DISORDERS OF ESOPHAGUS

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DISORDERS OF ESOPHAGUS

• DR.LATHADEVI
• PROFESSOR ENT

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Dysphagia, GERD, Barrett's Esophagus, Hiatal
Hernia, foreign bodies, Esophageal cancer
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Anatomy

• Mucosa, submucosa, muscularis propria, and
  adventitia
• Lack serosa vs. other GI tract
• Mucosa innermost (4 layers)
• contains squamous epithelium

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Muscularis Propria

• Continuation of inferior constrictor of the
  pharynx
• Two muscle bundles
• inner circular
• outer longitudinal
• Striated upper 1/3
• -vagus and its recurrent
• laryngeal branches
• Smooth lower 2/3
• -visceral nerve plexus derived
• from neural crest cells
• Left vagus anterior-liver/biliary tree
• Right vagus posterior-celiac plexus

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Esophageal Lymphatics
Lymphatics upper 2/3 cephalad, lower 1/3 caudad
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Anatomy
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Anatomic Areas of Narrowing

• Cricopharyngeal muscle
• Left mainstem bronchus and aortic arch
• Diaphragm

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Anatomic Areas of Narrowing
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UES

• 15 cm from incisors
• Cricophayrngeus muscle, recurrent laryngeal nerve
• Site of perforation is cricopharyngeus muscle
  (with EGD), aspiration if UES fail

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LES

• 40 cm from incisors
• No anatomic landmarks
• rise in pressure when transducer is pulled from
  the stomach
• Increased Pressure Alpha-adrenergics, BBs,
  gastrin, motilin, antacids, cholinergics,
  metoclopramide
• Decreased Pressure Alpha blockers, Beta
  andrenergics, CCK, estrogen, glucagon,
  progesterone, somatostatin, secretin,
  barbiturates, CCBs, caffeine, diazepam, dopamine,
  meperidine, ethanol, coffee, fat

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Gastroesophageal Reflux Disease

• 1/3 Western population experience symptoms at
  least once a month
• 4-7 daily
• Most patients with mild symptoms carry out
  self-medication
• The prevalence and severity of GERD is increasing

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Typical GERD Symptoms

• Heartburn
• substernal burning or chest pain
• worse with spicy foods, tomato sauce, citrus
  juices, chocolate, coffee, and alcohol
• 1 to 2 hours after eating, often at night,
  relieved by antacids and OTC H2 blockers
• Regurgitation
• sensation that fluid or food is returning into
  the esophagus
• worse at night or when lying down after a meal
• Dysphagia
• up to 40 of pts with GERD have sensation of food
  hanging up in the lower esophagus--esophageal
  dysphagia
• typically limited to only solid food, with normal
  passage of liquids, suggesting mechanical
  disorder
• develops slowly enough that the patient may
  adjust eating habits unknowingly

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Atypical GERD Symptoms

• Cough, asthma, hoarseness, and noncardiac chest
  pain
• primary complaint in 20-25
• more difficult to prove a cause-and-effect
  relationship
• trial of high-dose PPIs is helpful
• make sure patient doesnt have another cause for
  pain

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Pathophysiology of GERD

• Fundic distention because of overeating
• LES is taken up by the expanding fundus, exposing
  the squamous epithelium/LES to gastric juice
• Worsened by delayed gastric emptying with
  high-fat diet and hiatal hernia
• continued epigastic pain and possibly epithelial
  columnarization
• Extension of the inflammatory process into
• the muscularis propria
• leading to a permanently defective sphincter

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Diagnosis of GERD

• Based on symptoms alone?
• Correct in only 2/3 of patients
• these symptoms are not specific for GE reflux
• achalasia, diffuse spasm, esophageal carcinoma,
  pyloric stenosis, cholelithiasis, gastritis,
  gastric or duodenal ulcer, and coronary artery
  disease
• need objective diagnosis before the decision is
  made for surgical treatment

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Diagnosis of GERD

• First episode
• Initial therapy with H2 blockers or PPI for 12
  weeks
• Failure of H2 blockers or PPI to control the
  symptoms suggests that either the diagnosis is
  incorrect or the patient has severe disease
• EGD
• Opportunity for assessing the severity of mucosal
  damage
• 24-hour pH and bilirubin monitoring
• Measurement degree and pattern of esophageal
  exposure to gastric and duodenal juice
• Manometry
• Assess the status and function of the LES and
  esophageal body
• These studies identify features that predict a
  poor response to medical therapy, frequent
  relapses, and the development of complications

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Complications of GERD

• Mucosal complications-esophagitis and stricture
• Extraesophageal or Respiratory complications,
  such as laryngitis, recurrent pneumonia, and
  progressive pulmonary fibrosis
• Reflux (aspiration) vs reflex (vagal
  bronchoconstriction)
• Metaplastic and Neoplastic complications,
  Barrett's and esophageal adenocarcinoma
• Prevalence/severity of complications related to
  the degree of loss of the GE barrier and content
  of refluxed gastric juice, not symptoms

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Barretts Esophagus

• Squamous epithelium metaplasia ? columnar
  epithelium
• 7-10 of patients with GERD
• Presence of any columnar mucosa extending at
  least 3 cm into the esophagus (goblet
  cells)Barretts
• predisposed to malignant degeneration
• Increased risk of adenocarcinoma x50

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Classification and Management of Barretts
Esophagus with Dysplasia

• Indefinite for Dysplasia Aggressive antireflux
  therapy (60 mg PPI per day) and repeated biopsy
  in 3 months
• Low Grade Aggressive antireflux therapy vs.
  surgical treatment
• High Grade-Esophagectomy and PPI

