Published on February 19, 2010

Have You Ever Choked On Your Food?

Experienced gastroenterologists can alleviate many swallowing problems

Many people suffer a swallowing problem called dysphagia, which is the sensation of food sticking on the way down your throat.

It is an alarm symptom that indicates the need for immediate evaluation to determine the cause and initiate appropriate treatment. After careful evaluation, most people can be treated with diet, lifestyle changes, medication, and non-surgical endoscopic treatments. However, dysphagia is often preceded by symptoms like heartburn and acid regurgitation, so talk to your physician, who can help you get started with an experienced gastroenterologist.

Acid reflux may lead to swallowing problems
"Twenty to 30 percent of people in the U.S. suffer heartburn or regurgitation once a week," says Erling Larson III, M.D., a boardcertified gastroenterologist and partner at the Genesis Center for Digestive Health. "Three to six percent suffer one or both twice a week or more. Persistent symptoms over two or more years can cause damage to your food pipe and lead to alarm symptoms like dysphagia, weight loss, or bleeding. Early attention to heartburn and acid regurgitation can often alleviate these symptoms and help prevent long-term complications.

"We start with your complete medical history, including what foods cause symptoms, symptom progression over time, and whether you have any associated symptoms."

Persistent problems should be evaluated for GERD
Gastroesophageal reflux disease, or GERD is caused by abnormal reflux (backup) of gastric contents into the esophagus and confirmed by visible mucosal damage seen at endoscopy. Symptoms of GERD can include:

• Heartburn/regurgitation;
• Difficulty swallowing dueto acid reflux that causes inflammation, scarring or spasm;
• A sensation of having alump in the throat or painful swallowing;
• Nausea; or,
• Non-cardiac chest pain.

(Chest pain must be evaluated to ensure that it is not heartrelated before a gastrointestinal evaluation.)

Persistent GERD should be evaluated for Barrett's
"If you have persistent GERD, you should be screened for Barrett's esophagus," Dr. Larson continues, "which occurs when cells that normally line the food pipe are replaced by stomach lining cells, as your body fights the extra acid in your food pipe.

"Screening is important because of the risk of the stomach lining cells transforming into cancer over time.

"Barrett's itself produces no symptoms, but you may notice heartburn, regurgitation, difficulty swallowing, hoarseness, coughing, or wheezing from acid reflux. Diagnosis and treatment involve periodic examination and biopsies of the lower esophagus through upper endoscopy under sedation. Neglecting to diagnose and treat Barrett's can result in esophageal cancer that might have been prevented." Endoscopy involves the use of a thin, flexible scope with a video camera at its tip that permits visualization of the lining of your food pipe, stomach, and upper part of the small bowel.

"Endoscopy permits us to assess visible mucosal damage and obtain biopsies, because damage is often microscopic," explains Anjana Aggarwal, M.D., also a board-certified gastroenterologist and partner at the Center. "It is used in diagnosing GERD and its complications. It is used to screen for Barrett's. It is also used in evaluation of eosinophilic esophagitis, which is caused by allergic inflammation in the food pipe that may cause dysphagia. We also use pH testing, to measure acid back-up, and esophageal manometry, to evaluate muscular function, in your food pipe."

According to Dr. Aggarwal, "The goal is to stop damage to the esophageal lining. With treatment, the lining might improve to normal in a third of patients, remain the same in a third, and worsen in a third, despite medication; however, medication can help control symptoms, reduce complications, and may reduce the chances of developing cancer.

"Medications that reduce acid include proton pump inhibitors like Prilosec, Nexium, Prevacid, Aciphex, Protonix, Zegerid, and Kapidex. If you have severe reflux, significant reflux related complications, and inadequate response to medication, you may benefit from surgical anti-reflux procedures."

Early detection may prevent esophageal cancer
Dr. Aggarwal cautions that over time, Barrett's may progress from early precancerous changes to advanced precancerous changes and then to esophageal cancer. If not detected early, it can become invasive and spread to surrounding tissues. There is an up to 10 percent lifetime risk of Barrett's mucosa becoming cancerous (0.5 percent a year). For advanced precancerous changes and cancer, several options are available, including endoscopic ablation and surgical procedures.

Eosinophilic esophagitis is a common cause of dysphagia
"This condition results from allergic inflammation in the food pipe." Dr. Aggarwal says. "It causes stiffening from inflammation and scarring, which may cause dysphagia and, occasionally, non-cardiac chest pain. After acid reflux, it is the most common cause of dysphagia in Caucasians in their 40's. Diagnosis can only be made by endoscopy and biopsies at various areas in your food pipe. Treatment may require swallowed steroids initially, followed by identification of offending allergens and elimination of them from your diet or environment. Treatment may also involve very careful, gentle stretching of your food pipe, so only an experienced gastroenterologist should work with you in this phase of treatment."

Dr. Aggarwal notes differences between esophageal and oropharyngeal dysphagia, which, she says "is often caused by muscle or nerve dysfunction or tumors affecting structures in the mouth, throat, or neck.

"Symptoms may include difficulty initiating a swallow, coughing, choking, or nasal regurgitation with swallowing. Evaluation and treatment may require a multi-disciplinary team of gastroenterologists, neurologists, otolaryngologists, radiologists, and speech therapists."

Dr. Larson concludes: "Many swallowing problems can be alleviated, which can dramatically improve your health and quality of life. Some may signal more serious problems, and the earlier they are diagnosed, the more likely they can be treated effectively."

If you have questions, please call the Genesis Center for Digestive Health at (563) 449-3740.