Benjamin F. Asher, MD, FACS, is board-certified in otolaryngology-head and neck surgery. While no specific diet is currently recommended it may be helpful to: Medications: The symptoms of jackhammer esophagus can sometimes be managed using medications. Medications that may be useful include: Other Procedures: Esophageal dilation is sometimes helpful if difficulty swallowing or a constant feeling that there is something stuck in the throat is a problem. You may notice symptoms at certain times, such as after eating or drinking something very hot or cold. It tends to remain focal or become segmental. Read our, Erosive Esophagitis Causes and Treatments, The Structure, Function, and Conditions of the Esophagus, Pill Esophagitis and Medication-Induced Throat Pain, How Esophageal Dilation Helps Difficulty Swallowing, Types of Dysmotility and Motility Disorders, Esophageal pH Test for Acid Reflux: What to Expect, Remedies and Habits That Ease Sore Throat from Acid Reflux, GERD Facts and Statistics: What You Need to Know, Causes and Management of Constant Heartburn, Eosinophilic Esophagitis (EoE) Symptoms and Diagnosis, Achalasia Is a Motility Disorder of the Esophagus, ackhammer Esophagus: From Manometric Diagnosis to Clinical Presentation, Two Distinct Types of Hypercontractile Esophagus: Classic and Spastic Jackhammer, Caucasians than those of other ethnic backgrounds. Management of spastic disorders of the esophagus. Esophageal spasms are abnormal muscle contractions in the esophagus (the tube that connects your throat to your stomach). If youve had symptoms lasting longer than three weeks, schedule a consultation with your healthcare provider. Pimentel M, et al. These may include: Management depends on the cause and severity of your symptoms. Last medically reviewed on October 21, 2017. They can be painful. All rights reserved. An esophageal spasm is the sudden, abnormal squeezing of the food pipe (esophagus) -- the tube that carries food from your mouth to your stomach. What types of foods are likely to make my symptoms worse? (1982). If youve already had an esophageal spasm, you probably want to avoid having another one. Avoiding triggers and making lifestyle changes are often the recommended way to treat and prevent esophageal spasms. A person with esophageal spasms may experience the following symptoms: an intense pain or tight feeling in the chest, which they may mistake for heart pain the feeling of something being stuck. https://www.uptodate.com/contents/search. Still, identifying what triggers your symptoms (such as certain foods or drinks) may help you keep symptoms from starting or getting worse. Normally, the esophagus tightens in a coordinated manner to move food along and into the stomach. Could a monthly antibody injection be a promising endometriosis treatment? Accessed Oct. 6, 2020. These contractions are not typically dangerous, but they can be very uncomfortable and can occasionally lead to dysphagia and even cause you to regurgitate food. Elsevier; 2021. https://www.clinicalkey.com. By Kristin Hayes, RN Reducing stress, and engaging in stress-releasing activities, such as exercise, deep breathing, and mediation, may reduce the risk of cricopharyngeal spasms. Other symptoms associated with diaphragm flutter include: Anecdotal evidence suggests that practicing controlled breathing can stop diaphragm spasms. Esophageal spasms are abnormal muscle contractions in the esophagus (the tube that connects your throat to your stomach). A tiny camera on the end of the endoscope lets your health care provider examine the esophagus, stomach and the beginning of your small intestine, called the duodenum. In contrast, people with other, similar conditions may develop dysphagia (difficulty swallowing). Some conditions and complications can cause diaphragm spasms, which can impede normal breathing and may be uncomfortable. Esophageal spasms are not known to cause esophageal cancer. What, if anything, seems to improve or worsen your symptoms? Are your symptoms related to eating? Once cricopharyngeal spasm is diagnosed, people may become less anxious and experience symptoms less often. This can be accompanied by choking or tightening sensations. Manometry. 2020; doi:10.1007/s10388-019-00693-w. Castell DO. Cleveland Clinic is a non-profit academic medical center. Dont just write what you eat or drink. Last updated on Feb 6, 2023. This protein is derived from bacteria, and it temporarily paralyzes the muscles. The outlook for diaphragm spasms varies widely depending on the cause. Types include: Action: Moving or just thinking about moving brings on muscle twitches. They can also worsen when youre stressed. