HEALTH: When the Swallows Come
I t is a long, muscular organ that expands when stimulated. Many people typically think theirs is longer than it actually is. But if performance problems develop, Viagra is not the answer.
The adult esophagus is a narrow tube about 9 inches to 10 inches in length that begins at the back of the tongue, transverses the neck, and ends at the stomach. It takes a properly functioning esophagus to process Dale Curry’s savory eggplant medallions with crab meat béchamel (page 40) into a usable energy source.
The human equivalent to the U.S. Army Corps of Engineers controls a complex system of paired muscles and nerves to ensure problem-free movement of food from the mouth to the stomach. A flood or obstruction can disrupt function and cause havoc.
The most important anatomical flood gate protecting the esophagus is the lower esophageal sphincter, a smooth lock around the organ’s lower end, where it meets the stomach. In good times, this muscular lock prevents a backwash of acid and other digestive juices from escaping the stomach by opening only when a morsel of food is delivered by peristaltic action to the lower esophagus. Part of this complex swallowing mechanism also helps keep food and liquids out of the trachea and lungs.
The medical term for any swallowing difficulty is dysphagia.
Anything that disrupts or damages the muscles and nerves involved in swallowing can cause dysphagia.
Symptoms vary depending on the acuteness, duration and intensity of the problem. Children between 6 months and 3 years of age will swallow anything that goes
down a small esophagus. I speak from personal experience. When I was 2 years old and staying with my grandparents in Marianna, Fla., I swallowed a dime.
My grandmother somehow suspected what had happened. As only a devoted grandmother would do, she carefully strained everything that came out of my other end for a few days until she fished out what truly was then a “silver dime.” She taped it to a card that ended up in my baby book. I still have it. Toddlers today have more choices. In my youth, most batteries were the huge D size. Today miniature and button
batteries appeal to many young, exploring mouths. A bead from a broken strand of Mardi Gras beads is a classic, uniquely New Orleans swallow.
“Small batteries and other small, smooth objects mostly pass right through the stomach,” says Dr. William Ferrante, director of the training program in gastroenterology at LSU Medical Center. “If we see them, we usually try to get them
out as they tend sometimes to get hooked up in a narrowed segment of the intestines downstream from the esophagus and stomach,” he adds. Of course, a lodged battery can corrode.
Adults ingesting foreign objects are often mentally impaired or have a psychiatric
disorder. Others are under the influence of alcohol. Still others seek some sort of secondary gain, like prisoners who swallow something just to get out of jail and spend
a few days in the hospital. “It is not uncommon for mentally ill folks to swallow foreign objects.
Fortunately, most pass right through the esophagus and even the stomach without causing much of a problem. “Before the hurricane, we had a couple of patients at Charity Hospital who were always swallowing screws, bobby pins, straight pens and anything else they could get in their mouths. They provided learning opportunities for several generations of gastroenterology trainees on endoscopic removal of foreign objects from the stomach.
“One of these persons swallowed a small screwdriver once. His parents worked on jewelry and saw him gulp it down. We were able to get it out before it perforated anything.
With prompt medical care, these situations are rarely fatal. “The sickest patient I ever saw with a swallowed foreign body was at Ochsner years ago. A girl came into the
emergency room with severe abdominal pain. It turned out she had swallowed a piece of wire, probably from a hairbrush. The wire penetrated her intestinal wall and
caused an abscess. She tried to blame it on a hamburger from a fast-food restaurant, but I never believed that.”
Mentally competent adults with foreign body ingestions also end up in Ferrante’s office. For women, the objects of choice are bobby pins and straight pins. Toothpicks are more likely swallowed by men who are drinking. “Not that many people get in trouble swallowing toothpicks, but toothpicks present a special problem as they don’t show up on the usual X-ray. Most pass right through the GI tract, but if one lodges in the wall of the stomach or intestine, complications include perforation. The same thing can happen with fish or chicken bones,” Ferrante says.
The most common acute problem is not a foreign body but a hunk of partially chewed food. The term “café coronary” was devised to call attention to a life-threatening situation when food trapped in the throat interferes with breathing. This becomes a food breech of biblical proportions.
“I have only seen it once and know of it happening here one other time,” said Galatoire’s maitre d’ extraordinaire Arnold Chabaud. “It was either beef or lamb. I think it is more common when the meat is gristly.”
“It happened here once a couple of years ago,” says Darton Milton, manager of the Rib Room. “The diner was choking on a huge piece of prime rib. I did the Heimlich and saved him.”
The rarity of acute swallowing problems in restaurants may be related to menu changes.
“Nobody wants to chew anymore. That’s why hamburgers are so popular. I find stews and braised entrees are what people who eat out want. Braised meats cooked until the meat falls off the bones are what really sell these days. The perception is that if chewing is required, it is a tough and cheap piece of meat,” says chef Rene Bajeux, our city’s crown prince of French bistro fare.
Actually, choking on food occurs quite rarely and the truly life-threatening episodes are due to food blocking the trachea rather than becoming simply stuck in the esophagus. Most food that sticks in the esophagus passes spontaneously after a few seconds or after a sip of liquid to help ease it through.
Symptoms of a blocked esophagus include sudden onset of a burning or squeezing chest pain while swallowing. A person with a complete obstruction may appear to be drowning in their own saliva as it has nowhere to go. If the retained material is in the upper esophagus, airway obstruction from compression of the trachea can be life-threatening.
According to Ferrante, the typical victim has a new set of false teeth and is eating, drinking and talking at the same time. He once treated a dentist who swallowed his own new set of teeth.
Most persons with recurrent food-sticking problems have a damaged lower esophagus caused by long-term acid reflux, which scars and decreases the diameter of the organ. This condition is called a stricture and often requires endoscopic dilation to keep the channel wide and patent. Lodged food in the esophagus can also be the presenting symptom for esophageal cancer.
The barium swallow is a basic screening test to detect swallowing disorders. The patient drinks a cup or so of a barium slurry while a radiologist using fluoroscopy watches the
opaque liquid on its journey to the stomach. Problems within the esophagus itself can be detected during endoscopy, a process by which a gastroenterologist inserts a long,
narrow tube with a fiber-optic light source at the end to visualize the entire esophagus. If no diagnosis is obvious, more specialized tests to measure acid and pressure levels may be needed.
An accurate diagnosis is important as treatment options can range from dietary measures, to medications, to surgery depending on the actual cause of the dysphagia.