Disorders of the Esophagus

The esophagus is a narrow tube that permits the transfer of food from the mouth to the stomach. The upper third of the esophagus is composed of skeletal muscle, and the remaining two thirds is composed of smooth muscle. The upper portion works to propel food downward; the lower portion relaxes when food is propelled downward and then constricts (narrows) to ensure that nothing flows

262 backward from the stomach. The esophagus is not meant to store or hold swal-

Common lowed food or digestive juices, both of which can damage its delicate lining.

Health

Concerns

Common Symptoms

Difficulty swallowing is called dysphagia. It is a symptom of either an obstructive problem (such as cancer or scarring of the esophagus) or a muscular problem (such as megaesophagus, when the lower esophageal sphincter does not relax and allow food into the stomach).

Heartburn is another symptom of esophageal disorders. This burning pain rises in the chest and can be felt in the neck, throat, or face. Heartburn usually occurs after meals, after taking certain medications, or while lying down. Some people also may feel a burning pain or tightness when swallowing solids or liquids. Heartburn can indicate a problem with a medication or with the lower esophageal sphincter, the muscular valve that prevents stomach acid from rising up into the esophagus. (Heartburn also may be a symptom of coronary artery disease; see page 204.)

Some medications (especially aspirin, antibiotics, and quinidine) and vitamins and minerals (especially potassium chloride, vitamin C, and iron) may damage the esophagus if not taken properly. If you take a pill or a capsule without drinking enough water, it can release chemicals that irritate the lining of the esophagus and possibly cause ulcers, inflammation, or bleeding. If you are taking medications that can cause irritation on swallowing, be sure to drink plenty of fluid (at least 8 ounces) before and after taking them. Sit upright while taking the medication, and remain upright until you have drunk enough fluid to ensure that it has passed into the stomach. Be sure to tell your doctor if a certain pill or capsule continues to irritate your esophagus.

Gastroesophageal Reflux Disease

The most common disorder of the esophagus is gastroesophageal reflux disease (GERD). In GERD, the muscle at the bottom of the esophagus, the lower esophageal sphincter, does not close completely, allowing stomach acids and other irritants to flow backward (reflux) into the esophagus.

Certain medications can interfere with the action of this muscle, including nitrates, calcium channel blockers, theophylline, and anticholinergics. Smoking and diet also contribute to GERD. Excessive consumption of chocolate, peppermint, coffee, alcohol, and fried or fatty foods can weaken the lower esophageal sphincter.

Some people with GERD also have a hiatal hernia, in which a portion of the stomach protrudes through the diaphragm (the large muscle that separates the abdomen from the chest cavity) and allows stomach acid to remain trapped just beneath the sphincter muscle. Coughing, vomiting, straining, and sudden physi cal exertion can increase pressure in the abdomen, resulting in a hiatal hernia. 263

This condition is common among pregnant women, obese adults, and many oth- Digestive erwise healthy people over age 50. System

If you regularly experience heartburn, you should avoid the foods listed above as well as acidic foods that can cause additional irritation to the esophagus, such as citrus fruits and juices, tomatoes and tomato products, peppers, and onions. Eating smaller, more frequent meals may help. Also avoid lying down within 2 to 3 hours of eating. If you smoke, quit now (see page 107). If you are overweight, losing weight (see page 73) will help relieve gastroesophageal reflux disease symptoms. You can also try elevating the head of your bed on 6-inch blocks or sleeping on a specially designed foam wedge. Over-the-counter antacids may help, but if you find yourself taking them for longer than 3 weeks, talk to your doctor.

If changes to your diet and lifestyle do not improve GERD symptoms, your doctor may want to perform additional tests, such as an upper gastrointestinal (GI) series or an endoscopy (see "Diagnostic Procedures," page 282).

In cases of chronic heartburn and GERD, doctors usually prescribe medications to reduce the acid in the stomach and to hasten gastric emptying (moving food and acids out of the stomach and into the duodenum). In rare situations, surgery may be required to increase pressure on the lower esophagus. If the esophagus is badly scarred and narrowed, surgery also may be needed to widen the passageway.

Heartburn and GERD are more than painful and inconvenient. If left untreated, they can cause bleeding or ulcers in the esophagus and also may lead to frequent infections. The esophagus may become permanently narrowed due to scarring from the exposure to stomach acid. People who have had heartburn for 5 or more years are at increased risk for developing Barrett esophagus, a condition in which the cells that line the esophagus change from one type of cell to another. This condition cannot be cured and may lead to esophageal cancer.

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