Diseases of Esophagus & Dysphagia
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Diseases of Esophagus &
Dysphagia
Dr. Vishal Sharma
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Diseases ofesophagus
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Contents• Esophagitis, Barret’s esophagus & GERD
• Esophageal tear & perforation
• Esophageal web, ring, stricture, atresia
• Achalasia cardia
• Esophageal hiatus hernia
• Esophageal hypermotility disorder
• Esophageal vascular impression
• Esophageal neoplasm
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Esophagitis
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Etiology• Gastro-esophageal reflux disease (commonest)
• Infective: candidiasis, cytomegalovirus, HIV, herpes
simplex, tuberculosis, Crohn’s disease, actinomycosis
• Caustic ingestion
• Medication: Iron, vitamin C, doxycycline, NSAID
• Iatrogenic: nasogastric tube, radiation
• Others: graft vs. host disease, uremia, eosinophilic
esophagitis, benign pemphigoid, epidermolysis bullosa
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Savary Monnier classification of esophageal erosion
• Grade 1: Single erosion over single mucosal fold
• Grade 2: Erosions over multiple folds
• Grade 3: Circumferential mucosal erosions
• Grade 4: Erosion with definitive ulcer or stricture
• Grade 5: Columnar metaplasia (Barret’s esophagus)
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Grade 1 esophagitis
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Grade 2 esophagitis
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Grade 3 esophagitis
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Grade 4 esophagitis
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Grade 5 esophagitis
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Los Angeles Classification • Grade A: Mucosal break < 5 mm in length over
single mucosal fold
• Grade B: Mucosal break > 5mm over single
mucosal fold
• Grade C: Continuous mucosal break b/w > 2
mucosal folds but < 75% of esophageal
circumference
• Grade D: Mucosal break >75% of esophageal
circumference
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Los Angeles Classification
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Gastro- Esophageal Reflux Disease
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Predisposing factors
Inefficient lower esophageal sphincter due to:
Pregnancy Obesity
Fatty food, large meals Coffee, chocolate
Cigarette smoking Alcohol ingestion
Reflux promoting drugs (see under treatment)
Scleroderma Hiatus hernia
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Clinical features• Retro-sternal burning pain (heartburn / pyrosis)
• Dysphagia
• Chest pain
• Hoarseness, choking (laryngospasm),
• Bronchospasm / asthma
• Hematemesis & melaena
• Chronic cough due to aspiration pneumonia
• Symptomatic relief with trial of Pantoprazole
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GERD
• Burning pain
• Pain seldom radiates to
arms
• Produced by bending,
drinking hot liquids
• Relieved by antacids
• Dyspnea absent
Angina pectoris
•Gripping / crushing pain
•Pain radiates into neck,
shoulders & both arms
•Pain produced by
exercise
•Relieved by rest
•Dyspnea present
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Investigations1. Flexible upper GI endoscopy
2. Ambulatory 24-hour double-probe (esophageal &
pharyngeal) pH metry = gold standard
• Distal probe = 5 cm above lower esophageal sphincter
• Proximal probe = 1 cm above upper esophageal
sphincter, in hypopharynx behind laryngeal inlet
• Laryngo-pharyngeal reflux = acidic pH in both probes
• Gastro-esophageal reflux = acidic pH in distal probe only
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24 hour ambulatory double-probe pH monitoing
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pH metry
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GERD LPRD
Heartburn ++++ +
Hoarseness & dysphagia + ++++
Nocturnal (supine) reflux ++++ -
Daytime (upright) reflux + ++++
ed lower esophageal pH ++++ ++
ed pharyngeal pH - ++++
Pantoprazole treatment 40 mg OD X 6 wk
40 mg BD X 6 mth
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Treatment of GERD
A. Life style modifications:
1. Raise head end of bed by 6 inches. Sleep in left
lateral position. Maintain optimum weight.
