esophageal cancer in a patient with Barrett's esophagus is around one in 400 per year. The recommendation is to perform an endoscopy with biopsy every one to three years in patients with Barrett's esophagus. During endoscopy, we look for raised areas in the esophagus, as these are at higher risk for cancer. We also perform biopsies to look for dysplasia under the microscope (this is a precursor to cancer). Patients with dysplasia may be offered an endoscopic therapy to ablate the Barrett's esophagus. This decreases the risk of the Barrett’s esophagus progressing to cancer. Cleveland Clinic is a Center of Excellence for Barrett's esophagus. We are happy to help care for this condition.

In terms of medications, a recent study suggested that PPIs (proton pump inhibitors) actually decrease the risk of progression to cancer in patients with Barrett's esophagus. Therefore, we generally recommend that patients with Barrett’s esophagus continue these medications, even if you do not have reflux symptoms. Another large study found that aspirin may also decrease the risk of esophageal cancer, so I would not recommend that you stop your aspirin. I don't believe that Plavix® changes the risk of esophageal cancer, so I would not recommend stopping the Plavix® on behalf of your Barrett's esophagus. Although I think that the esophagus is a very important organ, I think that the heart is even more important! I would take whatever medications that your cardiologist recommends to help decrease your risk of any further heart problems.

As to the question of PPIs and bone loss, the relationship between the two remains controversial. Patients taking PPI seem to be at a slightly higher risk of fractures. However, a recent study from Canada demonstrated that patients taking PPIs for ten years did not have a significant acceleration in bone loss over that time period. It is important that you discuss your risk of bone fractures with your primary care physician to determine how to best decrease this risk.

Swellgal: Could intercatheter pain pump medicine, Dilaudid® (hydromorphone hydrochloride) nine mg daily, cause swallowing problems? I have one implanted for chronic back pain due to failed back surgery syndrome.

Scott_Gabbard,_MD: There have been recent studies to suggest that opiates can cause severe esophageal dysmotility. I am not sure if this was done in patients with intrathecal pumps, though I would imagine that they could also cause severe motility problems.

Diagnostic Testing

jklingen: I had radiation therapy 15 years ago for squamous cell carcinoma. In the last two years scar tissue grew on the radiation site, and this required placement of a stent in my carotid artery one year ago. I intermittently have very sore throat and a strong tickle that causes severe coughing fits. I take two Neurontin® (gabapentin) 300 mg twice daily and Ultram® (tramadol hydrochloride) 50 mg once daily along with Prilosec® (omeprazole) twice daily. What might other alternatives be to ease the sore throat and tickle?

Scott_Gabbard,_MD: We would first have to figure out if your cough was due to reflux or nerve sensitivity. The best way to determine this would be to perform pH testing or pH impedance testing to determine if your cough is due to reflux.

Swellgal: For the last 20 months I have only been able to swallow a few bites of most foods. Food seems to pile up in my esophagus. I then become mildly nauseous (and sometimes vomit), begin belching and hiccupping. This feeling eventually subsides, but I cannot eat again for several hours. I have had two esophagogastroduodenoscopies in April 2012 and August 2012. The first impression was gastritis with bleeding and esophagitis, but no cancer. The second impression showed the same finding with marked improvement of my gastritis and esophagitis. The hiatus was also stretched. I have had a chest x-ray, echocardiogram, ultrasound of the gall bladder, gall bladder motility study, barium swallow test (showing no aspiration unsmooth peristalsis), esophageal motility study (that was incomplete because the probe wouldn't pass through the hiatus), and CAT scan of the pancreas, liver, and gall bladder. An ENT examined my throat and found nothing. The gastroenterologist and ENT prescribed Nexium® ( magnesium) for GERD (gastroesophageal reflux disease). I have been taking it faithfully for 20 months, but with no improvement. I have also tried Prilosec® (omeprazole) and Gaviscon® (calcium carbonate), but they were of no help. I do not think it is GERD. Can you help with this chronic swallowing disorder?

