Oesophageal Disorder

Oesophageal disorders are a collection of conditions that affect the tube carrying food from your mouth to your stomach, with symptoms ranging from heartburn to difficulty swallowing that can significantly impact your daily life.

Table of contents

• What Are Oesophageal Disorders?
• Types of Oesophageal Disorders
• Associated Anatomy
• Risk Factors
• Symptoms
• Diagnosis
• Treatment Options
• Living with an Oesophageal Disorder

What Are Oesophageal Disorders?

Oesophageal disorders are conditions that affect how the oesophagus works. Your oesophagus, sometimes called the food pipe, is the part of the digestive system that helps food travel from your mouth to your stomach.^[1] It is a muscular tube that uses rhythmic waves of muscle contractions called peristalsis to move food downward.^[5]

Different diseases can affect the oesophagus, causing problems with swallowing or other uncomfortable symptoms. The most common oesophageal disorder is gastroesophageal reflux disease (GERD), which occurs when excessive stomach acid moves back into the oesophagus, causing inflammation.^[1]

The oesophagus has two bands of muscle called sphincters. Just below the junction of the throat and oesophagus is the upper oesophageal sphincter, and slightly above where the oesophagus meets the stomach is the lower oesophageal sphincter. When the oesophagus is not in use, these sphincters close so that food and stomach acid do not flow back up from the stomach to the mouth. During swallowing, the sphincters open so food can pass to the stomach.^[5]

Types of Oesophageal Disorders

There are many different types of oesophageal disorders. Each type affects the oesophagus in different ways and causes different symptoms.

GERD (Gastroesophageal Reflux Disease): This is the most common oesophageal disorder. It occurs when the lower oesophageal sphincter doesn’t close properly, allowing stomach acid and contents to flow backward into your oesophagus. This backwash is known as acid reflux, and it can irritate the lining of the oesophagus.^[1][3] When acid reflux happens repeatedly over time, it causes GERD.^[3]

Achalasia: The lower oesophageal sphincter doesn’t open or relax properly, preventing food from going into the stomach. Experts believe achalasia may be an autoimmune disease, but the exact cause is unknown. Something damages the nerves that control the muscles in the oesophagus.^[1] Achalasia has objective diagnostic criteria and effective treatments are available, and timely diagnosis results in better outcomes.^[7]

Barrett’s Oesophagus: For people with chronic, untreated acid reflux, the lining of the bottom part of their oesophagus starts looking like stomach lining, and the cells start to resemble intestinal cells. These changes take place where the oesophagus and stomach meet. This condition is associated with a higher risk of oesophageal cancer.^[1] Barrett’s oesophagus develops in some people who have chronic GERD or inflammation of the oesophagus. Not all patients with GERD get Barrett’s, but nearly all patients with Barrett’s have GERD.^[15]

Eosinophilic Oesophagitis: White blood cells called eosinophils become overabundant in the oesophagus. The result is inflammation or swelling of the oesophageal lining, a condition called oesophagitis. This condition is more common in patients with multiple allergies.^[1] It is an inflammatory condition in which the wall of the oesophagus becomes filled with large numbers of eosinophils, and the most common cause is allergy-induced inflammation.^[15]

Oesophageal Cancer: There are two types of oesophageal cancer: squamous cell carcinoma and adenocarcinoma. Generally speaking, smoking, radiation and HPV infection increases the risk of oesophageal squamous cell carcinoma, while smoking and acid reflux increase risks of adenocarcinoma.^[1]

Oesophageal Diverticulum: An outpouching occurs in a weak spot in the oesophagus. People with achalasia are more prone to developing diverticula.^[1]

Oesophageal Spasms: Abnormal muscle spasms or contractions occur in the oesophagus. This rare, painful condition keeps food from reaching the stomach.^[1] These are uncoordinated contractions of the oesophagus that affect the movement of food to the stomach and can cause difficulty swallowing, regurgitation and chest pain.^[15]

Oesophageal Strictures: The oesophagus becomes too narrow. Foods and liquids pass through slowly to the stomach.^[1]

Hiatal Hernias: The upper part of the stomach protrudes above an opening in the diaphragm and sits in the chest. This condition leads to more acid reflux.^[1]

Oesophageal Motility Disorders: These are conditions caused by weak or uncoordinated muscular contractions of the oesophagus, interfering with the movement of food or fluid from the throat to the stomach.^[15] They can cause chest pain, heartburn, or difficulty swallowing.^[7]

• Oesophagus
• Throat (pharynx)
• Stomach
• Upper oesophageal sphincter
• Lower oesophageal sphincter
• Diaphragm

Risk Factors

Several factors can increase the chances of developing an oesophageal disorder:

• Alcohol use
• Extra weight due to obesity or pregnancy
• Medications, including certain antibiotics, antidepressants and pain relievers
• Radiation therapy to your neck or chest
• Smoking, including exposure to secondhand smoke^[1]

With aging, the strength of oesophageal contractions and the pressure in the sphincters decrease. This condition makes older adults more prone to backflow of acid from the stomach.^[5]

Symptoms

Symptoms vary depending on the type of oesophageal disorder. Two of the most common symptoms are difficulty swallowing and chest or back pain.^[5] You may experience:

• Abdominal pain, chest pain or back pain
• Chronic cough or sore throat
• Difficulty swallowing or feeling like food is stuck in your throat
• Heartburn (burning feeling in your chest)
• Hoarseness or wheezing
• Indigestion (burning feeling in your stomach)
• Regurgitation (stomach acid or contents coming back up your oesophagus to your mouth) or vomiting
• Unexplained weight loss^[1]

