copy of esophageal diseases imag

8/14/2019 Copy of Esophageal Diseases Imag.

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ESOPHAGEAL DISEASESESOPHAGEAL DISEASES


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Upper esophageal sphincterUpper esophageal sphincter

Striated muscleStriated muscle

Consists of the cricopharyngeusConsists of the cricopharyngeusand inferior pharyngeal constrictorand inferior pharyngeal constrictor

muscles, striated musclesmuscles, striated muscles

innervated by excitatory somaticinnervated by excitatory somatic

lower motor neurons.lower motor neurons.


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Lower esophageal sphincterLower esophageal sphincter

(LES) is composed of smooth muscle.(LES) is composed of smooth muscle.

Innervated by parallel sets ofInnervated by parallel sets of

parasympathetic excitatory andparasympathetic excitatory andinhibitory pathways.inhibitory pathways.

Supplemented by the striated muscleSupplemented by the striated muscle

of the diaphragmatic crura, whichof the diaphragmatic crura, whichsurrounds the LES and acts as ansurrounds the LES and acts as anexternal LES.external LES.


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Fatty meals, smoking, andFatty meals, smoking, and

beverages with a high xanthinebeverages with a high xanthine

content (tea, coffee, cola) cause acontent (tea, coffee, cola) cause areduction in sphincter pressure.reduction in sphincter pressure.

Adrenergic agonists, gastrin, andAdrenergic agonists, gastrin, and

prostaglandin Fprostaglandin F22 cause itscause its

contractioncontraction..


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SYMPTOMSSYMPTOMS


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DysphagiaDysphagia

Sensation of sticking orSensation of sticking or

obstruction of the passage of foodobstruction of the passage of foodthrough the mouth, pharynx, orthrough the mouth, pharynx, or

esophagus.esophagus.


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OdynophagiaOdynophagia

painful swallowingpainful swallowing..


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Atypical chest painAtypical chest pain


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HeartburnHeartburn

Is a burning retrosternal discomfort thatIs a burning retrosternal discomfort thatmay move up and down the chest like amay move up and down the chest like awave.wave.


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RegurgitationRegurgitation

IIs the effortless appearance of gastric ors the effortless appearance of gastric oresophageal contents in the mouth.esophageal contents in the mouth.

The regurgitated material consists ofThe regurgitated material consists of

tasteless mucoid fluid or undigested food.tasteless mucoid fluid or undigested food.


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DiagnosticDiagnosticTestsTests


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EsophagoscopyEsophagoscopy

Esophagoscopy is the direct method ofEsophagoscopy is the direct method ofestablishing the cause of mechanicalestablishing the cause of mechanicaldysphagia and of identifying mucosaldysphagia and of identifying mucosallesions that may not be identified by thelesions that may not be identified by theusual barium swallow.usual barium swallow.

Endoscopic ultrasonography permitsEndoscopic ultrasonography permitsevaluation of intramural masses andevaluation of intramural masses andstaging of esophageal cancer.staging of esophageal cancer.


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http://www.gastrointestinalatlas.com/CaEscamous1.mpg


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Esophageal MotilityEsophageal Motility

The study of esophageal motility entailsThe study of esophageal motility entails

simultaneous recording of pressures fromsimultaneous recording of pressures from

different sites in the esophageal lumendifferent sites in the esophageal lumen

with pressure sensors positioned 5 cmwith pressure sensors positioned 5 cm

apart.apart.

The UES and LES appear as zones ofThe UES and LES appear as zones of

high pressure that relax on swallowing.high pressure that relax on swallowing.


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Motor DisordersMotor Disorders


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Striated MuscleStriated Muscle

Oropharyngeal ParalysisOropharyngeal Paralysis

Paralysis of oral muscle leads to difficultyParalysis of oral muscle leads to difficulty

initiating swallowing and drooling of foodinitiating swallowing and drooling of foodout of the mouth. Pharyngeal paralysis,out of the mouth. Pharyngeal paralysis,

characterized by dysphagia, nasalcharacterized by dysphagia, nasal

regurgitation, and aspiration duringregurgitation, and aspiration duringswallowing, occurs in a variety ofswallowing, occurs in a variety of

neuromuscular disorders.neuromuscular disorders.