Scott_Gabbard,_MD: While this may be a bit more difficult to answer here, I do wonder why the manometry catheter did not pass into your stomach. I would want to ensure that you do not have a condition called achalasia, which occurs when the lower esophageal sphincter doesn't open to allow solids and liquids to enter the stomach. I would ensure that you had a full barium esophagram and not a modified barium swallow. A modified barium swallow only evaluates the oropharynx and upper esophagus. It would not evaluate the bottom of the esophagus and the junction of the esophagus and stomach (where the catheter would not pass).

jc7: I have a cavernous malformation in the brainstem that has bled multiple times and one of my deficits is swallowing. (The left side of my throat is paralyzed.). Do you have any recommendations or had any successes in reversing this issue? I understand many stroke victims suffer from this.

Scott_Gabbard,_MD: You are correct, many patients have difficulty swallowing after a stroke. This is best managed with a multidisciplinary group consisting of gastroenterology, neurology, ENT and speech pathology. Often the best test is a modified barium swallow with a speech pathologist present. They can then instruct you regarding exercises to help improve your swallowing function.

sinaihospital: I have had GERD (gastroesophageal reflux disease) since 2002. I have been taking one or more medications, but it is getting worse for me. I've had more than four endoscopies, which indicated that the GERD has not gotten any better. I have tried medicines, but either had an allergy to the medication or it did not help me. Can surgery help this problem? I also have a stomach ulcer—can this cause my GERD to get worse? What type of tests do I need for my GERD problem?

Scott_Gabbard,_MD: Endoscopy can demonstrate inflammation from reflux and Barrett's esophagus, but a normal endoscopy does not completely rule out the presence of GERD. For patients with GERD symptoms and normal endoscopy, we will often perform pH testing to confirm that the patient has abnormal levels of acid reflux. pH testing can be performed with a catheter (a thin tube) in the nose, or with a wireless capsule that attaches to the esophagus and transmits data to a receiver that the patient wears. We generally check the pH of the esophagus for 24 to 48 hours, depending on the type of test that is performed. We would also perform esophageal manometry to ensure that there are no muscle disorders in the esophagus. Treatment options would depend on the results of the testing. Surgery may help with reflux symptoms in patients found to have abnormal levels of reflux. However, we often are able to control symptoms through adjustment of medications.


Olivia0905: What would you recommend as treatment for a hiatal hernia?

Scott_Gabbard,_MD: Interestingly, studies have shown that up to 55 percent of adults in the U.S. have a small hiatal hernia, but not everyone has symptoms from the hernia. If the patient has significant reflux that only partially responds to medications, one could consider surgical repair of the hernia, combined with anti-reflux surgery like a fundoplication. However, the majority of patients with hiatal hernia and GERD (gastroesophageal reflux disease) respond well to medications such as proton pump inhibitors (PPIs).

NEWYORKER: I am a 58-year-old female being treated for GERD (gastroesophageal reflux disease). I am having side effects from Nexium® (esomeprazole magnesium), but my cardiologist does not want me to try Prilosec® (omeprazole). (I have two right coronary artery stents and still take Plavix® [clopidogrel bisulfate]) or for that matter any PPI (proton pump inhibitor). What would you suggest as an over-the-counter (OTC) medication? I am making substantial changes to a rather spicy diet.

Scott_Gabbard,_MD: I would try smaller, low-fat meals and consider sleeping with a reflux wedge pillow. The PPI and Plavix® question is controversial. The most recent studies have suggested that there may not be any interaction between PPI and Plavix® (the COGENT study in particular), but I would defer this question to your cardiologist. In theory, Protonix® (pantoprazole), another PPI, should have less interaction with Plavix®. You could ask your cardiologist about this medication.

gatorfrog: Do you recommend neuromuscular electrical stimulation for swallowing therapy and what are the chances of recurrence? I had an endoscopy in May of this year that did not indicate any stricture or esophageal spasm. What medications are aimed at treating this disorder? I might possibly be on them already for my fibromyalgia.

Scott_Gabbard,_MD: I am not aware of using stimulators for fibromyalgia-induced dysphagia. The treatment options would depend on the results from manometry and barium esophagram.

Medication Side Effects

tcline52: Is tinnitus a known symptom that can result from GERD (gastroesophageal reflux disease)?

Scott_Gabbard,_MD: I am not aware of GERD as a possible cause of tinnitus. However, tinnitus is a rare side effect of proton pump inhibitors, which are used to treat reflux. I would consider discussing this further with an ENT physician.

