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Too much good living can result in reflux oesophagitis, and recurring scarring leads to a fluctuating degree of stricture and or spasm in the lower oesophagus. Hurry and nervous tension makes the spasm worse.

The problem causes an embarrassing inability to eat as quickly as a companion, and once the oesophagus starts to fill up, water brash aggravates it. Something's stuck. It may pass within minutes or it may involve hours of discomfort and drooling.

Some of the advice given to people in outpatients seems mistaken. Eating more slowly and chewing thoroughly is obvious, but the problem is often unpredictable.

Taking metoclopramide or domperidone makes it worse as these both constrict the cardia. Nitrates and calcium channel blockers may help to ease the spasm but sufferers are unconvinced of them as sure preventives. Reducing acid output with H2 antagonists or proton pump inhibitors definitely helps.

But what to do when the problem strikes? Deducing from anatomy and from personal experience and discussion with fellow sufferers, I've arrived at the following manoeuvre. Suck in the anterior abdominal wall to stretch the diaphragm forward, breathe out to shorten the oesophagus, and do a Valsalva manoeuvre to increase intrathoracic pressure. Also get someone to gently thump the back of the chest, or use a vibrating massage stick. Usually this results in a satisfying sensation of something passing through and shortly afterwards one can resume one's meal.

If this fails, relief involves the unpleasant business of lying face down with one's trunk over the edge of a high bed or table and regurgitating into a basin.

Sorry to spoil your lunch – but do tell your patients.

Dr A J Munro

Cranford, Middlesex

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