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Smooth MuscleSmooth Muscle

AchalasiaAchalasia

Achalasia is a motor disorder of theAchalasia is a motor disorder of the

esophageal smooth muscle in whichesophageal smooth muscle in whichthe LES does not relax normally withthe LES does not relax normally with

swallowing, and the esophageal bodyswallowing, and the esophageal body

undergoes nonperistalticundergoes nonperistaltic

contractions.contractions.


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LLoss of intramural neurons. Inhibitoryoss of intramural neurons. Inhibitory

neurons are predominantly involved.neurons are predominantly involved.

Pathophysiology of AchalasiaPathophysiology of Achalasia


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Clinical features ofClinical features ofAchalasiaAchalasia

Dysphagia, chest pain, and regurgitationDysphagia, chest pain, and regurgitation

are the main symptoms.are the main symptoms.

Dysphagia appears early, occurs with bothDysphagia appears early, occurs with both

liquids and solids, and is worsened byliquids and solids, and is worsened by

emotional stress and hurried eating.emotional stress and hurried eating.


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Diagnosis ofDiagnosis ofAchalasiaAchalasia

CChest x-rayhest x-ray shows absence of the gastric airshows absence of the gastric airbubble and sometimes a tubular mediastinalbubble and sometimes a tubular mediastinal

mass beside the aorta.mass beside the aorta.

AAir-fluid level in the mediastinum in the uprightir-fluid level in the mediastinum in the upright

position represents retained food in theposition represents retained food in the

esophagus.esophagus.

Barium swallowBarium swallow shows esophageal dilation,shows esophageal dilation,and in advanced cases the esophagus mayand in advanced cases the esophagus may

become sigmoid.become sigmoid.


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ManometryManometryLES pressure to be normalLES pressure to be normalor elevated, and swallow-inducedor elevated, and swallow-induced

relaxation either does not occur or isrelaxation either does not occur or is

reduced in degree, duration, andreduced in degree, duration, and

consistency.consistency.

The esophageal body shows an elevatedThe esophageal body shows an elevated

resting pressure.resting pressure.


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TreatmentTreatment

Nitroglycerin, is used sublinguallyNitroglycerin, is used sublingually

before meals and as needed forbefore meals and as needed for

chest pain.chest pain.

Isosorbide dinitrate, sublingually isIsosorbide dinitrate, sublingually is

used before meals.used before meals.

NNifedipine, orally or sublinguallyifedipine, orally or sublingually

before meals, is also effective.before meals, is also effective.


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Heller's extramucosal myotomy ofHeller's extramucosal myotomy of

the LES, in which the circular musclethe LES, in which the circular muscle

layer is incised.layer is incised.

Laparoscopic myotomy is theLaparoscopic myotomy is the

procedure of choice.procedure of choice.

Diffuse Esophagealuse sop agea


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Diffuse Esophagealuse sop ageaSpasm and Related MotorSpasm and Related Motor

DisordersDisordersDiffuse esophageal spasm isDiffuse esophageal spasm is

characterized by nonperistalticcharacterized by nonperistaltic

contractions, large amplitude andcontractions, large amplitude and

long duration.long duration.


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PathophysiologyPathophysiology

Nonperistaltic contractionsNonperistaltic contractions:: dysfunction ofdysfunction of

inhibitory nerves.inhibitory nerves.

Diffuse esophageal spasm may progress toDiffuse esophageal spasm may progress to

achachaalasia.lasia.


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Clinical featuresClinical features

Present with chest pain, dysphagia,Present with chest pain, dysphagia,

or both.or both.


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TreatmentTreatment

Sublingual nitroglycerinSublingual nitroglycerin

Isosorbide dinitrateIsosorbide dinitrate

Nifedipine.Nifedipine.TrTranquilizers are helpful in allayinganquilizers are helpful in allaying

apprehension.apprehension.


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Scleroderma EsophagusScleroderma Esophagus

The esophageal lesions in systemicThe esophageal lesions in systemic

sclerosis consist of atrophy of smoothsclerosis consist of atrophy of smooth

muscle, manifested by weakness in themuscle, manifested by weakness in the

lower two-thirds of the esophageal bodylower two-thirds of the esophageal bodyand incompetence of the LES.and incompetence of the LES.

The esophageal wall is thin and atrophicThe esophageal wall is thin and atrophic

and may exhibit areas of patchy fibrosis.and may exhibit areas of patchy fibrosis.


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SymptomsSymptoms

These patients usually also complainThese patients usually also complain

of heartburn, regurgitation, andof heartburn, regurgitation, and

other symptoms of gastroesophagealother symptoms of gastroesophageal

reflux disease (GERD).reflux disease (GERD).


