Oesophagus Information GERD/NERD. What are the symptoms of GERD? What causes GERD?

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1 Oesophagus Information GERD/NERD Gastroesophageal reflux disease (GERD) is a chronic digestive disease that occurs when stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms. Signs and symptoms of GERD include acid reflux and heartburn. Both are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with your daily life, doctors call this GERD. Most people can manage the discomfort of heartburn with lifestyle changes and over-the-counter medications. But for people with GERD, these remedies may offer only temporary relief. People with GERD may need stronger medications, even surgery, to reduce symptoms. What are the symptoms of GERD? GERD signs and symptoms include: A burning sensation in your chest (heartburn), sometimes spreading to the throat, along with a sour taste in your mouth Chest pain Difficulty swallowing (dysphagia) Dry cough Hoarseness or sore throat Regurgitation of food or sour liquid (acid reflux) Sensation of a lump in the throat When to see a doctor Seek immediate medical attention if you experience chest pain, especially when accompanied by other signs and symptoms, such as shortness of breath or jaw or arm pain. These may be signs and symptoms of a heart attack. Make an appointment with your doctor if you experience severe or frequent GERD symptoms. If you take over-the-counter medications for heartburn more than twice per week, see your doctor. What causes GERD? GERD is caused by frequent acid reflux the backup of stomach acid or bile into the esophagus. When you swallow, the lower esophageal sphincter a circular band of muscle around the bottom part of your esophagus relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

2 However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing frequent heartburn and disrupting your daily life. This constant backwash of acid can irritate the lining of your esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can erode the esophagus, causing complications such as bleeding or breathing problems. What is the risk factor? Conditions that can increase your risk of GERD include: Obesity Hiatal hernia Pregnancy Smoking Dry mouth Asthma Diabetes Delayed stomach emptying Connective tissue disorders, such as scleroderma Zollinger-Ellison syndrome What are the possible complications? Over time, chronic inflammation in your esophagus can lead to complications, including: Narrowing of the esophagus (esophageal stricture). Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing difficulty swallowing. An open sore in the esophagus (esophageal ulcer). Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult. Precancerous changes to the esophagus (Barrett s esophagus). In Barrett s esophagus, the color and composition of the tissue lining the lower esophagus change. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but your doctor will likely recommend regular endoscopy exams to look for early warning signs of esophageal cancer. What are the most common tests and diagnosis? If you re bothered by frequent heartburn or other signs and symptoms, your doctor may be able to diagnose GERD with that information alone. Your doctor may also suggest tests and procedures used to diagnose GERD, including: An X-ray of your upper digestive system. Sometimes called a barium swallow or upper GI series, this procedure involves drinking a chalky liquid that coats and fills the inside lining of your digestive tract. Then X-rays are taken of your upper digestive tract. The coating allows your doctor to see a silhouette of the shape and condition of your esophagus, stomach and upper intestine

3 (duodenum). Passing a flexible tube down your throat. Endoscopy is a way to visually examine the inside of your esophagus. During endoscopy, your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope allows your doctor to examine your esophagus and stomach. Your doctor may also use endoscopy to collect a sample of tissue (biopsy) for further testing. Endoscopy is useful in looking for complications of reflux, such as Barrett s esophagus. A test to monitor the amount of acid in your esophagus. Ambulatory acid (ph) probe tests use an acid-measuring device to identify when, and for how long, stomach acid regurgitates into your esophagus. The acid monitor can be a thin, flexible tube (catheter) that s threaded through your nose into your esophagus. During the test, the tube stays in place and connects to a small computer that you wear around your waist or with a strap over your shoulder. Or the acid monitor can be a clip that s placed in your esophagus during endoscopy. The probe transmits a signal to a small computer that you wear around your waist for about two days, and then the probe falls off to be passed in your stool. Your doctor may ask that you stop taking GERD medications to prepare for this test. A test to measure the movement of the esophagus. Esophageal motility testing measures movement and pressure in the esophagus. The test involves placing a catheter through your nose and into your esophagus. What are the recommended treatments and drugs? Treatment for heartburn and other signs and symptoms of GERD usually begins with over-th- -counter medications that control acid. If you don t experience relief within a few weeks, your doctor may recommend other treatments, including medications and surgery. Initial treatments to control heartburn Over-the-counter treatments that may help control heartburn include: Antacids that neutralize stomach acid. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums, may provide quick relief. But antacids alone won t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation. Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 25, Zantac 75, Zantac 150). H-2-receptor blockers don t act as quickly as antacids, but they provide longer relief. Stronger versions of these medications are available in prescription form. Medications that block acid production and heal the esophagus. Proton pump inhibitors block acid production and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec OTC). Contact your doctor if you need to take these medications two or more times a week or your symptoms are not relieved. Prescription-strength medications

