Treatment Guide Swallowing and Esophageal Disorders Esophageal disorders – especially those involving The Miller Family Heart & Vascular Institute is one swallowing problems – affect more than 15 million of the largest thoracic and cardiovascular specialty Americans of all ages. For many, they’re temporary groups in the world. The commitment of its physicians issues that can be managed with over-the-counter to research, education and patient care has led to medicines and lifestyle changes. But for others, they innovative treatment, better outcomes and improved are chronic concerns that plague daily life and can lead quality of life for patients. to more serious conditions. The good news is that esophageal disorders often USING THIS GUIDE can be successfully treated before long-term damage Please use this guide as a resource as you begin occurs. But it is important to get an early diagnosis and to learn about esophageal disorders and examine treatment plan. At Cleveland Clinic, we’ve assembled your treatment options. Remember, it is your right an entire team of all the specialists you need – as a patient to ask questions and to seek a second including gastroenterologists, radiologists, pathologists, opinion. thoracic surgeons and swallowing therapists – to offer leading-edge diagnosis and treatment options. Ranked No. 2 in the country and the top in Ohio by TABLE OF CONTENTS: U.S. News & World Report for gastroenterology, the Understanding swallowing problems ............................2 Digestive Disease Institute offers one of the few centers in the country dedicated to swallowing disorders. Esophagitis................................................................4 Through the Center for Swallowing & Esophageal GERD........................................................................4 Disorders, patients benefit from the extensive experience of physicians who diagnose and treat nearly Barrett’s esophagus.....................................................7 2,000 patients a year. Achalasia ..................................................................9 CLEVELAND CLINIC 216.444.7000 1 CLEVELAND CLINIC | GUIDE FOR SWALLOWING AND ESOPHAGEAL DISORDERS The mechanics of swallowing In order to understand diseases of the esophagus, it’s helpful to know what takes place during the swallowing process. The esophagus is a muscular tube through which food and drink pass from the mouth to the stomach. It is designed to push food into the stomach. To prevent food from moving backward – a condition called reflux – muscles at both ends of the esophagus close when food is not moving forward through them. These con- stricting, ring-shaped muscles are called sphincters. The sphincters act like valves and must constrict in an exact order for normal swallowing to occur. The upper muscles stop food from moving into the windpipe and voice box. The lower ones prevent food and stomach acid from moving back- ward into the esophagus. Problems with the relaxation of the sphincter muscles can result in choking or inability to eat. Difficulties with the constriction (tighten- ing) of the sphincter muscles cause reflux, which may result in symptoms such as heartburn or even damage to the esophagus. What are the symptoms of swallowing problems? There are a number of swallowing disorders that can cause a variety of symptoms. Early diagnosis and intervention are important to prevent long-term complications. See your physician if you experience any of the following: • 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 • Wheezing without a history of asthma or lung problems What causes swallowing problems? More than 15 million Americans have a swallowing disorder, such as esophagi- tis, gastroesophageal reflux or achalasia. 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 and cancer. Or they may occur because of a stroke. Certain medica- tions can also contribute to the disorder. 2 SAME-DAY APPOINTMENTS ARE AVAILABLE. CALL 216.444.7000 CLEVELAND CLINIC CLEVELAND CLINIC | GUIDE FOR SWALLOWING AND ESOPHAGEAL DISORDERS How are swallowing problems Cleveland Clinic Center diagnosed? for Swallowing and Your doctor can determine the location and the extent of the problem based on Esophageal Disorders symptoms, a physical examination and diagnostic tests, which may include: • Barium swallow – This special video X-ray study shows the entire swallowing process and anatomy. It is a painless test that can pinpoint specific problem Cleveland Clinic has one of the areas and determine appropriate treatment. nation’s few centers dedicated to swallowing disorders. Heading a • Motility study – A test that records movement and pressures of the esophagus. team of four physician specialists • X-rays – Imaging of the neck, head or thyroid can help diagnose swallowing and two full-time nurses is problems. Sigurbjorn Birgisson, MD, MA. • pH monitoring (conventional 24-hour pH/impedance and 48-hour Bravo Our Swallowing Center team capsule) – This test measures and records the pH in your esophagus to determine collaborates with multidisciplinary if you have gastroesophageal reflux disease (GERD). It can also be done to deter- specialists, including radiologists, mine the effectiveness of medications or surgical treatment for GERD. otolaryngologists, thoracic and general surgeons, pathologists, • Endoscopy – This test uses a long, flexible lighted tube with a camera called an speech pathologists and others, endoscope to look at the esophagus. to manage more than 2,500 • Endoscopic ultrasound – A type of ultrasound testing to determine the nature patients a year. Monthly meetings and extent of tumors and other lesions. gather the center’s staff with these colleagues from other specialties to discuss the management of How are swallowing problems treated? complex cases. “These sessions are stimulating,” Sometimes just learning different physical techniques is enough to improve swallow- says Dr. Birgisson, “and ing ability. Other times, and depending on the precise ailment, medical intervention, underscore the broad expertise and/or surgery may be needed. Here is a closer look at each type of treatment: and resources we can bring to PHYSICAL TECHNIQUES bear for patients with the most challenging swallowing and A swallowing therapist can tailor these general strategies to your particular situation: esophageal disorders.” • Avoid eating when tired or stressed • Change head position and posture when swallowing (chin to chest is usually best) • Minimize head movements • Eat smaller, more frequent meals • Lubricate dry food by mixing it with a sauce • Always swallow all of the food in your mouth before taking another bite • Do not eat foods that will stick together • Thicken liquids to make them easier to swallow MEDICAL TREATMENT Sometimes, medical interventions are needed. For instance, stretching the esopha- gus can be done without surgery. Also, medications are effective for some people. Some medications can do the following: • Reduce stomach acid • Overcome spasms of the esophagus • Allow the stomach to empty better CLEVELANDCLINIC.ORG/SWALLOWING SAME-DAY APPOINTMENTS ARE AVAILABLE. CALL 216.444.7000 3 CLEVELAND CLINIC | GUIDE FOR SWALLOWING AND ESOPHAGEAL DISORDERS SURGERY Lifestyle changes can help Surgery also may be an option for people with swallowing disorders. Surgical treatments depend on the location of the swallowing disorder and may involve strengthening or loosening the esophageal sphincters or removing scar tissue and/or Lifestyle changes may control your tumors from the esophagus. symptoms and help reduce your risk of complications from GERD. Choose from a variety of healthy foods, but keep a food diary to What is esophagitis? discover what foods trigger your Esophagitis is a general term for any inflammation of the lining of the esophagus. It reflux or heartburn. Common can be caused by leakage of stomach acid into the esophagus (known as gastroesoph- triggers include: ageal reflux disease, or GERD), vomiting, medications such as aspirin, and viruses, fungi, bacteria or diseases the weaken the immune system. • Citrus juices or fruits Symptoms include difficult and/or painful swallowing, heartburn and acid regurgitation. • Spicy foods, garlic and onion • Mint flavoring • Chocolate How is esophagitis diagnosed? • Alcohol 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 • Drinks with caffeine or include: carbonation • Endoscopy – This test uses a long, flexible lighted tube with a camera called an • Tobacco endoscope to look at the esophagus. • Fatty and fried food • 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. • Tomato-based foods, like spaghetti sauce, chili and pizza • 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 Eat smaller meals and avoid lying and shows up white on an X-ray. This characteristic enables doctors to view down for at least three hours after any abnormalities. eating. You also can sleep