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DiagnosticDiagnostic

Barium swallow shows dilation andBarium swallow shows dilation and

loss of peristaltic contractions in theloss of peristaltic contractions in the

middle and distal portions of themiddle and distal portions of the

esophagusesophagus


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GASTROESOPHAGEALGASTROESOPHAGEAL

REFLUX DISEASEREFLUX DISEASE

GERDGERD


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Gastroesophageal RefluxGastroesophageal Reflux

Disease (GERD)Disease (GERD)

Any symptoms or esophageal mucosalAny symptoms or esophageal mucosal

damage that results from reflux of gastricdamage that results from reflux of gastricacid into the esophagus.acid into the esophagus.

Classic GERD symptomsClassic GERD symptoms

Heartburn .Heartburn . Regurgitation.Regurgitation.


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Important Reasons to Diagnose andImportant Reasons to Diagnose and

Treat GERDTreat GERD

Negative impact on health-related quality ofNegative impact on health-related quality of

lifelife..

Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma..


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E h l


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ExtraesophagealExtraesophageal

Manifestations of GERDManifestations of GERDPulmonaryPulmonary

AsthmaAsthma

Aspiration pneumoniaAspiration pneumonia

Chronic bronchitisChronic bronchitis

Pulmonary fibrosisPulmonary fibrosis

OtherOther

Chest painChest pain

Dental erosionDental erosion

ENTENT

HoarsenessHoarseness

LaryngitisLaryngitis

PharyngitisPharyngitis

Chronic coughChronic cough

Globus sensationGlobus sensation

DysphoniaDysphonia

SinusitisSinusitis

Subglottic stenosisSubglottic stenosis

Laryngeal cancerLaryngeal cancer

Potential Oral and LaryngopharyngealPotential Oral and Laryngopharyngeal


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Potential Oral and LaryngopharyngealPotential Oral and Laryngopharyngeal

Signs Associated with GERDSigns Associated with GERD

Edema and hyperemia ofEdema and hyperemia oflarynxlarynx

Vocal cord erythema,Vocal cord erythema,

polyps, granulomas,polyps, granulomas,

ulcersulcers Hyperemia and lymphoidHyperemia and lymphoid

hyperplasia of posteriorhyperplasia of posterior

pharynxpharynx

Interarytenyoid changesInterarytenyoid changes Dental erosionDental erosion

Subglottic stenosisSubglottic stenosis

Laryngeal cancerLaryngeal cancer


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Pathophysiology ofPathophysiology of

Extraesophageal GERDExtraesophageal GERD


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Wh t P f Di tiWh t P f Di ti


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When to Perform DiagnosticWhen to Perform Diagnostic

TestsTests????Uncertain diagnosis.Uncertain diagnosis.

Atypical symptoms.Atypical symptoms.

Symptoms associated with complications.Symptoms associated with complications.Inadequate response to therapy.Inadequate response to therapy.

Recurrent symptoms.Recurrent symptoms.

Prior to anti-reflux surgery.Prior to anti-reflux surgery.


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Diagnostic Tests for GERDDiagnostic Tests for GERD

Barium swallow.Barium swallow.

Endoscopy.Endoscopy.

Ambulatory pHAmbulatory pH

monitoring.monitoring.

Esophageal manometry.Esophageal manometry.

Barium SwallowBarium Swallow


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Barium SwallowBarium Swallow

Useful first diagnostic test forUseful first diagnostic test forpatients with dysphagiapatients with dysphagia Stricture (location, length).Stricture (location, length).

Mass (location, length).Mass (location, length). Hiatal hernia (size, type).Hiatal hernia (size, type).

LimitationsLimitations

Detailed mucosal exam forDetailed mucosal exam forerosive esophagitis, Barrettserosive esophagitis, Barrettsesophagusesophagus

E dE d


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EndoscopyEndoscopy

Indications for endoscopyIndications for endoscopy

Alarm symptomsAlarm symptoms

Empiric therapy failureEmpiric therapy failure Preoperative evaluationPreoperative evaluation

Detection of BarrettsDetection of Barretts

esophagusesophagus

Ambulatory 24 hr pHAmbulatory 24 hr pH


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Ambulatory 24 hr. pHAmbulatory 24 hr. pHMonitoringMonitoring