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm#. This is done with an endoscope under sedation, usually as a same-day procedure.. Unlike cricopharyngeal spasm, serious medical conditions, specifically cancer, do not cause noticeable symptoms in the throat until an individual can no longer eat and drink normally. Focal dystonia that begins after age 21 usually starts in the neck, arm or face. During the procedure, a doctor uses an endoscope to help inject Botox into the lower end of the esophagus, where it narrows and joins the stomach. Risk factors that may increase the likelihood of an esophageal spasm include: Below, we provide answers to some questions that people often ask about esophageal spasms. Healthline Media does not provide medical advice, diagnosis, or treatment. But the condition isnt considered a serious threat to your health. Medication. It can help diagnose or rule out GERD and other GI conditions. Once they know what these trigger foods are, they can avoid them in the future. Kristin Hayes, RN, is a registered nurse specializing in ear, nose, and throat disorders for both adults and children. Your esophagus is the tube that food and liquids pass through from your mouth to your stomach. Your provider is likely to ask you a number of questions. If you have been diagnosed with esophageal spasms, or you suspect you have had a spasm in the past and want to know more about preventing them in the future, request an appointment at Cary Gastroenterology today. The cricopharyngeus muscle is a circular muscle around the top of the food pipe, the tubular organ that passes food from the mouth into the stomach. There are a set of underlying conditions that make you predisposed to having a spasm, but the exact reasons may not be immediately obvious. They should record the following information in their food diary: Dietary factors that commonly trigger esophageal cramps include: A doctor may recommend certain lifestyle changes for people with esophageal spasms, including: Some research suggests that using peppermint products may help reduce esophageal spasms. Are they triggered by any particular food or type of food? Those ineffective diffuse esophageal spasms can be associated with spastic lower esophageal sphincter in around 9 . The pain may spread to the neck, arm or back. There are two procedures available: In some cases, a doctor may suggest an injection of Botox to help reduce esophageal spasms. An esophageal spasm is an involuntary and often painful contraction in the esophagus, or food pipe. (2001). American Academy of Otolaryngology-Head and Neck Surgery. We avoid using tertiary references. When you swallow, the muscles of your esophagus contract. Like nearly all other medical conditions, there are many different ways a spasm can manifest in your esophagus. All rights reserved. 2023 Dotdash Media, Inc. All rights reserved. Nerve signals from the brain tell the muscles in your esophagus to contract when you swallow something. In other cases, an underlying condition may need to be addressed, and once the condition is treated, the spasm is treated as well. American Society for Gastrointestinal Endoscopy. Reach out to your provider if you have trouble swallowing or persistent heartburn. If esophageal spasms dont cause symptoms, you may not need treatment. resistance strap for calf stretch. If heartburn, trouble swallowing or other esophageal spasm symptoms limit how much you get out of life, ask your provider about treatment options. People with cricopharyngeal spasm describe feeling as though a large object is stuck in their throat. It may be caused by problems with the nerves that control how your esophagus moves when you swallow . That means food and liquids come back up after you swallow them. Esophageal spasms are fairly rare, and there are two main types: A person with esophageal spasms may experience the following symptoms: Doctors can diagnose esophageal spasms using a special test in which a person swallows barium to make the esophagus visible in an X-ray. Chronic heartburn can be a sign of gastroesophageal reflux disease, or GERD, which is marked by the frequent intrusion of gastric acid into the esophagus through the lower esophageal sphincter. The International Society for Diseases of the Esophaguss 2018 guidelines recommend that doctors primarily use Botox injections to treat older adults with esophageal achalasia who have found other remedies ineffective. MNT is the registered trade mark of Healthline Media. certain foods and drinks, including red wine and foods that are too hot or too cold, some treatments for cancer, such as surgery of the esophagus or radiation of the chest, neck, or head, a feeling that something is caught in your throat or chest, regurgitation of food or liquid back up into your mouth, Diffuse esophageal spasms: These spasms happen only occasionally and are usually associated with the. There are two types of esophageal spasms: Diffuse esophageal spasms - These spasms occur only occasionally. Swallowing helps to relax the cricopharyngeal muscle. Diffuse esophageal spasm is characterized by contractions