Umar Ali had a problem that was tough to swallow–literally. It was exceedingly painful for him to swallow food and even liquids, so much that he could barely eat. In a matter of months, the Union County man lost about 75 pounds.

"I wanted to lose weight, but not in that way," says Mr. Ali, who went from 265 pounds down to 180. "Food felt hard going down, and sometimes it came back up again. It wasn't until I stepped on the scale one day that I realized how little I was eating."

On and off for several years, Mr. Ali had difficulty with food he had swallowed coming back up his esophagus. He was told he had gastroesophageal reflux disease (GERD), commonly known as reflux.

However, about one year ago, Mr. Ali's symptoms became more severe. He ate what little he could by trying to relax his esophagus. Still, "It came to the point when I had trouble getting water to go down," says the 47-year old.

When Mr. Ali went to The Swallowing Center at University Hospital last December, he learned that his difficulties were not the result of reflux. After taking a thorough medical history and conducting a physical examination, Dr. Mark Sterling, the Center's gastroenterologist and an assistant professor of gastroenterology at New Jersey Medical School, ordered a special study of the esophagus known as manometry. This test measures pressure changes in the esophagus during swallowing and helps determine whether the esophagus can move elements to the stomach in a regular way.

"In Mr. Ali's case, we found that his lower esophagus was unable to relax properly during swallowing, a condition called achalasia," says Dr. Sterling. Two non-surgical options were considered: balloon pneumatic dilatation, in which a "balloon" is inflated to break apart the esophagus's muscular fibers, or injections of botulinum toxin, or Botox, to relax the muscle. However, both balloon dilatation and Botox are temporary solutions that would need to be repeated over time. While they often are used for patients who are considered high risk for surgery or are elderly, for a younger man such as Mr. Ali, a third option–surgery–was recommended.

On January 9, Dr. Joseph Kamelgard, assistant professor of surgery at New Jersey Medical School and a surgeon affiliated with The Swallowing Center, separated the muscle fibers in Mr. Ali's esophagus using laparoscopic instruments. The minimally invasive procedure, called a Heller myotomy, "breaks the squeeze" of the muscle, says Dr. Kamelgard, and is about 90 percent effective. Mr. Ali went home from University Hospital the next day and began an incremental journey back to a "regular" diet. At first he had liquids, then graduated to soft foods such as eggs and pudding. By early February, he was able to eat some homemade ziti. "I feel 1,000 times better," says Mr. Ali. "For the first time in many months, food is going down and staying down the way it should."

Down the Hatch

Swallowing is a reflex that involves many movements. It can be broken down into three phases: oral, pharyngeal, and esophageal. In the oral phase, food or liquid enters the mouth and is shaped into a ball known as a "bolus"; this bolus moves into the throat. The next phase is the pharyngeal phase, where the bolus passes down through the pharynx, or throat. During the esophageal phase, the bolus is moved through the esophagus and into the stomach.

"Swallowing is a carefully choreographed process," says Dr. Soly Baredes, associate professor of surgery and chief of the division of otolaryngology–head and neck surgery at New Jersey Medical School. "For example, the larynx, or 'voice box,' plays an integral part in swallowing. If its actions are not coordinated, the bolus can travel through the airway and into the lungs, possibly causing pneumonia."

Doctors refer to the difficulty of swallowing as dysphagia. Dysphagia can result from reflux and structural abnormalities in the swallowing mechanism. Swallowing disorders can also develop following a stroke or from other neurological disorders, such as Parkinson's disease and cerebral palsy. Even the normal degenerative changes that come with aging can cause the swallowing mechanism to weaken.

There are a whole host of symptoms associated with swallowing disorders: food feels "stuck" in the throat; coughing or choking while eating or drinking; drooling; a gurgling quality to the voice when eating; or food coming back up the esophagus, often with a sour taste. Over time, there could be unwanted weight loss or recurrent bouts of pneumonia.

It is normal for people to have occasional difficulty swallowing, such as with a tough piece of meat. Occasional heartburn from eating too much or too fast can also occur. What, then, sets swallowing disorders apart from the consequences of a hastily eaten meal?

