By S M Chen, posted 4-20-2016 by D Kovacs

We are indeed ‘fearfully and wonderfully made.’  – Ps. 139:14.

One of the important (but by no means salient, in that patients can survive for prolonged time periods by tube feeding) bodily functions is swallowing. Deglutition is a complex process initiated in the brain and brainstem, from which matters proceed southward.

Once initiated, the tongue and hypopharynx participate, propelling the bolus of ingested material, whether liquid or solid, or combination thereof, past the pharyngoesophageal junction into the esophagus and thence into the stomach, where some digestion occurs.

Normal primary peristalsis begins in the upper esophagus and proceeds in an orderly fashion with an uninterrupted smooth and regular motion toward the stomach. Along with gravity (most people ingest in an upright or semi-upright position), it accomplishes its intended purpose of transferring what is ingested from mouth to gut.

Our department performs video esophagrams, most commonly for dysphagia. We administer substances of varying viscosity and video record while the patient swallows. Results are helpful in determining what is safe for the patient to ingest without aspirating (aspiration pneumonia can be fatal and is best prevented).

A multitude of processes, ranging from neurologic (e.g. stroke, multiple sclerosis, Goldflam disease, ALS, Parkinson’s) to systemic (e.g. scleroderma, other autoimmune disorders) to more local (e.g. esophageal web, stricture, diverticula, inflammation, spasm, tumor, gastroesophageal reflux) can cause dysphagia.

We often administer a half-inch diameter barium pill and observe its passage from mouth to points southward. 12 mm is the diameter of the typical endoscope, and, if the pill, unmasticated, passes promptly into the stomach, it is assumed that there is no significant morphologic impediment.

Since our population tends to be older, consistent with the graying of the USA populace, we see a fair number of patients with esophageal motility disorder, wherein normal primary peristalsis is interrupted, disrupted or absent. Regardless of the cause (which is often GERD -gastroesophageal reflux disease – with or without esophageal hiatal hernia, in which part of the stomach herniates northward through the diaphragm into the chest), we often observe reverse peristalsis, wherein peristalsis in the lower esophagus will proceed northward, away from the stomach, rather than southward toward it. To and fro (forward and backward) peristalsis is sometimes seen. Patients are invariably upright, or semi-so, so gravity aids in esophageal emptying, and sometimes is the only cause of such.

This to-and-fro peristalsis is reminiscent of the perpetual conflict between good and evil. One could liken normal primary peristalsis to good, the way things were originally intended to be. Reverse peristalsis is a reasonable representation of evil. It thwarts and subverts the normal physiologic process. As in the body, sometimes good prevails; sometimes evil. Reverse peristalsis sometimes reverts to antegrade peristalsis. Or not. These matters are unpredictable.

Were it not for gravity, that law by which our planet and the universe operate, ingested material might never reach the stomach, or might happen so slowly as to preclude subsistence.

The upper esophageal sphincter is a bundle of muscles under voluntary control. Its purpose is to permit propulsion of ingested material and secretions into the esophagus rather than into the trachea.

The lower esophageal sphincter is also a bundle of muscles, not under voluntary control. Its relaxation allows material and secretions to travel aborally into the stomach. When closed, the sphincter prevents retrograde passage into the esophagus, which is not designed for acidic gastric content.

Relaxation of the sphincters may be akin to our allowing the unseen influence of divinity in our lives, which will be better if properly aligned in intended manner (the “at one ment” of atonement). If we close ourselves to such, it will not be forced upon us. Divine love is exceeded only by divine unwillingness to supersede our own will.

While the analogy between deglutition and spirituality is imperfect, the parallel serves to remind that the corrupting influence of alienation from divinity is widespread and can be seen, by even the casual observer, in many different, even unexpected places, including our own corpus.

Although to dust we are destined to return, rarely, it seems, is that dust untainted by blight, which is often brought on by our own doing. What is done often leaves us undone. There are countless examples of such, some intentional, some unintentional. Benign neglect often plays a role.

We can only hope for the intervention of incorruptibility and the transformation of the dust from whence we came into something more.