In achalasia, failure of the LES to relax may result in food retention in the oesophagus, even of soft, paste-like food. While endoscopic retrieval of the material is usually safe for small amounts of food, in the case of our patient, soft and solid food completely filled the whole length of the oesophagus resulting in poor visibility. In addition, many intubations and retrievals would have been necessary to clear the oesophagus, so placing the patient at repeated risk of aspiration, trauma or perforation. Pushing the material through the LES is hazardous (especially in the presence of an oesophageal diverticulum as in this case), and best avoided.
1 In view of these considerations, and being aware of the potentially reversible nature of the obstruction in achalasia by the use of a calcium channel blocker, we used nifedipine for cardiac sphincter relaxation, along with the liquefying action of Coca-Cola.
Calcium channel blockers, as well as nitrates, phosphodiesterase inhibitors and glucagon, are smooth muscle relaxants, which reduce the LES pressure and may be used as a supportive therapy for patients with achalasia.
2,3 The use of carbonated beverages to treat food obstruction was first described in 1981 by Felson in a patient with achalasia and stenosing cancer.
4 Others reported the use of carbonated soda water to dislodge oesophageal foreign bodies
5 and the use of Coca-Cola in the management of bolus obstruction in benign oesophageal stricture.
6 Fizzy drinks and sodium bicarbonate solutions
7 penetrate the bolus and are thought to disintegrate it by releasing carbon dioxide, which in turn triggers relaxation of the LES so that the liquified bolus enters the stomach. Other methods that have been suggested to relieve acute food obstruction include the topical use of proteolytic enzymes such as papain.
8 In our case we used solely Coca-Cola.
We advocate the cautious use of Coca-Cola in combination with a calcium channel blocker as safe and appropriate first line therapy in the case of elderly or frail patients, and where endoscopy is not readily available. It should also be used in all cases of achalasia where the amount or nature of the food impacted in the oesophagus is such as to render endoscopic removal hazardous. Others have also reasonably indicated that endoscopic clearance of the oesophagus is best reserved as second line therapy.
4Learning points
- In achalasia of the cardia, endoscopic clearance of impacted food material may be hazardous.
- Lower oesophageal sphincter relaxation with nifedipine in combination with Coca-Cola may safely resolve food impaction.
- Coca-Cola ± nifedipine may be appropriately used as first line therapy in the care of elderly or frail patients, when endoscopy is not readily available, and where many endoscopic intubations would be required to achieve clearance.
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