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CONTINUING MEDICAL EDUCATION MEDICAL STAFF The Center for Swallowing Disorders has continued active participation in graduate medical education by lectures at regional, national and international meetings and by contributions to the medical literature. Director . . . . . . . . . . . . . . . . . . . . . . H. Worth Boyce, Jr., M.D. Professor of Medicine Hugh F. Culverhouse Chair in Esophagology Lecture Presentations by CSD Staff Patient Care . . . . . . . . . . . . . . . . . . . . Janet L. Jones, B.A., CGC Coordinator Instructor of Medicine December 5-7, 2002: Joy McCann Culverhouse Center for Swallowing Disorders 4 th Annual Postgraduate Course, Esophagology for Clinicians: Esophageal Disorders: From A to Z for 2003: 1) Endoscopic Esophageal Anatomy: The Basis for Endoscopic Diagnosis, 2) Botulinum Toxin Type A Injection – Indications, Locating the LES and Details of Technique and 3) Uncommon, Complex, High Risk Strictures. Boardwalk Inn, Walt Disney World, FL (Boyce) December 5-7, 2002: Joy McCann Culverhouse Center for Swallowing Disorders 4 th Annual Postgraduate Course, Esophagology for Clinicians: Esophageal Disorders: From A to Z for 2003: Esophageal EUS Basics and Benign Disorders and Diagnosis and Medical Therapy of Esophageal Sequelae of GERD. Boardwalk Inn, Walt Disney World, FL (Johnson) January 20-21, 2003: 13 th Endoscopy Masters’ Forum: Endoscopic Surgery by Flexible Endoscopy: Advanced Technique/Technologies and Future Trends. Orlando, FL (Boyce) February 22, 2003: Mayo Clinic in Scottsdale Winter Gastroenterology Meeting: Esophageal Gastroenterology Linked to Endoscopy & Hepatology. Strictures: 1) Using Classification to Guide Therapy; 2) Endoscopic Anatomy of the LES and BOTOX Injection: Who, When, How? Scottsdale, AZ (Boyce) March 21-22, 2003: Walter Reed Gastroenterology Symposium: Rings, Webs, and Things: Diagnostic Clues and Caveats for Therapy. McLean, VA (Boyce) March 29, 2003: University of South Florida College of Medicine. Update on GERD & Common Swallowing Disorders For Primary Care. Clearwater, FL (Boyce, Johnson, Jones) Contributions To Medical Literature Boyce HW: Barrett esophagus: Endoscopic findings and what to biopsy. J Clin Gastro (accepted for publication 2003). Bloomston, M, Fraiji E, Boyce HW, Gonzalvo A, Johnson MC, Rosemurgy A: Preoperative Intervention Does Not Affect Esophageal Muscle Histology or Patient Outcomes in Patients Undergoing Laparoscopic Heller Myotomy. Jnl Gastrointest Surg 2003;7(2):181-190. Joy McCann Culverhouse Center for Swallowing Disorders University of South Florida University of South Florida Health Sciences Center 12901 Bruce B. Downs Blvd., MDC Box 72 Tampa, FL 33612 Medical Staff . . . . . . . . . . . . . . . . . . . . .Milton C. Johnson, M.D. Associate Professor of Medicine Assistant Patient Care . . . . . . . . . . . . . . . . Betsy J. Lamoy, R.N. Coordinator VOLUME 15 JUNE 2003 Office Manager . . . . . . . . . . . . . . . . . . . . . . . Candace K. Harley DIRECTOR’S FORUM Administrative Secretary . . . . . . . . . . . . . . . . . Natalie A. Ralyea ACHALASIA Appointment Secretary . . . . . . . . . . . . . . . . . . . Jennifer C. Rust Speech Pathology Consultants for Oropharyngeal Swallowing Disorders Speech Pathology . . . . . . Joy E. Gaziano, M.A., CCC/SLP Linda Stachowiak, M.S., CCC/SLP Things To Remember OFFICE HOURS: 8:00 a.m. ‘til 4:30 p.m. Monday through Friday. Telephone hours: 8:00 a.m. ‘til 5:00 p.m. Also, our emergency telephone number for after hours is (813) 974-2201 BILLING: Payment for services rendered is due at the time of your visit. Please be prepared to pay any co-payments due at the time of your visit to the Center. Patients who have problems with their physician or facility fee bills should contact Gayle Stephens, Financial Specialist, at the University of South Florida Medical Clinics at (813) 974-3575 between the hours of 9:00 a.m. and 4:00 p.m. Monday through Thursday. For those patients who are from out-of-town, a new toll-free number has been added for you to call with billing questions. The number is 1-888873-3627. This number is for calls originating in Florida and is only for billing questions and help with insurance authorizations. HAS YOUR INSURANCE COMPANY OR PRIMARY CARE PHYSICIAN CHANGED? With an ever changing medical insurance market (shopping for the best contract, companies merging, others closing their doors, etc), you may have changed insurance company. If you changed your insurance company you may have a new primary care physician. Maybe you have moved and had to choose a new doctor closer to your home. Regardless of the circumstances we would very much appreciate your contacting our office to let us know, (813) 974-3374. This will not only insure we can obtain the necessary authorizations/ pre-certifications and that your medical bills go to the right insurance company but it will help us make sure your medical records are forwarded to the right doctors. Thank you for helping us keep the records straight. NON-Profit Organization U.S. Postage PAID Tampa, FL Permit No. 1632 NUMBER 1 H. Worth Boyce, M.D. Professor of Medicine and Director The term chalasia means to loosen or relax. This condition is seen Endoscopy reveals a large esophagus with retained food and fluid. in newborns, especially premature infants who regurgitate after However, if the patient is properly prepared before this exam by most feedings for the first several months of life. At