Ingestion of a carbonated beverage decreases lower esophageal sphincter pressure and increases frequency of transient lower esophageal sphincter relaxation in normal subjects

Severe Airway Obstruction Caused by Esophageal Bezoar with Coca-Cola and Creon (Pancrelipase) in a Patient with Underlying Achalasia: A Comprehensive Case Report

Introduction

The occurrence of acute respiratory failure as a result of esophageal bezoars is a rare phenomenon. We present a patient who failed initial endoscopic intervention. Successful resolution was achieved through a novel approach involving a combination of Creon and Coca-Cola. Subsequently, the patient was diagnosed with achalasia, a condition that potentially contributed to the formation of the esophageal bezoar. Case Description. An 82-year-old man presented with respiratory distress, necessitating endotracheal intubation for airway protection. A chest computed tomogram (CT) showed pneumonia and a distended esophagus compressing the trachea, raising the possibility of an esophageal food bolus. Endoscopy revealed a severely dilated esophagus containing a significant amount of food and a phytobezoar in the lower esophagus. He failed various endoscopic techniques to remove the obstruction. Given the patient's poor surgical candidacy, he was started in a thrice-daily regimen of Creon dissolved in 165 mL of Coca-Cola, over a 4-day period. A subsequent endoscopy revealed no discernible evidence of food or bezoar. The patient was weaned from mechanical ventilation. A high-resolution esophageal manometry identified type 1 achalasia.

Conclusion

Esophageal food impaction leading to respiratory failure is rare. Endoscopy remains the mainstay approach. Surgical interventions carry significant risks. This case emphasizes the potential for noninvasive management in patients with esophageal bezoars and also underscores the significance of contemplating esophageal pathologies when addressing cases of respiratory failure. The use of Coca-Cola and Creon emerges as a safe, effective, and cost-efficient treatment, providing a feasible option when endoscopy proves unsuccessful before considering more aggressive interventions.

Efficacy of cola ingestion for oesophageal food bolus impaction: open label, multicentre, randomised controlled trial

OBJECTIVE

To determine the efficacy and safety of cola in resolving complete oesophageal food bolus impaction.

DESIGN

Open label, multicentre, randomised controlled trial.

SETTING

Emergency departments of five Dutch hospitals at the secondary and tertiary level, between 22 December 2019 and 16 June 2022.

PARTICIPANTS

51 adults presenting with complete oesophageal food bolus impaction, defined as a sudden inability to pass saliva after consumption of foods. Patients who ingested meat that contained bones, and patients with an American Society of Anesthesiologists (ASA) physical status classification of IV or higher were excluded.

INTERVENTIONS

28 patients in the intervention group were instructed to consume 25 mL cups of cola at intervals up to a maximum total volume of 200 mL. 23 patients in the control group awaited spontaneous passage. In either group, if complete resolution of symptoms did not occur, endoscopic removal was performed following current guidelines: within 6 hours for patients with complete obstruction, and within 24 hours for partial obstruction. In case of complete resolution of symptoms, elective diagnostic endoscopy was required.

MAIN OUTCOME MEASURES

Improvement of oesophageal food bolus obstruction as reported by patients (ie, aggregate of complete and partial passage), and evaluation of complete passage. The secondary outcome was any intervention related adverse event.

RESULTS

Cola did not have a meaningful effect on the improvement of food bolus obstruction (17/28 (61%) intervention v 14/23 (61%) control; odds ratio 1.00, 95% confidence interval 0.33 to 3.1; relative risk reduction 0.0, 95% confidence interval -0.55 to 0.36; P>0.99). Complete passage was reported more often in the intervention group but this difference was not significant (12/28 (43%) intervention v 8/23 (35%) control; odds ratio 1.4 (0.45 to 4.4); relative risk reduction -0.23 (-1.5 to 0.39); P=0.58). No severe adverse events occurred. However, six (21%) patients in the intervention group experienced temporary discomfort after drinking cola.

CONCLUSIONS

In this study, cola consumption did not lead to a higher rate of improvement of complete oesophageal food bolus impaction. Given the lack of adverse events in the treatment group and some events of resolution after treatment, cola might be considered as a first line treatment, but should not delay any planning of endoscopic management.

TRIAL REGISTRATION

Netherlands Trial Register (currently International Clinical Trial Registry Platform) NL8312.

