How to Manage Esophageal Conditions: Expert Pearls

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another GI Common Concerns.

I recently had the privilege of conversing with one of my former mentors, Dr Alvin Zfass, from Virginia Commonwealth University, at an event sponsored by the American College of Gastroenterology.

During our conversation, we discussed gastrointestinal (GI) pearls — ie, valuable things we've learned over time from books, lectures, or personal experience. Now, I'd like to share some of these GI pearls with you so that you can potentially apply them within your own practices.

Esophageal and Oropharyngeal Dysphagia

The first GI pearl I'd like to share relates to esophageal dysphagia.

Dr H. Worth Boyce, one of the "godfathers" of the esophagus, taught me to take a good history of esophageal dysphagia, and those lessons still apply.

When you ask patients suspected of having esophageal dysphagia if they have trouble swallowing solids, very frequently they'll say no. However, bread or meat commonly elicit trouble swallowing. I've also found that doughy bread and pasta may present difficulty upon chewing, as they can form something resembling a dough ball. So, when we ask about these foods, patients often change their answer and say that, in fact, they do have trouble. Some patients have told me that they now toast their bread to avoid the doughy textures that can complicate swallowing. We'll also ask them about foods with skins on them, such as fruits (eg, apples), vegetables, or potatoes, which can present swallowing difficulties.

Nearly all patients with an esophageal lumen ≤ 13 mm have dysphagia. This is why radiologists use a 13-mm barium tablet when performing a structural evaluation, which is something you should request that they do in patients suspected to have this condition. You would then combine these findings with advice to avoid particular food groups until they come in to have an esophageal dilation.

When it comes to oropharyngeal dysphagia, don't forget to advise your patients that simply tucking or turning their chin may beneficial. It slows the transit to the posterior pharynx and is helpful in situations where patient swallowing is accompanied by nasopharyngeal regurgitation.

This should also alert you that the dysphagia has a potentially neurogenic cause. I recently had a case in which a patient told me, "When I swallow, stuff comes back up through my nose." It can be a horrible experience for the patient and should drive you to consider neurogenic causes at that point.

Esophageal Dilation

Dr Zfass and I also discussed pearls around esophageal dilation.

The first of these is a simple reminder: Don't forget to deflate. During through-the-scope procedures, we get in and progressively dilate. Instead, we advise that you deflate between dilation, reinspect the mucosa, and then reinflate it, depending on mucosal disruption. If you continue to dilate without deflation, you may be infusing more air and causing gastric distension. The patient may retch and belch. When coupled with a closed balloon in the distal esophagus, this may create barotrauma, which is something you may have already observed. To avoid this, remember once again: Deflate, inspect, reinflate.

I've found injecting triamcinolone (Kenalog) to be helpful in patients with anastomotic strictures and strictures related to caustic injection or radiation. During my dilation procedures (again, remembering to deflate between dilations), I target the first area of mucosa that is disrupted with my first injections of triamcinolone. I really want to ensure that the triamcinolone is delivered here, as that's where the fibrosis is most intense. I then go on to make quadrant injections, typically using 40 mg of triamcinolone throughout the course of the technique.

Another surprisingly effective trick that I learned from one of my other mentors, Dr Donald Castell, was to use warm water and Altoids in patients with esophageal spasms.

When I dilate patients with eosinophilic esophagitis (EoE), I always warn them that they may experience mild chest pain. I routinely advise them to ingest some peppermint tablets; Altoids are a quicker option because they dissolve rapidly. By taking those tablets with a little bit of warm water, the peppermint can act as a smooth muscle relaxant. It's a helpful hint that you may want to recommend to your own patients after they undergo these dilation attempts.

Eosinophilic and Lymphocytic Esophagitis

We often use narrowband imaging to detect Barrett's esophagus. If you haven't seen what EoE looks like, I recommend that you employ narrowband imaging. In doing so, you'll see a vascular network that differs from what is normally observed. Instead, in patients with EoE, you'll see what I refer to as "a dot matrix" in the esophageal mucosa, rather than a lace-like vascular pattern.