about four two days of clear fluids, only a small amount of liquid content is months of age the lower esophageal sphincter (valve) begins to found. A clean esophagus is essential at the time any treatment is close normally between swallows and the regurgitation from the performed. The endoscope passes into the stomach through the stomach is prevented. The opposite is true for achalasia that occurs closed lower esophageal sphincter with mild to moderate resistance. at any age between childhood and the ninth decade having an equal The diagnosis of achalasia is best confirmed by performing an frequency between males and females. Achalasia is a disorder esophageal manometry (motility) study which confirms the loss characterized by a loss of peristalsis (propulsive muscle contractions of peristalsis in response to swallows and usually an elevated or movement) in the esophagus and failure of the lower esophageal pressure in the lower esophageal sphincter which typically relaxes sphincter to relax and allow emptying of the esophagus. incompletely or not at all after a liquid swallow taken during the The cause of achalasia is unknown (idiopathic). There is a loss of manometry study. nerve cells in the Auerbach plexus between the two muscle layers Once the diagnosis is established, a decision regarding therapy is in of the esophageal wall and in the lower esophageal sphincter. This order. Some patients with early achalasia and mild symptoms may defect results in the loss of peristalsis, which is needed to push food elect to delay treatment or try medical (drug) treatment. Such into the stomach, and the failure of the lower esophageal sphincter treatment with calcium channel blocker drugs may help by to relax and allow food to enter the stomach. These changes result transiently relaxing the closed sphincter but this response is usually in failure of esophageal emptying and retention of solid and liquid short-lived and not reliable for long-term use. foods in the esophagus. Over time the esophagus enlarges and Ultimately most patients opt for some form of treatment. None holds more and more contents. Regurgitation (return of of the treatments available will improve the peristalsis in the esophageal contents into the throat and mouth) occurs as a conseesophagus. All are designed to weaken the lower esophageal quence of both overflow and abnormal esophageal contractions. sphincter. The standard medical treatment option is dilation of Failure of emptying into the stomach, regurgitation and, in some, a the tight sphincter with balloon dilators, available in diameters of fear of eating, all may lead to weight loss. Patients learn to improve 30, 35 and 40 mm. These instruments are intended to over-stretch esophageal emptying by eating slowly and swallowing extra fluids the sphincter to the point that the muscle fibers lose their ability to which serve to flush esophageal contents into the stomach. The contract tightly and thereby allow the esophagus to empty more problems with esophageal emptying and regurgitation can cause efficiently. This form of therapy provides good to excellent considerable embarrassment in social settings. Regurgitation, improvement in from 70 to 90% of patients depending on the size especially at night when the patient is recumbent, can result in of balloon used. The main risk of this treatment is perforation or aspiration of fluid into the lungs causing bronchitis full-thickness tear of the esophagus that occurs and pneumonia. Another aggravating factor is sialin 2 to 5% of patients. If this occurs a surgical orrhea, which is the production of large amounts of operation usually is needed to close the tear. At saliva in response to the esophageal obstruction. the same operation a myotomy or muscle Patients notice the sialorrhea as a large amount of splitting operation to treat the achalasia is “foamy mucus” requiring frequent swallows or usually performed to provide definitive treatment. expectoration to keep the hypopharynx free from In past years, when balloon dilations had failed this bothersome fluid (see article herein). on two occasions, an operation called a Heller The diagnosis of achalasia should be first suspected myotomy (surgical cutting of the sphincter after the physician takes a complete history. A muscle) was recommended. This surgical barium swallow (esophagram) reveals a dilated procedure gave good or excellent results when esophagus with a large amount of retained barium performed by an experienced surgeon but and usually some food particles. The esophagus at required an incision through the chest wall the lower sphincter is tapered to show a narrow column of barium likened to the shape of a bird Figure 1. Barium esophagram of typical appearance of a dilated esophagus and a tight lower esophageal sphincter (arrows). Barium enters the stomach slowly by gravity depending on the level of pressure in the sphincter. beak (Figure 1). (thoracotomy). Currently a modification of the Heller myotomy, called a laparoscopic myotomy, can be performed using the laparoscope and accessory instruments through several small incisions in the abdominal wall. As more experience has been gained this procedure has become the preferred technique when the surgical approach is elected. Current long-term improvement is being confirmed in over 80% of cases. If the sphincter muscle is rendered too weak by myotomy, there is a risk for acid in the stomach to reflux into the esophagus and cause esophagitis or a