1. Disorders of the Upper Gastrointestinal Tract Dr. Aric Storck November 7, 2002

2. objectives • Review diagnosis and management of common disorders of the esophagus, stomach and duodenum • Will not discuss • disorders of bowel • GI bleed – covered next week

3. Esophagus – anatomy • 25-30 cm • Relation to adjacent structures • Prevertebral fascia posteriorly • Trachea / L mainstem bronchus/ heart anteriorly • Fixed at origin • Mobile throughout mediastinum • Two layers • Inner layer – circular • Outer layer – longitudinal • NB: No serosal layer

4. Proximal 1/3 • Striated muscle • Allows voluntary initiation of swallowing • innvervated by spinal accessory nerve • Middle 1/3 • Striated and smooth muscle • Dorsal motor nerve of vagus • Distal 1/3 • Smooth muscle • Dorsal motor nerve of vagus

5. Normal Healthy Esophagus

6. Esophageal Obstruction • 4 areas of narrowing • Cricopharyngeus (upper esophageal sphincter) • Aortic arch • Left mainstem bronchus • Diaphragmatic hiatus • Large foreign body in esophagus can obstruct airway

7. Esophageal obstructionclinical presentation • Complete • Unable to swallow • Drooling • Violent retching • Pain from neck to epigastrium • Proximal • Sudden cyanosis • Compression of trachea by food in upper esophagus or oropharynx

8. Esophageal obstructioncauses • Foreign bodies • Coins, food, batteries • Anatomic anomalies • Carcinoma • Schiatzki’s ring • Peptic / chemical stricture • Extrinsic compression • Thyroid enlargement • Zenker’s diverticulum • Aortic arch • Anomalous right subclavian artery • Bronchogenic carcinoma

9. Esophageal obstructiondiagnostic strategies • Endoscopy • Gold standard for diagnosis and treatment • Plain radiographs • If foreign body suspected • Not seeing it does not rule it out • Contrast studies • Gastrograffin vs barium • NB:radigraphs + contrast studies • False negatives <20% • False positives <1% • CT scan

10. Esophageal obstructionforeign body management • Oropharyngeal • Retrieve with Kelly / McGill forceps • Esophageal • Endoscopic removal • Foley catheter (controversial) • Lower esophagus • Often food impaction • Glucagon 1mg iv (maximum 2mg) • Relax sphincter enough to allow passage of food in 50% of patients • Affects only smooth muscle, thus not useful for proximal obstructions

11. Reflux esophagitis stricture pizza • Food impacted proximal to stricture • Could attempt glucagon

12. Esophageal Strictures • Caustic stricture • Narrowing of 2/3 of esophagus due to caustic ingestion years ago • Accidental in children • Suicide • Radiation stricture • Smooth midesophageal stricture

13. Esophageal obstructionforeign body management • Effervescent agents (pop …) • Sharp objects • Urgent intervention • Cause intestinal perforation in 15-35% • Batteries • “button” batteries – urgent removal • Zn, Li, Hg – leakage causes toxicity • Did you know …. There is a National Button Battery Ingestion Hotline (202) 525-3333

14. Bell in esophagus

15. Case A patient has been drinking heavily. He presents to the emergency room after several hours of severe vomiting and retching. He is complaining of severe epigastric pain radiating to the back. He has not had significant hematemesis. Diagnosis?

16. Esophageal perforation • Potentially life-threatening • Boerhaave’s syndrome • Vomiting • Valsalva maneuver • Cough • Childbirth • Cough • Iatrogenic • Endoscopy • Foreign body ingestion • Trauma

17. Esophageal perforationclinical presentation • Upper esophagus • Neck / chest pain • Dysphagia • Respiratory distress • Fever • Lower esophagus • Abdo pain / pain radiating to back • Pneumothorax • Pneumomediastinum • Subcutaneous emphysema (Hamman’s Sign)

18. Esophageal perforationDiagnosis • CXR / upright AXR • Subcutaneous emphysema • Pneumomediastinum • Mediastinal widening • Pleural effusion • Contrast studies • Gastrograffin/barium • CT • Mediastinal air • Extraluminal contrast • Fluid collections

19. Boerhaave’s Syndrome • Esophageal rupture • Contrast filling rounded area adjacent to distal esphagus • Arrows = rupture

20. Esophageal PerforationTreatment • Aggressive treatment • Boerhaave’s • Unstable • Contamination of mediastinum/pleura • Tx with broad spectrum ABX • Conservative treatment • Stable, afebrile • Endoscopic injury • Delayed presentation

21. Case • A 42 year old woman comes to emergency complaining of trouble swallowing. The food seems to get stuck in her throat. This has been happening for several weeks. What has she got?

