Introduction

Serious liver diseases such as cirrhosis can cause a number of complications, including esophageal varices — abnormally enlarged veins in the lower part of the esophagus, the tube that connects your throat and stomach. Esophageal varices develop when normal blood flow to the liver is blocked. The blood then backs up into smaller, more fragile blood vessels in the esophagus, and sometimes in the stomach or rectum, causing the vessels to swell.

Esophageal varices don’t produce symptoms unless they rupture and bleed — a life-threatening condition that requires immediate medical care. When not controlled, esophageal bleeding can be fatal.

To help prevent esophageal varices from bleeding, doctors usually prescribe medications that lower blood pressure. In cases where drugs aren’t effective, esophageal varices may be injected with a clotting solution or tied with elastic bands to prevent bleeding. These same procedures are often used to stop acute bleeding.

Signs and symptoms

About one-third of people with esophageal varices have bleeding. The signs and symptoms of esophageal bleeding range from mild to severe and include:

• Vomiting blood
• Black, tarry or bloody stools
• Decreased urination from unusually low blood pressure
• Excessive thirst
• Lightheadedness
• Shock, in severe cases

Causes

Normally, blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. But if scar tissue blocks circulation through the liver, the blood backs up, leading to increased pressure within the portal vein (portal hypertension). This forces blood into smaller veins in your esophagus, stomach and occasionally your rectum. The excess blood causes these fragile, thin-walled veins to balloon outward and sometimes to rupture and bleed. Once varices develop, they continue to grow larger.

Cirrhosis: A leading cause of esophageal varices
Esophageal varices are usually a complication of cirrhosis. This serious liver disorder, which is irreversible scarring of liver tissue, often results from alcoholic liver disease or hepatitis B or C infection. Another liver disorder, primary biliary cirrhosis, which destroys the small ducts that carry bile, can also cause scarring of liver tissue and lead to esophageal varices.

Sometimes chronic conditions other than cirrhosis lead to enlarged veins in the esophagus . These conditions include:

• Severe congestive heart failure. This occurs when your heart can’t pump enough blood to meet your body’s needs. In congestive heart failure, blood backs up into the vein between the liver and the right side of the heart, increasing blood pressure in the portal vein.
• Blood clot (thrombosis). A blood clot in the portal vein or in the splenic vein, which feeds into the portal vein, can cause esophageal varices.
• Sarcoidosis. This inflammatory disease starts in the lungs but can affect almost any organ in the body, including the liver.
• Schistosomiasis. This parasitic infection affects millions of people in the developing world, especially parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. It can damage the liver as well as the lungs, intestine and bladder.
• Budd-Chiari syndrome. In this rare condition, blood clots obstruct the veins that carry blood out of the liver.

Risk factors

Although many people with advanced liver disease develop esophageal varices, only about one-third of them have varices that bleed. Bleeding varices are more likely if you have:

• High portal vein pressure. The risk of bleeding increases with the amount of pressure in the portal vein.
• Large varices. The larger the varices, the more likely they are to bleed.
• Red marks on the varices. When viewed through an endoscope — a lighted, fiber-optic instrument — some varices show long, red streaks or red spots. These marks indicate a high risk of bleeding.
• Severe cirrhosis or liver failure. Most often, the more severe your liver disease, the more likely varices are to bleed.
• Fluid buildup. Liver disease can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). Several factors play a role in fluid buildup, including portal hypertension and changes in the hormones and chemicals that regulate fluids in your body. Having this excess fluid increases your risk of variceal bleeding.
• Continued alcohol use. If your liver disease is alcohol-related, your risk of variceal bleeding is far greater if you continue to drink than if you stop.
• Acid reflux. Stomach or bile acids that back up (reflux) into the esophagus erode the esophageal lining, which can trigger bleeding.

When to seek medical advice

See your doctor if you develop signs and symptoms of liver disease, such as:

• Weight loss
• Small, red spider veins under your skin or easy bruising
• Weakness
• Fatigue
• Yellowing of your skin and eyes and dark, cola-colored urine
• The buildup of fluid in your abdominal cavity, which causes it to swell (ascites)
• Itching on your hands and feet and eventually on your entire body
• Swelling of your legs and feet from retained fluid (edema)
• Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy)

If you’ve been diagnosed with esophageal varices and experience bloody vomit or stools, call 911 or your local emergency services right away.

Screening and diagnosis

If you have cirrhosis or other serious liver disease, your doctor may screen you for esophageal varices, sometimes as often as every year or two. These tests are usually used to look for varices:

• Endoscopy. For this test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they’re graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding. An esophageal endoscopy takes about 20 to 30 minutes, and the risks are generally minor. The most common side effect is a sore throat from swallowing the endoscope.
• Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used to diagnose esophageal varices. Unlike an endoscopy, these noninvasive tests also allow your doctor to examine your liver and circulation in the portal vein. But imaging tests aren’t as effective at finding varices as endoscopy is, and they’re not as useful for determining which varices are likely to bleed. For that reason, they’re most often used in addition to endoscopy or when endoscopy can’t be performed.

Complications

The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, you’re at greatly increased risk of another, especially during the first 48 hours. Recurrent bleeding is common in people with esophageal varices, and the likelihood of death increases with each episode. You’re at greater risk of repeat bleeding if you are older, have liver or kidney failure, or drink alcohol.