This is also what you'll see when using narrowband imaging to inspect lymphocytic esophagitis. There's been a number of times where I thought I had a patient with EoE, although I did not see it on biopsy. In such cases, I've called the pathologist and asked them to look for lymphocytes. And, lo and behold, the lymphocyte count was elevated, typically by > 20 lymphocytes per high-power field, which means the patient has lymphocytic esophagitis.

Lymphocytic esophagitis is typically seen in women who are 50-60 years of age. It's associated with Crohn's disease and lichen planus, and is also sometimes related to stasis. If you think it's EoE and it turns out not to be, then ask your pathologist to look for lymphocytes.

Retroflex of Nasal Pharynx

Retroflex of the nasal pharynx is easy to perform. I find it quite helpful when I do an evaluation of a patient with a GI bleed for which I don't find a source. In such instances, I'll come back and retroflex.

I perform this in the following manner: Just before getting distal to the uvula, I gently pull down on the inner knob (up/down control on endoscope) to the left with my right hand. (I'm right-handed.) That should put me into the area where I'm able to look directly up into the nasal pharynx. You'll see the nasal turbinates and the eustachian tubes bilaterally, allowing you to identify any nasopharyngeal sources of bleeding.

I also inspect the nasal turbinates if I'm considering whether a patient has laryngopharyngeal reflux, and I'm looking for an allergic component, atopic elements, or septal deviation. When performing this technique, you'll be able to easily identify this without causing any trauma. It's simply a matter of remaining aware.

Rumination and Singultus

When you encounter patients with rumination and singultus, don't forget to recommend diaphragmatic breathing. This is something I discussed in a previous video, which I recommend viewing if you've not yet learned this technique.

It's very easy to teach patients and is particularly rewarding to offer to those with rumination and singultus.

Although I consider this breathing technique the standard approach in such cases, it's often not taught in lectures or classes, making this a valuable GI pearl to apply going forward.

Laryngopharyngeal Reflux

We see a ton of patients with laryngopharyngeal reflux. In such cases, it's crucial that we rule out gastroesophageal reflux disease (GERD).

When such patients present, we may study them and observe that they're not refluxing. In determining what else could be causing their symptoms, I begin by taking a voice history, during which I ask about fatiguability of the voice and hoarseness.

I also look for signs of habituation or repetitive throat clearing, which we can often hear ourselves when they speak with us. If those habits are present, then we need to break them. It's not as simple as sending them back to the ENT or whichever physician referred them to you.

I talk to my patients about habituation and offer them helpful tricks for countering it. One such trick is to have them keep a bottle of water constantly nearby for swallowing. My recommendation is water, water, water!

Rather than try to clear or cough things up, I have them try some water and use a lozenge frequently throughout the course of the day. I prefer menthol lozenges, which help with a bit of the nasal pharyngeal clearance and in swallowing. The liquids help keep the viscosity low as it relates to the sticky secretions they get in the posterior pharynx and also decrease some of the urge toward habituation.

They may eventually require the assistance of a voice specialist. I personally refer them to a physical therapist who specializes in the voice, rather than a general physical therapist.

Additionally, don't forget that some patients with laryngopharyngeal reflux have a neurogenic component to their coughing or repetitive clearing, although I find it more often for coughing. This is another thing that, if we see it, allows us to rule out GERD.

To break their habits, such patients require a technique focused on the neurogenic component. I've used tramadol very successfully in such cases. I start with a low dose at bedtime, and then go to a twice-a-day dose. I've found this inordinately helpful when used over the course of a month, perhaps even 2 months. After that point, the patients start to decelerate, and I taper them off tramadol over the next month or two. Although some laryngeal experts I know have also used amitriptyline for this purpose, I've found tramadol to be the most helpful.

In summary, these GI pearls are things that you probably have not learned, heard of, or come across in books. However, I wanted to share some of them with you in the hopes that they prove helpful in improving your treatment approach to the esophagus.

In future discussions, I look forward to discussing pearls for other GI organ systems.

Until then, I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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