stricture. Surgeons may attempt to reduce this risk by performing an antireflux operation at the time of the myotomy. Even if this problem occurs the acid reflux can be adequately treated by acid suppressing drugs. Another treatment for achalasia used for the past 10 years is the injection of a bacterial toxin, clostridium botulinum toxin-A (Botox) into the esophageal sphincter. The botulinum toxin prevents the release of a chemical (acetylcholine) from the nerves in the lower esophageal sphincter resulting in relaxation and reduction of the high sphincter pressure. Botox is injected through a small needle passed through the endoscope. The procedure is performed as an outpatient procedure and requires about 10 minutes to complete. This effect prevents the muscle from contracting which leads to increased emptying and improvement of the patient’s swallowing and regurgitation in about 80% of cases. This technique fails in 10 to 15% of patients. Its only significant drawback is its limited duration of relief. The good effects are gradually lost over a 6 to 12 month period (some patients have good symptom relief for 12 to 18 months and a few even longer) as new nerve endings sprout and regrow with a return of the high sphincter pressure. Complications are very rare and in those who respond swallowing is greatly improved within several days. We have been using Botox injection for achalasia since 1993. This treatment is most useful in patients who are ill with other medical problems, those who refuse other forms of therapy, as an urgent temporizing therapy for students in the middle of a school year and those who are malnourished or otherwise not candidates for surgery. During the past 10 years we have had the opportunity to evaluate 514 patients with achalasia. Initial therapy has included pneumatic dilation or Botox injection in the majority. Laparoscopic myotomy has been effective in those not satisfied with or who fail medical treatments. This surgical option may be most appropriate as initial therapy in younger individuals since it produces the best long-term symptom relief. SIALORRHEA: AN OFTEN UNRECOGNIZED SIGN OF ESOPHAGEAL DISEASE Michael R. Bakheet, M.D. Sialorrhea or ptyalism is an excessive salivary flow leading to a common patient complaint of, “I have a lot of foamy mucus in my mouth!” Sialorrhea occurs with conditions that promote an increase in saliva secretion and/ or disturb its passage through the esophagus into the stomach. Within the oral cavity, three major salivary glands (parotid, submandibular, and sublingual) as well as several minor glands produce more than a quart of saliva each day. Consequently, the esophagus is continually bathed by a stream of saliva as it passes into the stomach. Esophageal conditions that promote sialorrhea are grouped into two broad categories: mechanically stimulated salivation due to an esophageal obstruction and chemically stimulated salivation due to esophageal inflammation. Ultimately, the function of such heightened salivary flow, via the esophago- salivary reflex, is to flush out the impacted object or to neutralize the offending agent. Variables such as salivary volume, viscosity, chemical makeup, and acidity (increased flow is associated with a more alkaline or higher pH saliva) are adjusted by the body in the resultant product based presumably on the offending condition or agent. Saliva contains over 65 different substances. The major ones include a lubricating glycoprotein (mucin) for food bolus passage, digestive enzymes (amylase and lipase) for preliminary starch and fat digestion and antimicrobial agents (lysosomal enzymes and IgA antibody) as well as several electrolytes (for example: hydrogen, potassium and sodium). Collectively, these products work in concert to support the digestive process, promote oral hygiene, participate in taste conduction, and protect the esophageal epithelium from noxious agents. Sialorrhea has significant implications due to its incessant nature, as well as its potential for several complications. At a minimum, laryngeal penetration (fluid enters only the larynx above the vocal cords) and aspiration of saliva below the vocal cords into the trachea (wind pipe) will lead to hoarseness, cough and a choking sensation. Aspiration is most prevalent in patients that have difficulty with the passage of saliva through the pharynx or esophagus due to oropharyngeal dysmotility, advanced obstruction (progressive cancer or stricture formation) or an esophageal neuromotor disorder, such as achalasia. Thus, the retained salivary pool accumulates in the lower pharynx and/ or esophagus and may eventually enter the larynx, trachea, bronchi, and ultimately the lung. Aspiration may lead to bronchitis and pneumonia as well as chronic cough. When aspiration volume is high, the resulting decreased oxygenation (hypoxia) may lead to rapid heart rate (tachycardia), chest pain, cyanosis, an altered mental state, and even respiratory failure. The risk of aspiration is greatest in patients with associated oropharyngeal dysmotility, extremes of age (elderly/ pediatric) or the severely debilitated patient. These persons may not sense the aspirated saliva (silent aspiration), fail to clear the saliva by coughing and thereby develop pneumonia. Other consequences of sialorrhea, albeit less detrimental, include social stigmas as the patient may have profound drooling or hypopharyngeal pooling requiring the need to regularly evacuate the oral cavity by spitting or