congenital atresia of the esophagus: with tracheo-esophageal fistula
Esophageal Disorders - School of Medicine · • Most common esophageal disorder • This is where...
Transcript of Esophageal Disorders - School of Medicine · • Most common esophageal disorder • This is where...
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Esophageal DisordersBy
George Vagujhelyi MD
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Cardinal symptoms
• Heartburn
• Bland or sour regurgitation
• Chest Pain
• Dysphagia
• Odynophagia
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Atypical Symptoms• Dyspepsia(epigastric burning and fullness)• Nausea and Vomiting• Hematemesis• Globus• Coughing• Throat clearing• Throat pain• Hoarseness• Wheezing/stridor• Dyspnea• Apnea• Halitosis
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Esophageal disorders
• Gastroesophageal Reflux Disease
• Barrett’s Esophagus
• Eosinophilic Esophagitis
• Intrinsic Structural disorders
• Systemic Disorders
• Iatrogenic
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Gastroesophageal Reflux• Most common esophageal disorder
• This is where gastric contents refluxes into the esophagus
• TLESR( transient lower esophageal sphincter relaxation)• <1 min inhibition of the tone LES• Decrease contraction of circular muscle of esophagus• Cessation of diaphragmatic • Contraction of the longitudinal esophageal muscle.• Requires an intact vagal nerve• Triggered by abd distension, awake and in postprandial state• All this is a normal physiological response to venting
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GERD
• People with GERD develop more acid reflux during TRLES and extended further proximally • Compounding factors:
• Obesity• Conditions that increase pressure difference between the abd and thoracic cavity• Delayed emptying • Delay in clearance of acid contents ( salivary production, peristalsis)
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GERD• Most commonly diagnosed GI disorder
• 9 million o/p visits annually
• Occurs in all ages
• 40 % of adults have an event monthly
• 18% report weekly
• Actual organ damage in fewer then 50% of patients who present with symptoms
• Of those who have EGD 10 % have esophagitis,3-4% Barrett’s, Adeno CA
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GERD risk factors• Obesity
• Hiatal hernia
• Smoking
• NSAIDS
• Aging
• IBS
• Anxiety/depression
• FHx
• HP and Chronic atrophic gastritis (inverse association)
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GERD complications• Esophagitis and ulceration
• Strictures• Peptic
• Distal location near GEJ• Erosions, ulcerations and Barrett’s
• Higher • Pill• Neoplasia• EoE
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GERD complications• Barrett’s Esophagus
• demonstrates salmon-colored mucosa and the biopsy shows intestinal metaplasia with goblet cells.
• Prevalence is about 1-2 %• Half don’t report typical GERD symptoms
• Risk factors• Erosive esophagitis• Male• White• Heavy ETOH• Hiatal hernia• Low LES • Dysfunctional peristalsis
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Extra esophageal manifestation of GERD• These structures are not normal exposed to acid reflux
• Thus no neutralizing mechanism• No clearance mechanism
• Asthma
• Aspiration pneumontitis/pul fibrosis
• Laryngitis/vocal cord lesions
• Chronic cough
• Dental erosions
• Sinusitis
• Otitis media
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Therapy• Lifestyle changes
• Medical therapy• PPI once a day prior to the first meal
• Twice a day dosage for those with erosive disease for a period of time only to be titrated down to control symptoms
• Non erosive reflux disease • Consider short course therapy to control symptoms
• Surgery• Initial results are good but then symptoms of dysphagia and gas-bloat may
off set• About half of the patients will require repeat surgery or medical therapy.
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Eosinophilic Esophagitis• Is an esophageal dysfunction accompanied by pathological evidence of
predominantly eosinophilic inflammation in the esophagus
• The eosinophilic infiltration is about 15/high powered field
• Prevalence <1 per 1000
• It seems to be increasing
• Diagnosis is less in the winter months
• More prevalent in Male non-Hispanic whites
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EoE• Clinical presentation
• Solid food dysphagia• Most common diagnosis in young people with food impaction• May have other atopic conditions ( eczema, allergic rhinitis,food allergy)
• Endoscopic findings• Corrugated mucosa• Longitudinal mucosal furrows• Whites spots/plaques• Focal rings and strictures• Diffusely small-caliber esophageal lumen• Fragile mucosa
• Try to involve an allergist
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EoE• Therapy
• Removal food impactions• Dilation which may need to be repeated, may results in rents and
odynophagia• However unless there is not a dominant stricture driving the dysphagia
• Defer dilation try avoidance of the food• Medical therapy
• PPI therapy 20-40 mg QD-BID• Systemic steroids 2mg/kg/d 60 mg max for 4 wks course severe symptoms• Fluticasone 880-1760 mcg/d risk of candida esophagitis• Elemental diet great for kids, expensive poorly tolerated do to feeding tube• Six food elimination( wheat,milk,eggs,soy,peanuts,fish,shell)• Targeted elimination based on allergy test ( low response rate)
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EoE• Associated conditions
• GERD• Eosinophilic gastritis • Celiac disease• IBD• Drug reactions• Hypereosinophilic syndromes• Infections• Autoimmune disorders
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Systemic Disorders
• Diabetes• Predispose to GERD
• Type 2 DM• Obese• Hyperglycemia increase TLESR response to gastric distension• Delayed gastric emptying• Less sensitive to abnormal amounts of reflux• Reflux esophagitis common finding in DKA• Candida esophagitis
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Systemic disorders• Connective tissue disorders
• Systemic sclerosis• Mixed connective tissue
• Reduced LES• Atrophic smooth muscle • Delayed gastric emptying
• Sjogrens syndrome• Reduced saliva
• Risk for iatrogenic causes secondary to immunosuppression, pill injury and bisphosphonates
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Dermatological disorders
• There is squamous epithelial tissue in the esophagus thus several systemic disease that affect the skin can manifest in the esophagus as well• Epidermolysis bullosa• Bullous phemphigoid• Pemphigus vulgaris• Steven-Johnson• Lichen planus
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iatrogenic• Pill induced
• ASA,NSAIDS• Bisphosphonates• KCL• Doxycycline/tetracycline• Ascorbic acid• Ferrous sulfate
• They cause symptoms of worsening heartburn, chest pain , dysphagia and/or odynophagia• Medications
• Inhibit smooth muscle tone and contractility• Calcium channel blocker• Theophylline• Beta-agonist• Anticholinergic properties• radiation
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Diagnosis • For patients with classical symptoms
• