Why do I find it so hard to swallow?

SINCE May I have had difficulty swallowing. The doctors tell me that my gullet has tightened and needs widening. However the attempts at this have made little difference, and my doctors are cautious about inserting a stent. Could T you give me your opinion? Mrs Eileen Smith, Hornsey. HIS is a difficult condition, and it sounds as if you have been unfortunate in your treatment. you are suffering from oesophageal stricture — a narrowing of the oesophagus, or gullet, the muscular tube that connects the mouth and stomach.

nearly all cases of this are due to scarring from a long history of acid reflux — where stomach acid splashes up into the gullet.

other symptoms include heartburn and cough, and it is usually caused by a weakness in the valve at the top of the stomach.

over time, this acid can damage the oesophagus and triggers inflammation and eventually scarring, leading to it thickening.

on occasions a stricture can be the consequence of radiotherapy, given perhaps for throat or stomach cancer. The typical symptom of a stricture is difficulty swallowing, the sense that food — or in severe cases liquid — is sticking in the throat.

Patients who have difficulty swallowing (called dysphagia) can be investigated with a number of methods. The first involves swallowing a drink, called barium sulphate, which is visible with X-ray, and tracking its progress down to the stomach.

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option is to investigate it by endoscopy, where a doctor inserts a thin flexible tube, with a light and camera on the end, down the throat.

once the diagnosis of a stricture is made, widening it is required.

The first approach is manually to stretch it. This is called dilatation and involves inserting a balloon down the throat, under local anaesthetic, and inflating it.

long-term treatment with a medicine that suppresses the production of stomach acid is essential after dilatation, as it reduces the chance of recurrence. But in some patients, particularly older ones, repeated dilatations are nearly always necessary.

If that is not successful, the next technique employed is to inject steroids into the site of the stricture, via the endoscope. We do not understand why this works, but it is assumed it is due to the anti-inflammatory effect. If this still doesn’t work, then doctors insert a small plastic tube — a stent — to widen it. This is in place only for a few weeks; however experts are cautious about the use of these.

Although experience has confirmed they can be effective, there have been cases where the stent has moved into the stomach and bowel, requiring a major operation to remove them. even when this doesn’t occur, followup studies show that only about 40 per cent of patients are free of difficulties one year later.

It seems the best approach would be further balloon dilatations and maybe further steroid injections to the site — I am confident you will eventually achieve relief of your symptoms. OVER the past 18 months I have been taken to hospital a number of times with a racing heart beat — around 250 beats per minute.

Each time I was told I’d had an episode of supraventricular tachycardia. Is this condition similar to atrial fibrillation?

I’m now waiting to have a catheter ablation procedure, which I believe is one of the treatments for atrial fibrillation.

Paul Kmiolek, Hednesford, Staffordshire. AlTHoUgH they can be frightening, heart rhythm abnormalities are an almost inevitable part of ageing. The most common of these is atrial fibrillation — I see patients with this nearly every day.

However the bouts of abnormal heart rhythm you describe, called paroxysmal supraventricular tachycardia, are much less common.

normally, the heart beats in a regular, coordinated way due to electrical impulses generated by the organ’s natural pacemaker.

This is located in the right side of the heart. Impulses spread throughout the tissue and signal it to contract in a coordinated manner. The resting heart rate is around 60 to 100 beats each minute, and faster rates occur during exercise, illness or in response to emotions such as stress or excitement.

Disturbances of rhythm result from problems with this pacemaker and the way the signal spreads through the heart.

Supraventricular tachycardia — fast heart rate — is due to a problem called re-entry. Under certain conditions the signal from the natural pacemaker becomes scrambled and the heart contracts too frequently.

The result of the heart going so fast is that it does not have time to fill properly between each beat — and less blood, and hence oxygen, is pumped around the body. This leads to shortness of breath and even chest pain. many episodes right themselves without the need for intervention.

However, if this doesn’t occur, doctors attempt to trigger the heart to fall back into rhythm.

This involves stimulating the vagus nerve, which runs from the heart to the brain and acts as a brake pedal on the heart. Signals sent along this nerve cause the heart beat to slow down.

There are a number of tricks to try that can activate this nerve — although we are still unclear exactly how these work.

The first approach is the valsalva manoeuvre (named after a 17thcentury physician), where the person is taught to try to breathe out, as if blowing an imaginary trumpet, but keeping the nose and mouth closed.

The air can’t escape and they continue doing this for a few seconds, and go red in the face.

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if this proves unsuccessful, another option is to immerse the face in icy water, or firmly massage the carotid artery on one side of the neck just below the angle of the jaw.

If these all fail then one of a number of different drugs to slow the heart beat may be tried, and you have no doubt had to undergo this, perhaps with adenosine or verapamil.

The long-term solution is the application of a recent innovation — catheter ablation.

This is a sophisticated technique which involves a cardiologist inserting, under X-ray, a catheter up into the heart via the femoral artery at the top of the leg.

This catheter then uses heat or minute electric shocks to destroy areas of abnormal tissue that scramble the heartbeat.

The process is carried out under anaesthetic and the patient can usually leave the following day.

This is the treatment which you will undergo shortly; hopefully it will be successful, and end the unpleasant and no doubt alarming episodes of racing heart.