Acute esophageal necrosis complicating diabetic ketoacidosis in a patient with type II diabetes mellitus and excessive cola consumption: a case report

Acute esophageal necrosis (AEN) implicates poor tissue perfusion, functionally defective mucosal barrier, and corrosive injury of the esophageal mucosa, typically characterized by diffuse, circumferential greyish or black discoloration of the esophagus in esophagogastroduodenoscopy. Low-volume states, as diabetic ketoacidosis (DKA), predispose to AEN. Cola drinks diminish the esophageal pH by decreasing the lower esophageal sphincter pressure. We report a 47-year-old male shepherd with chest pain, nausea, odynophagia and gradual decline in level of consciousness, who reported consumption of 6-7 L of cola beverages per day, and was diagnosed with DKA. The patient had a record of type 2 diabetes mellitus and coronary heart disease, and he was administered empagliflozin 25 mg q24 hours, vildagliptin 50 mg bid, metformin 1000 mg bid, and insulin glargine 24 IU q 24. Esophagogastroduodenoscopy was indicative of a diffuse, edematous, and eroded mucosa of grey colour from the upper to the lower esophageal sphincter. CT scan supported the diagnosis, revealing diffuse thickening and edematous imaging of the esophageal wall with an abnormal edge of the mucosa in the lower half of the esophagus. Seven days after rigorous treatment with fluid resuscitation, insulin restoration, esomeprazole, fluconazole, cefoxitine, and metronidazole, the patient was ameliorated. A second endoscopy revealed obvious improvement. Pathophysiology, diagnosis, and treatment of DKA/AEN intertwining are thoroughly discussed. In conclusion, clinicians should not disregard AEN in the differential diagnosis of patients with DKA and clinical symptoms of esophagitis.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13340-021-00537-y.

Cola therapy for oesophageal food bolus impactions a case series

Introduction

This retrospective case series describes the use of cola to immediately treat complete oesophageal food bolus obstructions in the emergency centre. Short of emergent endoscopy – which is invasive, expensive, not without adverse events, and often unavailable in low-resource settings – no other proven therapies exist to relieve oesophageal food impactions.

Methods

We performed a chart review of adults with complete oesophageal food bolus obstructions presenting to two Dutch emergency centres. Our primary outcome was cola’s success rate in resolving the obstruction. Our secondary outcome was adverse event occurrence.

Results

We identified 22 cola interventions in 19 patients, the majority of whom (77.3%) were male. The median age was 59 years (IQR 29–73). All presentations were due to meat impaction. Endoscopy revealed relevant upper gastrointestinal pathology in 54.5%. When initiated in the emergency centre, cola successfully resolved 59% of complete oesophageal obstructions. No adverse events were reported in patients successfully treated with cola.

Discussion

While keenly aware of our retrospective study’s limitations, we found a promising success rate for cola as an acute intervention for oesophageal food bolus impactions. We registered no adverse events attributable to cola. Also, given that cola is cheap, widely available and seemingly safe we believe it can be considered in patients with oesophageal obstructions due to food, either as pre-endoscopy treatment or in case endoscopy is not available at all. We think our findings provide an impetus for prospective research on this intervention.

Food and Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a chronic condition with a high prevalence in western countries. Transient lower esophageal sphincter relaxation episodes and a decreased lower esophageal sphincter pressure are the main mechanisms involved. Currently used drugs are efficient on reflux symptoms, but only as long as they are administered, because they do not modify the reflux barrier. Certain nutrients or foods are generally considered to increase the frequency of gastroesophageal reflux symptoms, therefore physicians recommend changes in diet and some patients avoid bothering foods. This review summarizes current knowledge regarding food and gastroesophageal reflux. For example, fat intake increases the perception of reflux symptoms. Regular coffee and chocolate induce gastroesophageal reflux and increase the lower esophageal exposure to acid. Spicy foods might induce heartburn, but the exact mechanism is not known. Beer and wine induce gastroesophageal reflux, mainly in the first hour after intake. For other foods, like fried food or carbonated beverages data on gastroesophageal reflux is scarce. Similarly, there are few data about the type of diet and gastroesophageal reflux. Mediterranean diet and a very low carbohydrate diet protect against reflux. Regarding diet-related practices, consistent data showed that a "short-meal-to-sleep interval" favors reflux episodes, therefore some authors recommend that dinner should be at least four hours before bedtime. All these recommendations should consider patient's weight, because several meta-analyses showed a positive association between increased body mass index and gastroesophageal reflux disease.