wiping the corner of the mouth with a tissue to achieve relief. When sialorrhea is severe, patients typically will have to carry a tissue or “spit cup” at all times. This creates a disturbing, major social incapacity. Nocturnal sialorrhea can cause chronic sleep disturbance, as the patient has to regularly wake up to “clear my throat.” This will lead to daytime fatigue, and somnolence. For those with intact oropharyngeal function, there will be a need to swallow often to clear the extra saliva. Each swallow delivers air into the gastrointestinal tract. Increased swallowing frequency may lead to symptomatic air swallowing (aerophagia) with resultant gas bloating, flatus, and pain. Any swallowed object that is retained within the esophagus will stimulate local mechanoreceptors (mechanical/ physical receptors) leading to increased salivation. Impacted foreign bodies (bones, coins, dentures, etc.) typically present in a characteristic combination of painful swallowing (odonophagia) and sialorrhea. A sufficiently prolonged impacted object can lead to scar tissue deposition and stricture formation. Ultimately, such scarring will lead to a decrease in lumen diameter and further promotion of sialorrhea. Neoplasms (malignant or benign tumors) that grow into the esophageal lumen will reduce the normal esophageal diameter causing a blockage. Similar to an impacted foreign object, such a growth in the esophageal wall will lead to sialorrhea. Webs, rings and strictures narrow the esophageal lumen producing prolonged eating times and food retention. Sialorrhea is typically noticed by the patient only after there is an acute blockage or impaction of food into one of these narrowed areas. Achalasia, is a pathologic condition that is defined by an absence of esophageal peristalsis or motility in the lower two thirds of the esophagus. Often, there is an excessively tight (hypertensive) lower esophageal sphincter causing food retention associated esophageal enlargement (megaesophagus) and chest pain. Food and saliva passage into the stomach is prevented leading to retrograde flow or regurgitation of saliva. The saliva or “foamy mucus” floats atop the retained food, typically appearing as the first substance to be regurgitated. Sialorrhea and its problems are a consistent occurrence in patients with achalasia. Similar to mechanically stimulated sialorrhea, inflammatory irritation (due to chemical ingestion, local viral infection, etc.) of the inner esophageal wall layers (mucosa and submucosa) will result in an increase of salivary flow. Local chemoreceptors (chemical receptors) enhance salivary secretion rate when stimulated. These receptors also have the capability to detect heat (thermoreceptors) or chemical concentrations (osmoreceptors). Gastroesophageal reflux, the most common cause of chemical irritation to the esophagus elicits water brash, a characteristic reflux- related variation of sialorrhea that has a typically bitter frothy quality detected in the patient’s mouth. It occurs as a reflex to provide protection of the esophageal mucosa from acid injury. Ingestion of corrosive substances (lye, acid, bleach, etc.) will irritate the mucosa and induce hypersalivation. Additionally, the tissue damage can lead to stricture formation and a narrowing of the lumen which may synergistically add to the sialorrhea. Other forms of mucosal injury may be due to esophageal viral infection (herpes simplex virus esophagitis) leading to the irritation and reflex salivation. Pill impaction, particularly with vitamin C, non steroidal anti- inflammatory drugs (aspirin, acetaminophen, ibuprophen, etc.) potassium chloride, quinidine gluconate, fosamax and other drugs that can impact, cause irritation, inflammation and possible stricture formation. Clinically, the patient experiences dysphagia and sialorrhea that may appear hours to weeks after pill ingestion depending on the type and degree of injury. Assessment of the abnormally salivating patient should begin with a thorough history and complete physical examination. Therapy for esophageal-related sialorrhea must be directed at treating the underlying disorder. Swallowed objects that become impacted should be promptly removed during an endoscopic exam. Esophageal obstruction by strictures can be treated with dilation and cancer obstruction by surgery or placement of an esophageal stent. Achalasia is managed medically by pneumatic dilation or with intrasphincteric botulinum toxin (Botox A) injection and surgically by laparoscopic myotomy. Therapy for reflux esophagitis is best done by prescribing proton pump inhibitors (PPI) and by laparoscopic antireflux surgery in severe cases. Direct therapy on the salivary glands may be used to reduce saliva production in severe cases. These include drugs, radiation therapy, Botox injection, and surgery. In conclusion, sialorrhea or enhanced salivary flow, is not only a relentless annoyance, but can also lead to serious complications. More importantly, excessive saliva may be indicative of a serious esophageal disease. Only by identifying and treating the underlying cause can the patient regain the qualities of physical and social life and potential complications be prevented. 