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Esophageal Diseases

Esophageal Diseases. M. Raza Anees, MD Chief, GI and Hepatology VAMC raza.anees@hotmail.com. Dysphagia Achalasia Diffuse esophageal spasms Lower esophageal rings Esophageal webs Esophageal strictures Malignant Obstruction GERD Barrett ’ s esophagus Esophageal Cancer. Dysphagia.

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Esophageal Diseases

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  1. Esophageal Diseases M. Raza Anees, MD Chief, GI and Hepatology VAMC raza.anees@hotmail.com

  2. Dysphagia • Achalasia • Diffuse esophageal spasms • Lower esophageal rings • Esophageal webs • Esophageal strictures • Malignant Obstruction • GERD • Barrett’s esophagus • Esophageal Cancer

  3. Dysphagia • Normal Swallowing ( Deglutition)    • Voluntary initiated • Involuntary UES relaxation and epiglottis closure • Peristaltic contraction of smooth muscle of body of esophagus • Relaxation of lower esophageal sphincter • Dysphagia: When swallowing does not proceed normally • Odynophagia: Painful swallowing

  4. Swallowing

  5. Causes of Dysphagia • Transfer Disorders • Neurological disorders that leads to oropharyngeal muscle dysfunction • Difficulty in transferring food from mouth to esophagus • Symptoms: Coughing, gagging and nasal regurgitation • CVA, ALS etc • Anatomical or Structural disorders: Obstruction of esophageal lumen • Schatzki ring, stricture, cancer • Motility disorders: • Failure of effective peristalsis and/ or failure of LES relaxation • Endogenous or exogenous causes • Achalasia, DES , systemic sclerosis

  6. Diagnosis of dysphagia • Always work up dysphagia, no empiric treatment • Barium swallow- first test perform • EGD • Esophageal manometry : if above test negative

  7. Previous healthy pt with new onset dysphagia EGD- unless pill- induce Odynophagia present? Yes No: Dysphagia workup Sx of Neuro dysfunction- cough , gagging Modified BA swallow yes no Ba Swallow LE ring stricture corkscrew Features of achalasia Normal EGD EGD Reassurance Medical rx GED and Manometry Consider EGD

  8. Achalasia • Unknown Pathogenesis • Neuronal denervation and ganglion cell degeneration of myenteric plexus • Loss of organized peristalsis in the esophageal body • Elevated pressure or resting tone of LES • Failure of LES relaxation with swallowing

  9. Features of Achalasia • Dysphagia for solids and liquids • Long-standing symptoms, usually yrs • Regurgitation of food especially at night • No age or gender predilection • Complication: Aspiration pneumonia and wt loss

  10. Diagnosis of Achalasia • First test- Barium swallow • Long dilated esophagus • Bird beak -tight LES • Long time to empty • EGD • 2nd test • confirm  • Exclude tumor • Esophageal Manometry • Last test • Lack of normal peristalsis • non-relaxing LES with swallowing

  11. Treatment of Achalasia • Open LES • Pneumatic dilation • Large balloon ( 3-4cm diameter) • 5% risk of perforation • Surgical Myotomy • Botulinum toxin • effective 65% • repeat- 6-12 months • alternate in high risk pts • Calcium channel blocker and Nitrates • Past • partial response

  12. Diffuse esophageal spasm • Simultaneous, non peristaltic contractions of the esophagus, often precipitated by cold or carbonated liquids • Occult reflux or reflux • Dysphagia or and chest pain (atypical) • Diagnosis: • Barium Swallow: Usually normal, cockscrew • Manometry:  • Confirm • non-peristaltic contractions • LES pressure ,low, normal or high (nonspecific) • 24hr pH recording or emperic trail of PPIs • If reflux is consider cause of spasms

  13. Treatment for DES • Reassurance • Calcium channel blocker- Diltiazem • Nitrates • Botox • Avoid cold beverages • emperic esophageal dilation (no rational)

  14. Anatomic Obstruction: Schatzki ring, cancer or strictures • Progress dysphagia • Solid first then liquids, when sever • Can be constant or intermittent • Younger patients; Schatzki ring • Older patients: Cancer or stricture

  15. Lower Esophageal Ring( Schatzki Ring) • Dysphagia • Younger patient • Intermittent solid food dysphagia esp meat and bread • may regurgitate to relief obstruction • Always associated with Hiatal hernia • Reflux may have a role in pathogenesis • On barium Swallow ring should be 13mm or less in diameter to cause symptoms • Treatment: endoscopic dilation, bougie method or hydrostatic balloon. • PPIs after dilation

  16. Esophageal Web •  Plummer-Vinson Syndrome • Rare •  cervical web • Dysphagia • Iron Def anemia • Female • Slight increase risk of esophageal cancer

