Benign Esophageal Diseases

Achalasia, also known as esophageal achalasia is a condition in which the esophagus (a tube that carries food from the mouth to the stomach) is unable to move the food into the stomach. Lower esophageal sphincter is a ring of muscle fibers that surrounds the lower-most end of the esophagus where it joins the stomach. LES acts like a valve between the esophagus and stomach preventing food from moving backward into the esophagus. In people with achalasia, the LES fails to relax during swallowing resulting in the back up of food.

The main symptoms of achalasia include difficulty swallowing (dysphagia), regurgitation of food, heartburn, weight loss, chest pain, and cough.

Your doctor may order the following tests to diagnose achalasia:

Barium swallow test: The test involves swallowing a barium preparation while X-rays are taken. The barium coats the walls of the esophagus and stomach and makes the abnormalities visible more clearly.

Endoscopy: This test allows the doctor to examine the inside of the patient’s esophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.

Manometry: It is a test that measures changes in pressures exerted by the esophageal sphincter.

Treatment options for achalasia include:

• Medications: Medications such as nitrates and calcium channel blockers are recommended to relax the lower esophagus sphincter.
• Botox: Botulinum toxin injection can be administered to help relax the sphincter muscles
• Balloon dilation (pneumatic dilatation): A small balloon is positioned at the LES and inflated to widen the opening for food to enter the stomach.
• Myotomy: It is a surgical procedure in which the sphincter muscle is cut to allow the esophagus to open.

Depending on your situation your doctor will decide which treatment is right for you.

Zenker’s diverticulum refers to an outpouching of the esophagus because of dysfunction of the pharyngoesophageal muscle. This dysfunction leads to increased pressure which causes the outpouching, usually on the left side. The diverticulum leads to food or pills getting stuck, causes bad breath, causes difficulty with swallowing, and can lead to aspiration pneumonia.

Surgery is recommended once it is diagnosed. The operation involves a left neck incision to divide the pharyngoesophageal muscle and then to either remove or suspend the diverticulum to prevent further complications. Most patients have complete resolution of their symptoms after surgery and are discharged home in 2-3 days’ time.

Hernia is an opening formed by the lining of the abdominal cavity. Abdominal wall hernia occurs when the contents of the intestine bulges out of the abdominal wall. Hernias are developed at birth (congenital) or may appear later (acquired).

Hernias may be present at birth and occurs when the lining around the abdominal organs, fails to close before birth. Hernia may also result if the connective tissue degenerates in the abdominal wall due to which, pressure builds up in the abdominal wall leading to a bulge in the abdomen. Some of the other factors that worsen hernia are chronic cough, obesity, constipation, pregnancy, poor nutrition, smoking and stretching or straining abdominal muscles while lifting heavy objects.

Hiatus hernia:

Normally, the stomach is completely below the diaphragm. In individuals with hiatus hernia part of the stomach slides through the diaphragm, the muscular sheet that separates the lungs and chest from the abdomen, and protrudes into chest cavity. Hiatal hernia is more common and affects people of all ages.

Hiatal hernias are of two types:

• Sliding hiatal hernia – The top portion of stomach slides up and down through the diaphragm with increased pressure on abdominal cavity
• Fixed Hiatal hernia – The top portion of stomach moves up into the chest cavity and does not slide down into normal position.

Obesity, chronic cough, chronic constipation, smoking, and hereditary factors increases the risk of developing hiatal hernias. Hiatal hernia may not cause any symptoms but patients may experience chest pain, heart burn, belching, and hiccups.

Your doctor can confirm the presence of hiatal hernia by performing physical examination. A special X-ray (using a barium swallow) will be ordered that allows your doctor to view the esophagus or with endoscopy.

Treatment

Surgery is the only treatment and is usually performed for hiatal hernias that enlarge in size due to increased intra-abdominal pressure causing intestinal obstruction and restricted blood supply which may lead to death of bowel tissues.

A hiatal hernia repair is usually performed as an outpatient surgery with no overnight stay in the hospital. The operation may be performed as an “open” or “keyhole” (laparoscopic) surgery.