2. Avoid the following:
• Tight fitting clothes & belts
• Lifting of heavy weight / straining / stooping
• Smoking
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B. Dietary modifications:
1. Take 6 small meals. Eat slowly & chew thoroughly.
2. Take high protein diet.
3. Avoid the following:
• Eating / drinking within 3 hours of reclining
• Fried food / excess fat / large meals
• Taking large amount of fluids with meals
• Aerated drinks / alcohol (especially in evening)
• Coffee / tea / chocolate / mint / citrus fruit juice
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C. Avoid following medicines:
• Tranquilizers & sedatives
• Muscle relaxants
• Calcium channel blockers
• Anti-cholinergic drugs
• Theophylline
• N.S.A.I.Ds
• Doxycycline
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Dietary + Life style modifications + avoid reflux
producing medicines + Liquid antacid (2 tsp 1 hour
before meals & at bed time)
no relief after 4 weeks
Ranitidine 150 mg BD
+ Cisapride 10 mg TID before meals
no relief after 4 weeks
Pantoprazole 40 mg OD before breakfast
no relief after 4 weeks
Nissen’s fundoplication + Hill’s posterior gastropexy
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Nissen’s complete fundoplication
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Nissen’s complete fundoplication
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Belsey Mark IV partial fundoplication
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Toupet repair
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Laparoscopic fundoplication
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Transoral fundoplication
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Hill’s fundoplication + posterior gastropexy
anterior & posterior phreno-esophageal bundles (esophagogastric
junction) sutured to pre-aortic fascia after fundoplication
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Complications of GERD
• Esophageal ulceration
• Esophageal stricture
• Iron-deficiency anemia
• Barrett's esophagus
• Laryngitis, laryngeal ulcers
• Bronchial asthma
• Aspiration pneumonia
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Barret’s esophagus
• Presence of gastric epithelium more than 3 cm
above gastro-esophageal junction caused by
columnar metaplasia of squamous epithelium due
to chronic acid exposure
• Pre-malignant condition for adenocarcinoma
• Rx: Pantoprazole + periodic esophagoscopy every
2 years to rule out dysplasia / malignancy
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Barret’s esophagus
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Barret’s esophagus with adenocarcinoma
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Esophageal ring, web, stricture & atresia
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Web• Only part of lumen
• Consists of mucosa
only
• Involves proximal
esophagus
• E.g. web of Plummer
Vinson Syndrome
Ring• Circumferential
• Consist of mucosa +
muscle
• Involves distal
esophagus
• E.g. Schatzki's ring of
lower esophagus
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Schatzki’s ring
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Plummer Vinson Syndrome• Synonym: 1. Patterson Brown Kelly syndrome
2. Sideropenic dysphagia
• Seen in middle-aged females due to iron
deficiency caused by atrophic gastritis or vitamin
B12 deficiency (pernicious anemia)
• Classical Triad: upper esophageal web
iron deficiency anemia (sideropenia)
cheilitis / glossitis
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Clinical features
• Dysphagia: more to solids than liquids. Due to
upper esophageal web caused by
sub-epithelial fibrosis.