Physiologic studyPhysiologic study

Quantify reflux inQuantify reflux in

proximal/distalproximal/distal

esophagusesophagus % time pH < 4% time pH < 4

Symptom correlationSymptom correlation

b l h i i


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Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

re ess, a e er- ree sop agea p


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, p g pMonitoring

Improved patientImproved patient

comfort and acceptancecomfort and acceptance

Continued normal work,Continued normal work,activities and diet studyactivities and diet study

Longer reporting periodsLonger reporting periods

possible (48 hours)possible (48 hours)

Maintain constant probeMaintain constant probe

position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages


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Esophageal ManometryEsophageal Manometry

Limited role in GERDLimited role in GERD


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Treatment Goals for GERDTreatment Goals for GERD

Eliminate symptoms.Eliminate symptoms.

Heal esophagitis.Heal esophagitis.

Manage or preventManage or prevent

complications.complications.

Maintain remission.Maintain remission.

Lifestyle Modifications areLifestyle Modifications are


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Lifestyle Modifications areesty e od cat o s a e

Cornerstone of GERD TherapyCornerstone of GERD Therapy

Elevate head of bed 4-6 inches.Elevate head of bed 4-6 inches.

Avoid eating within 2-3 hours of bedtime.Avoid eating within 2-3 hours of bedtime.

Lose weight if overweight.Lose weight if overweight.

Stop smoking.Stop smoking.

Modify diet:Modify diet:

Eat more frequent but smaller meals.Eat more frequent but smaller meals.

Avoid fatty/fried food, peppermint, chocolate,Avoid fatty/fried food, peppermint, chocolate,alcohol, carbonated beverages, coffee andalcohol, carbonated beverages, coffee and

tea.tea.

Acid Suppression Therapy forAcid Suppression Therapy for


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Acid Suppression Therapy forAcid Suppression Therapy for

GERDGERD

HH22-Receptor-Receptor

AntagonistsAntagonists

Cimetidine.Cimetidine.

Ranitidine.Ranitidine.

Famotidine.Famotidine.Nizatidine.Nizatidine.

Proton Pump InhibitorsProton Pump Inhibitors

(PPIs)(PPIs)

Omeprazole.Omeprazole.

Lansoprazole.Lansoprazole.

Rabeprazole.Rabeprazole.

Pantoprazole.Pantoprazole.Esomeprazole.Esomeprazole.

Eff ti f M di l Th i fEff ti f M di l Th i f


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Effectiveness of Medical Therapies forEffectiveness of Medical Therapies for

GERDGERD

TreatmentTreatment ResponseResponse

Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %

HH22-receptor antagonists-receptor antagonists 50 %50 %

Single-dose PPISingle-dose PPI 80 %80 %

Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %

Treatment Modifications forTreatment Modifications for


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Treatment Modifications forTreatment Modifications for

Persistent SymptomsPersistent Symptoms

Improve compliance.Improve compliance.

Optimize pharmacokineticsOptimize pharmacokinetics

Adjust timing of medication to 15 30Adjust timing of medication to 15 30

minutes before meals.minutes before meals.

Allows for high blood level.Allows for high blood level.

Consider switching to a different PPI.Consider switching to a different PPI.


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Erosi e EsophagitisErosive Esophagitis


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Erosive EsophagitisErosive Esophagitis

When to Discuss Anti RefluxWhen to Discuss Anti Reflux


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When to Discuss Anti-RefluxWhen to Discuss Anti-Reflux

Surgery with PatientsSurgery with Patients

Intractable GERD (rare):Intractable GERD (rare): Difficult to manage strictures.Difficult to manage strictures.

Severe bleeding from esophagitis.Severe bleeding from esophagitis.

Non-healing ulcers.Non-healing ulcers.

GERD requiring long-term PPI in aGERD requiring long-term PPI in ahealthy young patient.healthy young patient.

Persistent regurgitation/aspirationPersistent regurgitation/aspirationsymptoms.symptoms.


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Endoscopic GERD TherapyEndoscopic GERD Therapy


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Endoscopic GERD TherapyEndoscopic GERD Therapy

Radiofrequency energy delivered to theRadiofrequency energy delivered to the

LESLES ( (Stretta procedure)Stretta procedure)

Suture ligation of the cardiaSuture ligation of the cardia

((Endoscopic plication)Endoscopic plication)

Submucosal implantation of inertSubmucosal implantation of inert

material in the region of the lowermaterial in the region of the lower

esophageal sphincter.esophageal sphincter.


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