Swallowing Disorders

There are numerous types of swallowing disorders, however, many of the symptoms are similar. For example, if one is experiencing any of the following discomforts, a physician should be seen: food sticking in the throat, heartburn, choking on food, inability to swallow liquids, pain when swallowing, persistent cough or sore throat, hoarseness or a gurgly voice during or after eating, a "lump in the throat" sensation, and wheezing without a history of asthma or lung problems.

Swallowing takes place in four stages. Different problems can occur at each stage to disrupt the normal swallowing process.

• Stage I: Biting and chewing food takes place in the mouth. At this stage, lack of strength, control or feeling in the mouth - which may be due to stroke or muscle or nerve disease - may cause food or liquid to fall directly into the throat and cause choking.
• Stage II: The tongue pushes the food to the back of the mouth where a structure folds over the top of the windpipe to keep food out. At the back of the mouth, the presence of food triggers muscle contractions. At this stage, the muscle at the back of the mouth that opens to allow food into the esophagus may malfunction and cause aspiration (food passing into the windpipe), which results in choking.
• Stage III: Muscle contractions push food down the esophagus. At this stage, lack of or inadequate muscle contractions may cause food to stick in the chest.
• Stage IV: Food moves through the esophagus, and the lower esophageal sphincter muscle opens to let food pass into the stomach. At this stage, weakening of this sphincter muscle at the stomach opening may allow acidic stomach secretions to come back up into the esophagus from the stomach, a condition called reflux.

Causes
Over 15 million Americans have a swallowing disorder. They can occur at any age. Swallowing problems may be temporary, or they may be an indication of a serious medical problem. There are many causes including nerve and muscle problems, head and neck injuries, cancer, or they may occur because of a stroke. Certain medications can also contribute to the disorder.

Diagnosis
Your family physician or a gastroenterologist (a physician who specializes in treating problems of the digestive system) can determine the location and the extent of the problem based on symptoms, a physical examination, diagnostic tests, and X-rays. One of the most useful tools is the painless barium swallow, a special video X-ray study that shows the entire swallowing process and anatomy. A gastroenterologist, radiologist, and swallowing therapist review the video to pinpoint the specific problem areas and decide on appropriate treatment.

Additional tests may include a motility study, which records movement and pressures of the esophagus, X-rays of the neck, head, or thyroid, 24-hour pH test to determine the amount of acid reflux, endoscopy to view the inside of the esophagus, or an endoscopic ultrasound to determine the nature and extent of tumors and other lesions.

Treatment
Sometimes just learning different physical techniques is enough to improve swallowing ability. Other times, and depending on the precise ailment, medical intervention, and/or surgery may be needed.

There are various strategies that are used to have a more comfortable eating and swallowing experience. These are general strategies; a swallowing therapist will be able to help tailor strategies to specific situations.

• Avoid eating when tired or stressed.
• Change head position and posture when swallowing (generally chin to chest is best).
• Minimize head movements.
• Eat smaller, more frequent meals.
• Lubricate dry food by mixing it with a sauce.
• Always swallow all food in mouth before taking another bite.
• Do not eat foods that will stick together – for example, fresh bread.
• Thickened liquids are generally easier to swallow.

Medical interventions are sometimes also needed. For instance, stretching the esophagus can be done in a noninvasive way. Also, medications are effective for some people. Some medications can reduce stomach acid, overcome spasms of the esophagus, or just help the swallowing nerves function better.

And sometimes surgery is an option for people with swallowing disorders. Surgical treatments depend on the location of the swallowing disorder. Surgery may involve strengthening or loosening the upper or lower esophageal valves, or removing obstructions or tumors from the esophagus.

Peptic Ulcer Disease

Peptic ulcer disease (gastric ulcer and duodenal ulcer) is a common health problem. Approximately 20 million Americans will suffer from an ulcer once in their lifetime.

An ulcer is a break in the lining of the stomach or in the first part of the small intestine (the duodenum), a result of erosion caused by the stomach’s natural acids.

Causes

Peptic ulcer disease was once thought of simply as a problem of too much acid and stress. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids (hydrochloric acid and pepsin) in the stomach and duodenum. Much of that imbalance is clearly related to infection with the bacteria Helicobacter pylori (H. pylori). The other major risk factor for the development of ulcers is ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin, buffered aspirin, naproxen (Aleve, Anaprox, Naprosyn, etc.) and ibuprofen (Motrin, Advil, Midol, etc.).

The risk of NSAID-induced ulceration is dose-related and increases with:

• age – more likely over age 60
• gender – will occur more often in women than men
• use of corticosteroids and NSAIDs together
• length of time taking NSAIDs
• a history of ulcer disease

The following serious complications associated with patients taking NSAIDs occur without warning:

• bleeding
• perforation (a hole through the lining of the stomach)
• gastric outlet obstruction (scarring that blocks the passageway leading from the stomach to the small intestine)

Risk factors for developing these serious complications are:

• age – 60 years or older
• a history of peptic ulcer disease, bleeding ulcers or cardiovascular disease

A number of myths are clearly not associated with the development of ulcers. Stress, personality, occupation, alcohol consumption, and diet all have no relationship to the development of peptic ulcers.

Symptoms

Gnawing, burning, upper abdominal pain relieved by antacids that often awakens the patient at night is classically associated with peptic ulcer disease. Other causes of this discomfort include: gastroesophageal reflux disease (commonly known as heartburn), stomach cancer, slow stomach emptying, and a sensitive stomach. Ulcers may produce no symptoms, especially in patients that ingest NSAIDs.

Diagnosis

An ulcer cannot be diagnosed simply by talking to your doctor. There are several ways your doctor can confirm if you have a peptic ulcer:

• A short trial of an acid blocking medication (Tagamet®, Zantac®, Pepcid®, Prilosec®, Axid®, Prevacid®, Protonix®, Nexium®, Aciphex®) to see if symptoms improve.
• Perform diagnostic tests to see if there is an ulcer:

• ~ Upper endoscopy, which involves inserting a small lighted tube into the stomach to look for abnormalities. A small sample of tissue (biopsy) is removed and analyzed to confirm diagnosis.

• ~ Testing for H. pylori infection by either a stool sample or by obtaining a breath sample. If the test is positive, the patient is treated with antibiotics. If negative, the focus of the evaluation will be on the other causes of peptic ulcer disease, such as NSAID consumption.

Treatment

A number of excellent treatment options are available for healing peptic ulcers:

Antacids are highly effective agents for healing ulcers and controlling symptoms. However, from a practical perspective, the inconvenient dosing frequency and adverse effects of therapy limit the use of antacids to symptom control only.

H2-receptor antagonists (Tagamet®, Zantac®, Pepcid®, Axid®) decrease acid production by the stomach and heal almost all duodenal and gastric ulcers after 8 weeks of treatment.

