Esophageal foreign body obstruction. What causes esophageal obstruction?

Esophagus Obstructions

The esophagus is a muscular tube that propels food from the bottom of the throat to the stomach. It is ten inches in length and originates in the neck. Then it passes through the entire length of the chest until the lower end joins the stomach within the abdomen. The esophagus serves no digestive function and acts solely as a pathway for swallowed food. Diseases of the esophagus produce symptoms because they block it. Therefore the symptom they have in common is "difficulty in swallowing" or the "food gets stuck." Adults with disease in this area may also complain of upper abdominal burning and discomfort. Diagnostic problems for this organ are far less complicated than in other areas of the gut. The entire tube can be examined by direct inspection and parts of diseased tissue removed for diagnosis. Techniques of esophagus surgery, in all its segments, are well developed; some of the procedures for reconstructing the swallowing mechanism are quite ingenious.

Why do you place such importance on exactly how long I have had difficulty swallowing?

It gives me a clue to the possible cause. Recent onset is most often due to a tumor. Intermittent difficulty over several years is more likely due to an inflammation or a muscular disorder at its lower end.

What significance is there to my pointing out where I feel that the food gets stuck? 

This is a rough guide to the site of obstruction. Thus, if you were to point to the neck, it would sugest a developmental pouch (diverticulum) which blocks the food.

What is the pouch (diverticulum) in the neck? How does it arise and what is the treatment? 

This is a side pocket in the esophagus. One is born with it. It grows larger with time. The pouch represents the vestige of what is the gill in the fish. It causes trouble in swallowing when it grows too big, pushing aside the normal esophagus so food goes into it instead of going down the normal way. Patients frequently learn to empty it by squeezing and manipulating the bulge in the neck area. If the diverticulum causes no symptoms, it should be left strictly alone. If it causes symptoms, it should be removed. This operation is done through an incision in the neck; the outpocketing is removed and the normal straight path for food is restored.

How accurate is the X ray? 

In esophageal problems the X ray is extremely reliable and helpful. It serves to indicate the exact site of obstruction and accurately suggests its most likely cause.

Can there be no obstruction even though I have difficulty swallowing? 

In these instances the swallowing difficulty is not caused by a block. Less common causes of inability to swallow normally are due to impaired function, paralysis, weakness, or improper synchronization of the involved parts. These are encountered in individuals with strokes and certain brain and muscle diseases.

How do you determine the real cause? 

The final diagnosis of a tumor or inflammation is made by looking directly into the esophagus with a lighted tube and removing a piece of abnormal tissue for microscopic examination. This can be done under local anesthesia, with the throat numbed, or under a light sleep. The report on the tissue is usually available in twenty four hours.

How do you evaluate the muscles of the esophagus if the swallowing trouble is not due to a block? 

The contractile power of the esophagus is evaluated by determining its squeeze effect on a swallowed tube that contains three balloons spaced apart. By simultaneously recording the pattern of contraction or absence of contraction on each of these balloons, the specific site and character of esophageal function can be recorded. This diagnostic procedure is called esophageal manometry.

I have had trouble swallowing since my teens. I've been told that is was "spasms." What shall I do now? 

This diagnosis can be confirmed by a rapid exposure movie film X ray of the area. We actually make a movie of how the esophagus functions. The swallowed balloon study (esophageal manometry) is also a great help in this regard. By noting how each of the three balloons is affected, it is possible to localize the site at which the contractions are faulty, absent, or ineffectual. If the esophagus already shows evidence of significant obstruction, you should be treated. In about 80 percent of such problems (called achalasia or cardiospasm) the esophagus can be stretched at its lower end by a special balloon that disrupts the poorly functioning muscle and allows for normal swallowing. The disorder of the swallowing mechanism has been ascribed to muscle spasm of the lower esophagus. This is not true in most cases. The term "cardiospasm" is incorrect, but it continues to be employed. Treatment can be done on an ambulatory basis or an overnight hospital stay without general anesthesia. The patient feels pain briefly, and then it is all finished.. Surgery is advised only when symptoms persist, recur, or have not been relieved by a trial with the method of forceful dilatation.

You say that the esophagus is inflamed, ulcerated and swollen. What causes this?  What's to be done about it? 

This is usually due to a hernia through the diaphragm that allows the stomach juices to irritate the delicate lining of the esophagus. The irritated area becomes congested and narrows the esophageal opening. The first treatment is like that for a stomach ulcer. If medication and diet do not relieve the symptoms, surgery may be required. The operation will correct the hernia defect and allow the stomach to maintain its normal relation to the diaphragm.

The biopsy report is cancer. What is to be done? 

In general the treatment of cancer of the esophagus by any method is not satisfactory. Although there are good surgical techniques for doing this operation, the results are poor because the cancer spreads so widely into the neck, the chest and the abdomen. Yet these patients do require treatment because they cannot swallow. The swallowing difficulty may become so advanced that it even affects the saliva. You know that we swallow more than a quart of saliva a day. In these unfortunate individuals the saliva spills over into the lung and causes a variety of lung infections and pneumonias. The cancer may have already spread into the glands of the neck and into the liver when the patient is first seen.

In addition, many of these patients are elderly and have too many collateral problems in the lung and heart to consider the possibility of radical surgery. Although poor results in the treatment are a universal experience, some surgeons and institutions take very aggressive attitudes. Others take a pessimistic approach and have virtually abandoned extensive surgery as a curative method. Radiation (X-ray) treatments can be very effective.

What can you suggest as a possible curative measure? 

If the cancer is in the lower half of the esophagus or upper end of the stomach, curative surgery can be attempted if the general condition allows it. Otherwise and in othei areas, radiation treatment offers the best hope.

What is the long term outlook with this type of cancer? 

Very poor. Fewer than one in one hundred patients is alive five years after cancer of the esophagus is diagnosed.

Is it possible to improve the swallowing ever? if the condition cannot be cured? 

It is usually possible to put a plastic tube (prosthesis) through the tumor and restore swallowing. This is definitely worth doing.

He's losing so much weight and getting worse so rapidly. Is it possible to treat him by putting a feeding tube directly into the stomach? 

The procedure, called a tube gastrostomy, was frequently done thirty years ago. It doesn't solve the cancer problem or prolong survival, and it is no longer advised for this condition. However, it can be used effectively to help patients with neurologic diseases or temporary esophageal obstructions.

Could the cancer have been diagnosed earlier and wouli that have helped? 

It is impossible to suspect the diagnosis until the patient has symptoms. In general, the earlier the disease is diagnosed, the greater the opportunity of treating it effectively. In about two thirds of these patients the disease is already far advanced when first diagnosed.

What does the curative surgery entail? 

It involves removing the tumor containing area, to gether with a part of the adjacent stomach and esophagus, and then sewing together the cut ends to create a new opening through which the swallowed food can pass.

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