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Dysphagia

• Difficulty in transferring a food from the mouth
  to the stomach
• Regurgitation, chest pain, heartburn, and
  coughing or choking spells
• Oropharyngeal
• functional disturbance in the swallowing
  mechanism
• Esophageal
• mechanical obstruction or esophageal motility
  disorder

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Dysphagia

• Evaluation of a patient with dysphagia must be
  performed in a systematic manner
• Barium swallow
• Additional diagnostic tests
• EGScopy, manometry, 24-hour pH study, and
  possibly bronchoscopy and endoscopic
  ultrasonography (EUS).
• Diagnostic imaging by CT and PET in assessing
  patients with esophageal cancer

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Oropharyngeal Dysphagia

• inability to chew food, drooling, coughing during
  a meal, and nasal regurgitation of solids or
  liquids
• dysphagia within 1 second of swallowing
• The common causes can be grouped into three broad
  categories
• 1) generalized systemic conditions CVA,
  Myasthenia gravis
• 2) intrinsic functional disturbances Zenker's
  diverticulum
• 3) fixed mechanical obstruction Neoplasm, webs,
  previous surgical treatment, previous radiation
  therapy

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Esophageal Dysphagia

• Dysphagia with solids?
• Mechanical Obstruction
• Intermittent? Esophageal Ring or Esophagitis
• Progressive with GERD? Peptic Stricture
• Progressive with weight loss and anorexia?
  Esophageal Cancer
• Dysphagia for both liquids and solids?
• Motility Disorder
• Intermittent? Spasm (DES)
• Progressive with GERD? Scleroderma
• Progressive? Achalasia

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Schatzki's Ring

• symmetrical narrowing at SCJ, small hiatal
  hernia
• correlation with GERD
• barium swallow and esophagoscopy to confirm
• Asymptomatic? no specific treatment is needed
• Definitive treatment? dilatation of the ring with
  medical therapy for GERD. If refractory,
  dilatation plus antireflux surgery

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Peptic Stricture

• H/o GERD
• worsening dysphagia for years without weight loss
• End stage of ulcerative esophagitis, healing
  ulcer causes annular fibrosis
• Dx barium swallow followed by upper GI endoscopy
  
• greater length and more tapered than Schatzkis

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Esophageal Webs

• localized narrowing of the esophagus caused by
  intraluminal extension of the mucosa and part of
  the submucosa
• congenital or acquired (mc), usually secondary to
  conditions such as iron deficiency
  anemia/Plummer-Vinson syndrome and ulcerative
  colitis.
• Tx endoscopic dilatation

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Achalasia

• Dysphagia for liquids and solids and possibly
  weight loss.
• Barium swallow shows absent peristalsis and a
  dilated esophagus, possibly tapered narrowing in
  distal esophagusbird's beak
• Achalasia risk factor for squamous cell cancer
• Tx Pneumatic dilatation or surgery

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Diffuse esophageal spasm

• unknown etiology
• Nonprogressive dysphagia with solids and liquids
  and nonexertional chest pain that responds to
  nitroglycerin
• corkscrew on barium
• The diagnosis by manometry
• periodic occurrence of simultaneous
  high-amplitude contractions with intervening
  periods of normal peristalsis.
• Tx r/o CAD, then medical management of
  reassurance, nitrates, and CCBs
• Botulinum toxin injection, surgery does not have
  an established role

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Nutcracker Esophagus

• unknown etiology
• womengtmen
• Manometry peristaltic waves with significantly
  elevated amplitude (gt 180 mm Hg).
• Treatment is primarily medical

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Esophageal Diverticula

• lt 5 of all cases of dysphagia.
• False diverticula (pulsion) include only the
  mucosal layer
• underlying motor dysfunction
• True diverticula (traction) include all layers of
  the esophageal wall
• inflammatory process
• Esophageal diverticula may also be classified
  into three categories on the basis of the
  anatomic level at which they occur

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Pharyngoesophageal/Zenkers Diverticula

• from muscle incoordination that leads to
  herniation of the mucosa in prox esophagus
• Dysphagia symptom, halitosis, regurgitation,
  throat discomfort, palpable neck mass, recurrent
  aspiration pneumonia
• The best initial diagnostic tool is a barium
  swallow
• perforation in EGD

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Chemical Ingestion

• Alkali household cleaning agents
• Most occur accidentally in children, but suicide
  in adults
• Magnitude and site of the injury?
• Related to the length of the contact time
• Injury at any level, MC is distal esophagaus
• lead to submucosal scar formation?stricture and
  dysphagia
• Endoscopic exam is first step
• A barium swallow should be done in the first
  month after injury to detect any stricture and
  then serial swallows

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Hiatal Hernia

• I-Sliding, dilation of hiatus, most commonly
  associated with GERD
• -most with reflux have sliding, most with sliding
  dont have reflux
• II-Paraesophageal, defect in diaphragm alongside
  esophagus with normal GE junction
• --chest pain, dysphagia, early satiety
• III-Combined I and II
• IV-entire stomach in chest plus another organ
  (colon, spleen)

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Laparoscopic Antireflux Procedure

• Most commonly performed procedure is a
  fundoplication
• Nissen Fundoplication 360 degree fundoplication
• Laparoscopic approach reduces postoperative pain
  and shortens length of hospital stay
• Rapid increase in surgical treatment of GERD

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GERD

• Gastroesophageal reflux disease increases risk
  developing of
• A) Adenocarcinoma of the esophagus
• B) Squamous cell carcinoma of the esophagus
• C) Both
• D) Neither
• -SCC related to lye ingestion, achalasia and EtOH
  and tobacco
• -Adenocarcinoma now esophageal cancer, related
  to GERD

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CANCER

• PREMALIGNANT CONDITIONS
• P-V SYNDROME
• BARRETTS
• HIATUS HERNIA
• Etiology of esophageal cancer
• Clinical features
• Management