Other complications of bleeding esophageal varices include:

• Hypovolemic shock. This occurs when your body loses at least one-fifth of its blood volume. Symptoms include low blood pressure, a rapid pulse, weakness, sweating, anxiety, mental confusion and possibly unconsciousness.
• Encephalopathy. A damaged liver is less effective at removing toxins from your body — normally one of the liver’s key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include forgetfulness, confusion and mood changes, and in the most severe cases, delirium and coma.
• Infection. Aspiration pneumonia, which occurs when you inadvertently inhale vomit or other substance into your lungs, can be a life-threatening complication of bleeding varices or of certain treatments to control them.

Treatment

The primary aim in treating esophageal varices is to prevent bleeding. To help achieve this goal, doctors usually prescribe high blood pressure drugs (beta blockers) to reduce pressure in the portal vein. Other drugs may be used for people who don’t respond to beta blockers or who have severe side effects. Sometimes the varices may be injected directly with a solution that causes them to dissolve. Or they may be tied with elastic bands before they have a chance to bleed.

Treating bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. To stop bleeding, you’re likely to have one of the following procedures:

• Variceal ligation. This is the preferred treatment for bleeding esophageal varices. During the procedure, your doctor uses an endoscope to snare the varices with an elastic band, which essentially “strangles” the veins. Variceal ligation usually causes fewer serious complications than do other treatments. It’s also less likely to lead to episodes of repeat bleeding.
• Endoscopic injection therapy. In this procedure, the bleeding varices are injected with a solution that dissolves them. Bleeding is usually controlled after one or two treatments, but complications can occur, including perforation of the esophagus and trouble swallowing (dysphagia).
• Medications. When other therapies aren’t available, your doctor may initially prescribe medications to control bleeding.
• Shunt. In this procedure, called a transjugular intrahepatic portosystemic shunt (TIPS), a small tube called a shunt is placed between the portal vein and the hepatic vein, which carries blood from the liver back to your heart. The tube is kept open with a metal stent. By providing an artificial path for blood through the liver, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and encephalopathy, which may develop when toxins that would normally be filtered by the liver are passed through the shunt directly into the bloodstream. TIPS is mainly used when all other treatments have failed or as a temporary measure in people awaiting a liver transplant.
• Liver transplant. Because no treatment is entirely successful at preventing repeat bleeding episodes and because treatments themselves pose significant risks, liver transplant is an option for people with severe or recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs. You may face additional hurdles if your liver disease is the result of alcoholic hepatitis. Some medical centers won’t perform liver transplants on people with alcoholic liver disease or require that you abstain from alcohol for at least six months before you’re eligible for transplant surgery.

Prevention

It’s not always possible to prevent esophageal varices in people with liver disease or portal hypertension. But treating the underlying problem — alcohol abuse, iron overload, or exposure to toxic chemicals, for instance — is of primary importance. Equally important is the use of beta blockers or other medications to prevent increased blood pressure in the portal vein.

Almost everyone has had hiccups. Some people even have them before they’re born. “Singultus” is the medical term for hiccups, derived from the Latin word “singult,” which means the act of catching your breath while sobbing, an apt description of the way hiccups sound. Although they can be embarrassing — especially if the “hic” pops out of your mouth in a quiet room or during a meeting — hiccups are rarely cause for concern.

Often, there’s no obvious cause for hiccups. Sometimes they may be the result of eating a large meal, drinking a carbonated beverage or sudden excitement. Rarely, hiccups may be a sign of an underlying medical condition.

Hiccups usually disappear on their own. If your hiccups don’t go away after a few minutes, home remedies may help. If hiccups persist for more than 48 hours or if they are so severe that they interfere with eating or breathing, see your doctor.

Signs and symptoms

The characteristic sound of a hiccup, sometimes preceded by a small tightening sensation in your chest, abdomen or throat, are the only signs and symptoms associated with hiccups. People may have as few as four hiccups a minute or, rarely, as many as 60 hiccups a minute.

How long your hiccup episode lasts determines the type of hiccups you have:

• Transient or acute hiccups. This is the most common form of hiccups. Transient hiccups include hiccup episodes that last less than 48 hours. Most bouts of transient hiccups last only a few minutes.
• Persistent hiccups. These hiccups last longer than 48 hours, but less than a month.
• Intractable hiccups. Hiccups fall into this category when they last more than two months.

Causes

A hiccup is an unintentional contraction of your diaphragm — the muscle that separates your chest from your abdomen and plays an important role in breathing. This contraction makes your vocal cords close very briefly, which produces the sound of a hiccup.

Acute or transient hiccups
Although there’s often no clear cause for a bout of hiccups, some factors that can trigger acute or transient hiccups include:

• Eating spicy food. Spicy food may cause irritation to the nerves that control normal contractions of your diaphragm.
• Eating a large meal, drinking carbonated beverages or swallowing air. These can cause your stomach to expand (distend), which pushes up your diaphragm, making hiccups more likely.
• Drinking alcohol. Alcohol can relax your diaphragm and vocal cords, making it easier for other factors to trigger hiccups.
• Sudden temperature changes. A quick change in temperature, either inside or outside your body, such as drinking hot liquids and then cold liquids or your shower water switching suddenly from hot to cold, can set off hiccups.
• Tobacco use. Tobacco use may irritate the nerves that controls the diaphragm (phrenic nerves), causing hiccups.
• Sudden excitement or emotional stress. Although it’s not clear why stress or sudden excitement causes hiccups, it may be due to the effect being startled has on one of the nerves involved in the hiccup reflex (vagus nerves).