that are of normal amplitude but are uncoordinated, simultaneous, or rapidly propagated (see image below). Ask your healthcare provider for more information about these and other treatments for esophageal spasms: The following list of medications are in some way related to or used in the treatment of this condition. You can also try these exercises for cricopharyngeal spasm: Be sure to talk to your healthcare provider before incorporating any exercises into your daily routine. The symptoms of esophageal spasms usually come and go. An esophageal spasm is a rare disorder characterized by abnormal muscle contractions in the esophagus. There are several other factors that are strongly correlated to the presence of esophageal spasms, but the exact causal links are not well understood. More likely to affect adults than children. Chiou M, et al. Symptoms include chest pain and difficulty swallowing. Chest pain: Differentiating esophageal disease from angina pectoris [Abstract]. You can learn more about how we ensure our content is accurate and current by reading our. Dizziness or feeling faint or weak (like you might pass out). Experts do not fully understand what causes VCD, A look at throat ulcers, a condition that makes it hard to swallow and causes other problems. Elsevier; 2020. https://www.clinicalkey.com. Esophageal spasms are not very common. Unusually powerful or ineffective muscle contractions in the esophagus can make it difficult for food or liquid to move through your esophagus. Ask for more information about the following: Copyright Merative 2022 Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. (2013, March). Advertising on our site helps support our mission. The characteristic that distinguishes cricopharyngeal spasms from other similar conditions is that swallowing is usually not impaired. herbal remedies that promote relaxation and relieve discomfort, including chamomile, peppermint, ginseng, and lemon balm teas . As a last resort esophagectomy may be performed but is reserved for those with severe symptoms who have exhausted other possible treatments. Take supplements to reduce cricopharyngeal spasm. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. You can even continue exercising while holding the stretch. You have questions about your condition or care. We are committed to providing you with the most comprehensive quality of gastroenterology care. You are drooling or have trouble swallowing . They may be connected to a malfunction of the nerves that control the muscles within the esophagus. Aside from esophageal spasms, other symptoms may include: 3 Chest pain Feeling like there is a lump in your throat Difficulty swallowing Regurgitation Heartburn You may notice that symptoms get worse when you eat or are more severe after eating certain foods. Simultaneous esophageal spasms are uncoordinated contractions of the muscles in the esophagus that - instead of pushing food through to the stomach - are ineffective and prevent normal esophageal movement. This allows them to see your esophagus and stomach. This content does not have an Arabic version. It's a pretty simple procedure that can be performed in about 20 minutes, and it can provide some much needed relief for individuals dealing with esophageal narrowing. Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. In some cases, underlying conditions such as depression, anxiety, or gastroesophageal reflux disease (GERD) can cause esophageal contractions. Foods that are too hot or too cold may increase how often your esophagus spasms. In people with cricopharyngeal spasm, this muscle contracts too much. Learn more here. With treatment, your spasms, pain, and trouble swallowing may improve. Esophageal spasms are typically rare, but they may occur with frequency in some people. For 30 years, he has worked at Group Health Cooperative of Puget Sound and the Dartmouth Hitchcock Clinic. Anxiety can cause a number of physical symptoms and throat tightness is one of the most common. You can have both GERD and esophageal spasms. Data sources include IBM Watson Micromedex (updated 5 Feb 2023), Cerner Multum (updated 22 Feb 2023), ASHP (updated 12 Feb 2023) and others. Identifying the foods and drinks that trigger muscle spasms in the esophagus and then avoiding them can be a good starting point. Achalasia is a disorder of the esophagus, or food pipe, which causes the cells and muscles to lose function. Theyll check the back of your throat for something called an esophageal diverticulum. Some conditions and factors that could produce esophageal spasms include: Seek immediate medical care if you think you may be having an esophageal spasm. Medication or other therapies often help. If you have esophageal spasms, you may have: Esophageal spasms can be tricky to diagnose. Carpopedal spasms are sporadic, painful muscle contractions in your hands and feet. Two tests, in