4 If heartburn persists despite initial approaches, your doctor may recommend prescription-strength medications, such as: Prescription-strength H-2-receptor blockers. These include prescription-strength cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac). Prescription-strength proton pump inhibitors.prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).Rarely, these medications may lead to bone loss and increase the risk of a bone fracture. Your doctor may suggest that you take a calcium supplement to reduce these risks.these medications may decrease the effectiveness of the bloodthinning medication, clopidogrel (Plavix). If you are prescribed a proton pump inhibitor and are taking Plavix, tell your doctor. Medications to strengthen the lower esophageal sphincter. Called prokinetic agents, these medications help your stomach empty more rapidly and help tighten the valve between the stomach and the esophagus. Side effects, such as fatigue, depression, anxiety and other neurological problems, limit the usefulness of these medications. GERD medications are sometimes combined to increase effectiveness. Surgery and other procedures used if medications don t help Most GERD can be controlled through medications. In situations where medications aren t helpful or you wish to avoid long-term medication use, your doctor may recommend more invasive procedures, such as: Surgery to reinforce the lower esophageal sphincter (Nissen fundoplication). This surgery involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. Surgery can be open or laparoscopic. In open surgery, the surgeon makes a long incision in your abdomen. In laparoscopic surgery, the surgeon makes three or four small incisions in the abdomen and inserts instruments, including a flexible tube with a tiny camera, through the incisions. Surgery to create a barrier preventing the backup of stomach acid. A device (Esophyx) is inserted through the mouth into the stomach. The device is used to fold the tissue at the base of the stomach into a replacement for the sphincter valve, to keep stomach acid from washing into your esophagus. Your doctor may recommend this procedure if medications aren t effective or if you re not a candidate for Nissen fundoplication. It s not clear who is best suited for this treatment, and research is ongoing. A procedure to form scar tissue in the esophagus (Stretta procedure). This approach uses electrode energy to heat esophageal tissue. The heat creates scar tissue and damages the nerves that respond to refluxed acid. The scar tissue that forms as your esophagus heals helps to strengthen the muscles. Your doctor may recommend this procedure if medications aren t effective or if you re not a candidate for Nissen fundoplication. It s not clear who is best suited for this treatment, and research is ongoing. Surgery to strengthen the lower esophageal sphincter (Linx). The Linx device is a ring of tiny magnetic titanium beads that is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the opening between the two closed to refluxing acid, but weak enough so that food can pass through it. The new device has

5 been approved by the Food and Drug Administration. It can be implanted using minimally invasive surgery methods. What is the recommended lifestyle and home remedies? Lifestyle changes may help reduce the frequency of heartburn. Consider trying to: Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If your weight is healthy, work to maintain it. If you are overweight or obese, work to slowly lose weight no more than 1 or 2 pounds (0.5 to 1 kilogram) a week. Ask your doctor for help in devising a weight-loss strategy that will work for you. Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter. Avoid foods and drinks that trigger heartburn. Everyone has specific triggers. Common triggers such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine may make heartburn worse. Avoid foods you know will trigger your heartburn. Eat smaller meals. Avoid overeating by eating smaller meals. Don t lie down after a meal. Wait at least three hours after eating before lying down or going to bed. Elevate the head of your bed. If you regularly experience heartburn at night or while trying to sleep, put gravity to work for you. Place wood or cement blocks under the feet of your bed so that the head end is raised by six to nine inches. If it s not possible to elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head with additional pillows is not effective. Don t smoke. Smoking decreases the lower esophageal sphincter s ability to function properly. Could I rely on alternative medicine? No alternative medicine therapies are proven to treat GERD or to reverse damage to the esophagus. Still, some complementary and alternative therapies may provide some relief, when combined with your doctor s care. Talk to your doctor about what alternative GERD treatments may be safe for you. Options may include: Herbal remedies. Herbal remedies sometimes used for GERD symptoms include licorice, slippery elm, chamomile and marshmallow. Herbal remedies can have serious side effects, and they may interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy. Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of GERD. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery. Acupuncture. Acupuncture involves inserting thin needles into specific points on your body. One small study reported that acupuncture helped people with heartburn that persisted despite medication. Ask your doctor whether acupuncture is safe for you.

