Failed Esophageal manometry due to a strong gag reflex. Any suggestions? Gag reflex training?

October 15, 2012 10:38 AM

Failed Esophageal manometry due to a strong gag reflex. Any suggestions? Gag reflex training?

A friend wasn't able to complete an Esophageal manometry due to a strong gag reflex. The technician was good and and they tried lots of numbing (lidocane?), but an hour later and it just wouldn't stay down.

She may be asked to have another go at it in a month. Any suggestions or ideas? The test has to be performed when she's conscious.

It is my understanding that people sometimes try to train/control their gag reflex. Could training make any meaningful difference in a month?

Bonus round: She has a *serious* phobia of vomiting. Maybe some therapy sessions?

posted by elmonobonobo to health & fitness (8 answers total)

The only gag reflex training I've heard of is related to dental treatment. It was recommended to me that I use a large spoon and practice holding it in my mouth - against the roof of my mouth, the sides, the tongue. The theory is that eventually you desensitize yourself. I don't know how that would work for things going down the throat though.

Your friend can always ask for twilight sedation for the procedure. They may have to do it in the hospital or a different facility and it may involve a higher co-pay, but it's possible.
posted by PorcineWithMe at 10:47 AM on October 15, 2012

Ugh, how awful. As a fellow emetophobic, I understand her pain. I had an endoscopy done a while ago and I was super nervous! They gave me midazolam (Versed) and propofol and I was utterly unconscious the entire time, so it was 100% fine for me. Now, your friend needs to be able to swallow on command (right?), so they can't do deep sedation, but I'm sure they can partially sedate her and they can definitely give an anxiety medication. Any anxiety medication will probably help, and Versed often causes amnesia, so if she gets that, she might not even remember the procedure even if it's unpleasant (not a guarantee, of course).

If it helps her, you can tell her that when I had my endoscopy, I remember them saying "I'm going to give you some midazolam", and then I woke up 90 minutes later in the recovery room. There was a period of several minutes, I'm told, between when the administered the midazolam and when I was given propofol, but I have zero memory of it.

To allay another possible fear, neither medication caused me any nausea whatsoever upon awakening.
posted by Cygnet at 11:57 AM on October 15, 2012

I get acupuncture when at the dentists - it works very well
posted by mumimor at 1:12 PM on October 15, 2012

Yes, people do try and succeed at retraining their gag reflex. I think she should definitely try it, it cannot hurt. Several methods include touching as far back as you can in your mouth every time you brush your teeth using your toothbrush, pressing on your tongue further and further back with your finger (press several times in the same spot, then move further back). One old wives' method suggests putting a little salt on the tip of your tongue, not sure why this should work but I suspect it's placebo (your friend doesn't have to know that, though).

The important thing to remember is that a gag reflex is not all physical. It's partially psychological. From what you've described, it sounds highly likely that your friend's gag reflex is so strong because she is so afraid of vomiting. So in order to have success, she needs to really believe that she is not going to vomit during this procedure - a reasonable belief since vomiting in this procedure is rare. I think the therapy is a good idea as well, but I also think that she should talk to her physician about having a dose of anti-anxiety medication (not for sedation, just for anxiety), and a dose of anti-nausea medication before the procedure. Prophylactic anti-nausea medication is probably not typically done for this but I think it could help with this case and it is low risk.

Unfortunately, the sedation that other posters have described is not used during this procedure. Yes, propofol is considered "deep sedation" but procedural sedation is procedural sedation and the goal is to have a person breathing and conscious during the procedure but sedated. (Yes, even though Cygnet and many others believe they were unconscious during the procedure they had, they were not - they just are amnestic to the procedure, in fact, even people who experience significant pain while under the influence of propofol typically do not remember it, even though those present can attest that they appeared to be awake and in distress!). I speak as a physician trained in procedural sedation.
posted by treehorn+bunny at 1:17 PM on October 15, 2012 [3 favorites]

Just throwing it out there, I did a bit of looking around and it appears that procedural sedation is used in pediatric cases for esophageal manometry. Just throwing that out there because all the other literature I've read says that sedatives must be avoided at all costs because they could alter the results of the test (this might go for using anti-anxiety meds prior to the test as well even if not for purposes of sedation - have to ask your gastroenterologist), but clearly there are exceptions to this rule.
posted by treehorn+bunny at 1:44 PM on October 15, 2012 [1 favorite]

Using a spoon and similar methods to train your gag reflex do work, but not in such a short time. Even if you practise daily, several times, it takes longer than a month to be able to shove something down the throat without triggering the gag reflex. If your friend is also afraid of vomitting, a month is by far not enough.
Sedation seems the better option. Maybe hypnosis could help to reflex, too.
posted by MinusCelsius at 1:59 PM on October 15, 2012

I failed the first one I had, too, and came away embarrassed and frustrated - and tired out from gagging. A year or so later I had another test, with a different doctor/technician, and he just popped that thing past my gag reflex quick as can be and I had no trouble with it at all. I told him about the problems the first time and he said that sometimes doctors/techs are trying to be too easy on the patient, too gentle, and what they end up doing is just aggravating the gag reflex into hypersensitivity - by teasing it instead of quickly pushing past it.

I'd recommend a different tech or physician next time, preferably someone who's been doing this for many years.

Good luck.
posted by aryma at 8:21 PM on October 15, 2012 [1 favorite]

Follow Up: Another try with a more experience tech in the big city (does 8 of these a day) worked on the second go. Xanax (sp?) took some of the edge off. Still an awful experience.
posted by elmonobonobo at 2:44 PM on October 31, 2012