5TH ANNUAL POSTGRADUATE COURSE Esophageal and Gastric Disorders December 4-6, 2003 Location: Boardwalk Inn, Walt Disney World, Orlando, FL For further information contact: University of South Florida Office of Continuing Professional Education, P.O. Box 550610, Tampa, FL 33655-0610 Or Fax to: (813) 974-3217 (thoracotomy). Currently a modification of the Heller myotomy, called a laparoscopic myotomy, can be performed using the laparoscope and accessory instruments through several small incisions in the abdominal wall. As more experience has been gained this procedure has become the preferred technique when the surgical approach is elected. Current long-term improvement is being confirmed in over 80% of cases. If the sphincter muscle is rendered too weak by myotomy, there is a risk for acid in the stomach to reflux into the esophagus and cause esophagitis or a stricture. Surgeons may attempt to reduce this risk by performing an antireflux operation at the time of the myotomy. Even if this problem occurs the acid reflux can be adequately treated by acid suppressing drugs. Another treatment for achalasia used for the past 10 years is the injection of a bacterial toxin, clostridium botulinum toxin-A (Botox) into the esophageal sphincter. The botulinum toxin prevents the release of a chemical (acetylcholine) from the nerves in the lower esophageal sphincter resulting in relaxation and reduction of the high sphincter pressure. Botox is injected through a small needle passed through the endoscope. The procedure is performed as an outpatient procedure and requires about 10 minutes to complete. This effect prevents the muscle from contracting which leads to increased emptying and improvement of the patient’s swallowing and regurgitation in about 80% of cases. This technique fails in 10 to 15% of patients. Its only significant drawback is its limited duration of relief. The good effects are gradually lost over a 6 to 12 month period (some patients have good symptom relief for 12 to 18 months and a few even longer) as new nerve endings sprout and regrow with a return of the high sphincter pressure. Complications are very rare and in those who respond swallowing is greatly improved within several days. We have been using Botox injection for achalasia since 1993. This treatment is most useful in patients who are ill with other medical problems, those who refuse other forms of therapy, as an urgent temporizing therapy for students in the middle of a school year and those who are malnourished or otherwise not candidates for surgery. During the past 10 years we have had the opportunity to evaluate 514 patients with achalasia. Initial therapy has included pneumatic dilation or Botox injection in the majority. Laparoscopic myotomy has been effective in those not satisfied with or who fail medical treatments. This surgical option may be most appropriate as initial therapy in younger individuals since it produces the best long-term symptom relief. SIALORRHEA: AN OFTEN UNRECOGNIZED SIGN OF ESOPHAGEAL DISEASE Michael R. Bakheet, M.D. Sialorrhea or ptyalism is an excessive salivary flow leading to a common patient complaint of, “I have a lot of foamy mucus in my mouth!” Sialorrhea occurs with conditions that promote an increase in saliva secretion and/ or disturb its passage through the esophagus into the stomach. Within the oral cavity, three major salivary glands (parotid, submandibular, and sublingual) as well as several minor glands produce more than a quart of saliva each day. Consequently, the esophagus is continually bathed by a stream of saliva as it passes into the stomach. Esophageal conditions that promote sialorrhea are grouped into two broad categories: mechanically stimulated salivation due to an esophageal obstruction and chemically stimulated salivation due to esophageal inflammation. Ultimately, the function of such heightened salivary flow, via the esophago- salivary reflex, is to flush out the impacted object or to neutralize the offending agent. Variables such as salivary volume, viscosity, chemical makeup, and acidity (increased flow is associated with a more alkaline or higher pH saliva) are adjusted by the body in the resultant product based presumably on the offending condition or agent. Saliva contains over 65 different substances. The major ones include a lubricating glycoprotein (mucin) for food bolus passage, digestive enzymes (amylase and lipase) for preliminary starch and fat digestion and antimicrobial agents (lysosomal enzymes and IgA antibody) as well as several electrolytes (for example: hydrogen, potassium and sodium). Collectively, these products work in concert to support the digestive process, promote oral hygiene, participate in taste conduction, and protect the esophageal epithelium from noxious agents. Sialorrhea has significant implications due to its incessant nature, as well as its potential for several complications. At a minimum, laryngeal penetration (fluid enters only the larynx above the vocal cords) and aspiration of saliva below the vocal cords into the trachea (wind pipe) will lead to hoarseness, cough and a choking sensation. Aspiration is most prevalent in patients that have difficulty with the passage of saliva through the pharynx or esophagus due to oropharyngeal dysmotility, advanced obstruction (progressive cancer or stricture formation) or an esophageal neuromotor disorder, such as achalasia. Thus, the retained salivary pool accumulates in the lower pharynx and/ or esophagus and may eventually enter the larynx, trachea, bronchi, and ultimately the lung. Aspiration may lead to bronchitis and pneumonia as well as chronic cough. When aspiration volume is high, the resulting decreased oxygenation (hypoxia) may lead to rapid heart rate (tachycardia), chest