Re: long term follow up (and more on stretched-out esophagus)

[Guest guest]

I'm of the same mind as on this, on so many different levels.As for a dilated esophagus, mega-esophagus, sigmoid esophagus, etc., my understanding is that this is due to food being "backed up" into the esophagus and causing it to stretch. Easiest way for me to describe it is to use pantyhose as an example. (Guys, you'll just have to ask your wives about this, I guess!) When you first take a pair of hose out of the package, the legs are about 1.5-2 feet long and maybe 2 inches wide, with a completely straight shape. But when you cram your (in my case) big fat legs into the hose, you cause the hose to stretch. At the end of the day when you finally peel the danged things off (can you tell I hate to wear pantyhose?), they are now as long as your legs, as wide as your legs, and they are in the shape of your legs. That's what I envision in an achalasia esophagus that hasn't had treatment of the LES. If the LES doesn't relax enough to let the food go through, it sits there in the esophagus. Then as you finish your meal, it all just "piles up" down there, all crammed into the tube of your esophagus. But the esophagus isn't built to "hold" food over time like the stomach is.... and it gets stretched out, just like the pantyhose does. If you look at any basic anatomy chart (I've attached one for those who get posts via email, or you can see it in the Files section here -- title=esophagus-digestive system.gif :

achalasia/files/esophagus-digestive%20system.gif ), you'll see that the esophagus has a bit of a "curve" or "lean" to it at the very bottom -- between Sections 4 and 5 in this picture. That's because the esophagus doesn't actually attach to the tippy-top of the stomach, but rather to the side of the stomach near the top.

Well, the way I picture it, if you've got a couple cups (half a litre) worth of food just sitting in the esophagus, simple gravity is going to make the food get all compacted down at the bottom. The downward force of the food in the middle part (section 3 in the picture) is going to pack the food down into sections 4 and 5 just like you'd stuff a sausage casing.

Eventually, the esophagus tissues won't be able to hold back the constant pressure, and they'll start to sag outward. Again, simple gravity is going to cause there to be more pressure on the lower edge of the curve (the side with the numbers in the picture) than there is on the upper edge of the curve. Therefore, it would be expected for the bottom tissues to stretch more than the tissues on the top. What you end up with is an enlarged, L-shaped esophagus.

Once the dilation of the esophagus has progressed this far, you've got a compounding of the swallowing problem. At first, the loss of peristalsis wasn't such a big deal, because gravity would still help the food to go down. But now you no longer have a simple 'vertical chute' for the food to go down -- now you have an obstacle course for each item to navigate -- how is it supposed to get around the corner? At this point, even if you have a myotomy or dilation to open up the LES, you're still going to have problems getting the food to go from section 3 all the way around the bend in sections 4 and 5 to go through the now-open LES and into the stomach. And that's why it's necessary to do an esophagectomy on most patients with a very enlarged esophagus.

If my words didn't paint enough of a mental picture, check out this page:http://www.gastrointestinalatlas.com/English/Esophagus/Esophageal_Achalasia_/esophageal_achalasia_.html

You'll have to scroll down about halfway (it's a LONG page!) to the part that says "Video Endoscopic Sequence 3 of 16". Here you'll see a drawing of trapped food like I described, and just below that you'll see an x-ray of a barium swallow from an achalasia patient with an L-shaped esophagus. Unfortunately they loaded this image in reverse -- if you'll look at the text in the lower right-hand corner of the x-ray, you'll see that it says "R & K" only in mirror image. If you were to flip the picture around the way it's supposed to be, the big puddle of stuck barium would be on the other side. (In effect, this x-ray portrays a picture from BEHIND the patient, with the retained barium bulging in the direction of the right lung.)

So, what does this all mean? Delaying treatment of the LES means that more and more retained food is left sitting in the esophagus for longer and longer periods of time, and the longer that food sits there, the more the esophagus gets stretched out, and the more the esophagus gets stretched out, the less likely it is that future treatment of the LES will be successful (the LES may be open, but the food still won't go through because of the bend in the roadway) and the more likely it is that the esophagus will need to be removed entirely.

