The esophagus is a hollow tube beginning at the very back of the pharynx (throat) and ending at the stomach. Its function is to transport swallowed food and liquid from the throat through the chest into the stomach. It has little digestive function. In other words, it is not active in the breakdown or absorption of food.

ESOPHAGEAL DISORDERS

Reflux Esophagitis, Hiatal Hernia, Heartburn

These terms have all come to be associated with the same condition. The valve located at the very bottom of the esophagus just above the stomach is called the lower esophageal sphincter (see Figure 2). It generally remains closed unless a person swallows. With swallowing, the valve opens, allowing liquids and food to pass into the stomach and then the valve closes again. In some patients, for reasons we do not understand, the valve is incompetent and does not close properly. When the valve is not closed, acid is allowed to reflux (flow back up) from the stomach into the esophagus. This occurs more often when a person is lying down, because gravity does not keep the food in the stomach as easily as when sitting or standing. It also occurs after meals when the stomach is full, and this is a time when the stomach makes large amounts of acid to begin the process of digestion. Certain foods and other substances make this condition worse by further interfering with the valve function. Included are alcohol, peppermint, tobacco, caffeine, and particularly, fatty foods (fried or greasy foods). These all lower the pressure of the valve making it even more incompetent. Initial treatment for this problem involves medication. Patients with mild reflux may find relief with over the counter agents ie. Antacids, or hydrogen 2 (H2) receptor blockers ie. Axid, pepcid, zantac, tagamet. Prilosec OTC is the first available over the counter acid pump inhibitor. Stomach acid pump inhibitors are the strongest class of medication available to treat reflux. Most of these are available by prescription only ie. Prevacid, Nexium, Aciphex, Protonix, Zegerid and generic omeprazole. In general, most gastroenterologists will recommend a limited trial of these medications. If symptoms persist, an upper endoscopy (video camera exam of the upper gi) is needed before using these medicines for longer duration. In some cases medication is not effective in treating this problem. Laparoscopic surgery (Nissen fundoplication) may be required, and certain studies before surgery are needed ie. Esophageal manometry. More recently, innovative endoscopic technology is being used including the endoscopic plicator as well as other treatments.

Heartburn

A burning or hot sensation underneath the breastbone. Some patients state that they experience pain in the very pit of their stomach while other patients describe that the discomfort continues up under the breastbone and sometimes into the throat. If the stomach contents reflux up into the throat, a patient may complain of an increased flow of saliva, a salty taste, or a sour or acid material in the back of his/her throat. Some patients awaken choking at night. The esophagus is not designed to tolerate this acid and, as a result, the acid burns the lining of the esophagus. Many people experience minor degrees of heartburn. However, if it is a regular occurrence, the continual flow of acid up into the esophagus can cause ulceration of the esophagus. This leads to scarring at the bottom of the esophagus resulting in a stricture (narrowing). A stricture may prevent the passage of solid food especially bread or meat into the stomach. When such food becomes trapped above the stricture, a patient notes a feeling of suffocation or chest discomfort and will frequently try to vomit to clear the esophagus of the trapped food. In most people, this stricture can be easily dilated by a physician; thus allowing patient to eat normally.

Hiatal Hernia

The presence of part of the stomach which has herniated or been pushed up above the diaphragm (see Figure 2). The diaphragm is a sheet of muscle that separates the chest and the abdominal cavities. It was previously thought that hiatal hernias were the main problem that caused the reflux of the acid material from the stomach into the esophagus. Now studies have shown that many people over the age of 50 have hiatal hernias. Many of these people have no symptoms whatsoever. Often when a person thinks he has a "hiatel hernia," it likely not the real problem, but rather that the valve (lower esophageal sphincter) is not functioning properly.

Barrett's Esophagus

Some patients who have chronic reflux esophagitis develop a change in the type of cells that line the bottom part of the esophagus. The cells resemble those that line the stomach or even the small intestine. This change within the esophagus is called Barrett's Esophagus. The significance of this is that in some patients with this condition, cancer can develop. If a Barrett's Esophagus is established, periodic endoscopy is essential to sample the cells lining the esophagus to look for cancer or pre-cancerous cells.

Cancer of the Esophagus

Cancer occurs when there is growth of abnormal cells that are no longer under control of the body. This occurs most often in people who smoke and those with heavy alcohol consumption. These habits are the two most important factors related to cancer of the esophagus. Unfortunately, by the time many patients go to a doctor with symptoms from the cancer, it is already spread outside the wall of the esophagus. The symptoms associated with cancer of the esophagus are odynophagia (pain from the esophagus when a patient swallows and food passes the area of the cancer) and dysphagia (the sensation of food sticking or becoming trapped such that it cannot pass through the area where the cancer is located). Either of these symptoms should cause a person to seek immediate attention in hopes that the problem can be detected early and will be cured. As mentioned, these symptoms are often associated with benign conditions as well.

Basic Antireflux Program

• Elevate the head of your bed with 6-8" blocks or use a bed wedge to elevate your chest and head. (This allows us to use gravity to keep the acid contents of the stomach in the stomach while sleeping; just using extra pillows is not adequate).
• Nothing to eat for three hours prior to bedtime. (This reduces the volume of stomach contents at bedtime.)
• Do not lie down for at least three hours after meals. (This decreases reflux at a time when the stomach is most full and has the most acid.)

Diet

Certain food make reflux esophagitis worse by further interfering with the lower esophageal sphincter valve's function. These are alcohol, peppermint, caffeine, and particularly, fatty foods (fried or greasy foods). These substances all lower the pressure of the valve making it even more incompetent. You should avoid these. Citrus or acid containing foods and beverages may make reflux symptoms worse, but they do not increase reflux.

Smoking

Smoking not only irritates the lining of the esophagus, it interferes with the lower esophageal sphincter valve's function. If you smoke, you should stop or at least significantly reduce the amount you smoke. This is only one of the ways smoking cessation will help improve your health.