pain, cyanosis, an altered mental state, and even respiratory failure. The risk of aspiration is greatest in patients with associated oropharyngeal dysmotility, extremes of age (elderly/ pediatric) or the severely debilitated patient. These persons may not sense the aspirated saliva (silent aspiration), fail to clear the saliva by coughing and thereby develop pneumonia. Other consequences of sialorrhea, albeit less detrimental, include social stigmas as the patient may have profound drooling or hypopharyngeal pooling requiring the need to regularly evacuate the oral cavity by spitting or wiping the corner of the mouth with a tissue to achieve relief. When sialorrhea is severe, patients typically will have to carry a tissue or “spit cup” at all times. This creates a disturbing, major social incapacity. Nocturnal sialorrhea can cause chronic sleep disturbance, as the patient has to regularly wake up to “clear my throat.” This will lead to daytime fatigue, and somnolence. For those with intact oropharyngeal function, there will be a need to swallow often to clear the extra saliva. Each swallow delivers air into the gastrointestinal tract. Increased swallowing frequency may lead to symptomatic air swallowing (aerophagia) with resultant gas bloating, flatus, and pain. Any swallowed object that is retained within the esophagus will stimulate local mechanoreceptors (mechanical/ physical receptors) leading to increased salivation. Impacted foreign bodies (bones, coins, dentures, etc.) typically present in a characteristic combination of painful swallowing (odonophagia) and sialorrhea. A sufficiently prolonged impacted object can lead to scar tissue deposition and stricture formation. Ultimately, such scarring will lead to a decrease in lumen diameter and further promotion of sialorrhea. Neoplasms (malignant or benign tumors) that grow into the esophageal lumen will reduce the normal esophageal diameter causing a blockage. Similar to an impacted foreign object, such a growth in the esophageal wall will lead to sialorrhea. Webs, rings and strictures narrow the esophageal lumen producing prolonged eating times and food retention. Sialorrhea is typically noticed by the patient only after there is an acute blockage or impaction of food into one of these narrowed areas. Achalasia, is a pathologic condition that is defined by an absence of esophageal peristalsis or motility in the lower two thirds of the esophagus. Often, there is an excessively tight (hypertensive) lower esophageal sphincter causing food retention associated esophageal enlargement (megaesophagus) and chest pain. Food and saliva passage into the stomach is prevented leading to retrograde flow or regurgitation of saliva. The saliva or “foamy mucus” floats atop the retained food, typically appearing as the first substance to be regurgitated. Sialorrhea and its problems are a consistent occurrence in patients with achalasia. Similar to mechanically stimulated sialorrhea, inflammatory irritation (due to chemical ingestion, local viral infection, etc.) of the inner esophageal wall layers (mucosa and submucosa) will result in an increase of salivary flow. Local chemoreceptors (chemical receptors) enhance salivary secretion rate when stimulated. These receptors also have the capability to detect heat (thermoreceptors) or chemical concentrations (osmoreceptors). Gastroesophageal reflux, the most common cause of chemical irritation to the esophagus elicits water brash, a characteristic reflux- related variation of sialorrhea that has a typically bitter frothy quality detected in the patient’s mouth. It occurs as a reflex to provide protection of the esophageal mucosa from acid injury. Ingestion of corrosive substances (lye, acid, bleach, etc.) will irritate the mucosa and induce hypersalivation. Additionally, the tissue damage can lead to stricture formation and a narrowing of the lumen which may synergistically add to the sialorrhea. Other forms of mucosal injury may be due to esophageal viral infection (herpes simplex virus esophagitis) leading to the irritation and reflex salivation. Pill impaction, particularly with vitamin C, non steroidal anti- inflammatory drugs (aspirin, acetaminophen, ibuprophen, etc.) potassium chloride, quinidine gluconate, fosamax and other drugs that can impact, cause irritation, inflammation and possible stricture formation. Clinically, the patient experiences dysphagia and sialorrhea that may appear hours to weeks after pill ingestion depending on the type and degree of injury. Assessment of the abnormally salivating patient should begin with a thorough history and complete physical examination. Therapy for esophageal-related sialorrhea must be directed at treating the underlying disorder. Swallowed objects that become impacted should be promptly removed during an endoscopic exam. Esophageal obstruction by strictures can be treated with dilation and cancer obstruction by surgery or placement of an esophageal stent. Achalasia is managed medically by pneumatic dilation or with intrasphincteric botulinum toxin (Botox A) injection and surgically by laparoscopic myotomy. Therapy for reflux esophagitis is best done by prescribing proton pump inhibitors (PPI) and by laparoscopic antireflux surgery in severe cases. Direct therapy on the salivary glands may be used to reduce saliva production in severe cases. These include drugs, radiation therapy, Botox injection, and surgery. In conclusion, sialorrhea or enhanced salivary flow, is not only a relentless annoyance, but can also lead to serious complications. More importantly, excessive saliva may be indicative of a serious esophageal disease. Only by identifying and treating the underlying cause can the patient regain the qualities of physical and social life and potential complications be prevented. 