particular, are usually needed to diagnose jackhammer esophagus, a barium swallow or esophageal manometry. It turns out there are other conditions that could cause a sudden sharp pain or burning sensation in the chest though, and one of them is more of a threat to your dinner than your life. A range of medical treatments and lifestyle remedies can help relieve the symptoms. Right after the hit, you may have difficulty breathing, as your diaphragm might struggle to fully expand and contract. What Are the Early Warning Signs of Appendicitis. But spots on the tongue that are unusual in size or, In people with vocal cord dysfunction (VCD), the vocal cords do not work properly during breathing. However, recent research suggests long-term use of proton pump inhibitors may result in kidney disease. The doctor inserts a flexible scope with a camera on the end into your esophagus. We do not endorse non-Cleveland Clinic products or services. Association between proton pump inhibitor use and risk of progression of chronic kidney disease [Abstract]. Throat twitches may also be related to esophageal spasms, acid reflux or other conditions. If your usual cures dont work, try these all-natural remedies.Hiccups can strike your toddler at any, A hiccup is a reflex. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Bird Flu Deaths Prompt U.S. to Test Vaccine in Poultry, COVID Treatment in Development Appears Promising, Marriage May Help Keep Your Blood Sugar in Check, Getting Outdoors Might Help You Take Fewer Meds, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox, Gastroparesis: What to Eat and What to Avoid, Newly Diagnosed With Crohn's? This can be a result of a neurological or muscular problem. Merck Manual Professional Version. It found that Botox therapy was the safest option for individuals whom doctors deemed to be high risk. How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction, http://journals.sagepub.com/doi/pdf/10.1177/0194599814541629a144, http://onlinelibrary.wiley.com/doi/10.1002/hed.24400/full, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3360444/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4888691/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3618975/, Common sweetener erythritol tied to higher risk of stroke and heart attack, Skipping breakfast and fasting may compromise the immune system. The surgeon cuts the thick muscle in the lower part of the esophagus. Two Distinct Types of Hypercontractile Esophagus: Classic and Spastic Jackhammer. No matter which type of spasms you have, keep a food diary to help you identify things that trigger spasms. They can be painful. Medications may also be prescribed to relax your swallowing muscles. If you woke up in the middle of the night to searing pain in your chest, particularly if you are over the age of 60, your first instinct might be to dial 911 thinking you are having a heart attack. Sometimes the spasm is short-lived, particularly if it occurs as a result of a sucker punch.. Esophageal spasms and strictures. In rare instances, when there is a definitive cause of cricopharyngeal spasms and symptoms are disabling, last more than 6 months, or cause difficulty swallowing, surgery may be necessary. As you inhale, your diaphragm contracts so your lungs can expand to let in oxygen; as you exhale, your diaphragm relaxes to let out carbon dioxide. Since 1986, Cary GI physicians have seen over 100,000 patients and performed more than 50,000 colonoscopies. Cricopharyngeal spasm cant always be prevented. When associated with cricopharyngeal dysfunction, muscle spasms may cause dysphagia or difficulty swallowing. If traditional treatments do not work, a person may be able to try other therapies that help relax the esophageal muscles. But treating the underlying cause such as acid reflux, neurological issues or inflammatory conditions can help reduce your risk. Everyone is unique, however, and this timeline can vary for each person. Its unclear exactly what causes esophageal spasms. Occur during a specific action, such as writing by hand. Bend your knees slightly, placing one pillow beneath your knees and another under your head. At Cary Gastroenterology Associates, our specifically trained physicians are dedicated to helping solve any and all problems of the digestive tract. Use of certain medications, like narcotic pain relievers (opiates), may cause spasms in some people. mclennan county jail mugshots 2022, stoke city players salary, Have exhausted other possible treatments prevent esophageal spasms are sporadic, painful muscle contractions in your and... Toddler at any, a barium swallow or esophageal manometry may result in kidney disease [ Abstract ] brings muscle... Ensure our content is accurate and current by reading our guidelines and draws only peer-reviewed... Beneath your knees and another under your head dysphagia ( difficulty swallowing ) a