Persistent and intractable hiccups
Rarely, hiccups may be the result of an underlying medical condition. When this is the case, the hiccups usually last longer than 48 hours. More than 100 causes of persistent and intractable hiccups have been identified. They are generally grouped into the following categories:

• Nerve damage or irritation. Damage or irritation of one of your vagus nerves or phrenic nerves is the most common cause of persistent or intractable hiccups.The vagus nerve serves as a communication pathway between your brain and organs, such as your heart, lungs and intestines. There’s one vagus nerve on each side of your body. These nerves run from your brainstem through your neck and down to your chest and abdomen. The phrenic nerve controls movement of your diaphragm. There’s one phrenic nerve on each side of your body. The phrenic nerves run from your brainstem through your neck and down to your diaphragm.Examples of conditions that may damage or irritate these nerves include a foreign body (often a hair) in your ear, a tumor, cyst or goiter in your neck or chest, gastroesophageal reflux, or an abscess on your diaphragm.
• Central nervous system disorders. A tumor or infection in your central nervous system, or damage to your central nervous system as a result of trauma, can release your body’s normal control of the hiccup reflex.
• Metabolic disorders. Metabolic disorders that may cause hiccups include a condition that interferes with the ability of your kidneys to keep wastes from building to toxic levels (uremia) and a condition that results in less than the normal levels of carbon dioxide in your blood (hypocapnia).
• Surgery. General anesthesia and complications following surgery can cause intractable hiccups.
• Mental or emotional triggers. Anxiety, stress and excitement have been associated with some cases of persistent or intractable hiccups.

Risk factors

If you use tobacco or drink alcohol regularly, you may get transient hiccups more often than people who don’t. Men are more likely to have persistent or intractable hiccups.

When to seek medical advice

Make an appointment to see your doctor if your hiccups last more than 48 hours or if they are so severe that they cause problems with eating or breathing.

Screening and diagnosis

For hiccups lasting longer than 48 hours, your doctor will perform a physical exam and talk with you about your medical history. If your doctor suspects an underlying medical condition may be causing your hiccups, he or she may recommend one or more of the following tests:

• Blood tests. A laboratory exam of a blood sample may help reveal an infection, metabolic disorder or tumor.
• Chest X-ray. A chest X-ray may detect abnormalities affecting the vagus nerve, phrenic nerve or diaphragm.
• Ear exam. Examination of the external ear canal may reveal a foreign substance in your ear that could be causing your hiccups.
• Fluoroscopy. This exam is a type of X-ray that uses low-dose radiation to produce images of a body part in motion. Fluoroscopy can show if one side (unilateral) or both sides (bilateral) of your diaphragm are being affected by hiccup contractions. The results of fluoroscopy can help rule out some underlying medical conditions.

If the cause of your hiccups remains unclear after these tests, additional tests may be necessary, depending on your condition.

Treatment

Most cases of hiccups go away on their own, without medical treatment. If an underlying medical condition is causing your hiccups, treatment of that illness may eliminate the hiccups. If your hiccups are persistent or intractable, your doctor may recommend the following treatment:

• Medication. Several forms of medication may be effective for treating hiccups. The most commonly used is chlorpromazine (Thorazine). Other medications that may be helpful include metoclopramide (Reglan), anticonvulsants, benzodiazepines and baclofen (Lioresal).
• Carotid sinus massage. Your carotid sinus is located in your neck, just below your jaw and just above the point where your carotid artery — a blood vessel that supplies blood to your brain — divides into its two main branches. Massage of your carotid sinus may help eliminate hiccups. This hiccups treatment should be performed only by your health care provider. Don’t try carotid massage at home: It can be dangerous.
• Nasogastric (NG) tube. If your stomach is distended, a thin, flexible tube inserted through your nose and into your stomach (nasogastric tube) may stop hiccups by providing relief from stomach distention. The tube usually is removed as soon as the hiccups stop.
• Nerve block. Rarely, if other treatments aren’t effective, your doctor may recommend an injection of an anesthetic to block your phrenic nerve to stop hiccups.

Prevention

You may be able to decrease your frequency of transient or acute hiccups by avoiding common hiccup triggers, such as eating quickly, eating large meals or spicy foods, drinking carbonated beverages or alcohol, sudden changes in temperature, and using tobacco.

Self-care

Although there’s no surefire way to stop hiccups, if you have a bout of hiccups that lasts longer than a few minutes, the following home remedies may provide relief:

• Swallow a teaspoon of sugar
• Breathe temporarily into a paper bag
• Drink a glass of cold water
• Hold your breath for a count of 10
• Have someone startle you

Complementary and alternative medicine

When persistent or intractable hiccups don’t respond to other remedies, alternative treatments such as hypnosis and acupuncture may be helpful.