6 Barrett s Oesophagus Barrett s esophagus is a condition in which the cells of your lower esophagus become damaged, usually from repeated exposure to stomach acid. The damage causes changes to the color and composition of the esophagus cells. Barrett s esophagus is most often diagnosed in people who have long-term gastroesophageal reflux disease (GERD) a chronic regurgitation of acid from the stomach into the lower esophagus. Only a small percentage of people with GERD will develop Barrett s esophagus. A diagnosis of Barrett s esophagus can be concerning because it increases the risk of developing esophageal cancer. Although the risk of esophageal cancer is small, monitoring of Barrett s esophagus focuses on periodic exams to find precancerous esophagus cells. If precancerous cells are discovered, they can be treated to prevent esophageal cancer. What are the symptoms of Barrett's oesophagus? Barrett s esophagus signs and symptoms are usually related to acid reflux and may include: Frequent heartburn Difficulty swallowing food Chest pain Upper abdominal pain Dry cough Many people with Barrett s esophagus have no signs or symptoms. When to see a doctor If you ve had long-term trouble with heartburn and acid reflux, discuss this with your doctor and ask about your risk of Barrett s esophagus. Seek immediate medical attention if you: Have chest pain Have difficulty swallowing Are vomiting red blood or blood that looks like coffee grounds Are passing black, tarry or bloody stools What could cause Barrett's oesophagus? The exact cause of Barrett s esophagus isn t known. Most people with Barrett s esophagus have long-standing GERD. It s thought that GERD causes stomach contents to wash back into the esophagus, causing damage to the esophagus. As the esophagus tries to heal itself, the cells can

7 change to the type of cells found in Barrett s esophagus. Still, some people diagnosed with Barrett s esophagus have never experienced heartburn or acid reflux. It s not clear what causes Barrett s esophagus in these cases. Bile reflux Bile reflux occurs when bile a digestive liquid produced in your liver backs up (refluxes) into your stomach and esophagus (the tube that connects your mouth and stomach). Bile reflux may accompany acid reflux, the medical term for the backwash of stomach acids into your esophagus. Whether bile is important in reflux is controversial. Bile is often implicated as a cause of reflux when people respond incompletely or not at all to powerful acid-suppressant medications. But there is little evidence pinpointing the effects of bile reflux in people. Studies in lab animals indicate that over time, bile reflux may have serious consequences, potentially increasing your risk of esophageal cancer. Unlike acid reflux, bile reflux usually can t be completely controlled by changes in diet or lifestyle. Instead, bile reflux is most often managed with medications or, in severe cases, with surgery. What are the possible symptoms of Bile reflux? Bile reflux can be difficult to distinguish from acid reflux. The signs and symptoms are similar, and the two conditions may occur at the same time. It isn t clear what role bile plays in reflux conditions. Bile reflux signs and symptoms include: Upper abdominal pain that may be severe Frequent heartburn a burning sensation in your chest that sometimes spreads to your throat, along with a sour taste in your mouth Nausea Vomiting a greenish-yellow fluid (bile) Occasionally, a cough or hoarseness Unintended weight loss When to see a doctor Make an appointment with your doctor if you frequently experience symptoms of reflux, or if you re losing weight without trying. If you ve been diagnosed with gastroesophageal reflux disease (GERD) but aren t getting adequate relief from your medications, call your doctor. You may need additional treatment for bile reflux.

8 What could cause Bile reflux? Bile is a greenish-yellow fluid that is essential for digesting fats and for eliminating worn-out red blood cells and certain toxins from your body. Bile is produced in your liver and stored in your gallbladder. Eating a meal that contains even a small amount of fat signals your gallbladder to release bile, which flows through two small tubes (cystic duct and common bile duct) into the upper part of your small intestine (duodenum). Bile reflux into the stomach At the same time that bile flows into the duodenum, food enters your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach. The pyloric valve usually opens only slightly enough to release about an eighth of an ounce (about 3.5 milliliters) of liquefied food at a time, but not enough to allow digestive juices to reflux into the stomach. In many cases of bile reflux, the valve doesn t close properly, and bile washes back into the stomach. Bile reflux into the esophagus Bile and stomach acid can reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. The valve normally opens just long enough to allow food to pass into the stomach. But if the valve weakens or relaxes abnormally, bile can wash back into the esophagus. What leads to bile reflux? Bile reflux may be caused by: Surgery complications. Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass surgery for weight loss. Peptic ulcers. A peptic ulcer can block the pyloric valve so that it doesn t open enough to allow the stomach to empty as quickly as it should. Stagnant food in the stomach can lead to increased gastric pressure that refluxes bile and stomach acid into the esophagus. Gallbladder surgery (cholecystectomy). People who have had their gallbladders removed have significantly more bile reflux than do people who haven t had this surgery. What complications could you have? Sticky mucous coats and protects the lining of your stomach from the corrosive effects of stomach acid. The esophagus lacks this protection, so acid and bile reflux can seriously damage esophageal tissue. The combination of bile and acid reflux increases the risk of complications, including: GERD. Occasional heartburn usually isn t a concern. But frequent or continual heartburn is the most common symptom of GERD, a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis). GERD is most often due to excess acid. Although bile has been implicated, its importance in reflux is controversial. Barrett s esophagus. This serious condition can occur when long-term exposure to stomach acid, or to acid and bile, damages tissue in the lower esophagus. The damaged esophageal cells (metaplasia) have an increased risk of becoming cancerous. Animal studies have also linked bile reflux to the occurrence of Barrett s esophagus.