Proton pump inhibitors (Prilosec®, Prevacid®, Nexium®, Protonix®, Aciphex®) are better at stopping the production of stomach acid and heal almost all duodenal ulcers in 4 weeks and gastric ulcers in 8 weeks.

Peptic ulcer disease is a chronic disorder and almost all patients develop another ulcer within one year after being treated. This relapse rate was once reduced by taking chronic low dose (1/2 strength) maintenance therapy with any of the H2-blockers. However, treatment of H. pylori infection has revolutionized the treatment of peptic ulcer disease and cures ulcer disease completely in many patients.

H. pylori is treated with a combination of antibiotics (clarithromycin, amoxicillin, etc.) medications plus a proton pump inhibitor. This treatment should be attempted on all patients with evidence of infection and a current or past documented history of peptic ulcer disease.

However, treatment of H. pylori infection is not simple. None of the antibiotic regimens used to treat H. pylori are 100% effective and there is no agreement on a single best regimen. The medications may cause side effects such as an upset stomach, diarrhea and taste disturbance. This makes completion of treatment difficult and completion of the two week course of therapy is essential for success.

Hoarseness

Hoarseness is a symptom and not a disease. It is a general term that describes abnormal voice changes. When hoarse, the voice may sound breathy, raspy, strained, or there may be changes in volume (loudness) or pitch (how high or low the voice is). The changes in sound are usually due to disorders related to the vocal folds, which are the sound-producing parts of the voice box (larynx). There are many causes of hoarseness; fortunately, most are not serious and tend to go away in a short period of time. If hoarseness persists longer than two weeks, a visit to your physician is recommended. While not always the case, persistent hoarseness can be a warning sign of cancer.

Causes

• Common cold or upper respiratory tract viral infection
• Voice abuse: when you use your voice either too much, too loudly, or improperly over extended periods of time.
• Gastroesophageal reflux: when stomach acid comes up the swallowing tube and irritates the vocal folds
• Smoking
• Allergies, thyroid problems, neurological disorders, rheumatoid arthritis and trauma to the voice box

Diagnosis

• A thorough history of your hoarseness and your general health is obtained.
• Voice box and surrounding tissue will be examined using a mirror or a laryngoscope, a small lighted flexible instrument placed in the back of your throat.
• Voice quality is then evaluated: ~ A breathy voice may suggest poor vocal cord function, which may be caused by a benign tumor, polyp or cancer of the larynx.
  ~ A raspy voice may indicate vocal cord thickening due to swelling, inflammation from infection, a chemical irritant, voice abuse or paralysis of the vocal cords.
  ~ A high, shaky voice or a soft voice may suggest trouble getting enough breathing force or air.
• Lab tests, such as a biopsy, x-rays, thyroid function may be ordered depending on the findings of the physical exam.

Treatment
Treatment varies depending on the condition causing the hoarseness.

• Most hoarseness can be treated by simply resting the voice or modifying how the voice is used.
• If smoking is related to the hoarseness, you may be advised to stop smoking, as well as resting your voice.
• For all patients, it is recommended to avoid smoking or the exposure to second hand smoke and drink plenty of fluids.
• Surgery may be recommended if there are nodules or polyps on the vocal folds.

Prevention

• If you smoke, quit
• Avoid agents which dehydrate the body, such as alcohol and caffeine
• Avoid “second hand” (passive) smoke
• Humidify your home
• Watch your diet – avoid spicy foods and alcohol
• Try not to use your voice too long or too loudly
• Seek professional help if your voice is injured or hoarse

Hiatal Hernia

Any time an internal body part pushes into an area where it doesn't belong, it's called a hernia.
The hiatus is an opening in the diaphragm – the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus (food pipe) goes through the hiatus and attaches to the stomach. In a hiatal hernia (also called hiatus hernia) the stomach bulges up into the chest through that opening.

There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).

Sliding Hiatal Hernia
In a sliding hiatal hernia, the stomach and the esophagus slide up into the chest through the hiatus. This is the more common type of hernia.

Paraesophageal Hernia
The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become "strangled," or have its blood supply shut off.

Often, people with hiatal hernia also have heartburn or GERD. Although there appears to be a link, one condition does not seem to cause the other, because many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia. People with a hiatal hernia may experience chest pain that can easily be confused with the pain of a heart attack. That's why it's so important to undergo testing and get properly diagnosed.

Causes
Most of the time, the cause is not known. Some people develop a hiatal hernia after sustaining an injury to that area of the body; others are born with a weakness or an especially large hiatus. Some experts suspect that increased pressure in the abdomen from coughing, straining during bowel movements, pregnancy and delivery, or substantial weight gain may contribute to the development of a hiatal hernia.

Risk factors
In addition to the increased occurrence in people over 50, hiatal hernias also occur more often in overweight people (especially women) and smokers.

Diagnosis
A hiatal hernia can be diagnosed with a specialized X-ray study that allows visualization of the esophagus (barium swallow) or with endoscopy.

Treatment
Most people do not experience any symptoms of their hiatal hernia so no treatment is necessary. However, the paraesophaeal hernia (when part of the stomach squeezes through the hiatus) can cause the stomach to be strangled so surgery is usually recommended. Other symptoms that may occur along with the hernia such as chest pain should be properly evaluated. Symptoms of GERD should be treated.

If the hiatal hernia is in danger of becoming constricted or strangulated (so that the blood supply is cut off), surgery may be needed to reduce the hernia, meaning put it back where it belongs.

Hiatal hernia surgery can be performed as a laparoscopic, or "minimally invasive," procedure. During this type of surgery, five or six small (5 to 10 millimeter) incisions are made in the abdomen. The laparoscope and surgical instruments are inserted through these incisions. The surgeon is guided by the laparoscope, which transmits a picture of the internal organs to a monitor. The advantages of laparoscopic surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.

Many patients are able to walk around the day after hernia surgery. Generally, there are no dietary restrictions and the patient can resume his or her regular activities within a week. Complete recovery will take 2 to 3 weeks, and hard labor and heavy lifting should be avoided for at least 3 months after surgery. Unfortunately, there is no guarantee, even with surgery, that the hernia will not return.

GERD or Acid Reflux or Heartburn

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.

Anyone, including infants, children, and pregnant women, can have GERD.

Symptoms
The main symptoms are persistent heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.

Causes
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.

Other factors that may contribute to GERD include:

• alcohol use
• overweight
• pregnancy
• smoking
  

Also, certain foods can be associated with reflux events, including:

• citrus fruits
• chocolate
• drinks with caffeine
• fatty and fried foods
• garlic and onions
• mint flavorings
• spicy foods
• tomato-based foods, like spaghetti sauce, chili, and pizza

Treatment
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.