Celiac disease is a digestive condition triggered by consumption of the protein gluten, which is found in bread, pasta, cookies, pizza crust and many other foods containing wheat, barley or rye. Oats may contain gluten as well. When a person with celiac disease eats foods containing gluten, an immune reaction occurs in the small intestine, resulting in damage to the surface of the small intestine and an inability to absorb certain nutrients from food.

Eventually, decreased absorption of nutrients (malabsorption) can cause vitamin deficiencies that deprive your brain, peripheral nervous system, bones, liver and other organs of vital nourishment, which can lead to other illnesses. The decreased nutrient absorption that occurs in celiac disease is especially serious in children, who need proper nutrition to develop and grow.

No treatment can cure celiac disease. However, you can effectively manage celiac disease through changing your diet.

Signs and symptoms

There are no typical signs and symptoms of celiac disease. Most people with the disease have general complaints, such as intermittent diarrhea, abdominal pain and bloating. Sometimes people with celiac disease may have no gastrointestinal symptoms at all. Celiac disease symptoms can also mimic those of other conditions, such as irritable bowel syndrome, gastric ulcers, Crohn’s disease, parasite infections, anemia, skin disorders or a nervous condition.

Celiac disease may also present itself in less obvious ways, including irritability or depression, anemia, stomach upset, joint pain, muscle cramps, skin rash, mouth sores, dental and bone disorders (such as osteoporosis), and tingling in the legs and feet (neuropathy).

Some indications of malabsorption that may result from celiac disease include:

• Weight loss
• Diarrhea
• Abdominal cramps, gas and bloating
• General weakness
• Foul-smelling or grayish stools that may be fatty or oily
• Stunted growth (in children)
• Osteoporosis

Dermatitis herpetiformis is an itchy, blistering skin disease that also stems from gluten intolerance. The rash usually occurs on the elbows, knees and buttocks. Dermatitis herpetiformis can cause significant intestinal damage identical to that of celiac disease. However, it may not produce noticeable digestive symptoms. This disease is treated with a gluten-free diet, in addition to medication to control the rash.

Causes

Also known as celiac sprue, nontropical sprue and gluten-sensitive enteropathy, celiac disease occurs in people who have a susceptibility to gluten intolerance. Some experts speculate that celiac disease has been around since humankind switched from a foraging diet of meat and nuts to a cultivated diet including grains, such as wheat. Nonetheless, it has only been in the last 50 years that researchers have gained a better understanding of the condition.

Normally, your small intestine is lined with tiny, hair-like projections called villi. Resembling the deep pile of a plush carpet on a microscopic scale, villi work to absorb vitamins, minerals and other nutrients from the food you eat. Celiac disease results in damage to the villi. Without villi, the inner surface of the small intestine becomes less like a plush carpet and more like a tile floor, and your body is unable to absorb nutrients necessary for health and growth. Instead, nutrients such as fat, protein, vitamins and minerals are eliminated with your stool.

The exact cause of celiac disease is unknown, but it’s often inherited. If someone in your immediate family has it, chances are 5 percent to 15 percent that you may as well. It can occur at any age, although problems don’t appear until gluten is introduced into the diet.

Many times, for unclear reasons, the disease emerges after some form of trauma: an infection, a physical injury, the stress of pregnancy, severe stress or surgery.

Celiac disease may be much more common in the United States than previously believed. Recent estimates suggest that one in 133 people have the disease. Among those closely related to someone with celiac disease, such as a parent or sibling, prevalence is even higher: one in 22.

Part of the reason for the previous underdiagnosis of celiac disease may be because the disorder resembles several other conditions that can cause malabsorption. Another reason may be that if doctors believe a condition to be rare, they may look to more common disorders to explain a person’s signs and symptoms. In addition, specific blood tests now allow for diagnosis of people with celiac disease who have very mild signs and symptoms or none at all.

Risk factors

Although celiac disease can affect anyone, it tends to be more common in people of European descent and people with disorders caused by a reaction of the immune system (autoimmune disorders), such as:

• Lupus erythematosus
• Type 1 diabetes
• Rheumatoid arthritis
• Autoimmune thyroid disease
• Microscopic colitis

When to seek medical advice

If you notice or experience any of the signs or symptoms common to celiac disease, see your doctor. If someone in your family is known to have celiac disease, you may need to be tested. Starting the process will help you avoid complications associated with the disease, such as osteoporosis, anemia and certain types of cancer.

Seek medical attention for a child who is pale, irritable, fails to grow and who has a potbelly, flat buttocks and malodorous, bulky stools. Many other conditions can cause these same signs and symptoms, so it’s important to talk to your doctor before trying a gluten-free diet.

Screening and diagnosis

People with celiac disease carry higher than normal levels of certain antibodies (anti-gliadin, anti-endomysium and anti-tissue transglutaminase). Antibodies are specialized proteins that are part of your immune system and work to eliminate foreign substances in your body. In people with celiac disease, their immune systems may be recognizing gluten as a foreign substance and producing elevated levels of antibodies to get rid of it.

