Swallowing Difficulty & Pain

1. Swallowing Difficulty & Pain Tim Farrell, MD Tom Egan, MD

2. Assumptions • Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction.

3. Objectives Students will understand: • Differential diagnosis for a patient with dysphagia. • Symptoms and treatment of GERD. • Pathophysiology and treatment of achalasia and diffuse esophageal spasm. • Etiology and treatment of esophageal diverticula. • Common symptoms and management of hiatal hernias. • Management of adenocarcinoma of the E-G junction. • Presenting symptoms, etiology and treatment of esophageal rupture.

4. Case 1 • An 80-year-old man presents with a trouble swallowing for a year. He regurgitates after meals, has heartburn, but no other pain and is in good health otherwise. • He is thin, without neck mass. His chest is clear and his abdomen is soft and without masses.

5. Case 1 • What is the differential diagnosis? Anatomic Tumor, Stricture, Compression, Foreign Body Functional GERD Motility Disorder (achalasia, scleroderma) Neurologic (Parkinson’s, bulbar paralysis) Psychological Globus Hystericus

6. Case 1 • What test should be done, in what order, and why? Anatomic AssessmentFunctional Assessment Upper GI Series 24-hr pH EGD Esophageal Manometry Biopsy GES

7. GERD - Definition Protracted exposure of the esophageal lining to stomach juice

8. GERD - Causes • Lower esophageal sphincter • Incompetent valve • Inappropriate relaxations • Hiatal Hernia • Abnormal motility • Impaired esophageal clearing • Delayed gastric emptying • Defective cytoprotection

9. Atypical Symptoms Asthma Cough Hoarseness Chest Pain Typical Symptoms Heartburn Regurgitation Trouble Swallowing GERD - Symptoms

10. GERD - Complications • Peptic Stricture • Esophagitis / Ulcers • Barrett's Esophagus

11. Indications for further Dx-Rx • Persistent or frequent symptoms • Dysphagia • Frequent vomiting • Early satiety • Weight loss • Significant respiratory complaints • Age < 45

12. GERD - Diagnosis • Barium Swallow • Upper Endoscopy • Esophageal Manometry • 24-Hour Ambulatory Esophageal pH • Gastric Emptying Study

13. GERD - DiagnosisBarium Swallow

14. GERD - DiagnosisUpper Endoscopy

15. GERD - DiagnosisManometry

16. Environmental Medical - OTC Antacids H2-Blockers Medical -Prescription Proton-Pump Inhibitors Endoscopic Surgical Fundoplication GERD - Treatment

17. Dietary Modifications • Avoid large meals • Limit foods which decrease LES pressure • Fatty foods, chocolate, mints, and alcohol • Avoid irritating foods and beverages • Citrus, tomatoes, pepper, etc. • Limit caffeine and carbonated beverages • Increases acid production • Increased gastric distension • Candy or gum to increase saliva • Alkaline saliva neutralizes acid • Increases motility and clearance

18. Lifestyle Modifications • Weight Loss • Avoid smoking • Decreases LES pressure • Avoid lying down for 2-3 hours after meals • Limits supine reflux • Sleep with elevated head of bed • Improves esophageal clearance

19. Medications Worsening Reflux • Calcium channel blockers • Anticholinergics • Theophylline • Progesterone • β2-antagonists, α-antagonists • Nitrates • Meperidine • Diazepam

20. GERD - Medical Treatment Medications may be used to: • Neutralize acid • Increase LES tone • Improve gastric emptying

21. OTC H2 Blockers • Lower-dose formulations • Acute treatment or prophylaxis • Slower onset than antacids • Longer duration of acid inhibition

22. Proton Pump Inhibitors

23. Endoscopic Treatment Modalities Thermal (Stretta®) Thermal energy Mechanical / Neural

24. Endoscopic Treatment Modalities Endoscopic Suturing • Suturing or plication EndoCinch ®

25. Endoscopic Treatment ModalitiesBiocompatible Material Enteryx ®

26. GERD - Surgical Treatment

27. GERD - Surgical Treatment

28. Nissen FundoplicationTechnique

29. Nissen FundoplicationTechnique

30. Nissen FundoplicationTechnique

31. Nissen FundoplicationTechnique

32. Nissen FundoplicationTechnique

33. Nissen FundoplicationTechnique

34. Nissen FundoplicationTechnique

35. Procedure - 2 Hours Hospital - 1-2 Days Full Activity - 2 weeks Full Diet - 3 weeks Need to Open <1% Need for Blood <1% Off Medications - 95% Off Steroids - 50% Need 2nd Procedure - 5% GERD - Surgical TreatmentResults

36. Effects of Fundoplication Fundoplication • augments LES resting pressure • lessens frequency of transient LES relaxations • reestablishes anatomy of the LES and crura • may improve esophageal clearance • may improve gastric emptying

37. Case 2 • A 61-year-old man presents with progressive difficulty swallowing. He has history of indigestion and heartburn. Until 12 months ago, food would come up into his throat when he was supine, with a sour taste and sometimes a cough. About 12 months ago, these symptoms improved but he developed progressive dysphagia. • He smokes 1 PPD and drinks two beers at dinner. • Exam is unremarkable except for barrel chest.

38. Case 2 • What is the differential diagnosis? Anatomic Tumor, Stricture, Compression, Foreign Body Functional GERD, Motility Disorder (achalasia, scleroderma) Neurologic (Parkinson’s, bulbar paralysis) Psychological Globus Hystericus

39. Case 2 • How would you evaluate this patient? Anatomic AssessmentFunctional Assessment Upper GI Series 24-hr pH EGD Esophageal Manometry Biopsy GES

40. Case 2 • What are the treatment options for benign esophageal stricture? • Medications • Endoscopic Dilation • Surgery

41. Case 2 • What are the treatment options for carcinoma of the esophagus? • Esophagogastectomy • Ivor-Lewis • Transhiatal

42. Barrett’s EsophagusEpidemiology • Affects 10% of patients with severe GER • 40-fold increased risk of cancer • Patients require endoscopic surveillance • Esophagectomy for severe dysplasia/cancer

43. Barrett’s EsophagusEndoscopic Appearance

44. Barrett’s EsophagusPathologic Diagnosis • Normal squamous epithelium transforms to intestinal-type (columnar) epithelium 40x increased cancer risk No increased cancer risk

45. PPI-Induced Regression? Peters FT, et al., Gut 1999;45:489-94.

46. 56 Barrett’s patients had antireflux surgery • Annual flexible endoscopy • 24 Barrett’s regressed • 8 cm 4 cm • 9 Barrett’s progressed • 6 cm 10 cm • 23 No change Surgery-Induced Regression? Sagar: Br J Surg 1995;82:806-10.

47. Barrett’s EsophagusDevelopment of Cancer Based on Grade • No dysplasia 3% • Low-grade dysplasia 18% • High-grade dysplasia 28% Morales and Sampliner, Arch Int Med 1999;159:1411-16.

48. Barrett’s EsophagusFollowing Patients Without Dysplasia • Studies of cost-effectiveness are mixed • Few cancers found during surveillance are node-positive, versus >50% otherwise • Optimal surveillance interval debated, but data suggest q2-3 years

49. Barrett’s EsophagusPatients With Low-Grade Dysplasia • Repeat endoscopy to avoid sampling error • Surveillance q6 mo. x 1 year then q12 mo. • May regress allowing increased interval

50. Barrett’s EsophagusPatients With High-Grade Dysplasia • Must confirm the diagnosis • Treatment is controversial • Some advocate aggressive biopsy protocol • Some advocate esophagectomy