• Pallor: iron deficiency anemia
• Koilonychia (spoon nails): iron deficiency anemia
• Cheilitis + glossitis: vitamin B12 deficiency
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Investigations
• Barium swallow anterior wall web in
• Esophagoscopy upper esophagus
• Blood smear: microcytic, hypochromic anemia
• Serum iron: decreased
• Total iron binding capacity: increased
• Gastric juice analysis: achlorhydria
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Normal Iron levels
Male Female
Total Iron 45-160 g / dL 30-160 g / dL
Total iron binding capacity
220-420 g / dL 220-420 g / dL
Serum ferritin 20-323 ng /mL 10-291 ng /mL
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Upper esophageal web
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Treatment• Supplementation: iron + vitamin B12 + vitamin B6
+ folic acid
• Endoscopic dilatation of web with elastic bougie
or Hurst mercury pneumatic dilator
• Electrosurgical incision or surgical resection of
web for refractory cases
• Regular check endoscopy to rule out post-cricoid
malignancy (seen in 10% cases)
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Esophageal strictures
• Definition: narrowing of esophageal lumen
(normal diameter = 20 mm
• Dysphagia is main symptom (Solids > liquids)
• Etiology for multiple esophageal strictures: benign
pemphigoid, epidermolysis bullosa, caustic
ingestion, candidiasis, graft vs. host disease
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Causes of single stricture• GERD, esophagitis, Barret’s esophagus
• Caustic ingestion: corrosives, hot fluid
• Trauma: foreign body, external injury
• Medication capsules & tablets
• Radiotherapy, sclerotherapy
• Surgical anastomosis of esophagus
• Malignancy
• Congenital: involves lower 1/3rd
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Benign stricture
• Multiple
• Regular mucosa
• Proximal esophageal
dilation present
• At sites of normal
constrictions
Malignant stricture
• Single
• Irregular mucosa
• Proximal dilation absent
due to cancer invasion
• Involves any site in
esophagus
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Caustic stricture
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Benign pemphigoid
Multiple strictures
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Benign epidermolysis bullosa
Multiple strictures Hand contractures
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Asymmetric malignant stricture
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Esophageal compressionExtrinsic compression Intra-mural compression
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Esophagoscopy
• Confirms diagnosis
• Evaluates position of
stricture
• Evaluates length of
stricture
• Rules out malignancy
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Treatment of corrosive ingestionAcid = superficial coagulative necrosis (better)
Alkali = penetrating liquefaction necrosis (worse)
1. Hospitalize + treatment of shock & acid-base balance
2. Stricture prevention by:
• Steroid given within 48 hours for 6 weeks
• Careful nasogastric tube insertion for 3 weeks
• N-acetyl cysteine / Penicillamine: es collagen bonding
3. IV antibiotics + antacids + analgesics
4. Neutralize corrosive with weak acid / alkali within 6 hr
5. Discharge after 6 wk; life long follow up to r/o cancer
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Surgical treatment of stricture
1. Progressive stricture dilatation over months
a. Prograde: oral route with elastic bougie
b. Retrograde: gastrostomy route
2. Stent insertion
3. Stricture excision + reconstruction with colon
4. Esophageal bypass with jejunum / colon segment
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Esophageal atresia
1. Usually occurs with tracheo-esophageal fistula
2. Diagnosed at birth due to:
a. failure to pass nasogastric tube
b. absence of intestinal gas in X-ray abdomen
3. VACTERL: anomalies of Vertebra, Ano-genital,
Cardiac, Trachea, Esophagus, Renal, Limb
4. Rx: immediate repair of esophagus
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X-ray abdomen
• NG tube
unable to
pass into
stomach
• Absence of
intestinal gas
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Esophageal tear & perforation
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Etiology1. Instrumentation: involves upper esophagus
a. Esophagoscopy
b. Dilatation of esophageal stricture
2. Severe vomiting (alcoholic): lower esophagus
a. Superficial mucosal tear = Mallory Weiss tear
b. esophageal perforation = Boerhaave syndrome
3. ed esophageal lumen pressure: childbirth,
forced cough, defecation, seizure, weight lifting
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Clinical FeaturesEsophageal tear: painless hematemesis
Esophageal perforation: life threatening condition
• Severe pain in neck, chest, intra-scapular area
• Odynophagia, fever, prostration
• Tachypnea, tachycardia & hypotension
• Subcutaneous emphysema of neck
• Pneumo-mediastinum: Hamman’s mediastinal
crunch on auscultation
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Mallory Weiss syndrome
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Investigation of perforation
Chest X-ray: pneumothorax,
pneumomediastinum
Gastrograffin esophagogram:
shows perforation. Barium
increases mediastinitis.