A blood test can detect high levels of these antibodies and is used to initially detect people who are most likely to have the disease and who may need further testing. To confirm the diagnosis, your doctor may need to microscopically examine a small portion of intestinal tissue to check for damage to the villi. To do this, your doctor inserts a thin, flexible tube (endoscope) through your mouth, esophagus and stomach into your small intestine and takes a sample of intestinal tissue.

A trial of a gluten-free diet also can confirm a diagnosis, but it’s important that you not start such a diet before seeking a medical evaluation. Doing so may change the results of blood tests and biopsies so that they appear to be normal.

Complications

Left untreated, celiac disease can lead to several complications:

• Malnutrition. Untreated celiac disease can lead to malabsorption, which in turn can lead to malnutrition. This occurs in spite of what appears to be an adequate diet. Because vital nutrients are lost in the stool rather than absorbed in the bloodstream, malabsorption can cause a deficiency in vitamins A, B-12, D, E and K, folate and iron, resulting in anemia and weight loss. Malnutrition can cause stunted growth in children and delay their development.
• Loss of calcium and bone density. With continued loss of fat in the stool, calcium and vitamin D may be lost in excessive amounts. This may result in a bone disorder called osteomalacia, a softening of the bone also known as rickets in children, and loss of bone density (osteoporosis), a condition that leaves your bones fragile and prone to fracture. In addition, lack of calcium absorption can lead to a certain type of kidney stone (oxalate stone).
• Lactose intolerance. Because of damage to your small intestine from gluten, foods that don’t contain gluten may also cause abdominal pain and diarrhea. Some people with celiac disease aren’t able to tolerate milk sugar (lactose) found in dairy products, a condition called lactose intolerance. If this is the case, you need to limit food and beverages containing lactose as well as those containing gluten. Once your intestine has healed, you may be able to tolerate dairy products again. However, some people may continue to experience lactose intolerance despite successful management of celiac disease. If you’re among this group, you’ll need to limit products that contain lactose indefinitely.
• Cancer. People with celiac disease who don’t maintain a gluten-free diet also have a greater chance of getting one of several forms of cancer, especially intestinal lymphoma and bowel cancer.
• Neurological complications. Celiac disease has also been associated with disorders of the nervous system, including seizures (epilepsy) and nerve damage (peripheral neuropathy).

Treatment

Celiac disease has no cure, but you can effectively manage the disease through changing your diet.

Once gluten is removed from your diet, inflammation in your small intestine will begin to subside, usually within several weeks. If your nutritional deficiencies are severe, you may need to take vitamin and mineral supplements recommended by your doctor or dietitian to help correct these deficiencies. Complete healing and regrowth of the villi may take several months in younger people and as long as two to three years in older people.

Improvements after starting a gluten-free diet may be especially dramatic in children. Not only do their physical symptoms improve, but also their behavior improves. In addition, their growth starts to pick up.

Avoiding gluten is essential
To manage the disease and prevent complications, it’s crucial that you avoid all foods that contain gluten. That means all foods or food ingredients made from many grains, including wheat, barley and rye. This includes any type of wheat (including farina, graham flour, semolina and durum), barley, rye, bulgur, Kamut, kasha, matzo meal, spelt and triticale.

Amaranth, buckwheat and quinoa are gluten-free as grown, but may be contaminated by other grains during harvesting and processing. Cross-contamination may also occur if gluten-free products are prepared in unwashed bowls previously containing gluten products. Oats may not be harmful for most people with celiac disease, but oat products are frequently contaminated with wheat, so it’s best to avoid oats as well.

The question of whether people eating a gluten-free diet can consume pure oat products remains a subject of scientific debate. Difficulties in identifying the precise components responsible for the immune response and the chemical differences between wheat and oats have contributed to the controversy.

Your doctor may recommend that you meet with a dietitian who can instruct you on a gluten-free diet. There are still many basic foods allowed in a gluten-free diet. These include:

• Fresh meats, fish and poultry (not breaded or marinated)
• Most dairy products
• Fruits
• Vegetables
• Rice
• Potatoes
• Gluten-free flours (rice, soy, corn, potato)

Most foods made from grains contain gluten. Avoid these foods unless they’re labeled as gluten-free or made with corn, rice, soy or other gluten-free grain:

• Breads
• Cereals
• Crackers
• Pasta
• Cookies
• Cakes and pies
• Gravies
• Sauces

Many other foods have ingredients that contain gluten. Grains containing gluten are often used in food additives, such as malt flavoring, modified food starch and others. Other sources of gluten that might come as a surprise include medications and vitamins that use gluten as a binding agent, lipstick, postage stamps and contamination of gluten-free foods with foods containing gluten. Cross-contamination may occur anywhere ingredients come together, such as on a cutting board. You may also be exposed to gluten by using the same utensils as others, such as a bread knife, or by sharing the same condiment containers.

Gluten-free products abound
Fortunately for bread and pasta lovers with celiac disease, there are an increasing number of gluten-free products on the market. If you can’t find any at your local bakery or grocery store, check with a celiac support group or the Internet for availability. In fact, there are gluten-free substitutes for many gluten-containing foods, from brownies to beer. Many cities have specialty grocery stores that sell gluten-free foods.