5TH ANNUAL POSTGRADUATE COURSE Esophageal and Gastric Disorders December 4-6, 2003 Location: Boardwalk Inn, Walt Disney World, Orlando, FL For further information contact: University of South Florida Office of Continuing Professional Education, P.O. Box 550610, Tampa, FL 33655-0610 Or Fax to: (813) 974-3217 CONTINUING MEDICAL EDUCATION MEDICAL STAFF The Center for Swallowing Disorders has continued active participation in graduate medical education by lectures at regional, national and international meetings and by contributions to the medical literature. Director . . . . . . . . . . . . . . . . . . . . . . H. Worth Boyce, Jr., M.D. Professor of Medicine Hugh F. Culverhouse Chair in Esophagology Lecture Presentations by CSD Staff Patient Care . . . . . . . . . . . . . . . . . . . . Janet L. Jones, B.A., CGC Coordinator Instructor of Medicine December 5-7, 2002: Joy McCann Culverhouse Center for Swallowing Disorders 4 th Annual Postgraduate Course, Esophagology for Clinicians: Esophageal Disorders: From A to Z for 2003: 1) Endoscopic Esophageal Anatomy: The Basis for Endoscopic Diagnosis, 2) Botulinum Toxin Type A Injection – Indications, Locating the LES and Details of Technique and 3) Uncommon, Complex, High Risk Strictures. Boardwalk Inn, Walt Disney World, FL (Boyce) December 5-7, 2002: Joy McCann Culverhouse Center for Swallowing Disorders 4 th Annual Postgraduate Course, Esophagology for Clinicians: Esophageal Disorders: From A to Z for 2003: Esophageal EUS Basics and Benign Disorders and Diagnosis and Medical Therapy of Esophageal Sequelae of GERD. Boardwalk Inn, Walt Disney World, FL (Johnson) January 20-21, 2003: 13 th Endoscopy Masters’ Forum: Endoscopic Surgery by Flexible Endoscopy: Advanced Technique/Technologies and Future Trends. Orlando, FL (Boyce) February 22, 2003: Mayo Clinic in Scottsdale Winter Gastroenterology Meeting: Esophageal Gastroenterology Linked to Endoscopy & Hepatology. Strictures: 1) Using Classification to Guide Therapy; 2) Endoscopic Anatomy of the LES and BOTOX Injection: Who, When, How? Scottsdale, AZ (Boyce) March 21-22, 2003: Walter Reed Gastroenterology Symposium: Rings, Webs, and Things: Diagnostic Clues and Caveats for Therapy. McLean, VA (Boyce) March 29, 2003: University of South Florida College of Medicine. Update on GERD & Common Swallowing Disorders For Primary Care. Clearwater, FL (Boyce, Johnson, Jones) Contributions To Medical Literature Boyce HW: Barrett esophagus: Endoscopic findings and what to biopsy. J Clin Gastro (accepted for publication 2003). Bloomston, M, Fraiji E, Boyce HW, Gonzalvo A, Johnson MC, Rosemurgy A: Preoperative Intervention Does Not Affect Esophageal Muscle Histology or Patient Outcomes in Patients Undergoing Laparoscopic Heller Myotomy. Jnl Gastrointest Surg 2003;7(2):181-190. Joy McCann Culverhouse Center for Swallowing Disorders University of South Florida University of South Florida Health Sciences Center 12901 Bruce B. Downs Blvd., MDC Box 72 Tampa, FL 33612 Medical Staff . . . . . . . . . . . . . . . . . . . . .Milton C. Johnson, M.D. Associate Professor of Medicine Assistant Patient Care . . . . . . . . . . . . . . . . Betsy J. Lamoy, R.N. Coordinator VOLUME 15 JUNE 2003 Office Manager . . . . . . . . . . . . . . . . . . . . . . . Candace K. Harley DIRECTOR’S FORUM Administrative Secretary . . . . . . . . . . . . . . . . . Natalie A. Ralyea ACHALASIA Appointment Secretary . . . . . . . . . . . . . . . . . . . Jennifer C. Rust Speech Pathology Consultants for Oropharyngeal Swallowing Disorders Speech Pathology . . . . . . Joy E. Gaziano, M.A., CCC/SLP Linda Stachowiak, M.S., CCC/SLP Things To Remember OFFICE HOURS: 8:00 a.m. ‘til 4:30 p.m. Monday through Friday. Telephone hours: 8:00 a.m. ‘til 5:00 p.m. Also, our emergency telephone number for after hours is (813) 974-2201 BILLING: Payment for services rendered is due at the time of your visit. Please be prepared to pay any co-payments due at the time of your visit to the Center. Patients who have problems with their physician or facility fee bills should contact Gayle Stephens, Financial Specialist, at the University of South Florida Medical Clinics at (813) 974-3575 between the hours of 9:00 a.m. and 4:00 p.m. Monday through Thursday. For those patients who are from out-of-town, a new toll-free number has been added for you to call with billing questions. The number is 1-888873-3627. This number is for calls originating in Florida and is only for billing questions and help with insurance authorizations. HAS YOUR INSURANCE COMPANY OR PRIMARY CARE PHYSICIAN CHANGED? With an ever changing medical insurance market (shopping for the best contract, companies merging, others closing their doors, etc), you may have changed insurance company. If you changed your insurance company you may have a new primary care physician. Maybe you have moved and had to choose a new doctor closer to your home. Regardless of the circumstances we would very much appreciate your contacting our office to let us know, (813) 974-3374. This will not only insure we can obtain the necessary authorizations/ pre-certifications and that your medical bills go to the right insurance company but it will help us