9 Esophageal cancer. This serious form of cancer may not be diagnosed until it s quite advanced. The possible link between bile and acid reflux and esophageal cancer remains controversial, but many experts think a direct connection exists. In animal studies, bile reflux alone has been shown to cause cancer of the esophagus. What are the most common tests and diagnosis? A description of your symptoms is often enough for your doctor to diagnose a reflux problem. But distinguishing between acid reflux and bile reflux is difficult, and requires further testing. You re also likely to have tests to check for damage to your esophagus and stomach as well as for precancerous changes. Tests may include: Endoscopy. A thin, flexible tube with a camera (endoscope) is passed down your throat. The endoscope can show peptic ulcers or inflammation in your stomach and esophagus. Your doctor also may take tissue samples to test for Barrett s esophagus or esophageal cancer. Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid refluxes into your esophagus. In one test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus. In another (the Bravo test), the probe is attached to the lower portion of your esophagus during endoscopy. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux. Esophageal impedance. This test measures whether gas or liquids reflux into the esophagus. It s helpful for people who regurgitate substances that aren t acidic (such as bile) and can t be detected by an acid probe. As in a standard probe test, esophageal impedance uses a probe that s placed into the esophagus with a catheter. What are the recommended treatments and drugs? Although treatments for acid reflux can be very effective, medications for bile reflux may not be helpful for many people. There is little evidence assessing the effectiveness of bile reflux treatments, in part because of the difficulty of establishing bile reflux as the cause of symptoms. Medications Bile acid sequestrants. These medications, which disrupt the circulation of bile, may be helpful for some people with bile reflux. Side effects, such as bloating, may be severe. Ursodeoxycholic acid. This medication helps promote bile flow. It may lessen the frequency and severity of your symptoms. Prokinetic agents. These medications can help your stomach empty more rapidly and help tighten the lower esophageal sphincter. These medications have several side effects, including fatigue, depression, anxiety and other neurological problems. Proton pump inhibitors. These medications are often prescribed to block acid production, but they don t have a clear role in treating bile reflux. Surgical treatments Doctors may recommend surgery if medications fail to reduce severe symptoms, or there are

10 precancerous changes in your esophagus. Some types of surgery can be more successful than others, so be sure to discuss the pros and cons carefully with your doctor. The options include: Diversion surgery (Roux-en-Y). This procedure may be recommended for people who have had previous gastric surgery with pylorus removal (Billroth I or Billroth II). In Roux-en-Y, surgeons make a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach. Anti-reflux surgery (fundoplication). The part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. There is little evidence about the surgery s effectiveness for bile reflux. What is the recommended lifestyle and home remedies? Unlike acid reflux, bile reflux seems less related to lifestyle factors. But many people experience both acid reflux and bile reflux, so your symptoms may be eased by lifestyle changes: Stop smoking. Smoking increases the production of stomach acid and dries up saliva, which helps protect the esophagus. Eat smaller meals. Eating smaller, more-frequent meals reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening at the wrong time. Stay upright after eating. After a meal, waiting two to three hours before lying down allows time for your stomach to empty. Limit fatty foods. High-fat meals relax the lower esophageal sphincter and slow the rate at which food leaves your stomach. Avoid problem foods and beverages. Foods that increase the production of stomach acid and may relax the lower esophageal sphincter include caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, tomato-based foods, spicy foods and mint. Limit or avoid alcohol. Drinking alcohol relaxes the lower esophageal sphincter and irritates the esophagus. Lose excess weight. Heartburn and acid reflux are more likely to occur when excess weight puts added pressure on your stomach. Raise your bed. Sleeping with your upper body raised four to six inches may help prevent reflux symptoms. Raising your bed with blocks or sleeping on a foam wedge is more effective than is using extra pillows. Relax. When you re under stress, digestion slows, possibly worsening reflux symptoms. Relaxation techniques, such as deep breathing, meditation or yoga, may help. Could I rely on alternative medicine? Many people with frequent heartburn use over-the-counter or alternative therapies for symptom relief. Remember that even natural remedies can have risks and side effects, including potentially serious interactions with prescription medications. Always do careful research and talk with your doctor before trying an alternative therapy. Although no alternative therapies have been found specifically to relieve bile reflux, some may help