If you have GERD specifically, common symptoms include a burning sensation in the chest (often called heartburn), backwash of food or sour liquid in the throat, upper belly or chest pain, trouble swallowing, and sensation of a lump in the throat. Heartburn usually happens after eating and might be worse at night or while lying down.^[3]

If you have nighttime acid reflux, you might also experience an ongoing cough, inflammation of the vocal cords (known as laryngitis), or new or worsening asthma.^[3]

Diagnosis

Your healthcare professional will start by asking about your symptoms and giving you a physical exam. You may also need one or more tests to help diagnose your condition.^[1]

Endoscopy: This is a test used to check the digestive system. A healthcare professional guides a long, thin tube equipped with a tiny camera, called an endoscope, down the throat and into the oesophagus. Your healthcare professional can use an endoscope to see if the oesophagus looks different than usual. Small tissue samples may be taken for testing, which is called a biopsy. The oesophagus may look different depending on the cause of the swelling.^[10]

Barium X-ray: This test involves drinking a solution or taking a pill that contains a compound called barium. Barium is a contrast material that highlights specific areas of the digestive tract on X-rays, helping to develop images that show abnormalities.^[6]

Oesophageal pH Acidity Test: A test that measures the amount of acid flowing from the stomach into your oesophagus.^[6]

Manometry Test: A test that evaluates the strength and patterns of the oesophageal muscles to assess how well your oesophagus is working.^[6] High-resolution oesophageal manometry is required to confirm the diagnosis of achalasia.^[7]

Blood Tests: Your doctor may order blood tests to assist in making an accurate diagnosis, including evaluation for possible allergies or other causes of oesophageal disorders.^[6]

Treatment Options

Treatment depends on the specific problem you have. Some problems get better with over-the-counter medicines or changes in diet. Others may need prescription medicines or surgery.^[2]

Medications and Lifestyle Changes

Most people can manage the discomfort of GERD with lifestyle changes and medicines.^[3] Medications, along with dietary and lifestyle changes, can help with many oesophageal disorders.^[1]

For acid reflux, antacids, proton pump inhibitors (PPIs) and histamine receptor (H2) blockers can reduce stomach acid.^[14] Oesophageal motility disorders usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.^[7]

Simple lifestyle changes can make a big difference for GERD. These include eating smaller amounts more often, eating slowly and chewing food well, taking sips of a drink between mouthfuls, and trying to make the most of the times during the day that you feel able to eat.^[19]

Endoscopic Procedures

Advanced endoscopic procedures can treat oesophageal disorders without the need for traditional surgery. These treatments are done using a thin, flexible tube called an endoscope, which is gently guided through your mouth and into your oesophagus. During the same procedure, doctors can often examine the oesophagus, diagnose the condition and treat it using special instruments.^[11]

Examples of endoscopic treatment include reducing pain and muscle spasm with injections of botulinum toxin, stretching the lower oesophageal sphincter muscle in patients experiencing narrowing of their oesophagus, performing tissue biopsies, and removing abnormal tissue in the damaged lining of the oesophagus.^[6]

Surgery

Surgery may be your best treatment option depending on your unique case. Patients with achalasia should undergo definitive therapy when possible.^[7] Surgery and advanced endoscopic therapies have proven benefit in achalasia. However, invasive interventions are rarely indicated for hypercontractile motility disorders, which are typically benign and usually respond to lifestyle modifications.^[7]

An anti-reflux surgical procedure called a Nissen Fundoplication is very effective in controlling symptoms of GERD, Barrett’s Oesophagus, and achalasia. Another surgical procedure called a myotomy, in which the thick muscle of the oesophagus and stomach is cut, is used to relieve difficulty swallowing and achalasia.^[15]

In many cases, surgery can be done with minimally invasive techniques using robotic surgical systems, a laparoscope or video-assisted thoracic surgery. These techniques translate into smaller incisions, less pain, and quicker recovery times for patients.^[15]

Feeding Support

You may need a feeding tube down your nose or put into your small bowel if you can’t eat and drink enough. You can go home with the feeding tube in place. Your team will teach you or your carer how to use the tube once you’re at home.^[19]

Living with an Oesophageal Disorder

If an oesophageal disorder is treated successfully, you may not experience any long-term damage. Sometimes you can manage your symptoms with over-the-counter medications and lifestyle changes.^[14]

Eating problems can be difficult to cope with. They can cause tension within relationships or families. Social events and eating out with friends can be much harder when you have a problem swallowing. Talking to your dietitian or a counsellor can help.^[19]

It is important to eat and drink enough calories and protein to maintain your weight and strength. There will be a dietitian in the team looking after you who can help you cope with eating problems and suggest ways of dealing with diet difficulties.^[19]

You can help maintain your weight by making a few changes to what you’re eating. Try soft, moist foods that are easier to swallow. Use sauces, cream and gravies to moisten food. Soften meat and vegetables with long, slow cooking. You can also add calories to everyday foods by using whole milk instead of water, adding honey or sugar to foods, and drinking liquid food supplements.^[19]

When dining out, talk to the restaurant’s manager and chef, preferably in advance and when it is not busy, about your needs. Most restaurants really do want to help you. For social outings, arriving with a full stomach can help you resist the temptation to eat potentially unsafe foods. Always bring some safe food with you just in case you do get hungry.^[20]

Your eating may return to normal after a few months following treatment. But this can take time, especially if you need more treatment. For some people, it takes up to two years.^[19]