Identifying gluten-free foods can be difficult. Because a gluten-free diet needs to be strictly followed, you may wish to consult a registered dietitian who is experienced in teaching the gluten-free diet. A dietitian can advise you on how to best maintain the nutritional quality of your diet and help you come up with gluten-free alternatives. She or he will also help you identify your need for vitamin, calcium and mineral supplements. Revisiting the dietitian over the years will help keep you up-to-date on newer food products as well as answer your questions.

What if you eat gluten?
If you accidentally eat a product that contains gluten, you may experience abdominal pain and diarrhea. Some people experience no signs or symptoms after eating gluten, but this doesn’t mean it’s not hurting them. Even trace amounts of gluten in your diet can be damaging, whether or not they cause signs or symptoms. Going on and off a gluten-free diet can lead to serious complications.

Most people with celiac disease who follow a gluten-free diet have a complete recovery. Only a small percentage of people who have severely damaged small intestines don’t improve with a gluten-free diet. When diet isn’t effective, treatment often includes medications to help control intestinal inflammation and other conditions resulting from malabsorption.

Because celiac disease can lead to many complications, people who don’t respond to dietary changes need frequent monitoring for other health conditions.

Self-care

Following a gluten-free diet may leave you angry and frustrated, understandably so. But with time, patience and a little creativity, you’ll find there are many foods that you can still eat and enjoy. Following are some tips to help you on your way to a safe and healthy diet.

Read food labels
Food labels are your lifeline to better health. Always read the food label before you purchase any product. Some foods that may appear acceptable, such as rice or corn cereals, may contain gluten. What’s more, a manufacturer may change a product’s ingredients at any time. A food that was once gluten-free no longer may be. Unless you read the label every time you shop, you won’t know this.

As of 2006, the Food and Drug Administration (FDA) requires products containing wheat, milk, soy, peanuts, tree nuts, fish, shellfish or eggs to say so in plain English on the product’s label. By August 2008, the FDA will also issue a standard definition of “gluten-free” to make it easier for shoppers with celiac disease to identify products.

Call the manufacturer
If you can’t tell by the label if a food contains gluten, don’t eat it until you check with the product’s manufacturer. Some support groups produce a gluten-free shopper’s guide that can save you time at the market, although it may not be as current as that obtained from the manufacturer.

Adapt your favorite recipes
If your favorite foods contain gluten, don’t fret yet. You may be able to make a few changes in the recipes that will allow you to still enjoy them. Here are some helpful tips for the kitchen.

For 1 tablespoon of wheat flour, substitute one of these:

• 1 1/2 teaspoons cornstarch
• 1 1/2 teaspoons potato starch
• 1 1/2 teaspoons arrowroot starch
• 1 1/2 teaspoons rice flour
• 2 teaspoons quick-cooking tapioca

For 1 cup of wheat flour, substitute one of these:

• 3/4 cup plain cornmeal, coarse
• 1 cup plain cornmeal, fine
• 5/8 cup potato flour
• 3/4 cup rice flour

When using substitute starches and flours, you may find that the recipe turns out best if you bake the food longer and at a lower temperature. For more satisfactory baked products, experiment a bit with baking times, temperature settings and different combinations of substitutes — potato flour and rice flour, for example. In addition, gluten-free cookbooks are available that can give you a good start at recipe adjustments.

Don’t be afraid to eat out
Though preparing your own meals is the easiest way to monitor your diet, this doesn’t mean you can’t eat out. For an enjoyable dining experience, remember the following advice:

• Select places that specialize in the kinds of foods you can eat. You may want to call the restaurant in advance and discuss the menu options and your dietary needs.
• Be a repeat customer. Visit the same restaurants so that you become familiar with their menus and the personnel get to know your needs.
• Seek and share ideas. Ask members of your support group for suggestions on restaurants that serve gluten-free food. If there are enough gluten-sensitive people in your community, it’s likely that restaurant owners will try to satisfy your needs. Continue to share with the support group the names of any restaurants that add gluten-free foods to their menus.
• Follow the same practices you do at home. Select simply prepared or fresh foods and avoid all breaded or batter-coated foods, gravies and other foods with obvious or questionable ingredients.

Coping skills

Living with celiac disease isn’t always easy. Every day can be a challenge. Over time, however, managing your disease will become second nature. In the meantime, these suggestions may help you manage more easily:

• Gather information about celiac disease. Talk to your doctor, look for information on the Internet, and read books and pamphlets. Find cookbooks directed specifically toward a gluten-free diet. Being informed about your condition can help you take better charge of it.
• Seek out others with celiac disease. Talking to people who know what you’re going through can be reassuring. Your doctor may be able to refer you to a celiac disease support group in your community, or you may find one listed on the Internet or in your local paper.
• Don’t hesitate to seek guidance. If you’re having difficulty coming up with suitable menus, talk to a registered dietitian. A dietitian has extensive knowledge of the nutritional aspects of food and what you can and can’t eat. He or she can help you think in more creative ways about your favorite foods.

Occasional difficulty swallowing usually isn’t cause for concern, and may simply occur when you eat too fast or don’t chew your food well enough. But persistent difficulty swallowing may indicate a serious medical condition requiring treatment.

Difficulty swallowing (dysphagia) may mean it takes more time and effort to move food or liquid from your mouth to your stomach. Difficulty swallowing may also be associated with pain. In some cases, you may not be able to swallow.