Laparoscopic or Keyhole surgery: This surgery is performed under general anesthesia and several small incisions are made around the abdomen. Through one of the incision, a laparoscope a small, fiber-optic tube with a tiny camera is inserted that allows the surgeon to see inside the abdomen and the surgical instruments are inserted through the other incisions. Carbon dioxide (CO2) is put into the abdomen through a special needle that is inserted just below the navel. This gas helps to separate the organs inside the abdominal cavity, making it easier for the physician to see the organs during laparoscopy. The gas is evacuated at the end of the procedure.

As common with other surgeries, hernia surgery is also associated with certain complications such as local discomfort and stiffness, infection, damage to nerves and blood vessels, bruising, blood clots, wound irritation and urinary retention.

Acid reflux, also called gastro-esophageal reflux disease (GERD), is a condition where the stomach contents (food or liquid) rise from the stomach into the esophagus, a tube that carries food from the mouth to the stomach.

Normally the stomach contents do not enter the esophagus due to constricted LES. But in patients with acid reflux stomach content travels back into the esophagus because of a weak or relaxed lower esophageal sphincter (LES). Lower esophageal sphincter is a ring of muscle fibers that surrounds the lower-most end of the esophagus where it joins the stomach. LES acts like a valve between the esophagus and stomach preventing food from moving backward into the esophagus

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble in swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

The exact cause of what weakens or relaxes the LES in GERD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GERD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolates, caffeine containing drinks, mint flavorings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

There are several tests that can be performed to diagnose acid reflux and they include:

• Endoscopy: This test allows the doctor to examine the inside of the patient’s esophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.
• Barium X-rays: These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. You are asked to drink a liquid that contains barium. The barium coats the walls of the esophagus and stomach and makes the abnormalities visible more clearly. Then X-rays are taken to see if there are strictures, ulcers, hiatal hernias, erosions or other abnormalities.
• Twenty four-hour pH monitoring – In this procedure, a tube will be inserted through the nose into the esophagus and positioned above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into esophagus. A recorder, strap-like device that can be worn on wrist, will be connected to record the pH of the acid content. The tube will be left in place for 24 hours. Patients can also go back home and perform their regular activities and can record the pH of the acid content when they experience the symptoms. On the next day, the recorder will be connected to a computer and the data will be analyzed.
• pH Capsule: It is a new method of measuring acid exposure in the esophagus. A small wireless capsule which is introduced into the esophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the esophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the usual 24 hours. The capsule falls off the esophagus with time and is passed in the stool.
• Impedance study: This test is like pH test but requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Antacids are over-the-counter medicines that provide temporarily relief to heartburn or indigestion by neutralizing acid in the stomach. Other medications such as proton pump inhibitors and H2 antagonists may be prescribed to reduce the production of acid in the stomach.

Surgery may be an option for patients whose symptoms do not go away with the medications. Nissen’s fundoplication is a surgical procedure in which the upper part of the stomach is wrapped around the end of your esophagus and esophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into esophagus.

Endoluminal gastroplication or endoscopic fundoplication technique requires the use of an endoscope with a sewing device attached to the end, known as EndoCinch device. This instrument place stitches in the stomach below the LES to create a plate which helps reduce the pressure against the LES and help strengthen the muscle.

Chronic GERD left untreated can cause serious complications such as inflammation of the esophagus, esophageal ulcer, narrowing of the esophagus, chronic cough, and reflux of liquid into the lungs (pulmonary aspiration). Some people develop Barrett’s esophagus, in which there is changes in the esophageal lining that can lead to esophageal cancer.

General measures the patient can take to reduce reflux are:

• Avoid eating before going to bed as this may decrease the acid production
• Eat smaller and more frequent meals
• Lose weight if you are over weight
• Elevate the head of the bed
• Eliminate the foods that increases the reflux
• Avoid smoking and use of alcohol
• Check with the physician regarding side effects of prescription medications