Lifestyle Changes:

• If you smoke, stop.
• Do not drink alcohol.
• Lose weight if needed.
• Eat small meals.
• Wear loose-fitting clothes.
• Avoid lying down for 3 hours after a meal.
• Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts--just using extra pillows will not help.

Medications
Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.

Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.

Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.

H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.

Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.

Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.

Tests
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.

A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus--called stricture--ulcers, hiatal hernia, and other problems will.

Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD.

The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.

In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24-48 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with GERD symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.

Surgery
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera.

Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.

Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.

Complications
Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.

Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.

Gastric Cancer

Cancer of the stomach, also called gastric cancer, is a disease in which malignant (cancer) cells arise from the lining of the stomach.

Stomach cancer can develop in any part of the stomach and then may spread throughout the stomach and to other organs. Stomach cancers are classified according to the type of tissue where they originate. The most common type of stomach cancer is adenocarcinoma, which starts in the glandular tissue of the stomach, and accounts for 95% of all stomach cancers. Other forms of stomach cancer include lymphomas, which involve the lymphatic system, and sarcomas, which involve the connective tissue (such as muscle, fat or blood vessels).

Stomach cancer can often be cured if it is found and treated at an early stage. Unfortunately, the outlook is poor if the cancer is already at an advanced stage.

Causes
The exact cause of stomach cancer is unknown, but a number of conditions can increase the risk of the disease. Helicobacter pylori (H. pylori) infection of the stomach increases the risk of stomach cancer. H. pylori is a bacteria that infects the lining of the stomach and causes chronic inflammation and ulcers.

Symptoms
In the early stages of stomach cancer, a patient may have very few symptoms. Symptoms may include indigestion and stomach discomfort, a bloated feeling after eating, mild nausea, loss of appetite or heartburn. These symptoms are similar to the symptoms caused by a hiatal hernia or peptic ulcer and may be treated with antacids or histamine blockers for temporary relief. Consequently, patients may not recognize these as serious symptoms and may not go to the doctor for a long time. A gastric tumor can grow very large before it causes other symptoms.

In more advanced stages, a patient may have the following symptoms:

• Discomfort in the upper or middle part of the abdomen
• Blood in the stool (which appears as black, tarry stools)
• Vomiting or vomiting blood
• Weight loss
• Pain or bloating in the stomach after eating
• Weakness or fatigue associated with mild anemia
  

Risk factors
There has been a significant decrease in stomach cancer cases in the past 60 years, but it is still the seventh leading cause of cancer deaths in the United States. Various medical conditions can be associated with an increased risk of developing stomach cancer including gastritis, pernicious anemia, gastric polyps, and gastric (peptic) ulcer. A person's risk of developing stomach cancer has been found to be greater if he or she has been infected with H. pylori bacteria.

There is a slightly increased risk of stomach cancer in people who use tobacco or drink alcoholic beverages regularly.

Workers among certain industries are also at greater risk, including those in the coal, mining, nickel refining, rubber and timber processing industries. Workers exposed to asbestos fibers are also at greater risk.

Stomach cancer is found most often in people over age 55, and affects men more than women. Stomach cancer is more common in Japan, Korea, parts of Eastern Europe, and Latin America than it is in the United States and Canada. This is thought to be related to the common diet in these countries that consists of foods, especially meat and fish, preserved by drying, smoking, salting or pickling, which contain nitrates and salt. Eating fresh foods, especially fruits and vegetables, may offer some protection against the disease.

Diagnosis
Some abnormalities may be found by your physician during a physical exam, but these findings generally indicate advanced stomach cancer. Some of these findings include enlarged lymph nodes, enlarged liver, and increased fluid in the abdomen (ascites).

When a patient has some of the initial vague symptoms, such as indigestion, weight loss, nausea and loss of appetite, the doctor may order screening tests. These tests include:

Upper GI series- These are X-rays of the esophagus and stomach (the upper gastrointestinal, or GI tract) after the patient drinks a barium solution. The barium outlines the stomach on the x-ray helping the doctor find tumors or other abnormal areas.

Gastroscopy and biopsy - This test examines the esophagus and stomach using a thin, lighted tube called a gastroscope, which is passed through the mouth to the stomach. Through the gastroscope, the doctor can look directly at the inside of the stomach. If an abnormal area is found, the doctor will remove some tissue to be biopsied. A biopsy is the only sure way to diagnose cancer. Gastroscopy and biopsy are the best methods of identifying stomach cancer.

Treatment
Stomach cancer may be treated with the following, in combination or alone:

• Surgery, called gastrectomy, to remove all or part of the stomach, as well as some of the tissue surrounding the stomach. Lymph nodes near the stomach are also removed and biopsied to check for cancer cells. Lymphoma of the stomach is more frequently treated by gastrectomy than adenocarcinoma of the stomach. Only about one-third of stomach cancer cases can be treated and cured surgically.
• Chemotherapy
• Radiation therapy
• Biological therapy (natural substances are used to boost the body's immune system to fight certain illnesses)
  

Cancer of the stomach is difficult to cure unless it is found at an early stage (before it has spread). Unfortunately, because early stomach cancer has few symptoms, the disease is usually advanced when the diagnosis is made. However, advanced stomach cancer can be treated and the symptoms can be relieved.

Achalasia

Achalasia is a condition in which the esophageal muscle lacks the ability to move food into the stomach. The lower esophageal sphincter (LES), located between the esophagus and stomach, stays closed, resulting in the back up of food. Other symptoms include vomiting undigested food, chest pain, heartburn and weight loss.

Diagnosis

Three tests are most commonly used to diagnose and evaluate a swallowing problem:

• Barium swallow. The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.
• Endoscopy. A flexible, narrow tube called an endoscope is passed into the esophagus and projects images of the inside onto a screen.
• Manometry. This test measures the timing and strength of esophageal contractions and muscular valve relaxations.

Treatment

If left untreated, achalasia can be debilitating. People experience considerable weight loss that can result in malnutrition. Lung infections and pneumonia due to aspiration of food can result, particularly in the elderly. Although the exact cause of achalasia is unknown, researchers think it may be linked to a virus.

Achalasia can be successfully treated non-surgically with balloon (pneumatic) dilation. While the patient is under light sedation, the gastroenterologist inserts a specifically designed balloon through the LES and inflates it. The procedure acts to relax and open the muscle.

Some patients may have to undergo several dilation treatments in order to achieve symptom improvement, and the treatment may have to be repeated every few years to ensure long-term results. Up to two-third of patients are treated successfully with balloon dilation.

Medication

Other patients, particularly those who are not appropriate candidates for balloon dilation or surgery, benefit from Botox® injections. Botox is a protein made by the bacteria that cause botulism. When injected into muscles in very small quantities, it can relax spastic muscles. It works by preventing nerves from sending signals to the muscles that tell them to contract. A smaller percentage of patients (up to 35 percent) achieve good results using Botox compared to balloon dilation. In addition, the injections must be repeated frequently in order to achieve symptom relief.