When Sandi and I went to the medical conference at The Cleveland Clinic last spring, Dr. Rice mentioned that sometimes the esophagus is so terribly stretched out that it's like operating on a piece of tissue paper. That makes it pretty easy to understand why it's not that unusual to perforate the mucosa in the process of performing a myotomy.

Hope this makes sense -- I was rambling a bit and got interrupted a couple dozen times, so hopefully you can figure out what I was trying to say!Debbi in Michigan

PS -- I just thought of a non-pantyhose way to describe this, for the benefit of the guys. You know those LONG skinny balloons that clowns use to make balloon animals? They're like 2-3 feet long and about 1.5 inches across when blown up. What would happen if you used one of those skinny balloons to make a water balloon? As you're filling it, the water would all go down to the bottom of the balloon, and the bottom would bulge out like a bowling ball while the rest of it stayed skinny. Eventually the bottom wouldn't be able to stretch anymore and then the part just above that would start to bulge out.

Hey Everyone - well, we did raise some questions didn't we?For follow up - from what I have heard from many of my GI doc's over the years, we should have an upper GI & /or EGD every 3-5 years to watch the progression of the disease and to check for any abnormalities - we do have a slight increased risk of E-cancer. My current GI has now upped my EGD's to every 2 years -no big deal, I think it's more because I'm pushing 40 and I've had this a long time. All in all, I don't find these tests are all that bad (now if he wanted a menometry that often, we'd be going to the mat on that one).In saying that I'm careful and do not have much stretching, I'm not implying that some people are being careless or that we have much control - but - that being said, we do have some control and there are things we can take care with to keep the acid and irritation down and to keep our food moving through so as not to back up and stretch us out.I personally do have some reflux so I avoid reflux inducing foods - coffee, onions, oranges, mint and chocolate. I drink alot of water - all day long - so I figure even if there is some splashing up into my E - I'm pushing it right back down and diluting it. I take an acid blocker - have for years. I sleep elevated. I don't eat much late at night before bed.If I am going to have foods that will trigger spasms, I am careful the next day or so not to 'overload'. Like - I do drink decaf coffee occasionally, but not on a day or day after I've had a couple of beers. I just have to space apart my 'sins'.Now of course everyone is different too and what we all need to do is find the things that work for us. What has worked for me may be complete 'bunk' for someone else. I am a huge proponant though of routine follow up so that we can be proactive patients.**Carolyn - Camerons' momHow did Cameron wind up with the emergency surgery? This is the part that I don't understand.Also, no I am not in the military - they would not have taken me with the A. I do live in a military town though. I sell advertising for the local newspaper.I would invite anyone who wants to email me anytime at michelle.mcnair@... if you have any questions. My goal here is to offer hope of a pretty normal life to all of the new people. It's been over 20 years for me and life is pretty good.Happy Swallowing!- in VA.

[Guest guest]

Your are so right about the stretching of the esophagus, and over time in my case 40 years, it began to collapse in on itself and at that point your lucky to get liquids down. If I was eating in a restaurant, as I had to when traveling on business, I could hold an entire meal, and get back to my hotel, sit for a couple of hours sipping water allowing some food to go down, then I would empty what was left in the esophagus before going to bed. I did this when I was conducting business at the dinner table and did not want to embarrass myself by clamping my hand over my mouth and racing to the restroom or, just not eating at all. So I would recommend that anyone who is told that they have an over enlarged esophagus talk to there Dr. about an esophagectomy before it collapses, because at that point swallowing is not longer a good option.

