Swallowing Disorders:
Gastroesophageal Reflux Disease (GERD): A very common disease in the
United States affecting as many as one third of all adults. It most commonly
manifests as heartburn and/or acid regurgitation. However, many patients may
have difficulty swallowing, chest pain, cough, hoarseness, asthma, and other
respiratory complaints. Medications, usually proton pump inhibitors and
histamine blockers, are often effective in reducing the acidity of the reflux
thus decreasing symptoms and is usually the first line of therapy. The other
option is laparoscopic antireflux surgery. This is very safe operation utilizes
tiny incisions, decreasing the pain and recovery is usually only 1-2 days in
the hospital.
Barrett’s Esophagus: A manifestation of severe GERD, this is a change
in the cellular lining of the esophagus. It’s presence represents a 40 fold
increase in the risk of esophageal cancer. Those patients with significant GERD
symptoms for more than 1 to 2 years should have an endoscopy to screen for
Barrett’s esophagus. Patients with Barrett’s should be on effective medical or
surgical therapy, and need to have regular endoscopies (every 1-2 years) to
assure there is no progression to cancer.
Esophageal Cancer: This once rare form of cancer is rapidly
increasing in the United States and other western countries. Its treatment
requires removing part or all of the esophagus and replacing it with the
stomach or colon. This is a technically demanding operation, and has much lower
risks of complications and death if performed in a center that has significant
experience in such operations. Chemotherapy and radiation may be required
before operation to give a better chance for cure.
Achalasia:
A disease characterized by the loss of esophageal peristalsis, primarily in
the lower 2/3. Often the loss of peristalsis is accompanied by an increase in
the pressure of the lower esophageal sphincter. Patients usually complain of
dysphagia and retention of undigested food in the lower esophagus. The
pathologic finding in esophageal specimens is the loss of nerve fibers in the
wall of the esophagus. The cause remains unknown.
Other Esophageal Motility Disorders
Diffuse Esophageal Spasm (DES): A disease of
abnormal esophageal motor function characterized by non-peristaltic
contractions. The episodes are usually intermittent and associated with
dysphagia and/or chest pain. At present, DES is thought to be one member of a
family of motor disorders which include the Nutcracker esophagus and Hypertensive
LES.
Hypertensive Lower Esophageal Sphincter:
This disorder is less common than the other motility disorders. It is
characterized by a high resting pressure for the lower esophageal sphincter.
The primary symptom is retention of ingested material in the lower esophagus.
It is considered to be part of a spectrum of motility disorders due to its
occasional coexistence in patients with other swallowing problems.
Nutcracker Esophagus (NE): The Nutcracker Esophagus is a variant of DES. The
primary disorder is high amplitude contractions. The waves generated are
frequently disordered and result in poor peristalsis. The common symptoms
experienced by patients are intermittent chest pain and dysphagia. During 24
hour motor function surveillance studies it has been shown that many patients
with a clinical diagnosis of NE have periods of DES. Based on these findings,
the current view is that NE and DES are probably differing entities in a larger
family of swallowing disorders.
Diagnostic Testing
Esophageal Manometry: Esophageal manometry requires us to place a
small and tube into the mouth or nose through the esophagus and into the
stomach. With this catheter we are able to measure pressure in the esophagus.
The primary measurements of interest are the pressure and function of the Lower
Esophageal Sphincter and the peristalsis of the esophagus. The lower esophageal
sphincter’s role is to prevent the reflux of acid from the stomach to the
esophagus, so is often dysfunctional in patients with GERD. This sphincter may
also be too tight and fail to relax, making it difficult to swallow effectively
in diseases such as achalasia. Peristalsis is the rhythmic, serial contraction
of the esophagus that propels food from the mouth to the stomach.
24 Hour pH Monitoring: A 24 Hour pH Test also requires us to place a
tube into the mouth or nose. However, this tube is much smaller than the one
for the manometry study and has no water perfusing through it. This tube
extends from the nose into the esophagus and stops a couple of inches above the
sphincter. Once the tube has been placed the patient goes home with the
catheter and returns the equipment on the following morning.
This catheter measures the pH of the patients distal and mid esophagus
(acidity of the esophagus).
Endoscopy: A flexible tube with a camera on the tip.
This enables the viewing of the esophagus, stomach, and first portion of the
small intestine. Therefore, inflammation, ulceration, or tumors in these areas
can be seen, and thus is extremely important for diagnosing (and sometimes
treating) diseases of the gastrointestinal tract. Biopsies and other treatments
(such as dilations) can be performed with endoscopy as well.
Impedance: This is a new technique used to study GERD
and the esophageal swallowing mechanism. We have new catheters that not only
measure manometry and pH, but have impedance sensors attached so more sensitive
information may be collected, without additionally testing or discomfort. The
impedance sensors on the pH wire allow us to detect reflux episodes that are
not detected by pH (pH>4). These non-acid episodes can cause symptoms and
injury, but are not captured by traditional GERD monitors. Manometry measures
how strong the peristalsis of the esophagus is, which is an important piece of
information before performing an operation for GERD. Impedance sensors on the
manometry catheter measures the clearance of swallowed material from the
esophagus into the stomach. Therefore, impedance adds more information about
the swallowing mechanism, and may improve the outcomes from surgery on the
esophagus.