Other Digestive Disorders

Achalasia / Acid Reflux / Dyspepsia / Mid Gut Disorders / Bad Bowels

Achalasia:

Digestive motility problems often do not obediently restrict themselves to only one region of the digestive tract!

Individuals diagnosed with a motility disorder may experience challenging symptoms though out their digestive system. Each person is unique in the degree to which they are affected; and yet, the difficulties faced match a shared experience for all.

Fortunately, many people will remain with regional problems, while for some—dysmotilities can encompass other digestive regions. These dysmotilities represent a mixed bag from a ‘spastic’ nature to a flaccid nature—that is, without muscular tone or paralyzed.

Hypo-motility problems—achalasia, gastroparesis, chronic intestinal pseudo-obstruction and colonic inertia—do overlap with common symptoms. They also represent neuro-muscular malfunctioning or abnormalities; and frequently their cause cannot be found. The medical term for these primary problems which have no identifiable cause is “Idiopathic”.

Achalasia

The feeling of food stuck in your throat--we have all experienced this feeling at one time or another. In Achalasia, this difficulty slowly progresses over time to where even swallowing liquids is difficult. Difficultly with swallowing is called ‘dysphagia’.

 

The slow march of symptom severity makes early diagnosis of Achalasia difficult and frustrating. Early on, symptoms may be ascribed to stress or Gastroesophageal Reflux Disease (GERD).

 

What is happening?

In the normal functioning esophagus, swallowing is a very active process. Peristaltic muscular waves help to move food contents down toward the stomach. Near the end of the esophagus is a valve called the “lower esophageal sphincter”. It quickly relaxes to permit the entry of food—then, just as quickly, tightens-up again to keep food secured in your stomach.

The esophagus in achalasia has lost its ability to relax the lower esophageal sphincter as well as lost peristaltic action within the body of the esophagus. The esophageal body becomes weak and flaccid. Food piles up and has difficulty reaching the stomach.

The exact cause of this problem is unknown and it is rare. Only 1 in 100,000 people each year develop this primary motor dysfunction of the esophagus.

Men and women are equally affected. The age range for those afflicted is between 25-60 years with less than 5% of the cases occurring in children.

Obviously this is a unique digestive motility disease where men and women are equally represented.

The symptoms of achalasia, over time, can grow from troubling to oppressive. Not only are swallowing difficulties present, but the regurgitation of food, especially at night, can cause a sudden and frightening fight for breath. Severe and persistent night time coughing (when lying down) can result and be mistaken for asthma.

Weight loss is also a problem because food is not reaching the stomach and food avoidance occurs to try and escape symptoms.

As if trouble swallowing isn’t bad enough!

Many who suffer from Achalasia also experience discomfort or pain in their chest (just behind the breastbone), especially after eating.

This pain, (thought to result from cramping of the esophagus) may also develop without apparent provocation and bears resemblance to a heart attack: with sudden on-set, beginning in the chest and working its way up to the jaw; even occurring in the middle of the night. Fearfully intense, the episode may last for a couple of minutes or hours. A confusing visit to the emergency department has all baffled because the heart is found to be perfectly normal.

 

Complications.

• Retaining food in the esophagus for prolonged periods of time will result in stretching and dilating the esophagus.

• Retained food and liquids also can reflux or regurgitate into the lungs, especially at night, leading to Pneumonia.

 

Diagnostic tests

A number of diagnostic tests help to confirm Achalasia:

• Barium swallow

• Esophageal Manometry (motility study)

• PH monitoring (with a probe or ‘Bravo’ capsule)

• Endoscopy of the esophagus, stomach and upper part of the small intestine.

 

Treatments

Everyone is affected to different degrees depending upon the severity of their malfunctioning LES and lack of esophageal peristalsis. Treatments are aimed at relaxing or opening the LES in order to make the passage of food easier. Food texture and temperatures are also a key treatment component. Finding a specialist who is very experienced with treating Achalasia is your best beginning.

 

Physical approaches to treating milder problems are to use the advantages of gravity and force.

• Eating while standing-up,

• Shake a leg after eating or jump to help dislodge the food and move it down into the stomach.

• Drink lots of water with your food.

 

treatment approaches through the manipulation of diet are helpful, but also very individual and best achieved through consultation with a dietitian. What works for you may not be tolerated by someone else. Experimenting with different textures and temperatures is important too.

 

Generally:

• Warm foods or liquids,

• Non-carbonated beverages,

• Soft and semi-soft foods,

• Stewed chicken, fish, eggs or pastas,

• Canned fruits or vegetables,

• Liquid multi-vitamine supplements,

• Mashed vegetables and soups,

• Finally, nutritional liquid meal replacements like Boost or Ensure.

 

Small frequent meals are easier to process and you should avoid snacking in the evening in order to give your esophagus a chance to ‘clear-out’ residual food before bedtime.