22. Dysphagia • From Greek “dys” difficult “phagia” eating • sensation of food getting “stuck” • +/- pain • indicates esophageal problem • oropharyngeal • esophageal • 12% of patients in acute care hospital • up to 50% of patients in chronic care

23. Oropharyngeal dysphagia • Inability to transfer food to esophagus • food sticks immediately after swallowing • neurological • cortical - pseudobulbar palsy (UMN lesion) due to bilateral stroke • bulbar - ischemia, tumour (LMN) • peripheral - polio, ALS

24. Oropharyngeal dysphagia • Muscular • muscular dystrophy • cricopharyngeal incoordination • failure of UES to relax with swallowing • Zenker’s diverticulum

25. Esophageal Dysphagia Solid food only Solid or liquid food Mechanical obstruction Neuromuscular disorder intermittent progressive intermittent progressive Reflux Sx Respiratory symptoms Lower esophageal ring/web Age>50 heartburn DES scleroderma achalasia Peptic stricture carcinoma

26. Achalasia • Incomplete relaxation of LES (resting pressure >30mm Hg) • etiology • idiopathic - most common • Chagas disease - Latin America • secondary to cancer (esophagus, stomach)

27. Achalasia - Complications • Respiratory • aspiration • bronchiectasis • lung abscesses • GI • malnutrition • increased risk of esophageal cancer

28. Achalasia - Diagnosis • CXR • absent air in stomach • dilated fluid filled esophagus • barium esophagogram • prominent esophagus with “bird’s beak” • esophageal motility study • required for definitive diagnosis

29. Achalasia - Treatment • Nitrates, CCBs • balloon dilatation of LES • 50% successful • 5% perforation • Surgery • Heller myotomy

30. Achalasia Barium esophagogram. The dilated esophagus ends in a "bird's beak" that represents the nonrelaxing loweresophageal sphincter. Fluoroscopy during the swallow revealed no meaningful peristalsis in the esophageal body.

31. AchalasiaManometry • Failure of LES relaxation • Failure of peristaltic conduction to LES

32. Diffuse Esophageal Spasm • Normal peristalsis interspersed with abnormal high pressure waves • unknown etiology • diagnosis • barium esophagogram - corkscrew pattern • manometry • treatment • medical - nitrates, CCB, anticholinergics • surgery - long myotomy

33. DES • Nutcracker esophagus • note pseudodiverticula caused by spasm

34. CASE • A 51 year old woman presents with trouble swallowing. You also note generally tight skin, particularly around the fingers. She says she has Reynaud’s phenomenon. What is the most likely diagnosis?

35. Scleroderma • Microvascular disease and intramural neuronal dysfunction • aperistalsis & loss of LES tone … reflux … stricture … dysphagia

36. Scleroderma - Treatment • GERD prophylaxis • anti-reflux surgery - last resort

37. Scleroderma • Distal esophageal stricture

38. CASE • A teenager presents to the emergency department with a 2 day history of severe pain while swallowing. She has to spit out her saliva rather than swallow. She has acne and is taking tetracycline. Diagnosis?

39. Esophagitis • GERD (#1 cause) • Infectious esophagitis • Pill esophagitis • Caustic ingestion • Radiation • Sclerotherapy

40. Infectious Esophagitis • Rare in immunocompetent hosts • Risk factors • DM, EtOH, GC’s, elderly • Immunosuppressants, broad spectrum abx • Candida albicans – most common • Viral – HSV, CMV • Bacterial – uncommon • Trypanosoma cruzi, cryptosporidium

41. Infectious esophagitisclinical manifestations • +++ Odynophagia • Dysphagia • Solids & liquids • Fever (uncommon) • Bleeding (uncommon)

42. Esophagitis - diagnosis • Endoscopy • Infectious • Candida – white plaques • Herpes – vesicles • Definitive dx via biopsy

43. Candidal esophagitis • Common in • HIV • Antibiotics • Chemotherapy • +++dysphagia • Tx: fluconazole

44. HSV Esophagitis • Common in: • Chemotherapy • HIV • Tx: acyclovir

45. Esophagitis • Early Esophagitis • Diffuse nodularity of mucosal surface • Mod. Esophagitis • Thickened folds and nodularity in distal esophagus • Severe Esophagitis • Diffuse ulcerations and stricture

46. Infectious esophagitistreatment • Candida • Fluconazole 200mg po od x 3-4 weeks • HSV • Acyclovir 400mg po 5x/day x 2 weeks • CMV • Gancyclovir • Foscarnet • Antacids, topical anesthetics, sucralfate

47. Pill esophagitis • Pill fails to enter stomach and remains in esophagus • Risk factors • Age • Decreased esophageal motility • Compression • Large pills

48. Pill esophagitisclinical manifestations • Sudden onset odynophagia • +/- dysphagia • Hx of pill ingestion • Could be hours previously • +/- sensation pill is “stuck”

49. Pill esophagitistreatment • Prevention • 4oz liquid with any pill • Medications taken in upright position • Avoid use of pills if possible

50. GERD • Asymptomatic reflux in most people • GERD = reflux plus one of • Histopathologic changes of esophageal epithelial lining • Symptoms of reflux • Symptomatic reflux in • 7% daily • 14% weekly • 40% monthly