Difficulty swallowing can occur at any age, but is most common in older adults. The causes of swallowing difficulties vary, and treatment depends upon the cause.

Signs and symptoms

Signs and symptoms sometimes associated with dysphagia may include:

• Pain while swallowing (odynophagia)
• Not being able to swallow
• Choking or coughing while eating
• Sensation of food getting stuck in your throat or chest, or behind your breastbone (sternum)
• Bringing food back up (regurgitation)
• Frequent heartburn
• Food or stomach acid backing up into your throat
• Unexpected weight loss
• Recurrent pneumonia
• Coughing or gagging when swallowing

In infants and children, signs and symptoms of swallowing difficulties may include:

• Lack of attention during feeding or meals
• Tensing of the body during feeding
• Refusing to eat foods of different textures
• Lengthy feeding or eating times (30 minutes or longer)
• Breast-feeding problems
• Food or liquid leaking from the mouth
• Repeated swallowing
• Coughing or gagging during feeding or meals
• Spitting up or vomiting during feeding or meals
• Inability to coordinate breathing with eating and drinking
• Weight loss or slow weight gain or growth
• Frequent respiratory infections

Causes

You probably take swallowing for granted — you take a bite of food, chew and swallow. Most people don’t think much more about it. But for some people, difficulty swallowing makes every meal a challenge.

When you swallow, your tongue pushes food to the back of your throat. Muscle contractions quickly move food through your pharynx, the area that extends from the back of your throat to the top of your esophagus. Next, the food moves past your windpipe (trachea) and into your esophagus, the tube that connects your throat to your stomach.

Circular bands of muscles (sphincters) at the top and bottom of your esophagus open every time you swallow to let food pass, then quickly close. The lower sphincter allows food to enter your stomach and keeps stomach acid from coming up into your esophagus. Muscles in the wall of your esophagus help push food toward your stomach in a coordinated process (peristalsis). In all, it takes about 50 pairs of muscles and nerves to accomplish the simple act of swallowing.

When there’s a problem
Dysphagia occurs when there’s a problem with any part of the swallowing process.

A number of conditions can interfere with swallowing, and they generally fall into one of several main categories.

Esophageal dysphagia
This is the most common type of swallowing difficulties. It refers to the sensation of food sticking or getting hung up in the base of your throat or chest. Common causes of esophageal dysphagia include:

• Achalasia. This occurs when your lower esophageal muscle (sphincter) doesn’t relax properly to let food enter your stomach. Muscles in the wall of your esophagus are often weak as well. This can cause regurgitation of food not yet mixed with stomach contents, sometimes causing you to bring food back up into your throat.
• Aging. With age, your esophagus tends to lose some of the muscle strength and coordination needed to push food into your stomach. However, any persistent trouble swallowing needs to be evaluated by your doctor; it’s not necessarily a normal part of aging.
• Diffuse spasm. This condition produces multiple, high-pressure, poorly coordinated contractions of your esophagus usually after you swallow. Diffuse spasm is a rare disorder that affects the smooth (involuntary) muscles in the walls of your lower esophagus. The contractions often occur intermittently, and may become more severe over a period of years.
• Esophageal stricture. Narrowing of your esophagus (stricture) causes large chunks of food to get caught. Narrowing may result from the formation of scar tissue, often caused by gastroesophageal reflux disease (GERD), or from tumors.
• Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.
• Foreign bodies. Sometimes, food, such as a large piece of meat, or another object can become lodged in your throat or esophagus. Older adults with dentures and people who have difficulty chewing their food properly may be more likely to have an obstruction of the throat or esophagus. Children may swallow small objects, such as swallowing pins, coins, pieces of toys or other small objects that can become stuck. If an obstruction causes an inability to swallow, go to the nearest emergency department immediately. If an obstruction interferes with breathing, call for emergency help immediately.
• Gastroesophageal reflux disease (GERD). Damage to esophageal tissues from stomach acid backing up (refluxing) into your esophagus can lead to spasm or scarring and narrowing of your lower esophagus, making swallowing difficult. Long-term GERD can sometimes lead to Barrett’s esophagus, a condition in which the color and composition of the cells lining your lower esophagus change because of repeated exposure to stomach acid.
• Pharyngeal diverticula. A small pouch forms and collects food particles in your throat, often just above your esophagus, leading to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing. This disorder is more common as you age.
• Scleroderma. This disease is characterized by the development of scar-like tissue, causing stiffening and hardening of tissues. It can weaken your lower esophageal sphincter, allowing acid to reflux into your esophagus and causing symptoms and complications similar to those of GERD.

Oropharyngeal dysphagia
Certain neuromuscular problems can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus (pharyngeal paralysis). You may choke or cough when you attempt to swallow, or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia. Causes of oropharyngeal dysphagia include:

• Neurological disorders. Certain disorders, such as post-polio syndrome, multiple sclerosis, muscular dystrophy and Parkinson’s disease, may first be noticed because of oropharyngeal dysphagia.
• Neurological damage. Sudden neurological damage, such as from a stroke or brain or spinal cord injury, can cause difficulty swallowing or an inability to swallow.