11 protect against and relieve esophageal inflammation. If you decide to start any of these therapies, discuss them with your doctor. They include: Chamomile, which has anti-inflammatory properties. Chamomile teas are readily available and have a low risk of side effects. Licorice, which is commonly used to soothe inflammation associated with GERD, gastritis, ulcers and other digestive problems. However, licorice contains a chemical called glycyrrhizin (gly-cy- -RIH-zin) that s associated with serious health risks, such as high blood pressure and tissue swelling, if used long term. Talk with your doctor before trying this therapy. Prescription preparations are available that don t contain glycyrrhizin. Slippery elm, a product of a tree bark and root, may help soothe the digestive tract. Slippery elm can be mixed with water and taken after meals and before bed. But slippery elm may decrease the absorption of prescription medications. Marshmallow (Althea officinalis) is an herb not the puffy white candy that has been used for GERD symptom relief. Like slippery elm, marshmallow may cause problems with the absorption of medications. Esophageal cancer Esophageal cancer is cancer that occurs in the esophagus a long, hollow tube that runs from your throat to your stomach. Your esophagus carries food you swallow to your stomach to be digested. Esophageal cancer usually begins in the cells that line the inside of the esophagus. Esophageal cancer can occur anywhere along the esophagus, but in people in the United States, it occurs most often in the lower portion of the esophagus. More men than women get esophageal cancer. Esophageal cancer isn t common in the United States. In other areas of the world, such as Asia and parts of Africa, esophageal cancer is much more common. What are the symptoms of Esophageal cancer? Signs and symptoms of esophageal cancer include: Difficulty swallowing (dysphagia) Weight loss without trying Chest pain, pressure or burning Fatigue Frequent choking while eating Indigestion or heartburn Coughing or hoarseness Early esophageal cancer typically causes no signs or symptoms.

12 When to see a doctor Make an appointment with your doctor if you have any persistent signs and symptoms that worry you. If you ve been diagnosed with Barrett s esophagus, a precancerous condition that increases your risk of esophageal cancer caused by chronic acid reflux, ask your doctor what signs and symptoms to watch for that may signal that your condition is worsening. Screening for esophageal cancer isn t done routinely because of a lack of an easily identifiable highrisk group and the possible risks associated with endoscopy. If you have Barrett s esophagus, discuss the pros and cons of screening with your doctor. What could cause Esophageal cancer? It s not clear what causes esophageal cancer. Esophageal cancer occurs when cells in your esophagus develop errors (mutations) in their DNA. The errors make cells grow and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body. Types of esophageal cancer Esophageal cancer is classified according to the type of cells that are involved. The type of esophageal cancer you have helps determine your treatment options. Types of esophageal cancer include: Adenocarcinoma. Adenocarcinoma begins in the cells of mucus-secreting glands in the esophagus. Adenocarcinoma occurs most often in the lower portion of the esophagus. Adenocarcinoma is the most common form of esophageal cancer in the United States, and it affects primarily white men. Squamous cell carcinoma. The squamous cells are flat, thin cells that line the surface of the esophagus. Squamous cell carcinoma occurs most often in the middle of the esophagus. Squamous cell carcinoma is the most prevalent esophageal cancer worldwide. Other rare types. Rare forms of esophageal cancer include choriocarcinoma, lymphoma, melanoma, sarcoma and small cell cancer What is the risk factor? It s thought that chronic irritation of your esophagus may contribute to the DNA changes that cause esophageal cancer. Factors that cause irritation in the cells of your esophagus and increase your risk of esophageal cancer include: Drinking alcohol Having bile reflux Chewing tobacco Having difficulty swallowing because of an esophageal sphincter that won t relax (achalasia) Drinking very hot liquids Eating few fruits and vegetables Eating foods preserved in lye, such as lutefisk, a Nordic recipe made from whitefish, and some

13 olive recipes Having gastroesophageal reflux disease (GERD) Being obese Having precancerous changes in the cells of the esophagus (Barrett s esophagus) Undergoing radiation treatment to the chest or upper abdomen Smoking Other risk factors include Being male Being between the ages of 45 and 70 What complications could you have? As esophageal cancer advances, it can cause complications, such as: Obstruction of the esophagus. Cancer may make it difficult or impossible for food and liquid to pass through your esophagus. Cancer pain. Advanced esophageal cancer can cause pain. Bleeding in the esophagus. Esophageal cancer can cause bleeding. Though bleeding is usually gradual, it can be sudden and severe at times. Severe weight loss. Esophageal cancer can make it difficult and painful to eat and drink, resulting in weight loss. Coughing. Esophageal cancer can erode your esophagus and create a hole into your windpipe (trachea). Known as a tracheoesophageal fistula, this hole can cause severe and sudden coughing whenever you swallow. What are the most common tests and diagnosis? Tests and procedures used to diagnose esophageal cancer include: Using a scope to examine your esophagus (endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens (endoscope) down your throat and into your esophagus. Using the endoscope, your doctor examines your esophagus looking for cancer or areas of irritation. X-rays of your esophagus. Sometimes called a barium swallow, an upper gastrointestinal series or an esophagram, this series of X-rays is used to examine your esophagus. During the test, you drink a thick liquid (barium) that temporarily coats the lining of your esophagus, so the lining shows up clearly on the X-rays. Collecting a sample of tissue for testing (biopsy). A special scope passed down your throat into your esophagus (endoscope) or down your windpipe and into your lungs (bronchoscope) can be used to collect a sample of suspicious tissue (biopsy). What type of biopsy procedure you undergo depends on your situation. The tissue sample is sent to a laboratory to look for cancer cells. Esophageal cancer staging When you re diagnosed with esophageal cancer, your doctor works to determine the extent (stage) of the cancer. Your cancer s stage helps determine your treatment options. Tests used in staging