Re: long term follow up (and more on stretched-out esophagus)

I'm of the same mind as on this, on so many different levels.As for a dilated esophagus, mega-esophagus, sigmoid esophagus, etc., my understanding is that this is due to food being "backed up" into the esophagus and causing it to stretch. Easiest way for me to describe it is to use pantyhose as an example. (Guys, you'll just have to ask your wives about this, I guess!) When you first take a pair of hose out of the package, the legs are about 1.5-2 feet long and maybe 2 inches wide, with a completely straight shape. But when you cram your (in my case) big fat legs into the hose, you cause the hose to stretch. At the end of the day when you finally peel the danged things off (can you tell I hate to wear pantyhose?), they are now as long as your legs, as wide as your legs, and they are in the shape of your legs. That's what I envision in an achalasia esophagus that hasn't had treatment of the LES. If the LES doesn't relax enough to let the food go through, it sits there in the esophagus. Then as you finish your meal, it all just "piles up" down there, all crammed into the tube of your esophagus. But the esophagus isn't built to "hold" food over time like the stomach is.... and it gets stretched out, just like the pantyhose does. If you look at any basic anatomy chart (I've attached one for those who get posts via email, or you can see it in the Files section here -- title=esophagus-digestive system.gif :

achalasia/files/esophagus-digestive%20system.gif ), you'll see that the esophagus has a bit of a "curve" or "lean" to it at the very bottom -- between Sections 4 and 5 in this picture. That's because the esophagus doesn't actually attach to the tippy-top of the stomach, but rather to the side of the stomach near the top.

Well, the way I picture it, if you've got a couple cups (half a litre) worth of food just sitting in the esophagus, simple gravity is going to make the food get all compacted down at the bottom. The downward force of the food in the middle part (section 3 in the picture) is going to pack the food down into sections 4 and 5 just like you'd stuff a sausage casing.

Eventually, the esophagus tissues won't be able to hold back the constant pressure, and they'll start to sag outward. Again, simple gravity is going to cause there to be more pressure on the lower edge of the curve (the side with the numbers in the picture) than there is on the upper edge of the curve. Therefore, it would be expected for the bottom tissues to stretch more than the tissues on the top. What you end up with is an enlarged, L-shaped esophagus.

Once the dilation of the esophagus has progressed this far, you've got a compounding of the swallowing problem. At first, the loss of peristalsis wasn't such a big deal, because gravity would still help the food to go down. But now you no longer have a simple 'vertical chute' for the food to go down -- now you have an obstacle course for each item to navigate -- how is it supposed to get around the corner? At this point, even if you have a myotomy or dilation to open up the LES, you're still going to have problems getting the food to go from section 3 all the way around the bend in sections 4 and 5 to go through the now-open LES and into the stomach. And that's why it's necessary to do an esophagectomy on most patients with a very enlarged esophagus.

If my words didn't paint enough of a mental picture, check out this page:http://www.gastrointestinalatlas.com/English/Esophagus/Esophageal_Achalasia_/esophageal_achalasia_.html

You'll have to scroll down about halfway (it's a LONG page!) to the part that says "Video Endoscopic Sequence 3 of 16". Here you'll see a drawing of trapped food like I described, and just below that you'll see an x-ray of a barium swallow from an achalasia patient with an L-shaped esophagus. Unfortunately they loaded this image in reverse -- if you'll look at the text in the lower right-hand corner of the x-ray, you'll see that it says "R & K" only in mirror image. If you were to flip the picture around the way it's supposed to be, the big puddle of stuck barium would be on the other side. (In effect, this x-ray portrays a picture from BEHIND the patient, with the retained barium bulging in the direction of the right lung.)

So, what does this all mean? Delaying treatment of the LES means that more and more retained food is left sitting in the esophagus for longer and longer periods of time, and the longer that food sits there, the more the esophagus gets stretched out, and the more the esophagus gets stretched out, the less likely it is that future treatment of the LES will be successful (the LES may be open, but the food still won't go through because of the bend in the roadway) and the more likely it is that the esophagus will need to be removed entirely.

When Sandi and I went to the medical conference at The Cleveland Clinic last spring, Dr. Rice mentioned that sometimes the esophagus is so terribly stretched out that it's like operating on a piece of tissue paper. That makes it pretty easy to understand why it's not that unusual to perforate the mucosa in the process of performing a myotomy.

