Esophagus Disorders

The esophagus is the tube that carries food, liquids and saliva from your mouth to the stomach. You may not be aware of your esophagus until you swallow something too large, too hot or too cold. You may also become aware of it when something is wrong.

The most common problem with the esophagus is gastroesophageal reflux disease (GERD). It happens when a band of muscle at the end of your esophagus does not close properly. This allows stomach contents to leak back, or reflux into, into the esophagus and irritate it. Over time, GERD can cause damage to the esophagus. Other problems include heartburn and cancer.

Treatment depends on the problem. Some get better with over-the-counter medicines or changes in diet. Others may need prescription medicines or surgery.

Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach.

When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.

What causes GERD?

No one knows why people get GERD. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.

You're really thirsty and you take a huge gulp of a cold, carbonated beverage. Suddenly, you experience a severe pain in your midchest that lets up after a couple of seconds. This is one form of an esophageal spasm. In some people, esophageal spasms occur with much greater frequency and can lead to chronic swallowing problems and pain.

Your esophagus is a long tube-like structure that connects your throat to your stomach. A healthy esophagus moves food into your stomach through a series of coordinated muscular contractions, called peristalsis. Esophageal spasms disrupt this process.

Esophageal spasms are an uncoordinated series of muscle contractions that prevent food from traveling properly from your esophagus to your stomach. These spasms can be very painful. Chest pain is a common symptom of esophageal spasms.

The cause of esophageal spasms is unknown. Esophageal spasms are more common in people with acid reflux disease, and your likelihood of developing the condition increases with age.

Treatment of esophageal spasms in the short term may involve using medications to quickly relax the esophageal muscles. Long-term treatment may involve managing any contributing health condition, taking additional medications, altering your eating habits, and other approaches.

Esophageal spasms affect the smooth (involuntary) muscles in the walls of your lower esophagus. These spasms may occur in two forms:

For both forms of esophageal spasms, periods of contractions often occur intermittently, becoming more severe over a period of years.

Esophageal spasms can be difficult to diagnose because of their similarity with other disorders, such as gastroesophageal reflux disease (GERD), a condition in which stomach acid or bile flows back (refluxes) into your esophagus, irritating its lining.

Esophageal spasms are more common in women, and the incidence increases with age. If you have gastroesophageal reflux disease, you may be more prone to esophageal spasms. Your doctor may test you for reflux or try a medication targeted at acid reflux.

Your diet may have a dramatic effect on reducing esophageal spasms. Pay attention to which foods seem to cause the spasms.

Avoiding hot, cold or spicy foods, large meals, or foods with a high acid content (such as fruit juice, chocolate and tomatoes) may decrease the occurrence of spasms.

Most people are familiar with acid reflux - the backflow of caustic stomach acids into the esophagus, the tube that connects your throat and stomach. Less well known is bile reflux, which occurs when bile - a digestive fluid produced in the liver - flows upward (refluxes) from the small intestine into the stomach and esophagus.

Bile reflux often accompanies acid reflux, and together they're a formidable team, inflaming the lining of the esophagus and potentially increasing the risk of esophageal cancer. Bile reflux also affects the stomach, where it causes further inflammation.

Unlike acid reflux, bile reflux usually can't be controlled by changes in diet or lifestyle. Instead, bile reflex is most often managed with certain medications or, in severe cases, with surgery. Neither solution is uniformly effective, however, and some people continue to experience bile reflux even after treatment.

Bile reflux can be difficult to distinguish from acid reflux - the signs and symptoms are similar, and the two conditions frequently occur at the same time. But unlike acid reflux, bile reflux inflames the stomach, often causing a gnawing or burning pain in the upper abdomen. Other signs and symptoms include:

Bile is a greenish-yellow fluid that's essential for digesting and absorbing fats and for eliminating worn-out red blood cells and certain toxins from your body. It's produced in the liver and stored in the gallbladder in a highly concentrated form. Eating a meal that contains even a modest amount of fat signals the gallbladder to release bile, which flows through two small tubes (cystic duct and common bile duct) into the upper part of the small intestine (duodenum).

At the same time, food enters the small intestine through the pyloric valve, a heavy ring of muscle that sits at the outlet of your stomach. Ordinarily, the pyloric valve opens just slightly - enough to release about an eighth of an ounce of liquefied food at a time, but not enough to allow digestive juices to flow back into the stomach. In many cases of bile reflux, the valve doesn't close properly, and bile backwashes into the stomach, where it causes irritation and inflammation (gastritis).

Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass operations for weight loss. Other causes of bile reflux include:

Peptic ulcer. Sometimes a peptic ulcer can obstruct the pyloric valve. Rather than not closing tightly, the valve doesn't open enough to allow the stomach to empty as quickly as it should. The stagnant food and liquid can lead to increased gastric pressure that causes bile and stomach acid to back up into the esophagus.
Gallbladder surgery (cholecystectomy). People who have had their gallbladders removed have significantly more bile reflux than do people who haven't had this surgery.

Reflux into the esophagus
Bile and stomach acid reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. Normally, it opens only to allow food to pass into the stomach and then closes tightly. But if the valve relaxes abnormally or weakens, stomach acid and bile can wash back into the esophagus, causing heartburn and ongoing inflammation that may lead to serious complications.

Screening and diagnosis

Doctors often can diagnose a reflux problem from a description of symptoms. But distinguishing between acid reflux and bile reflux is notoriously difficult and requires further testing. You're also likely to have tests to check for damage to your esophagus and stomach as well as for precancerous changes.

Endoscopy. In this test, your doctor places a thin, flexible tube with a light and camera (endoscope) down your throat. The endoscope can show ulcerations or inflammation in your stomach or esophagus and can reveal a peptic ulcer. The test, technically called an esophagogastroduodenoscopy, also allows your doctor to take tissue samples to test for Barrett's esophagus - a condition in which cells in the esophagus undergo precancerous changes - or esophageal cancer, two potential complications of acid and bile reflux.
Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid regurgitates into your esophagus. In the standard tube test, a thin, flexible tube (catheter) is threaded through your nose into your esophagus to insert the probe, which is placed just above the lower esophageal sphincter. A second probe may be placed over your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or over your shoulder during the test. After the probe is in place, you go about your life, the device records pH levels every four seconds for 24 hours, and then you return to have the device removed.
The test is somewhat uncomfortable, makes sleeping and showering difficult, and isn't always accurate; eating a highly acidic meal can skew the results. Tests are available that may be more comfortable, however. The Bravo test, for example, eliminates the need for a nose tube because the probe is attached to the lower portion of your esophagus during endoscopy. And rather than having to be removed, the probe detaches on its own and passes through your intestinal tract in a week or so.
Esophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux into the esophagus. It's helpful for people who have regurgitation of substances that aren't acidic and therefore wouldn't be detected by a pH probe. As in a standard probe test, esophageal impedance uses a probe that's placed into the esophagus with a catheter.

Complications

A sticky mucous coating protects your stomach from the corrosive effects of stomach acid, but the esophagus lacks this protection, which is why bile reflux and acid reflux can seriously damage esophageal tissue. And although bile reflux can injure the esophagus on its own - even when the pH of the reflux is neutral or alkaline - the combination of bile and acid reflux seems to be particularly harmful, increasing the risk of complications, such as:

Heartburn and gastroesophageal reflux disease (GERD). Millions of people experience heartburn, sometimes on a daily basis. Occasional heartburn usually isn't a concern, although a severe episode can mimic a heart attack. But frequent or constant heartburn is the most common symptom of gastroesophageal reflux disease (GERD), a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis).
Esophageal narrowing (stricture). Repeated exposure to stomach acid, bile or both can cause scar tissue to form in the lower esophagus. This narrows the tube, interfering with swallowing and increasing the risk of choking.
Barrett's esophagus. In this uncommon but serious condition, long term exposure to stomach acid or a combination of acid and bile cause a change in the color and composition of the tissue in the lower esophagus (metaplasia). The new cells resemble glandular tissue in the stomach - under a microscope, they look like shag carpeting - and although they're resistant to stomach acid, they have a high potential for malignancy. Only a small percentage of people with GERD have Barrett's esophagus, but those who do have a greatly increased risk of esophageal cancer.
Esophageal cancer. This serious form of cancer can occur almost anywhere along the length of the esophagus, but it frequently starts in the glandular cells closest to the stomach (adenocarcinoma).Because esophageal cancer may not be diagnosed until it's quite advanced, the outlook for people with the disease is often poor. The link between esophageal cancer and bile reflux and acid reflux remains controversial, but many experts think a direct connection exists. In animal models, bile reflux alone has been shown to cause cancer of the esophagus.
Gastritis. In addition to causing irritation and inflammation in the esophagus, bile reflux can cause stomach irritation (gastritis). Although not always serious, untreated gastritis can lead to stomach ulcers and to bleeding, a potentially life-threatening problem that requires immediate medical care. Chronic gastritis can also increase the risk of stomach cancer, especially when there is extensive thinning of the stomach lining or a change in the makeup of the stomach cells.

