Esophageal Disorders

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Esophageal Disorders:

Esophageal Disorders Ingram Roberts, M.D., M.B.A.

Topics for Discussion:

Topics for Discussion Symptoms of Esophageal Diseases Work-up of Esophageal Diseases Therapy of Esophageal Diseases

PowerPoint Presentation:

The esophagus is one organ whose length varies dependent on patient height!

Symptoms:

Symptoms Odynophagia (painful swallowing) Dysphagia (non-painful discomfort or “sticking of food” Chest pain Aspiration, choking, regurgitation Excessive salivary output and inability to swallow Esophageal “catastrophes”

Odynophagia:

Odynophagia Esophageal ulcer “Pill” esophagitis (tetracycline, etc.) Viral esophagitis (CMV, HSV, HIV) Fungal esophagitis (Candida) Atypical GERD

Dysphagia:

Dysphagia Solid dysphagia ONLY Peptic stricture Esophageal cancer Schatzki ring (intermittent dysphagia only) Liquid and solid dysphagia Achalasia Lesion is always at level patient indicates or BELOW

Chest pain:

Chest pain May be indistinguishable from angina?! Esophageal spasm Achalasia? GERD “nutcracker” esophagus Typical “burning” substernal pain GERD Hiatus hernia?

Aspiration, regurgitation, choking:

Aspiration, regurgitation, choking Oropharyngeal dysphagia CVA Bulbar and pseudobulbar palsy Oculopharyngeal muscular dystrophy Late ALS Cricopharyngeal achalasia (“bar”) Head and neck cancer Myasthenia gravis

Excessive salivary output and inability to swallow:

Excessive salivary output and inability to swallow Complete esophageal obstruction Relative medical emergency Treated with glucagon or other agents in ED, but may require urgent endoscopy if no relief Food bolus is either extracted from above or pushed down into the stomach endoscopically

Other catastrophes:

Other catastrophes Mallory-Weiss tear: Hematemesis with tear seen by endoscopy Boerhaave’s syndrome (1724-Baron Jan von Wassenaer, Dutch admiral): Rx with antibiotics, mediastinal drainage with eventual repair Meckler’s triad: subcutaneous emphysema, vomiting and lower chest pain in only 50% of cases Variceal bleeding (an entire topic to itself)

Herman Boerhaave:

Herman Boerhaave

Work-up of esophageal diseases:

Work-up of esophageal diseases Barium (or gastrograffin) swallow Endoscopy (transoral and transnasal) Cine esophagram Esophageal motility “Pill” cam CT scan EUS 24 hr. pH probe

Barium swallow:

Barium swallow Best for non-oropharygeal dysphagia Usually safe to perform when a patient indicates the throat is the “level” of the dysphagia (lesion is always at that level of below) Limitations Can’t biopsy Not sensitive and specific enough to diagnose motility disorders

Gastrograffin swallow:

Gastrograffin swallow Definitive way to diagnose Boerhaave’s syndrome If this Dx is suspected, don’t order barium

“Cine” esophagram:

“Cine” esophagram Best to look at oropharyngeal swallowing process Not for body of the esophagus diseases Watch for evidence of aspiration and disordered upper esophageal sphincter and palate problems

Esophageal motility:

Esophageal motility THE test used to diagnose achalasia Allows a look at peristalsis, upper and lower esophageal function and coordination May be abnormal in DES, nutcracker esophagus, GERD Not specific or sensitive except for achalasia Most common findings seen in a referral practice lab will be low LES pressure and non-specific abnormalities in peristalsis

Endoscopy:

Endoscopy Transnasal (unsedated) endo becoming popular as esophagitis may be seen (limitation is that biopsy not performed) Traditional endoscopy is the method of choice for the evaluation of odynophagia and dysphagia (biopsies and cytology if needed)

“Pill” cam:

“Pill” cam Swallowed capsule that allows a look at the esophagus non-invasively Still experimental in my opinion and reimbursement questionable Again, biopsy not possible

CT Scan/MRI:

CT Scan/MRI Of little use in the workup of esophageal diseases Only use should be for possible staging of esophageal and lung cancers to look at mediastinum and surrounding structures

EUS (Endoscopic ultrasound):

EUS (Endoscopic ultrasound) Not the first test of choice in the workup of esophageal diseases Excellent test for staging of esophageal and lung tumors (TMN) Tissue planes very well seen with EUS

24 hr. pH probe:

24 hr. pH probe Can be useful both ON and OFF GERD therapy to determine if pain is acid related or not Newer techniques allow for impedance and alkaline reflux to be determined Has replaced the Bernstein test (HCl and saline perfusion via an NG tube)

Therapy of esophageal diseases:

Therapy of esophageal diseases GERD Motility disorders Achalasia DES, nutcracker Schatzki ring Esophageal cancer

GERD (GORD in UK) :

GERD (GORD in UK)  Diet and lifestyle modifications PPIs and H2 blockers Who to R/O Barrett’s esophagus? Certainly white men age 30-70 with symptoms Patients with new reflux symptoms over age 40 “Alarm” Sx: dysphagia, anemia, wt. loss, etc.

Eosinophilic esophagitis:

Eosinophilic esophagitis Regaining popularity as a “true entity” Originally thought to be a GERD manifestation ?Familial ?Allergic ?Elevated serum IgE Usual presenting Sx is dysphagia Rx: swallowed fluticasone Bottom line: a disease in “evolution”

Achalasia:

Achalasia Diagnostic criteria: aperistalsis and inability of lower esophageal sphincter (LES) to relax completely “bird beak” tapering of lower esophagus on Barium swallow Endoscope enters stomach with gentle pressure Rx: Pneumatic dilatation or myotomy Botox injection in patients who are poor candidates for the above therapies Cancer patients may develop “pseudoachalasia”

Diffuse esophageal spasm (DES):

Diffuse esophageal spasm (DES) Disordered peristalsis with concomitant atypical chest pain Rx with nitrates and/or calcium channel blockers. GERD on occasion may be a cause of DES! May be missed on conventional manometry (24 hr. ambulatory manometry available in certain centers)

“Nutcracker” esophagus:

“Nutcracker” esophagus Very high amplitude peristaltic contractions associated with atypical chest pain Rx similarly to DES

Schatzki ring:

Schatzki ring Mucosal circumferential ring that leads to intermittent dysphagia Rx: single Hurst 50 F bougienage

Esophageal cancer:

Esophageal cancer Squamous: associated with alcohol and smoking Adenocarcinoma: associated with Barrett’s esophagus and chronic GERD Rx: Surgery (if resectable) If unresectable, consider RT, chemoRx, laser ablation or photodynamic Rx

Esophageal diseases:

Esophageal diseases Always consider in the differential Dx of chest pain Patients below age forty may be empirically given a “PPI test” to see if Sx improve (and/or checked for H. pylori serology) Also “fleas and lice” may be present: patients have both cardiac and esophageal pathology 

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