Fly Well: A Bitter Pill To Swallow

The esophagus is a muscular tube connecting mouth to stomach, and swallowing initiates propulsive waves propelling ingested food downward. Waves in the opposite direction are prompted by eating something disagreeable, or drinking too many adult beverages. A valve at the bottom of the esophagus allows pizza to progress, but prevents stomach contents heading back up. Valve failure permits stomach acid to wash back up into the esophagus, causing inflammation and esophageal erosion, which one experiences as heartburn. This common condition is known as gastroesophageal reflux disease (GERD). Chronic acid exposure from long-term repetitive heartburn induces changes leading to narrowing—hence food sticking—and even cancer. This makes food hard to swallow.

That feeling is evoked by the expression “to stick in one’s craw,” which derives from the Middle Dutch word crage, meaning neck.

Esophageal spasm can occur in the presence or absence of GERD and induces a feeling something is stuck, vomiting, and—what gets most people’s attention—sudden, extremely intense squeezing chest pain lasting minutes or hours. That feeling of chest discomfort, spreading to arm or jaw, can mimic a heart attack and provoke anxiety which, in turn, worsens symptoms. Possibly induced by exceptionally hot or cold food and red wine, spasms can be diffuse, which tend to be occasional, or of the “nutcracker” variety—which occur with more regularity but tend to cause less vomiting.

If you have chest pain, get medical attention, pronto. Cardiac pain—angina—is experienced as gripping or oppressive, possibly spreading into jaw or arm; nausea; sweating; and a feeling of impending doom. Sound familiar? Esophageal spasm can be uncannily similar—and as both are ameliorated by popping a nitroglycerin tablet (GTN) under the tongue, that is not much use as a means to distinguish angina from spasm. One needs to have an electrocardiogram (ECG or EKG) and blood tests to rule out a cardiac cause for pain.

The feeling of chest discomfort, spreading to arm or jaw, can mimic a heart attack. If you have chest pain, get medical attention, pronto.Once cardiac disease has been excluded, and if your doctor suspects spasm, a range of tests will be ordered, probably starting with an endoscopy to look at your esophageal lining or a barium swallow, where X-rays are taken while drinking a substance that shows the esophagus in action. Measuring esophageal pressures with a thin tube passed through your nose (manometry) and acid flow (24-hour ambulatory
pH monitoring) will also help define whether there is any GERD and the nature and location of spasms.

Treatment might just involve reassurance and avoiding precipitating factors. GTN or antispasmodics under the tongue, and certain anti-anxiety medications, may be useful, as is sipping warm water. In severe cases, where episodes are frequent and oppressive, injecting botulinum toxin to paralyze disordered nerves has found favor. Poetry is a beautiful art form—and although reading poems to an esophageal spasm sufferer may not ease the pain, performing a per oral endoscopic myotomy (POEM) might. This minimally invasive technique involves splitting esophageal muscle under guidance of a scope passed through the mouth, a procedure that is sometimes also performed surgically.

If GERD is present, pull back on your bedtime yoke—sleeping in a slightly head-up attitude may help. One should avoid certain food and drink, stop smoking—of course—and use medicines to limit acid production or to create a protective barrier for the lower esophagus. Surgery, often performed by minimally invasive techniques to create a new valve, also is effective.

As always, attend to your medical issues first, and then consider aviation implications. Once a diagnosis has been reached, discuss treatment options with your doctor and obtain advice from your aviation medical examiner or AOPA Pilot Protection Services.

American rapper Vanilla Ice released an album called Hard to Swallow, and while rap is not my thing, I do know that having esophageal spasm—or any of the chronic gullet diseases—is something that might stick in your craw.AOPA