Assessment of the Acute Effects of Carbonated Beverage Consumption on Symptoms and Objective Markers of Gastric Reflux

Previous studies have suggested that carbonated beverages may cause gastro-oesophageal reflux. Pepsin (the major enzyme secreted by the stomach) has been suggested to be an objective, acute marker of a reflux event. This pilot study aimed to investigate whether intake of carbonated beverages could affect pepsin concentration in saliva or reflux symptoms. This was assessed by a randomised, crossover trial where participants consumed 330 mL of beverage (carbonated cola, degassed cola or water) at separate visits. Saliva samples and symptom questionnaires were collected at baseline and over the 30 min postprandial period. Pepsin was detected in all saliva samples. No difference was found in the salivary pepsin concentrations between treatments at all time points. There were significantly higher scores (p > 0.05) for feelings of fullness, heartburn, urge to belch and frequency of belches after ingestion of carbonated cola than degassed cola and water. The ingestion of carbonated beverages did not appear to increase postprandial pepsin concentration in saliva compared to other beverages but did evoke higher levels of reflux-related symptoms such as fullness, heartburn and belching. This suggests carbonated beverages may cause symptoms associated with reflux but do not drive detectable levels of gastric juice to reach the oral cavity.

Risk factors associated with gastroesophageal reflux disease relapse in primary care patients successfully treated with a proton pump inhibitor

BACKGROUND

There are no studies on the factors associated with gastroesophageal reflux disease (GERD) relapse in primary care patients.

AIM

To identify the risk factors associated with GERD relapse in primary care patients that responded adequately to short-term treatment with a proton pump inhibitor.

PATIENTS AND METHODS

A cohort study was conducted that included GERD incident cases. The patients received treatment with omeprazole for 4 weeks. The ReQuest questionnaire and a risk factor questionnaire were applied. The therapeutic success rate and relapse rate were determined at 4 and 12 weeks after treatment suspension. A logistic regression analysis of the possible risk factors for GERD relapse was carried out.

RESULTS

Of the 83 patient total, 74 (89.16%) responded to treatment. Symptoms recurred in 36 patients (48.64%) at 4 weeks and in 13 patients (17.57%) at 12 weeks, with an overall relapse rate of 66.21%. The OR multivariate analysis (95% CI) showed the increases in the possibility of GERD relapse for the following factors at 12 weeks after treatment suspension: basic educational level or lower, 24.95 (1.92-323.79); overweight, 1.76 (0.22-13.64); obesity, 0.25 (0.01-3.46); smoking, 0.51 (0.06-3.88); and the consumption of 4-12 cups of coffee per month, 1.00 (0.12-7.84); citrus fruits, 14.76 (1.90-114.57); NSAIDs, 27.77 (1.12-686.11); chocolate, 0.86 (0.18-4.06); ASA 1.63 (0.12-21.63); carbonated beverages, 4.24 (0.32-55.05); spicy food 7-16 times/month, 1.39 (0.17-11.17); and spicy food ≥ 20 times/month, 4.06 (0.47-34.59).

CONCLUSIONS

The relapse rate after short-term treatment with omeprazole was high. The consumption of citrus fruits and NSAIDs increased the possibility of GERD relapse.

Carbonation as a sensory enhancement strategy: a narrative synthesis of existing evidence

PURPOSE

Sensory enhancement techniques, like other compensatory strategies, aim to reduce dysphagia symptoms. The use of carbonated liquids has been proposed as a possible sensory technique, however to date, there is limited information of its efficacy or guidance for clinical implementation. A narrative synthesis was completed to determine the quality and strength of the evidence base for use of carbonation as a compensatory strategy in dysphagia rehabilitation.

METHODS

From 101 articles initially identified, 14 articles met the study criteria. Eleven papers described the effects of carbonation on swallowing in healthy participants whereas three described the impact of carbonation in dysphagic populations. A narrative synthesis of papers was undertaken given the diversity of identified studies.

RESULTS

Synthesis of findings was challenging given the exploratory phase of most research activity with diverse populations described and extensive differences in research methodologies. There is currently weak, but potentially positive evidence to support using carbonation as a compensatory technique in dysphagia rehabilitation.

CONCLUSION

Despite future potential, existing evidence fails to provide clear direction for the clinical implementation of carbonation. Validation of carbonation use with the dysphagic population requires further research with consistent, controlled methodologies, and larger cohorts of participants to inform potential for dysphagia rehabilitation. Implications for Rehabilitation The use of carbonated liquids has been proposed as a possible sensory enhancement technique which may facilitate changes to swallow physiology. However to date, there is limited information to direct clinical implementation. This paper provides a narrative synthesis of existing knowledge and highlights possible limitations of findings reported. Research to date has used disparate research methodologies in varied populations making synthesis of current findings challenging.