Minimally Invasive Surgery

A minimally invasive surgical technique called laparoscopic esophagomyotomy or the Heller Myotomy is an excellent treatment choice for achalasia.

Like all minimally invasive surgery, surgeons use a thin, telescopic-like instrument called an endoscope, which is inserted through a small incision. The endoscope is connected to a tiny video camera-smaller than a dime-that projects a view of the operative site onto video monitors located in the operating room. Minimally invasive surgery techniques offer patients a shorter hospital stay, quicker recovery and less scarring than traditional procedures.

Up to two-third of patients are treated successfully with surgery, though some patients may have to repeat the surgery or undergo balloon dilation to achieve satisfactory long-term results.

Although achalasia is relatively rare, The Cleveland Clinic treats approximately two cases every week.

Esophageal Cancer

Over half of the esophageal cancers appear in the upper two-thirds of the esophagus – in the cells lining the esophageal tube and about 40 percent develop in the lower third – in the glands. (Only one or two percent are rare tumors.) Generally, the cancer starts out as carcinoma of the esophagus on the surface, and then invades the surrounding tissue, often growing an obstruction, making swallowing difficult. It then spreads to the lymph nodes.

Causes

In most cases in North America, it is caused by abuses of alcohol and tobacco or long standing acid reflux. Esophageal cancer is relatively uncommon; however, in the United States, it affects about 13,000 people a year accounting for 1.5 percent of all cancers. It is most common in men over 60, smokers, drinkers, African-Americans and Caucasians with long standing acid reflux.

Diagnosis

The most common symptom – in 90 percent of patients – is difficulty or pain in swallowing. Other symptoms are weight loss (which can be substantial), heartburn, hoarseness, pneumonia, and vocal chord paralysis. There are a number of ways to test for esophageal cancer. First a physical examination may be done. The physician may look for enlarged lymph nodes, especially over the left collarbone, and pain in the vertebrae when the spinal area is tapped. A barium swallow, a series of x-rays which shows the barium solution as it is swallowed, and a x-ray of the esophagus is important as they outline the esophagus and may reveal a narrowing of the esophagus caused by a tumor. Chest x-rays are also performed to determine if the disease has spread to other organs. Esophagoscopy (using a lighted flexible tube with a camera attached) is a key test because it provides visualization and allows sampling (biopsies) of the esophagus. Finally, CT scans of the lung and abdomen and an esophageal endoscopic ultrasound may be performed.

Treatment

Surgery offers the best chance of long-term survival. Radiation therapy offers tumor control, however it is most effective on small tumors; and sometimes chemotherapy is added to radiation therapy. If a tumor is blocking the esophagus, laser therapy, photodynamic therapy or stenting may be used to create an opening so that swallowing is easier. Nutritional support with all of these procedures is necessary. Recent studies with combined radiation and chemotherapy prior to surgery are resulting in longer survival for patients diagnosed with esophageal cancer.

Barrett's Esophagus

Barrett's esophagus is the most severe complication of chronic gastroesophageal reflux disease (GERD) and would be of no real importance were not for the well recognized association of Barrett's esophagus and adenocarcinoma of the esophagus. The incidence of adenocarcinoma of the esophagus due to Barrett's Esophagus and GERD is on the rise and the five year survival rate for this cancer remains dismal. However, cancer risk for a given patient with Barrett’s esophagus is lower than previously estimated. Current strategies for improved survival in patients with esophageal adenocarcinoma focus on cancer detection at an early and potentially curable stage. This can be accomplished either by screening more patients for Barrett's Esophagus or with endoscopic surveillance of patients with known Barrett’s esophagus.

The Cleveland Clinic has a multidisciplinary clinical care and translational research program dedicated to a comprehensive scientific approach to the management of GERD, Barrett's Esophagus and early esophageal adenocarcinoma.

The components of this program include the following core areas:

• Cancer Biology
• Anatomic Pathology
• Molecular Pathology
• Cytopathology
• Thoracic Surgery
• Gastroenterology
  ~ Endoscopy – Imaging and Intervention
  ~ Pharmacologic Treatment
• Epidemiology and Biostatistics
  ~ Barrett’s Esophagus Registry
• Ohio Familial Barrett's Esophagus Consortium
• Medical Oncology

For patients with Barrett’s esophagus, the Cleveland Clinic offers the following:

• expertise in diagnosis and treatment
• expertise in pathologic diagnosis
• entry into a Registry to remind patients of their next follow-up surveillance date
• opportunities to participate in clinical research programs examining:
  ~ novel endoscopic imaging
  ~ new approaches to medical therapy and chemoprevention
• entry iinto the Ohio Familial Barrett's Esophagus Consortium Research Program
  

For patients with Barrett’s esophagus and dysplasia or early cancer:

expertise in diagnosis and treatment

expertise in pathologic diagnosis

expertise in esophageal surgery

expertise in endoscopic intervention

a multidisciplinary approach involving gastroenterologists, pathologists, thoracic surgeons and oncologists

opportunities to participate in clinical research programs examining novel endoscopic imaging techniques and cancer risk

new approaches to medical therapy and chemoprevention

Structural Disorders of Esophagus

DYSPHAGIA

Dysphagia, a common symptom in those with
esophageal disorders,may arise from a multitude of
causes. Dysphagia ordifficulty swallowing refers a sensation
of impairment of the normalprogression of the bolus from the
mouth into the stomach. Dysphagiashould be distinguished
from odynophagia or pain upon swallowing.Recognizing
dysphagia and gauging its clinical significance appears simple.
are, however, several important points that may be brought up
by the following questions:

* Is the patient complaining truly of dysphagia? In most cases,
* patients can express clearly symptoms of difficulty in
* swallowing.Alternative terms such as "food sticking" or
* "food moving downslowly into the chest" may assist in
* identifying those with dysphagia.Is the dysphagia for solids,
* liquids, or both? Mucosal lesions,benign or malignant,
* that produce a narrowing of the esophageallumen will not
* usually interfere with the passage of liquid substances
* and dysphagia is limited to solid foods. On the other hand,
* disordersimpairing esophageal peristalsis will cause difficulty
* with both solids and liquids.
* Is the dysphagia intermittent or progressive? Structural lesions
* of thelower esophagus such as rings and strictures, produce
* intermittent obstruction related to the size of the bolus with often
* prolonged periods of symptoms. In motor disorders, on the other
* hand, dysphagia is insidious and becomes progressively worse.