Achalasia: Botox and Surgery

Bassgab: In a patient with achalasia who is not a good operative risk, is there a limit to the number of times Botox® (botulinum toxin) injections can be used—and does it become progressively less effective with time? How effective in your experience is medical therapy of achalasia with nitrates, calcium blockers, etc.? Is there any other medical therapy?

Siva_Raja,_MD,_PhD: Regarding the efficacy of Botox®, I defer to Dr. Gabbard. However, a Heller myotomy is a very well tolerated, minimally intrusive procedure. As such, before being considered a poor operative candidate, I would recommend seeking a second opinion at a high-volume tertiary care center where a significant amount of achalasia surgeries are being performed. We are happy to provide a second opinion on surgical risks.

Scott_Gabbard,_MD: In terms of Botox®, there is actually no maximum number of times it can be done. I know of a few patients who have undergone over 20 injections over a 15-year span. At Cleveland Clinic Swallowing Center, we often perform a 20 mm balloon dilation after injecting Botox® into the LES (lower esophageal sphincter). This seems to help more than injections alone. It is something that we are thinking of performing a study on it here at Cleveland Clinic. In terms of medications, Sildenafil has been shown to help with symptoms, but it is quite expensive and often not covered by insurance.

Bassgab: In a patient with achalasia who is a good surgical risk, how do you choose between pneumatic dilatation, laparoscopic Heller myotomy or POEM (peroral endoscopic myotomy)?

Siva_Raja,_MD,_PhD: I believe that a pneumatic dilation is reserved for someone who might be acutely obstructed, and does not have access to a surgeon who performs surgery for achalasia. Laparoscopic Heller myotomy is the gold standard treatment currently for the treatment of achalasia. This has a long track record of success. Alternate therapies like Botox® increase scarring in the lower esophageal sphincter and increase the technical difficulty of a subsequent myotomy.

Feeding Tubes

loveitaly: My daughter is 32 years old. She has developmental disabilities from birth (cerebral palsy and seizure disorder) and other medical conditions, including GERD (gastroesophageal reflux disease) caused by a seizure medication Carbatrol® (carbamazepine extended-release) 20 years ago. She began Reglan® (metoclopramide), but she stopped it because of neurological side effects. She also took Propulsid® (cisapride), but it’s off the market now, and Prevacid® 30 mg twice daily for the past 15 years. She eats pureed food, and her menu is limited. She eats well, but a lesser amount now. Her physicians say when you have GERD, the stomach shrinks due to the calories used in the digestion. Her fluids are thickened due to a swallowing disorder. Pediatric gastroenterologists wanted to do fundoplication and a G-tube (gastrostomy tube), but the G-tube couldn't be done without fundoplication. Adult gastroenterologists don't want to do anything invasive to her due to her medical conditions. Many days she is ok, but other days she has discomfort. Those days she needs Maalox® and chest massages. She is sitting a period of two and a half hours after meals, her bed is semi elevated, etc. Why are there different opinions from pediatric to adult doctors?

Scott_Gabbard,_MD: I am sorry that your daughter has had so much difficulty eating over the years. While I don't think that I can give you a specific answer to this question, I will describe our approach. We will generally have the patient meet with multiple members of our Swallowing Center during the initial consultation (i.e., meet with both the gastroenterologist and the surgery staff). We can then determine the optimal approach to feeding. Feeding tubes can be helpful in patients who are losing weight or unable to swallow adequate nutrition. Feeding tubes can be placed directly into the stomach or directly into the jejunum (small intestine). Placing a feeding tube directly into the jejunum may help to prevent reflux of the tube feeds, although I would hesitate to make any specific suggestions without reviewing the records and meeting your daughter.

Surgical Treatment Options

derekl: Have there been any surgical improvements for treating GERD (gastroesophageal reflux disease)? Using long-term PPIs (proton pump inhibitors) seems to be the typical treatment, but they can lead to additional problems.