14 esophageal cancer include computerized tomography (CT) and positron emission tomography (PET). The stages of esophageal cancer are: Stage I. This cancer occurs only in the top layer of cells lining your esophagus. Stage II. The cancer has invaded deeper layers of your esophagus lining and may have spread to nearby lymph nodes. Stage III. The cancer has spread to the deepest layers of the wall of your esophagus and to nearby tissues or lymph nodes. Stage IV. The cancer has spread to other parts of your body. What are the recommended treatments and drugs? What treatments you receive for esophageal cancer are based on the type of cells involved in your cancer, your cancer s stage, your overall health and your preferences for treatment. Surgery Surgery to remove the cancer can be used alone or in combination with other treatments. Operations used to treat esophageal cancer include: Surgery to remove very small tumors. If your cancer is very small, confined to the superficial layers of your esophagus and hasn t spread, your surgeon may recommend removing the cancer and margin of healthy tissue that surrounds it. Surgery for very early-stage cancers can be done using an endoscope passed down your throat and into your esophagus. Surgery to remove a portion of the esophagus (esophagectomy). Your surgeon removes the portion of your esophagus that contains the tumor and nearby lymph nodes. The remaining esophagus is reconnected to your stomach. Usually this is done by pulling the stomach up to meet the remaining esophagus. In some situations, a portion of the colon is used to replace the missing section of esophagus. Surgery to remove part of your esophagus and the upper portion of your stomach (esophagogastrectomy). Your surgeon removes part of your esophagus, nearby lymph nodes and the upper part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two. Esophageal cancer surgery carries a risk of serious complications, such as infection, bleeding and leakage from the area where the remaining esophagus is reattached. Surgery to remove your esophagus can be performed as an open procedure using large incisions or with special surgical tools inserted through several small incisions in your skin (laparoscopically). How your surgery is performed depends on your situation and your surgeon s experience and preferences. Surgery for supportive care Besides treating the disease, surgery can help relieve symptoms or allow you to eat. Relieving esophageal obstruction. A number of treatments are available to relieve esophageal obstruction. One option includes using an endoscope and special tools to widen the esophagus and place a metal tube (stent) to hold the esophagus open. Other options include surgery, radiation

15 therapy, chemotherapy, laser therapy and photodynamic therapy. Providing nutrition. A surgeon inserts a feeding tube (percutaneous gastronomy) so you can receive nutrition directly into your stomach or intestine. This is usually temporary until the surgical site heals or until you re finished with chemotherapy and radiation therapy. Chemotherapy Chemotherapy is drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs are typically used before (neoadjuvant) or after (adjuvant) surgery in people with esophageal cancer. Chemotherapy can also be combined with radiation therapy. In people with advanced cancer that has spread beyond the esophagus, chemotherapy may be used alone to help relieve signs and symptoms caused by the cancer. The chemotherapy side effects you experience depend on which chemotherapy drugs you receive. Radiation therapy Radiation therapy uses high-powered energy beams to kill cancer cells. Radiation can come from a machine outside your body that aims the beams at your cancer (external beam radiation). Or radiation can be placed inside your body near the cancer (brachytherapy). Radiation therapy is most often combined with chemotherapy in people with esophageal cancer. It can be used before or after surgery. Radiation therapy is also used to relieve complications of advanced esophageal cancer, such as when a tumor grows large enough to stop food from passing to your stomach. Side effects of radiation to the esophagus include sunburn-like skin reactions, painful or difficult swallowing, and accidental damage to nearby organs, such as the lungs and heart. Combined chemotherapy and radiation Combining chemotherapy and radiation therapy may enhance the effectiveness of each treatment. Combined chemotherapy and radiation may be the only treatment you receive, or combined therapy can be used before surgery. But combining chemotherapy and radiation treatments increases the likelihood and severity of side effects. Clinical trials Clinical trials are research studies testing the newest cancer treatments and new ways of using existing cancer treatments. Clinical trials give you a chance to try the latest in cancer treatment, but they can t guarantee a cure. Ask your doctor if you re eligible to enroll in a clinical trial. Together you can discuss the potential benefits and risks. Q: What is the recommended lifestyle and home remedies Poor appetite, difficulty swallowing, weight loss and weakness often accompany esophageal cancer. These symptoms may be compounded by cancer treatments and by the need for a liquid diet, tube feeding or intravenous feeding during the course of treatment. Ask your doctor for a referral to a registered dietitian, who can help you find solutions to dealing