Flexible esophagoscopy for
difficult cases
CT scan chest for mediastinitis
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Boerhaave syndrome
Mallory Weiss tear
Onset Vomiting Vomiting
Alcoholism Yes Yes
Tear Trans-Mural Mucosal
Hematemesis Absent Present
Pain Present Absent
Investigation Gastrograffin esophagogram
Endoscopy
Treatment Emergency repair Self limiting,Cauterization
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Treatment• Conservative: for upper esophageal rupture detected
within 12 hours & peptic stricture ruptures
• Thoracotomy & urgent repair of perforation: for
lower esophageal rupture detected within 12 hours
• Esophageal bypass / resection & anastomosis /
indwelling Celestin feeding tube: for perforation
detected after 12 hours & stricture perforations of
malignancy, caustic ingestion & post-radiotherapy
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Conservative treatment
1. Nil by mouth
2. Parenteral nutrition
3. IV high dose broad-spectrum antibiotics
4. Endoscopic insertion of nasogastric tube
5. Continuous nasogastric tube suction for 1 week
• Most perforations heal within 2 weeks
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Achalasia Cardia (Cardiospasm)
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Etiology: 1. degeneration of ganglion cells of inhibitory
neurons in Auerbach’s myenteric plexus
2. Chagas disease (American trypanosomiasis)
Pathogenesis: failure of lower esophageal sphincter
relaxation + uncoordinated peristalsis food
retention dilated + tortuous lower esophagus
Clinical features:
– Dysphagia more to liquids than solids
– Regurgitation of undigested food
– Weight loss, aspiration pneumonia
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• Chest X-ray: mediastinal widening + air-fluid level
• Barium swallow: Smooth fusiform lower esophageal
dilation (mega-esophagus) with abrupt tapering of
lower end (bird's beak appearance). Absence of
fundic gas shadow. Absence of peristalsis.
• Esophagoscopy: sudden dilatation of lower
esophageal lumen (like entering a dirty cave). Rule
out malignancy (0.15% ) causing pseudo-achalasia.
• Esophageal manometry: pressure in esophageal
body; pressure at lower esophageal sphincter
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Barium swallow
![Page 75: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/75.jpg)
Fluoroscopic barium swallow
![Page 76: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/76.jpg)
Esophagoscopy
![Page 77: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/77.jpg)
Esophageal manometry
![Page 78: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/78.jpg)
Treatment• Smooth muscle relaxants (nitrates or calcium
channel blockers): afford short-lived relief
• Endoscopic Botulinum toxin injection into lower
esophageal sphincter: gives relief for many weeks
• Endoscopic dilatation of lower esophageal
sphincter: with elastic bougie / pneumatic dilator
• Heller’s laparoscopic cardio-myotomy: surgical
division of lower esophageal sphincter + Nissen’s
complete fundoplication to prevent post-op reflux
![Page 79: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/79.jpg)
Heller’s cardiomyotomy
![Page 80: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/80.jpg)
Laparoscopic cardiomyotomy
![Page 81: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/81.jpg)
Fundoplication
![Page 82: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/82.jpg)
Scleroderma (CREST syndrome)
• Atrophy & fibrosis of
esophageal smooth muscle
+ incompetent LES
• C/F: GERD + Calcinosis +
Raynaud’s phenomenon +
Esophageal dysmotility +
Sclerodactyly + Telengiectasia
• Rx: Pantoprazole + Cisapride
![Page 83: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/83.jpg)
Esophageal hiatus hernia
![Page 84: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/84.jpg)
• Definition: herniation of part of stomach above
esophageal hiatus in diaphragm
• Sliding hiatus hernia: gastro-esophageal junction slides >
2 cm above esophageal hiatus in diaphragm.
Esophagoscopy is diagnostic.
• Para-esophageal or rolling hernia: part of gastric fundus
rolls up via esophageal hiatus in diaphragm, alongside
esophagus. Gastro-esophageal sphincter remains below
diaphragm & is competent . Esophagogram is diagnostic.