Scott_Gabbard,_MD: I think that this would be a good time to discuss what GERD is, and then we can discuss treatment options. Normally, the stomach secretes very strong acid to help digestion. High levels of acid are generally well tolerated in the stomach. The bottom of the esophagus is made up of a ring of muscle called the lower esophageal sphincter. This ring of muscle acts as a valve that prevents stomach acid from refluxing up into the esophagus. We now think that the main cause of GERD is due to the sphincter transiently relaxing. This results in an open conduit for acid to enter the esophagus. Many patients also have a hiatal hernia—this occurs when the junction of the esophagus and stomach is located above the diaphragm muscle. While hiatal hernias do not directly cause reflux, they can increase the risk of having GERD. Medical treatment options have generally revolved around decreasing the levels of acid in the stomach. PPIs like Nexium® are the most common medications that are used to decrease levels of stomach acid. To date, there are no medications approved by the FDA that decrease transient lower esophageal sphincter relaxation. Baclofen has been found to decrease these sphincter relaxations. However, it is not approved by the FDA for the treatment of GERD (though some gastroenterologists will use it off-label for this purpose). Sometimes patients have normal levels of acid in their esophagus, but the cause of their symptoms is the nerves in their esophagus are extra-sensitive to acid. In these cases, we often prescribe medications that decrease the nerve sensitivity in the esophagus. These often help patients who do not have a full response to the medications I listed above.

Siva_Raja,_MD,_PhD: The treatment of GERD still remains predominantly medical. Surgical options are reserved for patients who have failed therapy or are having complications or side effects from treatment. The reason is that even in the best of settings, surgical treatments of GERD—while eliminating reflux—have their own set of unique side effects. The standard treatment is a Nissen fundoplication and repair of hiatal hernia if it's present. There are many new treatment modalities that are being investigated that are thought to be less invasive, but are investigational at this time.

I would consider having the manometry repeated. At Cleveland Clinic’s Swallowing Center, we will place the manometry catheter with the help of a scope in cases where the catheter doesn't pass on its own. I think that this would be a very important step in the management of your condition.

JJM552: Does Cleveland Clinic offer any of these surgeries you're talking about robotically that are minimally invasive? How do you determine if a patient has a traditional open surgery vs. a minimally invasive procedure?

Siva_Raja,_MD,_PhD: We do offer most of our minimally invasive procedures as laparoscopic or robot-assisted procedures. In patients who have had multiple prior surgeries, open surgery is beneficial in dealing with the scar tissue from prior surgeries. Minimally invasive surgery has been shown to have decreased pain, small surgical scars, shorter hospital length of stay and quicker return to pre-operative functional status. We perform minimally invasive surgery for a variety of esophageal diseases when appropriate.

MommaB: I have a 25-year-old son with spastic cerebral palsy. He has a swallowing dysfunction that has been progressively getting worse. He had a gastrostomy button and Nissen fundoplication at three years old. He takes nothing by mouth. When he was ten years old, he had a tracheostomy. Since January of this year, he has been hospitalized four times with aspiration pneumonia. The doctors say he is aspirating on his secretions. They have him on two scopolamine patches to dry up oral secretions. I am also in the process of getting a Hill-Rom Vest® for him to help his lungs. Do you have any recommendations that may be helpful?

Siva_Raja,_MD,_PhD: Aspiration risk can be mitigated by changing the feeding access from a gastrostomy tube to a jejunostomy tube. Given that he does not have oral intake, the assumption is the aspiration is from his gastric contents. Despite a Nissen fundoplication, people can have issues with regurgitation and vomiting. Unfortunately, not many other good solutions exist for this problem.

Nighttime Reflux Remedies

rspecter: I have heartburn mostly at night when I go to sleep. Is there anything I can do aside from taking extra doses of my reflux medication?

Scott_Gabbard,_MD: My first recommendation would be to eat a smaller, low-fat meal for dinner—preferably at least three hours prior to lying down. Fatty foods actually cause the lower esophageal sphincter to relax; thus, they are often the cause of reflux after a meal. Most solid food empties from the stomach in three to four hours. Therefore, not eating for three hours before bed may help with reflux.

Using a reflux wedge pillow (with an eight-inch incline) has been shown to decrease reflux episodes at night, compared with sleeping flat. At the American College of Gastroenterology Conference last month, a study using a system that combined a reflux wedge pillow with a body pillow found that sleeping on the left side with the wedge significantly decreased reflux events compared to using the wedge alone or sleeping flat. Interestingly, sleeping on the right side produced the most reflux at night.

Alternative Therapies

franklin: For 15 years I have suffered esophageal spasms on a random basis. The duration of the spasms is anywhere from one-half hour to two hours. I am not able to identify a cause for these spasms and one gastroenterologist prescribed a nitroglycerin sublingual spray to treat my condition, but it is ineffective. The episodes are painful and scary. Do you have any other suggestions to provide relief for this condition?