Treatment

Drugs called proton pump inhibitors are considered the best treatment for GERD and Barrett's esophagus. Although the primary purpose of these medications, which include esomeprazole (Nexium), lansoprazole (Prevacid) and rabeprazole (AcipHex), is to block acid production, they may also help reduce bile reflux.

Still, the most commonly prescribed drug for bile reflux is ursodeoxycholic acid, which helps promote bile flow. If bile reflux results from delayed stomach emptying, doctors may prescribe drugs to increase the rate at which food moves through your stomach.

Surgical treatments
When medications fail to reduce severe symptoms or there are precancerous changes in the esophagus, doctors sometimes recommend surgery. Because some types of operations are often more successful than others, be sure to discuss the pros and cons carefully with your doctor.

Surgical options include:

Diversion surgery. This is usually the preferred procedure for treating bile reflux. In what is called a Roux-en-Y operation, surgeons make a new connection for bile drainage further down in the intestine, thereby diverting bile away from the stomach.
Anti-reflux surgery. Typically used to treat acid reflux, this operation - known medically as fundoplication - may be less successful in people who have bile reflux problems. During the procedure, the part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This increases the pressure at the lower end of the esophagus and reduces acid reflux. People with bile reflux may continue to have symptoms after fundoplication, however.

Self-care

Unlike acid reflux, which can be caused or aggravated by eating certain foods and by smoking, obesity and excess alcohol consumption, bile reflux seems unrelated to lifestyle factors. But because many people experience both acid reflux and bile reflux, making some lifestyle changes may help relieve your symptoms:

Stop smoking. When it comes to acid reflux, smoking is a double threat: It increases the production of stomach acid, and it dries up saliva, which normally helps protect the esophagus.
Eat smaller meals. Eating smaller, more frequent meals reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening at the wrong time.
Stay upright after eating. After a meal, waiting at least three hours before taking a nap or going to bed allows time for your stomach to empty.
Limit fatty foods. High-fat meals relax the lower esophageal sphincter and slow the rate at which food leaves your stomach.
Avoid problem foods and beverages. Although the same foods don't trouble everyone, the worst offenders for most people include caffeinated drinks, chocolate, onions, spicy foods and mint because they increase the production of stomach acid and may relax the lower esophageal sphincter. Unfortunately, if your lower esophageal sphincter is severely weakened, you're likely to have acid reflux no matter what you eat or drink.
Limit or avoid alcohol. Drinking alcohol relaxes the lower esophageal sphincter and irritates the esophagus.
Lose excess weight. heartburn and acid regurgitation are more likely to occur when excess weight puts added pressure on your stomach.
Relax. When you're under stress, digestion slows, worsening reflux symptoms. Some studies indicate that relaxation techniques such as deep breathing, meditation or yoga may help.

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Esophageal Rings And Webs

Esophageal rings and webs are folds that block your esophagus either partially or completely. Rings are bands of normal esophageal tissue that form constrictions around the inside of the esophagus. Webs are thin layers of cells that grow across the inside of the esophagus. Esophageal rings and webs usually occur in the upper esophagus, and may make it difficult to swallow solid food.

Experts aren't sure what causes esophageal rings and webs. The condition may be congenital (inherited), or may develop after birth. People with esophageal rings and webs commonly have reflux symptoms. When esophageal rings or webs occur together with iron deficiency anemia, the condition is known as Plummer-Vinson syndrome.

Symptoms

Most esophageal rings and webs do not cause any symptoms, and are discovered when people have barium X-rays or endoscopy for unrelated reasons. When rings or webs do cause symptoms, the most common complaint is difficulty swallowing solids. Foods, especially meats and breads, may feel like they get stuck in the same place.

Food occasionally can become lodged in the esophagus and may require you to spit it back up. If this happens frequently, you may have developed a new problem, such as a stricture, which is a fixed, firm narrowing of the esophagus.