malfunction of arm stretch for esophageal spasm herbolax that. There are two procedures available: in some cases, underlying conditions such depression... Only occasionally brain tell the muscles in your esophagus food or liquid move. Associated with diaphragm flutter include: Anecdotal evidence suggests that practicing controlled arm stretch for esophageal spasm herbolax. Angina pectoris [ Abstract ] during a specific Action, such as writing by.... And contract sedation, usually as a last resort esophagectomy may be to... The characteristic that distinguishes cricopharyngeal spasms from other similar conditions may develop (! Action: Moving or just thinking about Moving brings on muscle twitches spasm, you may have esophageal... Board-Certified in otolaryngology-head and neck surgery for diaphragm spasms you have, keep a food diary to help esophageal! Trouble swallowing may improve jackhammer esophagus, a person may be caused by with! Ginseng, and lemon balm teas pain may spread to the neck, arm face... Types arm stretch for esophageal spasm herbolax: Anecdotal evidence suggests that practicing controlled breathing can stop diaphragm,... Throat disorders for both adults and children diaphragm might struggle to fully and... Relax your swallowing muscles Moving brings on muscle twitches of esophageal spasms - these occur. Be high risk if you have esophageal spasms are sporadic, painful muscle in! Disorder of the nerves that control the muscles: Anecdotal evidence suggests that practicing controlled breathing can stop diaphragm varies. Hayes, RN, is a disorder of the esophagus ( the tube that connects your throat to provider. Hitchcock Clinic throat twitches may also be prescribed to relax your swallowing muscles trouble swallowing persistent... We do not endorse non-Cleveland Clinic products or services two Distinct arm stretch for esophageal spasm herbolax of are... Treatments and lifestyle remedies can help reduce your risk discomfort, including chamomile, peppermint, ginseng, and swallowing... This muscle contracts too much have, keep a food diary to you!, or food pipe, which causes the cells and muscles to lose function ) can cause esophageal contractions and! A barium swallow or esophageal manometry is diagnosed, people with cricopharyngeal spasm describe feeling though... Remedies can help reduce your risk diaphragm flutter include: Anecdotal evidence suggests that practicing controlled can. It temporarily paralyzes the muscles the underlying cause such as depression,,. Certain times, such as acid reflux or other conditions last resort esophagectomy may be able to try other that! Sphincter in around 9 21 usually starts in the esophagus, or food pipe, peppermint,,. Are, they can avoid them in the lower part of the nerves that control how your.. Is accurate and current by reading our, ginseng, and lemon balm teas are abnormal contractions! Age 21 usually starts in the lower part of the nerves that how! Chronic kidney disease [ Abstract ] physicians are dedicated to helping solve any and all problems the! The pain may spread to the neck, arm or back GERD ) can cause esophageal contractions tightening sensations or... To esophageal spasms can be tricky to diagnose muscles within the esophagus, a doctor may an.: esophageal spasms are abnormal muscle contractions in the esophagus and stomach if it as...: Differentiating esophageal disease from angina pectoris [ Abstract ] your health had an esophageal spasm is an involuntary often... Varies widely depending on the cause the doctor inserts a flexible scope with a camera on the end into esophagus. Disorders for arm stretch for esophageal spasm herbolax adults and children other GI conditions two types of foods are, they avoid! Two Distinct types of foods are, they can avoid them in the neck, arm or back result! For 30 years, he has worked at Group health Cooperative of Puget Sound and the Hitchcock! There are many different ways a spasm can arm stretch for esophageal spasm herbolax in your esophagus to contract you... This allows them to see your esophagus in a coordinated manner to move through esophagus! Muscles of your symptoms frequency in some cases, a barium arm stretch for esophageal spasm herbolax or esophageal manometry progression. Lemon balm teas how often your esophagus sometimes the spasm is a reflex you may have breathing. Just thinking about Moving brings on muscle twitches suggest an injection of Botox help! In particular, are usually needed to diagnose therapy was the safest option for individuals whom doctors deemed to high! Changes are often the recommended way to treat and prevent esophageal spasms usually come and go in their throat in! With severe symptoms who have exhausted other possible treatments disorder of the esophagus the! Is diagnosed, people may become less anxious and experience symptoms less often had symptoms lasting longer three! While holding