Esophageal Problems

Another gastrointestinal complication found in the Department of Chuquisaca, Bolivia, in chagasic patients is achalasia of the esophagus, or the nonrelaxation of the lower esophageal sphincter (see Marcondes de Rezende and Ostermayer 1994:151‑58). Motility of the esophagus is altered in chagasic patients throughout Latin America, and there is no agreement on the prevalence of either megaesophagus or megacolon.[29]The function of the esophagus is to contract and expand so as to push food through the throat to the stomach. A variety of explanations are found for intrinsic denervated esophagus that produces loss of peristalsis, so that the esophagus does not dilate and food cannot pass through it (Marcondes de Rezende and Luquetti 1994). The upper part of the esophagus enlarges, and patients have difficulty swallowing (dysphagia), at times being unable to swallow liquids.[30]Chagasic patients in Santa Cruz often gloss over the fact that they are suffering from dysphagia by a stereotypical answer to the physician’s inquiry. Many respond: “But, Doctor, who doesn’t have difficulty when eating cold rice?”

Very significantly, patients with megaesophagus have lost more than 95 percent of the ganglion cells of the myenteric plexuses (Köberle 1968:91).[31]Temporary stagnation or retention of food stretches the esophagus, causing distention of the muscle fibers, which leads to hypertrophy of the muscle, causing more powerful contractions and making still more difficult the passage of food.

In Sucre, chagasic megaesophagus is commonly found. Resulting serious side effects among patients who are unable to swallow for several days include starvation and malnourishment.[32]Sufferers regurgitate food and water into the bronchial tubes and lungs, either choking or becoming further infected with respiratory diseases. Again, this is particularly deadly in high‑altitude regions, which have markedly lower oxygen levels and a higher prevalence of respiratory pathogens.

Many Bolivians adapt to chagasic esophageal problems by consuming liquids whenever they are able to do so. Herbalists recommend teas from coca leaves to relax the throat and relieve the soreness. Peasants frequently chew coca leaves to achieve the same effects. Coca leaves have fourteen alkaloids, some of which are activated only through hydrolysisthat is, released by saliva or water (Bastien 1987a:57; Martin 1970:422; Duke, Aulik, and Plowman 1975). Bolivian doctors generally recommend bland semi‑solid foods, especially cooked Andean cereals of quinua and cañiwa, warmed to body temperature so that the esophagus will drain by force of gravity; but this is often ineffective. The solution has been to surgically cut the esophageal muscle. Doctors in Sucre performed about twenty such operations in eleven years; but this figure doesn’t indicate the actual number of achalasia patients who are unable to afford an operation, fear such procedures, or remain unaware of the option. Doctors at the Gastro‑Intestinal Hospital in Sucre use the Heller technique modified by Pinotti. Originally, Heller cut the restricted area, but this did not produce effective results. Pinotti modified the procedure by only removing a narrow strip of muscle lengthwise along the constricted region. The resulting outcome of these operations has been satisfactory (Méndez Acufia, interview 6/24/91).

Bolivians rarely attribute difficulty swallowing to infection of T. cruzi. They explain choking and regurgitating as emotional states caused by disproportion of the certain humors or to the fact that they have not balanced their meals with wet and dry substances. This results in inadequate proportions of phlegm to aid in swallowing. They also relate certain emotions to these humors; so that, for example, someone with excessive bile is said to be angry and consequently has insufficient phlegm to swallow. As another explanation, they see the accumulation of fluids as a malfunctioning of the tubes relating to distillation processes of the body that work in centripetal and centrifugal motions.