• Rx: Reduction of hernia + Nissen’s fundoplication
![Page 85: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/85.jpg)
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Sliding hernia
![Page 87: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/87.jpg)
![Page 88: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/88.jpg)
Para-esophageal hernia
![Page 89: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/89.jpg)
Para-esophageal hernia
![Page 90: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/90.jpg)
Mixed hiatus hernia
![Page 91: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/91.jpg)
Esophageal Hypermotility
disorders
![Page 92: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/92.jpg)
Cricopharyngeal spasm
• Cricopharyngeous muscle
remains contracted
between swallows
• Smooth posterior
impression in hypopharynx
seen at C6 level
• Cricopharyngeal myotomy
![Page 93: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/93.jpg)
Diffuse esophageal spasm• Dysphagia & chest pain mimicking myocardial
infarction especially on drinking cold liquids
• Barium swallow: simultaneous, uncoordinated,
non-peristaltic contractions in esophagus body
(cork-screw esophagus). Normal LES relaxation.
• Esophageal manometry: simultaneous repetitive
contractions in esophageal body
• Treatment: Nitrates, Nifedipine, Amytriptilline
![Page 94: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/94.jpg)
Barium esophagogram
![Page 95: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/95.jpg)
Esophageal manometry
Coordinated, normal amplitude contractions in
normal esophagus
![Page 96: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/96.jpg)
Esophageal manometry
simultaneous, uncoordinated, non-peristaltic
contractions in esophagus body in diffuse
esophageal spasm
![Page 97: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/97.jpg)
Esophageal manometry
High amplitude contractions in nutcracker esophagus
![Page 98: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/98.jpg)
Esophageal vascular impressions
![Page 99: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/99.jpg)
Vascular impressionsA. Intrinsic esophageal varices
• Uphill: in portal hypertension
• Downhill: in superior vena cava obstruction
B. Extrinsic (dysphagia lusoria)
• Aberrant right subclavian artery
• Right aortic arch
• Double aortic arch
• Aberrant left pulmonary artery
![Page 100: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/100.jpg)
Esophageal varices
![Page 101: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/101.jpg)
• Etiology: portal hypertension & SVC obstruction
• Clinical presentation: hematemesis
• Endoscopy: bluish esophageal varices
• Barium swallow: string of black pearls appearance
• Treatment: a. Cure of etiology
b. Endoscopic variceal sclerotherapy
c. Endoscopic variceal ligation (banding)
d. Porto-systemic vascular shunt
e. Devascularization of lower 5 cm of esophagus
![Page 102: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/102.jpg)
Esophagoscopy
![Page 103: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/103.jpg)
String of black pearls
These filling
defects change
shape during
respiration due to
venous emptying
![Page 104: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/104.jpg)
Uphill varices
![Page 105: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/105.jpg)
Downhill varices
![Page 106: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/106.jpg)
Aberrant Rt subclavian artery
![Page 107: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/107.jpg)
Aberrant Rt subclavian artery
Fluoroscopic barium
swallow shows
esophageal
compression at level
of third & fourth
thoracic vertebrae
![Page 108: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/108.jpg)
Double aortic arch
![Page 109: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/109.jpg)
Aberrant left pulmonary artery
![Page 110: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/110.jpg)
Forrestier’s disease
• Dysphagia caused by
cervical esophageal
compression by vertebral
column osteophyte
• Inv: a. X-ray neck lateral
b. Esophagogram
• Rx: Osteophytectomy
![Page 111: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/111.jpg)