Hope this makes sense -- I was rambling a bit and got interrupted a couple dozen times, so hopefully you can figure out what I was trying to say!Debbi in Michigan

PS -- I just thought of a non-pantyhose way to describe this, for the benefit of the guys. You know those LONG skinny balloons that clowns use to make balloon animals? They're like 2-3 feet long and about 1.5 inches across when blown up. What would happen if you used one of those skinny balloons to make a water balloon? As you're filling it, the water would all go down to the bottom of the balloon, and the bottom would bulge out like a bowling ball while the rest of it stayed skinny. Eventually the bottom wouldn't be able to stretch anymore and then the part just above that would start to bulge out.

Hey Everyone - well, we did raise some questions didn't we?For follow up - from what I have heard from many of my GI doc's over the years, we should have an upper GI & /or EGD every 3-5 years to watch the progression of the disease and to check for any abnormalities - we do have a slight increased risk of E-cancer. My current GI has now upped my EGD's to every 2 years -no big deal, I think it's more because I'm pushing 40 and I've had this a long time. All in all, I don't find these tests are all that bad (now if he wanted a menometry that often, we'd be going to the mat on that one).In saying that I'm careful and do not have much stretching, I'm not implying that some people are being careless or that we have much control - but - that being said, we do have some control and there are things we can take care with to keep the acid and irritation down and to keep our food moving through so as not to back up and stretch us out.I personally do have some reflux so I avoid reflux inducing foods - coffee, onions, oranges, mint and chocolate. I drink alot of water - all day long - so I figure even if there is some splashing up into my E - I'm pushing it right back down and diluting it. I take an acid blocker - have for years. I sleep elevated. I don't eat much late at night before bed.If I am going to have foods that will trigger spasms, I am careful the next day or so not to 'overload'. Like - I do drink decaf coffee occasionally, but not on a day or day after I've had a couple of beers. I just have to space apart my 'sins'.Now of course everyone is different too and what we all need to do is find the things that work for us. What has worked for me may be complete 'bunk' for someone else. I am a huge proponant though of routine follow up so that we can be proactive patients.**Carolyn - Camerons' momHow did Cameron wind up with the emergency surgery? This is the part that I don't understand.Also, no I am not in the military - they would not have taken me with the A. I do live in a military town though. I sell advertising for the local newspaper.I would invite anyone who wants to email me anytime at michelle.mcnair@... if you have any questions. My goal here is to offer hope of a pretty normal life to all of the new people. It's been over 20 years for me and life is pretty good.Happy Swallowing!- in VA.

[Guest guest]

Thanks for the "been there / done that" account, . I'm so glad that you were finally able to get *some* treatment, even if that meant complete removal of your esophagus.

Debbi

Your are so right about the stretching of the esophagus, and over time in my case 40 years, it began to collapse in on itself and at that point your lucky to get liquids down. If I was eating in a restaurant, as I had to when traveling on business, I could hold an entire meal, and get back to my hotel, sit for a couple of hours sipping water allowing some food to go down, then I would empty what was left in the esophagus before going to bed. I did this when I was conducting business at the dinner table and did not want to embarrass myself by clamping my hand over my mouth and racing to the restroom or, just not eating at all. So I would recommend that anyone who is told that they have an over enlarged esophagus talk to there Dr. about an esophagectomy before it collapses, because at that point swallowing is not longer a good option.

Re: long term follow up (and more on stretched-out esophagus)

I'm of the same mind as on this, on so many different levels.As for a dilated esophagus, mega-esophagus, sigmoid esophagus, etc., my understanding is that this is due to food being "backed up" into the esophagus and causing it to stretch. Easiest way for me to describe it is to use pantyhose as an example. (Guys, you'll just have to ask your wives about this, I guess!) When you first take a pair of hose out of the package, the legs are about 1.5-2 feet long and maybe 2 inches wide, with a completely straight shape. But when you cram your (in my case) big fat legs into the hose, you cause the hose to stretch. At the end of the day when you finally peel the danged things off (can you tell I hate to wear pantyhose?), they are now as long as your legs, as wide as your legs, and they are in the shape of your legs. That's what I envision in an achalasia esophagus that hasn't had treatment of the LES. If the LES doesn't relax enough to let the food go through, it sits there in the esophagus. Then as you finish your meal, it all just "piles up" down there, all crammed into the tube of your esophagus. But the esophagus isn't built to "hold" food over time like the stomach is.... and it gets stretched out, just like the pantyhose does. If you look at any basic anatomy chart (I've attached one for those who get posts via email, or you can see it in the Files section here -- title=esophagus-digestive system.gif :

achalasia/files/esophagus-digestive%20system.gif ), you'll see that the esophagus has a bit of a "curve" or "lean" to it at the very bottom -- between Sections 4 and 5 in this picture. That's because the esophagus doesn't actually attach to the tippy-top of the stomach, but rather to the side of the stomach near the top.