"When symptoms persist for more than a couple of weeks or their severity increases, it's important to seek medical help," says Dr. Baredes. "Occasionally, a patient comes to my office and says he choked on food and needed the Heimlich maneuver, only to find the root cause was a swallowing disorder."

Top to Bottom

The average adult's esophagus is about 9 inches long, and from a swallowing perspective, there can be problems at both ends of this muscular canal. Conditions that affect the upper esophagus, head, and neck are the specialty of an otolaryngologist, also known as an ear, nose, and throat (ENT) doctor. "Swallowing disorders present in two main ways in this area of the body: an inability to propel food downward or an inability to protect the airway," says Dr. Baredes. An inability to protect the airway means that food gets down into the windpipe, commonly known as "aspiration." If a patient experiences enough aspiration, pneumonia can develop. "Sometimes the cause is structural, from scar tissue, for example. In other cases, there are neurological factors or a tumor is found."

Problems such as achalasia and esophageal spasm, a motility disorder of the esophagus that can cause chest pain, are two swallowing disorders that affect lower portions of the esophagus and are treated by gastroenterologists. But by far the most common, notes Dr. Sterling, is reflux disease, which develops when a weakened valve–the lower esophageal sphincter–permits partially digested food and stomach acid to travel up the esophagus. A 24-hour pH study, in which a tube is inserted through the patient's nose and into the esophagus, tests for acidity. "The lower the pH level, the more the esophagus is bathed in acid," says the gastroenterologist. "The pH study, along with manometry, are two tests that aid in the diagnosis of reflux disease."

Many reflux patients benefit from dietary changes and acid-suppressing medications. A class of drugs known as proton pump inhibitors have been very effective but are expensive. For appropriately selected patients, such as younger people who might otherwise be on these costly medications long term, surgery can be an option. One commonly performed procedure is fundoplication, in which part of the stomach is wrapped around the esophagus to create a new valve. Dr. Sterling says a promising new endoscopic procedure involving radiofrequency ablation might soon be available to reflux patients at University Hospital. Radiofrequency ablation, which is also used to treat certain cardiac arrhythmias and malignant liver tumors, uses electrical current to heat (and subsequently destroy) unwanted tissue or cells.

Although reflux disease seems innocuous enough, it's unwise to ignore the problem. "Chronic reflux can lead to abnormal changes in the esophageal lining known as Barrett's esophagus," says Dr. Sterling, "and between 5 percent to 10 percent of patients with this condition develop cancer of the esophagus."

Patients with swallowing problems often are referred to a speech-language pathologist. The speech-language pathologist, along with radiology, performs X-ray studies of the swallowing mechanism to visualize swallowing movement. "We also teach patients ways to better manage their swallowing difficulties," says Ann Gulyas, CCC-SLP, manager of Speech-Language Pathology Services at University Hospital and a specialist in swallowing disorders. "These compensatory strategies include dietary modifications or ways to position their head while eating. Our goal is to teach patients how to eat safely, minimizing their risks for aspiration."

Simplifying the Menu

For the person with symptoms of a swallowing disorder, knowing which specialist to go to can be confusing. "The symptoms might not be that clearly defined, and a patient could spend a lot of time trying to find the right doctor to care for his or her problem or having redundant testing," says Dr. Baredes. That's one reason why University Hospital has established a comprehensive team approach to diagnosing and treating swallowing problems.

"We believe that by coordinating communication and services, our dedicated team provides a more optimal level of care to patients with swallowing disorders," says Ms. Gulyas. Patient answers a screening questionnaire regarding their difficulty swallowing. The answers on the questionnaire triage the patient to the doctor and testing best suited for his or her care. The Swallowing Center draws from the specialties of gastroenterology, otolaryngology, general surgery, speech-language pathology, physiatry, and radiology. "We discuss each patient together as a team to determine the cause of the problem and which doctor is the best to provide treatment," says Dr. Sterling.

For more information or to make an appointment, call The Swallowing Center at (973) 972-5614.