make sure your medical records are forwarded to the right doctors. Thank you for helping us keep the records straight. NON-Profit Organization U.S. Postage PAID Tampa, FL Permit No. 1632 NUMBER 1 H. Worth Boyce, M.D. Professor of Medicine and Director The term chalasia means to loosen or relax. This condition is seen Endoscopy reveals a large esophagus with retained food and fluid. in newborns, especially premature infants who regurgitate after However, if the patient is properly prepared before this exam by most feedings for the first several months of life. At about four two days of clear fluids, only a small amount of liquid content is months of age the lower esophageal sphincter (valve) begins to found. A clean esophagus is essential at the time any treatment is close normally between swallows and the regurgitation from the performed. The endoscope passes into the stomach through the stomach is prevented. The opposite is true for achalasia that occurs closed lower esophageal sphincter with mild to moderate resistance. at any age between childhood and the ninth decade having an equal The diagnosis of achalasia is best confirmed by performing an frequency between males and females. Achalasia is a disorder esophageal manometry (motility) study which confirms the loss characterized by a loss of peristalsis (propulsive muscle contractions of peristalsis in response to swallows and usually an elevated or movement) in the esophagus and failure of the lower esophageal pressure in the lower esophageal sphincter which typically relaxes sphincter to relax and allow emptying of the esophagus. incompletely or not at all after a liquid swallow taken during the The cause of achalasia is unknown (idiopathic). There is a loss of manometry study. nerve cells in the Auerbach plexus between the two muscle layers Once the diagnosis is established, a decision regarding therapy is in of the esophageal wall and in the lower esophageal sphincter. This order. Some patients with early achalasia and mild symptoms may defect results in the loss of peristalsis, which is needed to push food elect to delay treatment or try medical (drug) treatment. Such into the stomach, and the failure of the lower esophageal sphincter treatment with calcium channel blocker drugs may help by to relax and allow food to enter the stomach. These changes result transiently relaxing the closed sphincter but this response is usually in failure of esophageal emptying and retention of solid and liquid short-lived and not reliable for long-term use. foods in the esophagus. Over time the esophagus enlarges and Ultimately most patients opt for some form of treatment. None holds more and more contents. Regurgitation (return of of the treatments available will improve the peristalsis in the esophageal contents into the throat and mouth) occurs as a conseesophagus. All are designed to weaken the lower esophageal quence of both overflow and abnormal esophageal contractions. sphincter. The standard medical treatment option is dilation of Failure of emptying into the stomach, regurgitation and, in some, a the tight sphincter with balloon dilators, available in diameters of fear of eating, all may lead to weight loss. Patients learn to improve 30, 35 and 40 mm. These instruments are intended to over-stretch esophageal emptying by eating slowly and swallowing extra fluids the sphincter to the point that the muscle fibers lose their ability to which serve to flush esophageal contents into the stomach. The contract tightly and thereby allow the esophagus to empty more problems with esophageal emptying and regurgitation can cause efficiently. This form of therapy provides good to excellent considerable embarrassment in social settings. Regurgitation, improvement in from 70 to 90% of patients depending on the size especially at night when the patient is recumbent, can result in of balloon used. The main risk of this treatment is perforation or aspiration of fluid into the lungs causing bronchitis full-thickness tear of the esophagus that occurs and pneumonia. Another aggravating factor is sialin 2 to 5% of patients. If this occurs a surgical orrhea, which is the production of large amounts of operation usually is needed to close the tear. At saliva in response to the esophageal obstruction. the same operation a myotomy or muscle Patients notice the sialorrhea as a large amount of splitting operation to treat the achalasia is “foamy mucus” requiring frequent swallows or usually performed to provide definitive treatment. expectoration to keep the hypopharynx free from In past years, when balloon dilations had failed this bothersome fluid (see article herein). on two occasions, an operation called a Heller The diagnosis of achalasia should be first suspected myotomy (surgical cutting of the sphincter after the physician takes a complete history. A muscle) was recommended. This surgical barium swallow (esophagram) reveals a dilated procedure gave good or excellent results when esophagus with a large amount of retained barium performed by an experienced surgeon but and usually some food particles. The esophagus at required an incision through the chest wall the lower sphincter is tapered to show a narrow column of barium likened to the shape of a bird Figure 1. Barium esophagram of typical appearance of a dilated esophagus and a tight lower esophageal sphincter (arrows). Barium enters the stomach slowly by gravity depending on the level of pressure in the sphincter. beak (Figure 1).