Scott_Gabbard,_MD: The bottom of the esophagus is actually made up of smooth muscle. This is a different kind of muscle than skeletal muscle such as your biceps. The treatment of esophageal spasm typically involves medications that relax the smooth muscle of the esophagus. There are various medications that can accomplish this. Peppermint oil is actually a powerful smooth muscle relaxant. One well-done medical study demonstrated that five drops of McCormick® Pure Peppermint Extract in 10 cc's of water decreased muscle spasms in the esophagus. Warm peppermint tea can also relax the esophagus. Other treatments for esophageal spasm include some blood pressure medications (because arteries are also made up of smooth muscle). There are also endoscopic and surgical treatments for patients with esophageal spasm who do not respond to the medication.

Olivia0905: Should peppermint oil be used to treat GERD (gastroesophageal reflux disease)?

Scott_Gabbard,_MD: Peppermint oil may actually make GERD worse! Peppermint oil can relax the lower esophageal sphincter and increase the risk of reflux. Peppermint oil can be a great treatment for esophageal muscle spasms though. I often recommend it to my patients. Additionally, peppermint oil capsules can be used to treat irritable bowel syndrome, many patients get nice relief with this medication.

New and Investigational Therapies

Swellgal: Could testing at Cleveland Clinic reveal whether or not Dilaudid® is causing the problem or if it is due to some other swallowing problem?

Scott_Gabbard,_MD: The problem with testing is that opiate-induced dysmotility would look the exact same on manometry as severe GERD (gastroesophageal reflux disease). Manometry would only show the severity of the disorder, but it could be of some value. Therefore, in a healthy individual, this is a definitive treatment for achalasia. POEM (peroral endoscopic myotomy) is being performed in certain centers under an investigational fashion in the U.S. It holds great promise to replace laparoscopic Heller myotomy. However, it remains an untested treatment modality with only short-term follow up being available.

Bassgab: You spoke previously of investigational therapies. Do you have an opinion or experience with anti-reflux procedures such as LINX or some of the endoscopic-based therapies?

Siva_Raja,_MD,_PhD: We do not have significant experience in performing anti-reflux procedures such as LINX™ or EsophyX™. Our only experience comes from dealing with the complications of those procedures. I realize that this is an unfair sampling of the complication risk of those procedures as we only see the failed ones, not the successful ones.

Surgeon Selection

JohnS_42: How does someone go about finding an anti-reflux surgeon?

Siva_Raja,_MD,_PhD: Anti-reflux surgery is performed commonly throughout the U.S. This procedure can have a long-term benefit when performed for the right clinical indication. To determine whether it is the right clinical indication often involves a work up by a swallowing disorders specialist. I cannot stress the importance of a thorough workup, as the best results are achieved with the first surgery. The outcomes for redo esophageal surgery are not nearly as good as for primary anti-reflux procedures. This surgical expertise can be found locally but if not available, I would seek out a high-volume esophageal surgery center. This last recommendation is most true for those seeking opinions on redo esophageal surgery. At Cleveland Clinic’s Swallowing Center, We are happy to provide a consultation to determine if anti-reflux surgery or a redo anti-reflux surgery may be appropriate for you.


Moderator: I am sorry to say that we are at the end of our chat. We appreciate your participation and hope you will join us for other chat topics in the future.

Thank you, Dr. Gabbard and Dr. Raja, for sharing your expertise and answering questions today about new advances in treating swallowing disorders.

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 and Surgery Institute, please call 216.444.7000 or 800.223.2273, ext. 47000 (toll-free). You can also visit us online at

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

For More Information

On Cleveland Clinic

Ranked second in the United States and top in Ohio by U.S. News & World Report for gastroenterology, Cleveland Clinic offers one of the few centers in the country dedicated to swallowing disorders. Through the Center for Swallowing & Esophageal Disorders, patients benefit from the extensive experience of physicians who diagnose and treat nearly 2,000 patients a year. An entire team of specialists——including gastroenterologists, radiologists, pathologists, thoracic surgeons and swallowing therapists——offer leading-edge diagnosis and treatment options.

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Reviewed: 12/13

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