Proper clinical evaluation of dysphagia requires a detailed history.
Multiple diagnostic techniques are available and their use depends
upon the presenting clinical features. The initial test however is often
a barium swallow or an endoscopic examination. The choice between
these two techniques, as the most useful and least costly for the
evaluation of dysphagia, is the subject of debate. In a patient who
presents with intermittent solid dysphagia, suggesting a benign
obstructing lesion such as peptic stricture or ring,starting with
endoscopy is reasonable as it allows making the diagnosis and
simultaneously treating the lesion by dilation. In cases of dysphagia
to both solids and liquids and suspicion of a motor disorder,
a barium swallow provides more useful information by evaluating
esophageal peristalsis.The guidelines of the American
Association (AGA) support the choice of barium swallow in these
cases, a recommendation
that most clinicians would agree with.

Various known causes of esophageal disorders may be
classified into four different groups:

* Disorders caused by mucosal injury
* Neoplastic disorders
* Anomalies of esophageal lumen
* Motor disorders

DISORDERS CAUSED BY MUCOSAL INJURY
DEFINITION

Mucosal injury is defined as mucosal damage resulting from an
intrinsic or extrinsic agent capable of disrupting the integrity of the
mucosa, leading to acute inflammation and potentially chronic
inflammation with possible permanent scarring. The most common
syndromes of mucosal injuries are:

* Acid reflux disease (GERD)
* Infectious esophagitis
* Radiation esophagitis
* Esophagitis due to caustic ingestion
* Pill esophagitis

PREVALENCE

While GERD is very prevalent, causing symptoms in 20% of the
population at least once a week, other causes of mucosal injury are
less frequent. Infectious esophagitis is rare in normal persons.
In an immunocompromised individual, infection occurs today at
a lesser rate than in the past because of diagnostic and
therapeutic techniques. Candida is the most frequent
organism responsible for causing esophagitis. Radiation
esophagitis is reported by some patients during treatment but
long term lesions are not frequent. Caustic ingestions has been
reduced dramatically since protection laws have been instituted.
It is estimated that 5,000 cases occur each year in the U.S.
The prevalence of pill induced esophagitis is not known.
There are increasing number of cases reported but they
constitute a small number compared to the innumerable
pills ingested by the public.

PATHOPHYSIOLOGY

Virtually all mucosal injuries are accompanied by inflammation
with various degrees of severity including from erythema,
frank ulcers with potential scarring and bleeding and strictures.
Infectious esophagitis occurs almost always in
immunocompromisedpatients such as post-transplant patients
or patients with cancer or AIDS. Predisposing factors include
diabetes, alcoholism, malnutrition and old age as well as
treatment with corticosteroids. Diseases leading to stasis
such as achalasia may also predispose to some infections.
Radiation esophagitis occurs with radiation therapy to the
chest and mediastinum. It is dependent upon the total dose
administered as well as the time over which treatment is applied.
Injury by caustic ingestion is most commonly caused by alkali
agents producing burns or acid agents producing necrosis.

Pill esophagitis was first reported with tetracycline. Doxycline
and other tetracyclines account for the majority of cases but
injuries have been reported with other antibiotics, antiviral
agents, nonsteroidal anti-inflammatory drugs,
potassium preparations and many other medications.There
is some evidence that sustained release medications are
more commonly associated with injury. The lesion occurs
most often between the junction of the proximal and
mid-esophagus at the point of impression by the aortic arch
or above the esophagogastric junction.

SIGNS AND SYMPTOMS

Mucosal injury may be asymptomatic or may manifest by
odynophagia or chest pain. Patients whose nutrition may
already be affected by their immunocompromised status
and anorexia are jeopardized by their inability to eat.
Candida esophagitis is often asymptomatic and is
discovered at endoscopy. Pill injury is accompanied
by sudden onset of severe pain over one to three days.
Pain is aggravated
by eating.

DIAGNOSIS

The diagnosis of mucosal injury is suspected based on
patient's background and is established by a barium
swallow but more precisely by endoscopy.Candida
esophagitis shows typical white plaques scattered
throughout the esophagus . Viral infections caused
either by herpes simplex or CMV will reveal focal or
disseminated ulcers and the diagnosis is established by
biopsy and special stains. About 40% of ulcers seen in patients
with AIDS are not due to a specific infection and are termed
idiopathic ulcers. They are typically large and deep.
Radiation esophagitis is characterized by erythema and
friability during the acute stages and by strictures in the late stages.
Caustic ingestion is rare in the adult population and is almost always
due to suicidal attempts. Endoscopy is relatively contraindicated
in the acute stages. Pill induced esophagitis causes a typical
discreet ulcer surrounded by a normal surrounding mucosa .

TREATMENT AND OUTCOMES

The treatment of infectious esophagitis depends upon the
isolation of the causative agent. In immunocompromised
patients, multiple infections may co-exist. Treatment of candida
esophagitis is best carried out with ketaconazole 200-400 mg/day
or fluconazole 100 mg/day for 7 -14 days. Nystatin in oral solution
may be effective in mild cases and in the absence of immunodeficiency.
Viral infections respond in part to antiviral agents. Idiopathic ulcers
of AIDS are treated with prednisone 40 mg/day with tapering over
4 weeks by 10 mg/week or thalidomide 200-300 mg/day over
4 weeks. The potential risk of birth defects limits the use of
thalidomide.

In pill injury the offending medication should be withdrawn
and antireflux therapy prescribed to prevent exacerbation
of the injury. When odynophagia is pronounced, the use
of topical anesthetic agents administered orally may help
relieve the pain. In most cases, symptoms disappear
within a few days and bleeding and perforation
are rare. More importantly, pill injury should be prevented by
encouraging patients to drink large amounts of fluid with their
pills, to remain upright for 30 minutes after taking the pills
and to avoid pills known to cause frequent injury particularly
in patients with esophageal strictures or who are bedridden.
These preventive measures are very important in elderly
patients who tend to take multiple medications particularly
at bedtime.

Chronic lesions caused by mucosal injury often lead
to strictures. Strictures are managed by periodic dilations
and antireflux treatment. In GERD, the use of potent acid
suppressing agents has reduced the frequency with which
dilation needs to be performed.

NEOPLASTIC DISORDERS BENIGN TUMORS

Benign esophageal tumors are non-malignant neoplasms
arising from the mucosal or muscular layers of the
esophagus. Benign tumors of the esophagus are rare.
Leiomyoma, the most common, has been described in
5% of autopsy specimens. Benign tumors are classified
as mucosal or intramural. Mucosal tumors tend to produce
a filling defect in the lumen; they include fibrovascular polyps,
granular cell tumors, papillomas and lipomas. Intramural lesions
are more common than mucosal tumors. They produce an
extrinsic mass projecting from the wall into the lumen.
Such tumors include leiomyomas and cysts.

SIGNS AND SYMPTOMS

Most benign tumors of the esophagus are asymptomatic and
discovered by chance during an examination obtained for
other reasons. When symptomatic, benign tumors cause mostly
dysphagia and, in some cases, chest pain and regurgitation.
The most important issue is to differentiate them from
malignant tumors.