Well, the way I picture it, if you've got a couple cups (half a litre) worth of food just sitting in the esophagus, simple gravity is going to make the food get all compacted down at the bottom. The downward force of the food in the middle part (section 3 in the picture) is going to pack the food down into sections 4 and 5 just like you'd stuff a sausage casing.

Eventually, the esophagus tissues won't be able to hold back the constant pressure, and they'll start to sag outward. Again, simple gravity is going to cause there to be more pressure on the lower edge of the curve (the side with the numbers in the picture) than there is on the upper edge of the curve. Therefore, it would be expected for the bottom tissues to stretch more than the tissues on the top. What you end up with is an enlarged, L-shaped esophagus.

Once the dilation of the esophagus has progressed this far, you've got a compounding of the swallowing problem. At first, the loss of peristalsis wasn't such a big deal, because gravity would still help the food to go down. But now you no longer have a simple 'vertical chute' for the food to go down -- now you have an obstacle course for each item to navigate -- how is it supposed to get around the corner? At this point, even if you have a myotomy or dilation to open up the LES, you're still going to have problems getting the food to go from section 3 all the way around the bend in sections 4 and 5 to go through the now-open LES and into the stomach. And that's why it's necessary to do an esophagectomy on most patients with a very enlarged esophagus.

If my words didn't paint enough of a mental picture, check out this page:http://www.gastrointestinalatlas.com/English/Esophagus/Esophageal_Achalasia_/esophageal_achalasia_.html

You'll have to scroll down about halfway (it's a LONG page!) to the part that says "Video Endoscopic Sequence 3 of 16". Here you'll see a drawing of trapped food like I described, and just below that you'll see an x-ray of a barium swallow from an achalasia patient with an L-shaped esophagus. Unfortunately they loaded this image in reverse -- if you'll look at the text in the lower right-hand corner of the x-ray, you'll see that it says "R & K" only in mirror image. If you were to flip the picture around the way it's supposed to be, the big puddle of stuck barium would be on the other side. (In effect, this x-ray portrays a picture from BEHIND the patient, with the retained barium bulging in the direction of the right lung.)

So, what does this all mean? Delaying treatment of the LES means that more and more retained food is left sitting in the esophagus for longer and longer periods of time, and the longer that food sits there, the more the esophagus gets stretched out, and the more the esophagus gets stretched out, the less likely it is that future treatment of the LES will be successful (the LES may be open, but the food still won't go through because of the bend in the roadway) and the more likely it is that the esophagus will need to be removed entirely.

When Sandi and I went to the medical conference at The Cleveland Clinic last spring, Dr. Rice mentioned that sometimes the esophagus is so terribly stretched out that it's like operating on a piece of tissue paper. That makes it pretty easy to understand why it's not that unusual to perforate the mucosa in the process of performing a myotomy.

Hope this makes sense -- I was rambling a bit and got interrupted a couple dozen times, so hopefully you can figure out what I was trying to say!Debbi in Michigan

PS -- I just thought of a non-pantyhose way to describe this, for the benefit of the guys. You know those LONG skinny balloons that clowns use to make balloon animals? They're like 2-3 feet long and about 1.5 inches across when blown up. What would happen if you used one of those skinny balloons to make a water balloon? As you're filling it, the water would all go down to the bottom of the balloon, and the bottom would bulge out like a bowling ball while the rest of it stayed skinny. Eventually the bottom wouldn't be able to stretch anymore and then the part just above that would start to bulge out.