  17. Esophageal stricture • Constant not intermittent dysphagia for solid food • Long history of reflux • Other • Prolong NG tube placement • Lye injury • rare now • increase risk of esophageal cancer • Diagnosis • Barium Swallow: • Narrowing at EG junction • Treatment • Dilation • PPI

  18. Malignant Obstruction • Squamous cell carcinoma • Adenocarcinoma • extrinsic compression from non esophageal cancer • Rapid progression of symptoms • Solid to Soft solid to liquid

  19. GE- Reflux Disease (GERD):Overview: • Result of inappropriate, transient relaxation of the LES • transient relaxation  • Overdistention of stomach • reflex sec to presence of fatty food in duodenum • Hiatal hernia facilitate reflux • LES pressure is increased by • Motilin • Acetylcholine • Gastrin • LES pressure is decrease by • Progesterone ( pregnancy increases reflux) • Chocolate • smooking • Meds ( eg anticholinergic)

  20. Extra-esophageal manifestations of GERD • Nonproductive cough which is worse at night, hoarseness, continual clearing of the throat. • Fullness in the throat • Frequent Sore throat • Loss of dental enemal • Non- Cardiac chest pain: • 70% are casued by GERD • Usually not associated with heartburn or dysphagia

  21. Extra-esophageal manifestations of GERD • Two respiratory disorders • Excerbation of Asthma • Some asthma patient show improvement with GERD treatment (even without GERD symptoms) • Always ask for Asthma symptoms with GERD pts, esp night time asthma • VCD( vocal cord dysfunction) • Night time wheezing • Usually among younger pts in competitive sports • Stress reaction • Inspiratory stridor (pts can not differentiate it from wheezing) • Can be associated with GERD, so emperic rx help

  22. Complications • Esophageal ulcers • Stricture • Bleeding • Barrett esophagus • Both asthma and GERD are associated with increase BMI

  23. Diagnosis of GERD • Hearburn only • Therapeutic Trial of PPIs • EGD only if trial fails • Alarm symptoms - Start with EGD • Nausea/ emesis • Blood in the stool • Family history of PUD • Weight loss • Anorexia • Anemia • Abnormal physical exam • Long duration of frequent symptoms, especially in while males >45yrs old • Failure to respond to full doses of a PPI • Dysphagia/Odynophagia

  24. Diagnosis of GERD • 24 -hr esophageal pH monitor for atypical causes • refractory symtoms and normal egd • hoarseness, coughing, or atypical chest pain,but no classic symptoms of gerd • failure to responds to PPIs

  25. Treatment of GERD • General Measures • Raise head of bed  • encourage wt loss of >10lb if overweight or recent weight gain • Small meals • No fatty meals in the evening • Eat dinner at least 3 hrs before bed time • No sweets at bedtime • Stop smoking • Antacid PRN • Avoid acidic beverages (e.g;. colas, orange juice, wine) • excessive alcohol

  26. If unsuccessful try antisecretory drugs • PPI or H2 receptor blockers • PPIs before breakfast after a nocturnal fast • Antireflux surgery : Fundoplication in sever GERD • young patient with sever GERD • Refractory to medication • alternative to long term medical therapy • 60% of patient will require PPIs after surgery

  27. Barrett esophagus • Change in cell type from esophageal squamous to specialized intestinal metaplasia- caused by chronic GE reflux • 10-20% of men with chronic reflux • 2% of women with chronic reflux • Screening is controversial • BE is associated with adenocarcinoma • Incidence of adeno in BE patient is 30x then normal rate • Linked to  • Length of BE segment • Hiatal hernia • Degree of dysplasia • Smooking • Risk of adeno in pts with BE is 0.4% per yr • Neither medication or reflux surgery reverse the epithelial changes or eliminate cancer risk

  28. BE follow up • 2 EGDs with biopsies within a yr if no dysplasia repeat in 3 yrs • Low grade dysplasia, repeat in 6months then yearly egd till two consecutive egds are negative for dysplasia • High grade dysplasia, repeat in 3 months • mucosal resection • esophgectomy • repeat q 3 months

  29. Esophageal Cancer • Two types • Squamous cell cancer • Location : Midesophagus • Incidence: 2.2/100,000(white) 15/100000 (blk) • M:F: males >female • Risk factors: • Alcohol • Tobacco • Strictures • Fanconi's anemia • Plummer-vinson syndrome • tylosis  • Scleroderma

  30. Esophageal cancer • Adenocarcinoma • Incidence: 3/100000 (white males), 0.5/100,000(bm) • M:F: 8:1 • Location: Distal esophagus • Risk Factors: • Barrett's metaplasia • GERD • Obesity • Tobacco

  31. Symptom: Progressive dysphagia • Diagnosis:  • Barium Swallow • EGD with biopsy • CT scan and Ultrasound for staging • Treatment • Small or Localized • Surgery • Large or metastasized • Combination chemo plus radiation

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