Gastrointestinal and Esophageal Issues in Myositis

Dr. Soumekh gave a brief summary of the structure and function of the gastrointestinal (GI) tract:

The esophagus is a long muscular tube with a top and bottom valve. Food moves from the mouth through the esophagus and to the stomach. The esophagus both moves the food forward and prevents the backward flow of food and acid. The stomach is a muscular sac that receives food, sending small amounts of the food through the rest of the tract. It churns and secretes acid to break down food. The small intestine is an approximately 22-foot long tube that completes digestion and absorbs nutrients. The colon or large intestine is another tube, approximately five feet long, which primarily absorbs salt and water, and helps turn liquid waste into formed, solid stool. The method by which food is moved through the digestive tract is called peristalsis.

For the purposes of this discussion, Dr. Soumekh described gastrointestinal (GI) and esophageal issues that may be more likely to affect people with myositis, focusing on oropharyngeal disorders, esophageal disorders, and stomach disorders.

The most common area of the GI tract to be affected in myositis is the mouth, throat, and upper part of the esophagus; the most common occurrence to affect people with myositis is oropharyngeal dysphagia – a problem with the swallowing process that involves the mouth and pharynx (which is the part of the throat that is behind the mouth). Much less commonly, the esophagus and stomach may be affected.

Symptoms of oropharyngeal dysphagia may include:

• Coughing while eating
• Food entering the airway
• Chronic aspiration (food entering the lungs)
• Food passing back through the nasal passages

Gastrointestinal issues in myositis may be evaluated by a speech pathologist. The two main testing options (performed by a physician) are:

• Modified Barium Swallow, in which liquid, semi-solid, and solid barium material are swallowed, and  x-rays are done as the patient swallows
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES), in which a camera that sits in the throat provides a real-time view how a patient swallows liquids and solids

Testing options for esophageal dysphagia and reflux may include:

• Barium esophagram, in which liquid, semi-solid and solid barium is swallowed, and the esophagus is x-rayed in real time
• Upper endoscopy, in which a fiberoptic camera is used to directly visualize the esophagus,  stomach and part of the small intestine, and obtain biopsies, while the patient is under anesthesia
• Manometry, in which a probe sits in the esophagus and directly measures the movement and pressures created by the esophagus during swallowing
• pH testing, in which a device directly measures acid reflux in the esophagus

Some other GI and esophageal abnormalities that may be found include:

• Gastroparesis, in which spontaneous movement (motility) of muscles in the stomach does not function normally and may cause food to move more slowly through the digestive tract
• Gastroesophageal reflux (GERD)
• Esophageal dysmotility, in which the esophagus does not move normally
• Esophageal infections
• Gastritis, or inflammation of the stomach
• Peptic ulcer disease

Treatments for GI issues in myositis may include:

• For oropharyngeal dysphagia:
  • Work with a speech pathologist and ENT (ear, nose and throat specialist), who can help with certain exercises to help regain function
  • Adjust diet (thin or thicken liquids)
  • Depending on the specific issue, adjust position when eating, eat mindfully and slowly, chew carefully, and/or avoid straws
• For esophageal disorders:
  • Acid suppressants, typically proton pump inhibitors (such as Prevacid, Prilosec, Nexium) may be recommended by your doctor
  • Dietary changes – for example, minimizing possible reflux triggers such as alcohol, spicy foods, large fatty meals (consider eating small, more frequent meals), and acidic foods – may be recommended by your doctor
  • It is important to remember to chew food well
  • Additional recommendations may include: avoiding nicotine, remaining upright after eating, avoiding eating for two hours prior to going to bed, elevating the head of your bed to a 30-degree angle
  • Speak with your doctor about possible effects of non-GI medications
  • Other medications and other treatments may be recommended by your doctor
• Stomach disorders:
  • Similar to recommendations for esophageal disorders: Avoid acid triggers as noted above, eat smaller, more frequent meals, suppress acid through the use of proton pump inhibitors; and speak with your physician about adjusting non-GI medications
  • Avoid non-steroidal anti-inflammatory drugs (NSAIDS)
  • Ask your doctor about the possibility of needing a “coating” for your stomach, such as Gaviscon or Maalox
  • Depending on your individual situation, your physician may also recommend medications for motility

Learn more about the HSS Myositis Support Group, a free support and education group, held monthly for people with myositis and their family and friends.

Summary by Suzan Fischbein, LCSW, Program Coordinator, Myositis Support Group

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