GI Woe

Jim Atkinson cures what ails us.

December 2007By Comments

Ever take a bite of, say, steak that’s just a bit too large and chew it just a bit too little and feel it lodge briefly in your esophagus? I’ll bet you do what I’ve always done: Pause, swallow again—and the food moves right along. Well, this is what I thought would happen with a piece of T-bone I ate this past Labor Day weekend. Except that when I tried the double clutch on it, it wouldn’t budge, causing a low-grade gag. “It’s like I have this really big burp,” I told my wife, “but it won’t move.” I was breathing fine. You choke, rather than gag, when food goes down the trachea, a problem with a ready antidote: the Heimlich maneuver. But you can’t Heimlich something in your food tube. You either have to coax it into your stomach or—worst case—regurgitate it. Sitting there at the table, I realized how unequipped I was in matters of the gullet. We’re all familiar with the colon these days (Katie Couric, anyone?). But consider the other end: When’s the last time you paid attention to your esophagus?

Inner Focus

Nothing I tried would move the food bolus in either direction. I drank water to force it down, only to spit the liquid up. Other than my poor chewing, what had caused this?

You write about medicine for fifteen years, as I have, and what you know becomes a curse. And unfortunately, when something gets stuck in your food tract, there are a lot of scary explanations. First? Cancer of the throat or the esophagus. This is not too common (about 20,000 deaths each year, compared with 52,000 from colon or rectal cancer), but I am a former smoker—and the fact that I haven’t had a drag in a decade doesn’t get me out of the woods. Then there’s esophageal diverticula, in which the esophagus lining gets herniated and impedes the passage of food. It’s generally not fatal but can involve complicated surgery to repair. Or, I thought, it might be a diffuse esophageal spasm. Or maybe it was a hiatal hernia, in which the stomach can protrude through the diaphragm and into the esophagus. Then again, perhaps it was the aftermath of gastroesophageal reflux disease (GERD), a destructive condition that, despite being well publicized by drug ads, is not entirely understood by the public. While most of us know it as simple heartburn, it can cause secondary conditions ranging from esophageal strictures to ulcers.

Duct Work

I learned something else on this adventure: The Sunday before Labor Day is a good time for emergency treatment. The Presbyterian Hospital of Dallas’s ER was practically empty, and I was whisked to a room for a barrage of questions from nurses and doctors. Do you smoke? No, quit ten years ago. Drink? No, quit fifteen years ago. Any throat, esophageal, or colon cancer in the family? My dad died of colon cancer at 81—but everyone dies of something at that age. Acid reflux problems? No, just some occasional heartburn.

They injected me with glucagon in hopes of loosening my lower esophageal sphincter, the muscle between the esophagus and the stomach, and allowing the bolus to pass. No luck. “We’re going to have to perform an endoscopy,” the gastroenterologist on duty, William E. Stevens, announced. The procedure, as I learned—though I was then put under for its duration—involves passing a tiny camera down your esophagus for a digital view of the tissue; any irregularity is photographed. And, as in my case, the head of the camera can be used to push an obstruction—mine was right at the lower sphincter—into the stomach. When a nurse roused me twenty minutes later, I could swallow again.

Soon Stevens was back with pictures of the real problem. I had an esophageal ring—a narrowing of the tube—near the lower sphincter. The ring, explained Stevens, was probably caused by a slight hiatal hernia he had also detected and scarring from related GERD.

GERD Yourself

Gastroesophageal reflux disease is incredibly common: During any given year, said Stevens, 45 percent of the population suffers some symptom of it. Twenty percent of us experience it more than twice a week, yet only 5 percent of us see a doc about it. The condition occurs because of a defect in the anti-reflux barrier (ARB) between the stomach and the esophagus. Normally the ARB—of which the lower sphincter forms a part—serves to prevent bile and stomach acid from backwashing into the esophagus. But if the sphincter muscle is too weak (due to damage or congenital defects), the acid seeps into the food tube, where the tissue is susceptible.

In general, patients with GERD are given medications that include antacids, H2 receptor antagonists such as Zantac, or proton pump inhibitors such as Prilosec (see “Tube Lube”). About one percent suffer the condition severely enough to opt for surgery. The most common technique is called Nissen fundoplication, which these days is performed laparoscopically and reconstructs the junction between the esophagus and the stomach. Studies have shown it to be 75 to 90 percent effective in alleviating heartburn.

But left untreated, GERD may lead to scarring in the food tract and cause a lower esophageal ring. There are two types of rings, A and B. The former is rare; the B ring, like mine (also known as a Schatzki ring), affects about 10 percent of the population, though many cases are asymptomatic, said Stevens. He deemed my case minor, but he did put me on Prilosec until he could get back in and dilate the ring. Apparently, my occasional bouts of heartburn had been worse than I’d thought.

Gut Instincts

About a month later, I saw Stevens again, this time at the Dallas Endoscopy Center. We went through the same ritual, except this time, he attached a balloon to the camera’s fiber-optic cable so that once he got to the ring, he could inflate it and stretch my esophagus back to normal size.

Stevens kept me on a daily dose of Prilosec and said to check back if it wasn’t working. So, I asked him, should we middle-aged types all be getting endoscopies as well as colonoscopies, so that problems like mine can be caught earlier? “Because the incidence of esophageal cancer is so low in Americans, routine screening has not been widely accepted,” said Stevens. “However, anyone with trouble swallowing should undergo an endoscopy. People with chronic GERD that is bad enough to require daily treatment should also consider having one.”

Of course, it also pays to look into your heartburn, however minor it may seem; the consequences, as I’ve learned, can be serious. Oh, and take smaller bites of that T-bone.

Tube Lube: The lowdown on acid reflux meds.

Among the dizzying array of medications—and TV ads—now available for gastroesophageal reflux disease, is there one that’s better than the others? It’s a tough call. The class of drugs known as H2 receptor antagonists (Axid, Pepcid, Tagamet, Zantac) inhibit the action of histamine in the stomach—histamine stimulates acid production—whereas proton pump inhibitors, or PPIs (AcipHex, Nexium, Prevacid, Prilosec), block the stomach’s acid-secretion cells directly. Both limit gastric acid, but one of the most comprehensive studies on GERD treatments by the Agency for Healthcare Research and Quality did conclude that PPIs are somewhat more effective. More significantly, the study found that PPIs are just as successful at alleviating GERD as laparoscopic surgery.

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