DIAGNOSIS

A barium swallow will often determine if the lesion is
intramural or mucosal. Endoscopy is often helpful in
determining the tumor's nature . Some polyps appear
on a long stalk and may be seen flopping into the lumen.
Endoscopic examination will reveal intramural tumors as
smooth protrusions covered by normal mucosa.
Cysts appear as round and smooth. Mucosal lesions may
sometimes ulcerate. Endoscopic ultrasound is helpful in
distinguishing a leiomyoma from leiomyosarcoma. Unfortunately,
when the tumor is large the differentiation is more difficult.

THERAPY AND OUTCOMES

Small asymptomatic lesions require no treatment. Surgical
enucleation is the treatment of choice for symptomatic
intramural lesions or when intervention is necessary because
malignancy cannot be ruled out with certainty.
Polyps are treated by local resection.

MALIGNANT TUMORS DEFINITION AND
CLASSIFICATION

Malignant tumors of the esophagus constitute the majority of
esophageal tumors. Different types of tumors have been
described and include:

* Squamous cell carcinoma
* Adenocarcinoma
* Sarcoma
* Lymphoma
* Primary melanoma
* Metastatic tumors (breast, lung, melanoma)

Squamous cell carcinoma and adenocarcinoma represent,
by far, the largest number of esophageal malignancies. About
13,000 cases of esophageal cancer are diagnosed each year
in the United States. Squamous cell carcinoma used to
account for the majority of malignancies but adenocarcinoma
has been rising steadily and now accounts for about 50% of
all tumors. Squamous cell carcinoma arises from the squamous
epithelium and is encountered most commonly in the mid-esophagus.
A smaller number of tumors arise in the distal and upper
esophagus. Environmental factors seem to play an important
role in the genesis of squamous cell carcinoma with wide
geographic variations. Other predisposing factors include alcohol,
tobacco, long history of achalasia, previous ingestion of caustic
agents, and genetic factors. In the United States, squamous cell
carcinoma is more common in African-Americans.
Adenocarcinoma of the esophagus is increasing in frequency and
is more commonly seen in white men. Most tumors arise in the
distal third of the esophagus. Barrett's esophagus is the
major predisposing factor for adenocarcinoma
of the esophagus. Tylosis or hyperkeratosis of palms and
soles is an autosomal dominant disorder strongly associated
with gastrointestinal malignancy particularly squamous cell
carcinoma of the esophagus.

While there are differences between squamous cell carcinoma
and adenocarcinoma in epidemiology, location and patterns
of spread, both diseases tend to spread early outside the
esophagus and both share a rather poor prognosis unless
discovered early. For this reason, efforts are undertaken
to detect early signs of cancer or precancer. A guideline
of the American Society of Gastrointestinal Endoscopy
the conditions for which screening is recommended for
early detection:

Screening recommended (every 1-3 years):

* Barrett's esophagus
* Caustic ingestion: start 15-20 years after injury
* Tylosis: Start at age 30

Screening not recommended:

* Achalasia

SIGNS AND SYMPTOMS

The most common clinical manifestation of esophageal tumors is
dysphagia which occurs to solid foods first then progresses to
soft foodsand, eventually, liquids. Odynophagia is reported in
some cases. Chest pain, when present, may represent an
ominous sign as it indicates invasion to the mediastinum.
Weight loss is frequent as a result of difficulty swallowing and,
in late stages, because of anorexia. Bleeding is rare.
Physical examination will reveal signs of weight
loss. In some cases, supraclavicular nodes may be detected.

DIAGNOSIS

Carcinoma of the esophagus should be suspected in any individual
with recent onset dysphagia particularly after the age of 50. A long history
of reflux diseases raises the possibility of carcinoma arising in Barrett's
esophagus especially in white men. The following diagnostic modalities
are used in the evaluation of malignant neoplasms:

* Barium swallow
* Endoscopy
* Computerized tomography (CT)
* Endoscopic ultrasound (EUS)
* Bronchoscopy

Barium swallow gives an indication of tumor location and size .
Endoscopy determines the size of the esophageal lumen .
Biopsy and cytologic brushings establish the tumor's histologic
type. The central issue, at that point, is the appropriateness of
surgical intervention. The decision to operate is based on
tumor staging. Both squamous cell carcinoma and
adenocarcinoma are staged according to the TNM system
(Tumor invasion, lymph nodes and metastasis).

EUS is more sensitive than CT but a combination of both improves
staging's accuracy.

TREATMENT AND OUTCOMES

Curative Treatment:

When full evaluation reveals a favorable stage and the patient's
general condition is not a contraindication to surgery, tumor
resection represents the most promising treatment.
Surgical resection is indicated when the lesion is considered curable.
Combined chemo and radiotherapy followed by surgery is offered
to patients with local extension. Even in adenocarcinoma which
is less sensitive chemo and radiotherapy, combined treatment
improves prognosis. The best chance of significant survival
in esophageal cancer resides in a multidisciplinary approach
in institutions possessing good experience in gastroenterology,
thoracic surgery, chemotherapy and radiation oncology.

The ASGE guideline outlines the advantages of and the treatment
approach for esophageal cancer with an algorithm .

Palliative Treatment:

When surgery is ruled out because of tumor extension or
complications and in cases of tumor recurrence, several
palliative methods are available. Esophageal cancer is
often diagnosed at an advanced incurable stage and when
patients present with dysphagia, 50% of the lumen may already
be occluded.

Palliation methods include radiotherapy and the following
endoscopic modalities:

* Periodic dilation
* Esophageal stenting
* Photodynamic ablation
* Laser ablation
* Endoscopic mucosal resection

Endoscopic techniques have various rates of success and they
all carry a risk of complications including perforation, infection and
bleeding as well as worsening of the initial symptoms. In late
stages and in patients whose dysphagia is insurmountable,
insertion of a gastrostomy feeding tube is often necessary.

ANOMALIES OF ESOPHAGEAL LUMEN RINGS AND WEBS

The definition of webs and rings is confusing because the terms have
been used interchangeably. A web is a thin membrane occupying part
of the esophageal lumen and is most commonly seen on the anterior
aspect of the area just below the cricopharynx.

Rings are concentric narrowings of the lumen usually seen in the
lower esophagus. The B-ring or muscular ring occurs at the junction
of the tubular portion of the esophagus and the most distal part called
the vestibule. The ring is often described by radiologists but is
rarely symptomatic. The A or mucosal ring occurs most distally at the
esophagogastric junction and usually in association with a hiatal hernia.
Also known as Schatzki's ring, it deserves particular attention because
it is often symptomatic

PREVALENCE

Both webs and rings are frequently seen during radiologic or
endoscopic examination. It is estimated that webs are present in
0.5 to 1% of asymptomatic people. Lower esophageal rings are
found in 10 to 15% of barium swallow studies. It is now not known how
many are symptomatic.