Dysphagia in infants and children
Common causes of swallowing difficulties in infants and children include:

• Developmental problems due to premature birth or low birth weight
• Nervous system disorders, such as cerebral palsy or meningitis
• Cleft lip or cleft palate

Unexplained dysphagia
Some people experience dysphagia that has no anatomical cause. Unexplained swallowing difficulties include:

• Difficulty taking oral medications. Some people can’t seem to swallow pills or tablets, even though they have no other difficulty swallowing.
• Lump in your throat (globus). Some people feel the sensation of a foreign body or lump in their throats when, in reality, no foreign body or lump exists. Stress or excitement may worsen this sensation. Oftentimes, resolving the stress alleviates the problem. Actual difficulty swallowing usually isn’t present.

Risk factors

The following are risk factors for difficulty swallowing:

• Aging. Due to natural aging and normal wear and tear on the esophagus, older adults are at higher risk of swallowing difficulties.
• Premature birth. Babies born prematurely are more prone to developmental problems, including gastrointestinal disorders, that may cause difficulty swallowing.
• Certain health conditions. People with neurological or nervous system disorders are more likely to experience difficulty swallowing.

When to seek medical advice

• If it’s difficult to breathe. If an obstruction interferes with breathing, call for emergency help immediately. If you’re unable to swallow due to an obstruction, go to the nearest emergency department.
• For ongoing problems. Slight or occasional difficulty swallowing usually isn’t cause for concern. But difficulty swallowing can indicate a serious medical problem, such as esophageal cancer. See your doctor if you regularly have difficulty swallowing.
• For your child. If you suspect that your child has trouble swallowing, contact your child’s doctor. He or she may refer you and your child to a doctor who specializes in treating children with feeding and swallowing disorders (speech pathologist).

Screening and diagnosis

Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.

Depending on the cause, your doctor may refer you to an ear, nose and throat specialist (otolaryngologist), a doctor specialized in treating disorders of the esophagus (gastroenterologist) or an expert in diseases of the nervous system (neurologist).

Tests that your doctor or a specialist uses may include:

• Barium X-ray. For this test, you drink a barium solution. The barium coats the inside of your esophagus, allowing it to show up better on X-rays. Your doctor can then see changes in the shape of your esophagus and can assess the muscular activity. Your doctor may also have you swallow solid food or a pill coated with barium to watch the muscles in your throat as you swallow or to look for subtle blockages in your esophagus that the liquid barium solution may not identify.
• Endoscopy. A thin, flexible, lighted instrument (endoscope) is passed down your throat so that your doctor can view your esophagus.
• Esophageal muscle test. In this test, called manometry (muh-NOM-uh-tre), a small tube is inserted into your esophagus and connected to a pressure recorder. This allows measurement of the muscle contractions of your esophagus as you swallow.

Complications

Difficulty swallowing can lead to:

• Malnutrition and dehydration. Dysphagia can make it difficult for you to take in enough food and fluids to stay adequately nourished. People with difficulty swallowing are at risk of malnutrition and dehydration.
• Respiratory problems. If food or liquid enters your airway (aspiration) as you attempt to swallow, respiratory problems or infections can occur, such as frequent bouts of pneumonia or upper respiratory infections.

Treatment

Treatment for swallowing difficulties is often tailored to the particular type or cause of your swallowing disorder:

• Oropharyngeal dysphagia. For oropharyngeal dysphagia, your doctor will most likely refer you to a throat specialist or neurologist for further diagnostic testing and to a speech or swallowing specialist for therapy. Certain exercises may help coordinate your swallowing muscles or restimulate the nerves that trigger the swallowing reflex. You may also learn simple ways to place food in your mouth or to position your body and head to help you swallow successfully.
• Esophageal dysphagia. For a tight esophageal sphincter (achalasia) or an esophageal stricture, your doctor may use an endoscope with a special balloon attached to gently stretch and expand the width of your esophagus or pass a flexible tube or tubes to stretch the esophagus (dilatation).For an esophageal tumor or pharyngeal diverticula, you may need surgery to clear your esophageal path.

  Difficulty swallowing associated with GERD can be treated with prescription oral medications to reduce stomach acid after a stricture is dilated. You may need to take these medications for an extended period of time.

  If you have esophageal spasm but your esophagus appears normal and without GERD, you may be treated with medications to relax your esophagus and reduce discomfort.

• Severe dysphagia. If difficulty swallowing prevents you from eating and drinking enough to maintain a healthy weight and avoid dehydration, your doctor may recommend special liquid diets. In severe cases of dysphagia, you may need a feeding tube to bypass the part of your swallowing mechanism that isn’t working normally.

Prevention

Although swallowing difficulties can’t be prevented when the cause is neurological damage or disorders, you can reduce your risk of occasional difficulty swallowing by eating slowly and chewing your food well. Early detection and effective treatment of GERD can lower your risk of developing dysphagia associated with an esophageal stricture.

Coping skills

Living with swallowing difficulties can be challenging. Dysphagia may affect your interaction with friends and family, your productivity at work and the overall quality of your life.

You may find that talking to a counselor or therapist can help you cope with the effects of swallowing difficulties. Or you may find encouragement and understanding in a support group.

Although support groups aren’t for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences. If you’re interested, your doctor may be able to recommend a support group in your area.