Esophagogram
![Page 112: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/112.jpg)
Esophageal neoplasm
![Page 113: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/113.jpg)
Benign esophageal tumors
• Rare condition
• Types:
• Leiomyoma (commonest)
• Fibro-vascular polyp
• Squamous papilloma
• > 50% are asymptomatic
• Endoscopic / thoracotomy
excision for dysphagia
![Page 114: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/114.jpg)
Esophageal malignancy
• Squamous cell carcinoma (upper 2/3rd)
• Adenocarcinoma (lower 1/3rd)
• Spindle cell carcinoma
• Leiomyosarcoma
• Lymphoma
• Metastasis
![Page 115: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/115.jpg)
Clinical features
• progressive, painless dysphagia for solid foods
• acute food bolus obstruction
• weight loss in late stages
• chest pain or hoarseness: mediastinal invasion
• coughing after swallowing, pneumonia & pleural
effusion: tracheo-esophageal fistula
• cervical lymphadenopathy: node metastasis
![Page 116: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/116.jpg)
Risk factors Smoking Alcohol consumption
Betel nut chewing Tobacco chewing
Vitamin A deficiency Vitamin C deficiency
Barret’s esophagus Achalasia cardia
Corrosive stricture Human Papilloma Virus
Plummer Vinson syndrome
Tylosis (familial hyperkeratosis of palms & soles)
![Page 117: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/117.jpg)
Investigations
1. Barium swallow:
a. shouldering: malignant ulcer with everted margin
b. rat tail appearance: narrow lower 1/3rd with no
proximal dilatation
c. apple core appearance: narrow middle 1/3rd only
2. Esophagoscopy & biopsy from growth
3. CT scan chest: for staging of malignancy
![Page 118: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/118.jpg)
Shouldering
![Page 119: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/119.jpg)
Rat tail appearance
Also seen in
advanced
cases of
achalasia
cardia
![Page 120: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/120.jpg)
Palliative treatment 70% patients have advanced disease at
presentation & require palliative treatment
1. Endoscopic tumour ablation using laser
2. Low dose intra-cavitary radiotherapy
3. Indwelling feeding tube (Mousseau-Barbin, Celestin)
4. Feeding jejunostomy
5. Chemotherapy (5 Fluorouracil)
6. Nutritional support & analgesia with morphine
![Page 121: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/121.jpg)
Definitive TreatmentUpper 1/3rd: early: radical radiotherapy (5500 cGy)
advanced: chemo-radiation
Middle 1/3rd: early: radical RT or radical surgery
advanced: radical surgery + CT
Lower 1/3rd: early: radical surgery
advanced: radical surgery + CT
Radical surgery: esophagectomy + gastrectomy +
reconstruction with gastric / jejunal flap
Chemotherapy (CT): Cisplatin + 5-fluorouracil
![Page 122: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/122.jpg)
Evaluation of dysphagia
![Page 123: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/123.jpg)
Extra-esophageal causes
• Neoplasm: jaw / oral cavity / oropharynx /
hypopharynx / supraglottis
• Inflammation: TM joint arthritis / aphthous ulcer /
Ludwig’s angina / tonsillitis / quinsy / epiglottitis /
retropharyngeal abscess / parapharyngeal abscess
• Paralysis: tongue / soft palate
![Page 124: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/124.jpg)
Esophageal intra-luminal causes
• Impacted foreign body / food bolus
• Esophageal atresia
• Esophageal web (Plummer Vinson Syndrome)
• Esophageal ring (Schatzki’s ring)
• Esophageal stricture: benign / malignant
• Esophageal neoplasm: benign / malignant
![Page 125: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/125.jpg)
Esophageal intra-mural causes
• Inflammation: esophagitis (GERD commonest)
• Hypomotility disorders: Achalasia / scleroderma
• Hypermotility disorders: cricopharyngeal spasm /
diffuse esophageal spasm / nutcracker esophagus
• Other neuro-muscular disorders: Myasthenia
gravis / Multiple sclerosis / Motor neuron disease
![Page 126: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/126.jpg)
Esophageal extra-mural causes
• Pharyngeal pouch
• Hiatus hernia