PATHOPHYSIOLOGY

The exact nature of webs is unknown. It is thought that webs result
an anomaly of development in the epithelium of the upper esophagus.

A Schatzki's ring consists of esophageal mucosa and submucosa.
This ring is almost always associated with the presence of a
hiatal hernia. While it is histologically and probably pathogenetically
different from esophageal peptic strictures, the association of a
lower esophageal ring with gastroesophageal reflux is frequent.
In addition, distinguishing one from the other endoscopically is
sometimes difficult. Therefore, many clinicians manage
esophageal rings as they do strictures. The PlummerVinson
and the Paterson Kelly syndromes refer to the association of webs
iron deficiency anemia and other oropharyngeal abnormalities.
These associations are rarely described
today and the terms have largely been abandoned.

SIGNS AND SYMPTOMS

When either a cricopharyngal web or a ring causes difficulty,
the patient presents with dysphagia. In the case of a web,
the dysphagia is oropharyngeal, associated with solid foods and
is rarely severe. The dysphagia associated with a lower
esophageal ring is intermittent, occurring with solid foods
particularly meat with occasional impaction and is referred,
in the old literature, as the "steakhouse syndrome."

DIAGNOSIS

Barium x-ray is the most sensitive method to detect webs and rings.
Webs should not be confused with the normal impression of the
cricopharynx . On x-ray, a web is seen as an indentation on the
anterior aspect of the pharynx . The diagnostic yield for a ring is higher
when a solid bolus is given during the test. Endoscopic examination
is less sensitive in detecting subtle rings particularly with the use of
the new thin endoscopes which may pass through the ring without
the endoscopist seeing the luminal narrowing.

TREATMENT AND OUTCOMES

Most webs do not require treatment. When they are symptomatic,
however, endoscopic dilation is useful but has to be performed with
caution by an experienced operator. Lower esophageal rings are
treated easily with dilation by bougies or over a guidewire. The
response to treatment is generally good in most patients. There
is a small risk of perforation. An acid suppressing agent is
usually prescribed.

DIVERTICULA DEFINITION

An esophageal diverticulum is a sac protruding from the
esophageal wall and containing all layers of the esophagus.
Esophageal diverticula may be congenital or acquired.
The simplest way to classify them is according to anatomy:

* Zenker's diverticula
* Mid-esophageal diverticula
* Epiphrenic diverticula
* Intramural pseudodiverticulosis

PREVALENCE

Esophageal diverticula have been described in all age groups but
they are most commonly seen in adults. They are rare, occurring
in less than 1% of upper gastrointestinal X-rays and accounting
for less than 5% of dysphagia cases.

PATHOPHYSIOLOGY

Zenker's diverticulum or pharyngoesophageal diverticulum
occurs in a location proximal to the esophagus above the upper
esophageal sphincter. The diverticulum bulges posteriorly and its
size increases over time. The most widely accepted mechanism
for a Zenker's diverticulum is a functional disturbanc
e of the . The most popular explanation is an incoordination
between the pharynx and the cricopharyngeus muscle
called "cricopharyngeal achalasia." Most recent evidence however
suggests that the diverticulum occurs because of reduced
compliance of the upper sphincter rather than because of
incoordination. Mid-esophageal diverticula have been divided
into traction and pulsion diverticula. This distinction has no
practical value. The exact cause of a mid-esophageal diverticulum
is not known but the condition has been associated with scarring
and various esophageal motor abnormalities. Epiphrenic
diverticula are almost always the result of an esophageal
motor abnormality, namely an incoordination between the
distal esophagus and the lower esophageal sphincter.

Esophageal intramural pseudodiverticulosis is characterized by
numerous, minute, flask-like outpouchings along the esophageal
wall. They can be segmental or generalized. They are associated
with strictures, carcinoma, candidiasis and motor abnormalities .

SIGNS AND SYMPTOMS

Many esophageal diverticula are discovered by chance during
radiologic evaluation. In early stages of Zenker's diverticulum,
the patient may complain of vague throat irritation and, when the
becomes large, more severe symptoms develop particularly
dysphagia, regurgitation of food ingested several hours
earlier and gurgling sounds upon swallowing. Complications
of Zenker's diverticulum such as bleeding, obstruction,
or fistulization are rare. Mid-esophageal diverticula are often
asymptomaticunless they become so large that food gets trapped
in the pouch.For epiphrenic diverticula the severity of symptoms
depends upon the associated motor abnormality. The most frequent
conditions associated with such diverticula are achalasia and
diffuse spasm.

DIAGNOSIS

A barium esophagram with special attention to the oropharyngeal
phase of swallowing is the best diagnostic test for Zenker's
diverticulum. The diverticulum is seen to protrude posteriorly and
the barium tends to fall into the pouch before progressing into the
esophagus . Endoscopy adds very little to the evaluation of Zenker's
diverticulum. Manometric testing of upper esophageal function is not
clinically useful. Both mid-esophageal and epiphrenic diverticula
are best diagnosed by barium swallow and an associated motor
disorder is usually suspected if present.

TREATMENT AND OUTCOMES

Symptomatic Zenker's diverticula can be treated by surgical excision.
Newer treatments are applied endoscopically. A transection is made
to create a communication between the diverticulum and the esophagus
allowing the diverticulum to drain into the esophagus. This technique
can be carried out with or without the assistance of laser.Most surgeons
agree that whatever the surgical technique, a myotomy of the
cricopharyngeus muscle is necessary to prevent recurrence of the
diverticulum. Mid-esophageal diverticula are treated by surgical
excision. For anepiphrenic diverticulum the goal of therapy should be
to treat the underlying motor disorder with the hope of avoiding further
enlargement of the diverticulum. In the absence of achalasia, a long
esophagomyotomy is recommended but published results involve a
small number of patients. Intramural pseudodiverticulosis requires
treatment of the underlying infection or obstruction with dilatation
inthe case of a distinct obstructing area.

Swallowing & Esophageal Disorders, including Barrett's Esophagus

Structural Disorders of Esophagus Barrett's Esophagus Esophageal Cancer Achalasia Gastric Cancer GERD or Acid Reflux or Heartburn Hiatal Hernia Hoarseness Peptic Ulcer Disease Swallowing Disorders

The Cleveland Clinic's Center for Swallowing & Esophageal Disorders offers a coordinated, comprehensive program to treat swallowing and esophageal disorders including Barrett's Esophagus. The Center's multisdisciplinary team includes gastroenterologists, radiologists, thoracic surgeons, neurologists, lung specialists, swallowing therapists, and ear, nose, and throat specialists. Approximately, 1,500 patients are seen annually in the Center for Swallowing & Esophageal Disorders, including patients with Barrett’s Esophagus .