Diagnosis

To determine if you have a ring or a web, your doctor may order one of these tests:

Barium swallow test - This allows the doctor to examine the esophagus with an X-ray. You will be required to swallow barium sulfate, a chalky drink.
Endoscopy - Your doctor inserts a tubelike camera through your mouth into your esophagus.

Webs are thin and pliable, and may be difficult to detect. Your doctor may miss them with either test. One advantage of endoscopy is that your doctor may be able to widen an area of narrowing during the process, opening up the esophagus.

Expected Duration

Treating the rings or webs usually solves your problem immediately. Webs and rings can come back, though, so you may need repeated treatments for them. Some people can live with the annoyance of rings and webs, and decide not to have treatment.

Prevention

There is no way to prevent esophageal rings or webs. However, because this condition may be related to acid reflux or iron deficiency anemia, you can take measures to prevent and treat these disorders. Avoid foods that promote acid reflux, especially coffee, chocolate, fatty foods, spicy foods, carbonated beverages, peppermint, spearmint, citrus fruits, tomatoes, whole milk and onions. The treatment of iron deficiency anemia varies depending on the cause of the problem.

Treatment

If you have acid reflux and rings or webs, treatment will be directed at improving the reflux. Because iron deficiency may contribute to the development of esophageal rings and webs, your doctor probably will order a blood test for iron levels and, if you are deficient, prescribe iron supplements.

If swallowing difficulties continue, you will be referred to a specialist who performs endoscopy and esophageal dilation. Dilation involves stretching and widening the narrowed part of the esophagus. The doctor first will locate the web or ring with the endoscope, then will insert a specially designed balloon through the scope to the narrowed area. The balloon will be inflated to stretch the rings and break up the webs.

A few people have rings in the lower esophagus that don't improve even after repeated dilation therapy. In this case, you may be treated with surgery.

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Esophagitis

What is esophagitis?
Esophagitis is an inflammation of the lining of the esophagus, the tube that connects the throat to the stomach. If left untreated, this condition can become very uncomfortable, causing difficulty in swallowing and ulcers or scarring of the esophagus. In rare instances, a condition known as Barrett's esophagus may develop, which is a risk factor for cancer of the esophagus.

What causes esophagitis?
Esophagitis is caused by an infection or irritation in the esophagus. An infection can be caused by bacteria, viruses, fungi or diseases that weaken the immune system. Irritation can be caused by any of the following:

A backflow of acid fluid from the stomach to the esophagus (GERD)
Vomiting
Surgery
Medications such as aspirin and anti-inflammatories
Hital hernias

What are the symptoms of esophagitis?
Symptoms of esophagitis include:

Difficult and/or painful swallowing
Heartburn
Acid regurgitation

If you have any of these symptoms, you should contact your health care provider as soon as possible.

How is esophagitis diagnosed?
Once your doctor has performed a thorough physical examination and reviewed your medical history, there are several tests that can be used to diagnose esophagitis. These include:

Endoscopy: A test in which a long, flexible lighted tube called an endoscope is used to look at the esophagus
Biopsy: During this test, a small sample of the esophageal tissue is removed and then sent to a laboratory to be examined under a microscope.
Barium x-ray: During this procedure, x-rays are taken of the esophagus after the patient drinks a barium solution. Barium coats the lining of the esophagus and shows up white on an x-ray. This characteristic enables doctors to view any abnormalities.

How is esophagitis treated?
Treatment for esophagitis depends on its cause. While medications that block acid production may be recommended, other medications may be prescribed for infectious causes of esophagitis. To treat pain brought on by esophagitis, your doctor may give you an analgesic to gargle with and then swallow.

While being treated for esophagitis, there are certain steps you can take to help limit any discomfort that you may feel. These include:

Avoiding spicy foods such as those with pepper, chili powder, curry and nutmeg
Avoiding hard foods such as nuts, crackers, and raw vegetables
Avoiding acidic foods and beverages such as tomatoes, oranges, grapefruits and their juices. Instead, try nectars and imitation fruit drinks with vitamin C
Including more soft foods such as applesauce, cooked cereals, mashed potatoes, custards, puddings and high protein shakes in your diet
Taking small bites and chewing your food thoroughly
Avoiding alcohol and tobacco

What is the prognosis for esophagitis?
The causes of esophagitis usually respond to treatment, however some causes, such as acid reflux, may require long-term treatment.

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Information obtained from National Institute of Health