Esophageal spasms

Spasms of the esophagus are not unique to achalasia. Spasms may result from time to time for anyone suffering with digestive motility problems. The on-set and expression of this pain will vary for everyone, but it is different than the dull ache of heart burn.

Esophageal spasms are sharp, intense and often transitory. The spasms can be mistaken for a heart attack. They can be very difficult to manage.

 

Treatments continued:

The next level of care if gravity and diet changes are not helping will be the use of prescription medications which aim to relax the lower esophageal sphincter.

These medications may not be very effective and may be used as a stop-gap treatment; or in older people who are not good candidates for more invasive treatments.

The medications may cause headaches and lower blood pressure resulting in dizziness or even fainting.

Standard drugs are:

• Nifedipine (Adalat^®),

• Isosorbide dinitrate (Isordil^®)

Your doctor will advise regarding the timing and strength of your medications

Of note, Sildenafil (Viagra^®) has been used with some good results. Viagra^® helps to relax the LES.

 

Other, more invasive treatments:

Botox injections into the LES—

Botox has come into wide spread use in plastic surgery, the treatment of Gastroparesis, and a variety of other disorders where a muscle needs to be “relaxed” or temporarily paralyzed. Injected under controlled conditions, the localized paralyzing effect may last for many months.

Done via endoscopy by a Gastroenterologist; Botox injections into the LES seems like a quick fix for Achalasia--but may not be the best long term solution to a problem that is not going to go away! This treatment approach carries about a 30% effectiveness rate and, at best, will only relieve symptoms of dysphasia (difficulty swallowing), for up to one year, or much less. Also, it can cause an inflammatory reaction making future, more definitive surgical treatments a much more difficult procedure for the surgeon. This treatment should be reserved for older people where the risk of surgical treatment is too great.

 

Balloon Dilation of the LES

This is the recommended treatment. A balloon is inserted via endoscopy and gently introduced into the LES. Once there, it is inflated to stretch open this valve. Success rate with this technique is 70 to 80%, but does carry a risk of rupturing the LES and can only be done a couple of times, otherwise the risk of rupturing the LES increases with each dilation. The dilation can provide many with long term (10 years) symptom relief. For those who this approach does not work or fails over time, then another surgical procedure is available.

 

The Heller Myotomy

This is a surgical technique done through laparoscopic surgery (minimally invasive) or an open surgical approach. The surgeon goes in and cuts open the LES. Usually a wrap (fundoplication) of the LES is also needed and done at the same time to prevent stomach acid washing back up into the esophagus. The Heller Myotomy has a success rate of 80 to 90% for relieving dysphasia, unfortunately it may not help with relief of esophageal spasm pain--which for some can be debilitating.

After surgery, thought still needs to go into your food selection since surgery does not restore the loss of peristaltic action in the body of the esophagus. Eating while sitting straight up, remaining up-right after a meal and drinking plenty of water is recommended.

 

What to do for esophageal spasms!

As mentioned, esophageal spasm pain can be a bane for many people suffering with Digestive Motility Diseases. Most often, these spasms are fleeting and infrequent. For others, they are a daily and painfully debilitating problem. The medications already mentioned may be used to help relieve this pain--however, results are often not satisfactory.

One medication that is fast acting (within minutes) and highly effective is: Hyoscyamine sulfate (Levsin). It comes in dissolvable tablets (just place on your tongue), drops, liquid, or extended release capsules. The medication is also safe in young children.

Levsin is an “anti-spasmdic” medication used in treating spasms in the stomach, bladder or intestinal area where cramps are thought to be a problem.

This pain relief is a better option than other types of pain medications which could further slow down your already sluggish motility. As well, the short acting formulations of Levsin would be a better option since this medication is in a pharmacological class of drugs called: anticholinergic. Anticholinergic can slow down gut motility.

Other measures to help relieve esophageal spasms:

 

• Try placing a hot water bottle on your chest or a heating pad.

• Experiment with warm or cold liquids, even a fizzy drink like coke may help.

• Yoga and slow deep breathing may help to relax the spasm.

• Above all, try and remain calm and work through the painful spam.

 

Who can develop Achalasia?

Most causes of Achalasia are unknown, or Idiopathic. Yet some other typesof diseases may express themselves with Achalasia problems. Many people with Scleroderma develop significant ‘dysmotilities: in their esophagus. Systemic Scleroderma may also express as severe dysmotilities from the esophagus downwards, while limited Scleroderma (Also known as CREST) May stay confined to a dysmotility within the esophagus.

Chagas disease is another identifiable disease which can lead to achalasia, but also can cause profound constipation (Colonic Inertia) and heart failure. Chagas is caused by a parasite which is prevalent in Central and South America, infecting 16 to 18 million people. When the infection is chronic then damage to these other organs can occur.

Chagas destroys enteric (gut) nerves in the colon and or esophagus, but spares the stomach and small intestine.

The problems and challenges encountered by people suffering from digestive dysmotilities are similar. Educating yourself as to what treatments are available is an important first step in order to advocate for better quality of life and more treatment options.