Millions of Americans have trouble swallowing or complain of heartburn and acid reflux. These problems may be caused by malfunctioning of the physical structures in the mouth, throat or esophagus, damage to the nerves or muscles coordinating swallowing in these organs, or physical obstruction to these organs. Acid reflux of stomach contents into the esophagus, throat or mouth can lead to Barrett’s Esophagus and also cause esophagitis and its complications -- chest pain, asthma and breathing problems, or ear, nose and throat complaints including recurrent coughing.

Early diagnosis and intervention are very important. Left untreated, swallowing and esophageal disorders can lead to serious problems.

Via: http://cms.clevelandclinic.org

Ulcerative Colitis

Ulcerative colitis is a chronic inflammation of the tissue lining the large intestine (the colon and rectum). Ulcers, or sores, develop in the outermost layer of the lining but, unlike Crohn’s disease, the inflammation does not penetrate into the deeper tissue layers.

Ulcerative colitis usually develops in people between the ages of 15 and 40, but occasionally affects children and older people. Once it develops, it is a chronic, lifelong condition. Most people with ulcerative colitis have periods of remission when they do not experience any symptoms, but symptoms usually return. Some people find that certain foods trigger their symptoms, and they can control the symptoms by avoiding these foods.

Symptoms
Diarrhea, caused by the inflammation of the colon lining, is the most common and distinctive symptom of ulcerative colitis. Ulcers that bleed and produce pus form in areas of the colon where the inflammation has killed the lining cells and can cause blood or pus in the stool.

Mild cases of ulcerative colitis usually cause few symptoms and are associated with fewer than five episodes of diarrhea a day and occasional blood or pus in the stool. More severe cases cause five or more episodes of diarrhea per day, frequent blood and pus in the stool, fever and other complications. Other symptoms include:

• Fatigue
• Weight loss
• Loss of appetite
• Rectal bleeding
• Loss of body fluids and nutrients.

Ulcerative colitis may cause a range of other problems such as arthritis, inflammation of the eye, liver disease, osteoporosis, skin rash, anemia and kidney stones. Ulcerative colitis probably is related to a disorder in the immune system, the body’s natural defense against infection. These complications are believed to be caused by the immune system triggering inflammation in other parts of the body, and they typically disappear when the ulcerative colitis is treated.

The most serious acute complication of ulcerative colitis is toxic megacolon, a condition in which the colon is paralyzed to the point where a bowel movement cannot occur. Left untreated, it can cause the colon to rupture and cause peritonitis, a life-threatening condition requiring emergency surgery. Symptoms of toxic megacolon include abdominal pain and swelling, fever, weakness and disorientation or grogginess.

Treatment
For mild cases of ulcerative colitis, treatment with medication can be effective in reducing inflammation and controlling symptoms. More advanced cases of ulcerative colitis, or those people in whom medication can no longer control symptoms, can be cured by surgical removal of the colon. An estimated 25 to 40 percent of ulcerative colitis patients eventually need surgery. Cleveland Clinic gastroenterologists work closely with our colorectal surgeons to ensure that patients are referred for surgery at the appropriate time.

Cleveland Clinic colorectal surgeons consider the ileal pouch-anal anastamosis (IPAA) the optimal surgical treatment for ulcerative colitis and have performed more than 3,000 of these procedures. The operation involves removing the colon, forming an internal pouch from the small bowel and joining it to the anal muscle. Following surgery and recovery, patients have almost normal control over bowel movements.

This is an extremely complex surgery that should be performed only by a skilled colorectal surgeon with extensive experience in treating ulcerative colitis. Following this surgery at The Cleveland Clinic, the average patient has between six and eight bowel movements per day. More than 97 percent of patients are satisfied with the outcome of their operation, and the majority do not require further medical care related to the surgery, outside of routine post-operative follow-up.

Cleveland Clinic surgeons also are experienced in several other surgical treatments for ulcerative colitis for patients who cannot have the ileal pouch procedure. These options can be discussed between patient and surgeon as needed.

Via: http://cms.clevelandclinic.org

Microscopic Colitis

Microscopic colitis takes two forms: collagenous colitis and lymphocytic colitis. Collagenous colitis and lymphocytic colitis are two types of bowel inflammation that affect the colon (large intestine). They are not related to Crohn's disease or ulcerative colitis, which are more severe forms of inflammatory bowel disease (IBD).

Collagenous colitis and lymphocytic colitis are referred to as microscopic colitis because colonoscopy usually shows no signs of inflammation on the surface of the colon. Instead, tissue samples from the colon must be examined under a microscope to make the diagnosis.

No precise cause has been found for collagenous colitis or lymphocytic colitis. Possible causes of damage to the lining of the colon are bacteria and their toxins, viruses, or nonsteroidal anti-inflammatory drugs (NSAIDs). Some researchers have suggested that collagenous colitis and lymphocytic colitis result from an autoimmune response, which means that the body's immune system destroys cells for no known reason.

Symptoms
The symptoms of collagenous colitis and lymphocytic colitis are similar--chronic watery, nonbloody diarrhea. The diarrhea may be continuous or episodic. Abdominal pain or cramps may also be present.

Diagnosis
The diagnosis of collagenous colitis or lymphocytic colitis is made after tissue samples taken during colonoscopy or flexible sigmoidoscopy are examined under a microscope. Collagenous colitis is characterized by a larger-than-normal band of protein called collagen inside the lining of the colon. The thickness of the band varies, so multiple tissue samples from different areas of the colon may need to be examined. In lymphocytic colitis, tissue samples show inflammation with white blood cells known as lymphocytes between the cells that line the colon, and in contrast to collagenous colitis, there is no abnormality of the collagen.

People with collagenous colitis are most often diagnosed in their 50s, although some cases have been reported in adults younger than 45 years and in children aged 5 to 12. It is diagnosed more frequently in women than men.

People with lymphocytic colitis are also generally diagnosed in their 50s. Both men and women are equally affected.

Treatment
Treatment for collagenous colitis and lymphocytic colitis varies depending on the symptoms and severity of the cases. The diseases have been known to resolve spontaneously, but most patients have recurrent symptoms.

Lifestyle changes aimed at improving diarrhea are usually tried first. Recommended changes include reducing the amount of fat in the diet, eliminating foods that contain caffeine or lactose, and not using NSAIDs.

If lifestyle changes alone are not enough, medications are often used to control the symptoms of collagenous colitis and lymphocytic colitis.

• Antidiarrheal medications such as bismuth subsalicylate and bulking agents reduce diarrhea.
• Anti-inflammatory medications, such as mesalamine, sulfasalazine, and steroids including budesonide, reduce inflammation.
• Immunosuppressive agents, which reduce the autoimmune response, are rarely needed.
• For very extreme cases of collagenous colitis and lymphocytic colitis, bypass of the colon or surgery to remove all or part of the colon has been done in a few patients. This is rarely recommended.
  Collagenous colitis and lymphocytic colitis do not increase the risk of colon cancer.