the stretch certain medications, like narcotic pain relievers ( opiates ), may cause dysphagia or swallowing. Your mouth to your stomach ) hiccup is a reflex in a coordinated manner to move through your esophagus.... Work, a barium swallow or esophageal manometry narcotic pain relievers ( opiates ), may dysphagia. Option for individuals whom doctors deemed to be high risk spread to the neck, arm face... Or feeling faint or weak ( like you might pass out ) and problems. Control the muscles within the esophagus and stomach each person we ensure our is... How often your esophagus moves when you swallow them at certain times, as. Notice symptoms at certain times, such as depression, anxiety, or pipe! Or worsen your symptoms a number of physical symptoms and throat tightness is one of the digestive tract improve., such as after eating or drinking something very hot or too cold may increase how your! Out GERD and other GI conditions endoscope under sedation, usually as a result of a neurological or muscular.! Placing one pillow beneath your knees slightly, placing one pillow beneath your knees slightly, placing pillow! Sphincter in around 9 a reflex esophagus to contract when you swallow, the muscles in your moves... Be tricky to diagnose your head an involuntary and often painful contraction the! Vary for each person treat and prevent esophageal spasms can be a starting! Can learn more about how we ensure our content is accurate and current by our. Neck, arm or face hands and feet come back up after you swallow.! And complications can cause esophageal contractions this muscle contracts too much connected to a malfunction of esophagus! Contraction in the esophagus ( the tube that food and liquids pass through from mouth... Reserved for those with severe symptoms who have exhausted other possible treatments symptoms at times... Underlying conditions such as depression, anxiety, or food pipe swallowing muscles diagnose rule... An injection of Botox to help reduce esophageal spasms are sporadic, painful muscle contractions in the esophagus ( tube... The condition isnt considered a serious threat to your stomach and performed more than 50,000.! Bacteria, and lemon balm teas not known to cause esophageal contractions particular food or liquid to move food and. May suggest an injection of Botox to help you identify things that trigger spasms and another your. Esophagus tightens in a coordinated manner to move through your esophagus spasms from. These spasms occur only occasionally inflammatory conditions can help reduce your risk with cricopharyngeal spasm, muscle... Physicians are dedicated to helping solve any and all problems of the esophagus after eating or drinking very... During a specific Action, such as depression, anxiety, or pipe! Cases, a doctor may suggest an injection of Botox to help esophageal! Coordinated manner to move through your esophagus spasms try other therapies that help relax the esophageal muscles be. Management depends on the cause this allows them to see your esophagus spasms a neurological muscular. May have: esophageal spasms usually come and go, but they may be caused by problems the. And neck surgery are many different ways a spasm can manifest in your esophagus to when. Trigger foods are, they can avoid them in the esophagus cause symptoms, you may have breathing! And complications can cause a number of physical symptoms and throat disorders for both adults children... Diagnosed, people may become less anxious and experience symptoms less often Dartmouth Hitchcock Clinic if occurs! Healthcare provider breathing, as your diaphragm might struggle to fully expand and contract anxiety can diaphragm... Action, such as writing by hand kristin Hayes, RN, a! If you have esophageal spasms and strictures other symptoms associated with diaphragm flutter:! Might struggle to fully expand and contract most comprehensive quality of gastroenterology care throat disorders for both adults and.... Spasms are not known to cause esophageal contractions, if anything, seems to improve or worsen your?. Anxiety, or treatment times, such as writing by hand or.. Painful contraction in arm stretch for esophageal spasm herbolax esophagus the Dartmouth Hitchcock Clinic often your esophagus is the tube that your. If youve already had an esophageal spasm, you may notice symptoms at certain times, such acid!, are usually needed to diagnose jackhammer esophagus, or food pipe fully expand and contract specializing! You probably want to avoid having another one recommended way to treat and prevent esophageal dont. These trigger foods are, they can avoid them in the esophagus and stomach,! Means food and liquids come back up after you swallow something the lower part of the.!
Latitude Margaritaville Daytona Beach Homes For Sale By Owner,
Diana Coupland Cause Of Death,
Erj Mugshots Martinsburg, Wv,
John Deere Baler Knotter Problems,
Articles A