16 with difficulty eating or a loss of appetite. In the meantime, try to: Choose easy-to-swallow foods. If you have trouble swallowing, choose foods that are soothing and easy to swallow, such as soups, yogurt or milkshakes. Eat smaller meals more frequently. Eat several small meals throughout the day instead of two or three larger ones. Keep nourishing snacks within easy reach. If snacks are readily available, you re more likely to eat. Talk to your doctor about vitamin and mineral supplements. If you haven t been eating as much as you normally would or if your usual foods are restricted, you could be deficient in a variety of nutrients. Can I rely on alternative medicine? Complementary and alternative therapies may help you cope with the side effects of cancer and cancer treatment. For instance, people with esophageal cancer may experience pain caused by cancer treatment or by a growing tumor. Your doctor can work to control your pain by treating the cause or with medications. Still, pain may persist, and complementary and alternative therapies may help you cope. Options include: Acupuncture Guided imagery Hypnosis Massage Relaxation techniques Ask your doctor whether these options are safe for you. Difficulty swallowing Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your mouth to your stomach. Difficulty swallowing may also be associated with pain. In some cases, you may not be able to swallow at all. Occasional difficulty swallowing usually isn t cause for concern, and may simply occur when you eat too fast or don t chew your food well enough. But persistent difficulty swallowing may indicate a serious medical condition requiring treatment. Difficulty swallowing can occur at any age, but it s more common in older adults. The causes of swallowing problems vary, and treatment depends on the cause. What are the symptoms of Difficulty swallowing?

17 Signs and symptoms that can be associated with dysphagia may include: Pain while swallowing (odynophagia) Not being able to swallow Sensation of food getting stuck in your throat or chest, or behind your breastbone (sternum) Drooling Hoarseness Bringing food back up (regurgitation) Frequent heartburn Food or stomach acid backing up into your throat Unexpected weight loss Coughing or gagging when swallowing In infants and children, signs and symptoms of swallowing difficulties may include: Lack of attention during feeding or meals Tensing of the body during feeding Refusing to eat foods of different textures Lengthy feeding or eating times (30 minutes or longer) Breast-feeding problems Food or liquid leaking from the mouth Coughing or choking during feeding or meals Spitting up or vomiting during feeding or meals Trouble breathing while eating and drinking Weight loss or slow weight gain or growth Recurrent pneumonia When to see a doctor Obstructions. If an obstruction interferes with breathing, call for emergency help immediately. If you re unable to swallow due to an obstruction, go to the nearest emergency department. Ongoing problems. Slight or occasional difficulty swallowing usually isn t cause for concern or action. But see your doctor if you regularly have difficulty swallowing or if difficulty swallowing is accompanied by weight loss, regurgitation or vomiting. Children. If you suspect that your child has trouble swallowing, contact your child s doctor. Your child may be referred to a doctor who specializes in treating children with feeding and swallowing disorders. What could cause Difficulty swallowing? It takes about 50 pairs of muscles and nerves to accomplish the simple act of swallowing, and a number of conditions can interfere with this process. These conditions generally fall into one of two categories: esophageal and oropharyngeal. Sometimes, however, the cause of dysphagia can t be identified. Esophageal dysphagia Esophageal dysphagia refers to the sensation of food sticking or getting hung up in the base of your throat or in your chest. Some of the causes of esophageal dysphagia include:

18 Achalasia. This occurs when your lower esophageal muscle (sphincter) doesn t relax properly to let food enter your stomach. Muscles in the wall of your esophagus may be weak as well. This can cause regurgitation of food not yet mixed with stomach contents, sometimes causing you to bring food back up into your throat. This type of dysphagia tends to get worse over time. Diffuse spasm. This condition produces multiple, high-pressure, poorly coordinated contractions of your esophagus usually after you swallow. Diffuse spasm affects the involuntary muscles in the walls of your lower esophagus. Esophageal stricture. Narrowing of your esophagus (stricture) can cause large pieces of food to get caught. Narrowing may result from the formation of scar tissue, often caused by gastroesophageal reflux disease (GERD), or from tumors. Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present. Foreign bodies. Sometimes, food, such as a large piece of meat, or another object can partially block your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food properly may be more likely to have a piece of food become lodged in the throat or esophagus. Children may swallow small objects, such as pins, coins or pieces of toys, that can become stuck. Esophageal ring. This thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods. Gastroesophageal reflux disease (GERD). Damage to esophageal tissues from stomach acid backing up (refluxing) into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus, making swallowing difficult. Eosinophilic esophagitis. This condition, which may be related to a food allergy, is caused by an overpopulation of cells called eosinophils in the esophagus, and can lead to difficulty swallowing. Scleroderma. This disease is characterized by the development of scar-like tissue, causing stiffening and hardening of tissues. This can weaken your lower esophageal sphincter, allowing acid to back up into your esophagus and cause frequent heartburn. Radiation therapy. This cancer treatment can lead to inflammation and scarring of the esophagus, which may cause difficulty swallowing. Oropharyngeal dysphagia Certain problems related to your nerves and muscles can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus (pharyngeal paralysis). You may choke, gag or cough when you attempt to swallow, or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia. Causes of oropharyngeal dysphagia include: Neurological disorders. Certain disorders, such as post-polio syndrome, multiple sclerosis, muscular dystrophy and Parkinson s disease, may first be noticed because of oropharyngeal dysphagia. Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can cause difficulty swallowing or an inability to swallow. Pharyngeal diverticula. A small pouch forms and collects food particles in your throat, often just above your esophagus, leading to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing. Cancer. Certain cancers and some cancer treatments, such as radiation, can cause difficulty

19 swallowing. Esophageal spasms Esophageal spasms are painful muscle contractions that affect your esophagus, the hollow tube between your throat and your stomach. Esophageal spasms can feel like sudden, severe chest pain that lasts from a few minutes to hours. Esophageal spasms usually occur only occasionally. But for some people, the muscle contractions are frequent and can prevent food and liquids from traveling through the esophagus. Esophageal spasms can lead to chronic pain and swallowing problems. What are the symptoms of esophageal spasms? Signs and symptoms of esophageal spasms can include: Squeezing pain in your chest, often intense, which you might mistake for heart pain (angina) Difficulty swallowing (dysphagia) The feeling that an object is stuck in your throat (globus) The return of food and liquids back up your esophagus (regurgitation) When to see a doctor The squeezing chest pain that esophageal spasms can cause can also be caused by a heart attack or angina. If you experience squeezing chest pain, especially if it is a new symptom, seek medical care right away to make sure it s not a heart problem. What could cause esophageal spasms? It s not clear what causes esophageal spasms. A healthy esophagus normally moves food into your stomach through a series of coordinated muscle contractions (peristalsis). Esophageal spasms disrupt this process by making it difficult for the muscles in the walls of your lower esophagus to coordinate in order to move food to your stomach. Types of esophageal spasms Esophageal spasms may occur in two forms: Diffuse esophageal spasms are occasional contractions in the esophageal muscles. This type of spasm is often accompanied by regurgitation of food or liquids. Nutcracker esophagus is the term for painfully strong contractions in the esophageal muscles. Nutcracker esophagus is less likely to cause regurgitation of food and liquids. What is the risk factor?

20 Esophageal spasms are more common in women than in men. Other factors that increase the risk of esophageal spasms include: Eating or drinking very hot or very cold foods or drinks Heartburn Gastroesophageal reflux disease (GERD) Anxiety What are the most common tests and diagnosis? Based on your signs and symptoms, your doctor may recommend these tests: X-rays of your esophagus, after you drink a contrast liquid Esophageal manometry, to measure muscle contractions in your esophagus when you swallow water Endoscopy, to view the inside of the esophagus Esophageal ph monitoring, to determine if stomach acid is flowing back into your esophagus (acid reflux) What are the recommended treatments and drugs? If you experience esophageal spasms only occasionally, you may not need treatment. Your doctor may recommend avoiding food or situations that trigger your esophageal spasms. If your esophageal spasms make it difficult to eat or drink, your doctor may recommend: Managing any underlying conditions, such as heartburn, GERD, anxiety or depression. Treating these conditions may lessen the likelihood of esophageal spasm symptoms. Medications to relax your swallowing muscles, which can reduce the severity of contractions. Surgery is sometimes recommended to treat acid reflux that doesn t respond to medication, or to cut the muscle at the lower end of the esophagus, which can weaken esophageal contractions. What is the recommended lifestyle and home remedies? To help you cope with occasional esophageal spasms, try to: Identify your triggers. Make a list of things that cause your esophageal spasms, such as cold or hot foods and drinks, or red wine. Avoid these triggers. Choose food that is warm or cool. Let foods and drinks that are very hot or very cold sit for a bit before eating or drinking them. Find ways to control stress. Esophageal spasms may be more common or more severe when you re stressed. Some stress is inevitable, so find healthy ways to cope. Esophageal varices Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus the tube that