• Thyroid enlargement: benign / malignant
• Mediastinal: Ca left bronchus / lymphadenopathy /
cardiomegaly / aortic aneurysm /
neoplasm
• Vascular ring: dysphagia lusoria
• Cervical spine osteophyte: Forrestier’s disease
![Page 127: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/127.jpg)
History taking• Level of dyphagia: oral cavity / pharynx / esophagus
• Acute onset: foreign body / trauma / inflammation
• Intermittent: hypermotility disorder
• Progressive: malignancy / stricture
• More for liquids: neuromuscular disorder
• Difficulty in initiation of swallow or after swallow
• Fever + odynophagia: inflammation
• Esophageal trauma / caustic ingestion
![Page 128: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/128.jpg)
History taking• Hoarseness / stridor: laryngo-tracheal invasion
• Hemoptysis: Ca bronchus
• Heartburn: GERD
• Hematemesis: esophageal varices
• Regurgitation: pharyngo-esophageal obstruction
• Neck mass: metastatic lymph node / goitre
• Neurological disorder
• Smoking & alcohol consumption
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![Page 130: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/130.jpg)
Examination
• General: pallor + koilonychia = Plummer Vinson synd
• Oral cavity, oropharynx
• Indirect laryngoscopy: larynx, pyriform sinus,
posterior pharyngeal wall, post cricoid
area
• Laryngeal crepitus: absent in post-cricoid
malignancy, retropharyngeal abscess
• Neck node & cranial nerve examination
![Page 131: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/131.jpg)
Investigations
• Barium swallow with or without air contrast
• Video-fluoroscopic (modified) Barium swallow
• Esophagoscopy: flexible & rigid
• Esophageal manometry: achalasia, esophageal spasm
• 24 hour double probe ambulatory pH monitoring
• Fibreoptic Endoscopic Evaluation of Swallowing
with Sensory Testing (FEESST)
![Page 132: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/132.jpg)
Investigations
Bolus scintigraphy
Chest X-ray: mediastinal mass / cardiomegaly
CT scan chest: mediastinal or pulmonary tumor
Bronchoscopy: Ca bronchus
Thyroid scan: thyroid malignancy
Angiography: vascular rings (dysphagia lusoria)
Peripheral blood smear: Plummer Vinson syndrome
![Page 133: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/133.jpg)
Barium SwallowPlain Air-contrast
![Page 134: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/134.jpg)
Video-fluoroscopic swallow study
![Page 135: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/135.jpg)
Video-fluoroscopic swallow study
![Page 136: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/136.jpg)
Rigid Esophagoscopy
![Page 137: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/137.jpg)
Flexible (oral) esophagoscopy
![Page 138: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/138.jpg)
Esophageal manometry
![Page 139: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/139.jpg)
24 hour ambulatory double-probe pH monitoing
![Page 140: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/140.jpg)
Bravo capsule
Capsule has
no catheter.
Transmits
radio signals.
![Page 141: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/141.jpg)
Fibreoptic Endoscopic Evaluation of Swallowing with Sensory Testing
• Air-pulse stimuli delivered to ary-epiglottic fold
mucosa innervated by superior laryngeal nerve to
elicit laryngeal adductor reflex for airway
protection
• Swallowing evaluation performed with variety of
food consistencies containing green food dye
• Look for aspiration into larynx
![Page 142: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/142.jpg)
Sensory Testing with air pulse
![Page 143: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/143.jpg)
Fibreoptic Endoscopic Evaluation of Swallowing
Complete aspiration Minimal aspiration
![Page 144: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/144.jpg)
Normal swallowing
![Page 145: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/145.jpg)
Bolus scintigraphy
Uses food bolus with radio-isotope to quantify
amount of reflux
![Page 146: Diseases of Esophagus & Dysphagia](https://reader038.fdocuments.in/reader038/viewer/2022102415/56813eef550346895da969ee/html5/thumbnails/146.jpg)
Thank You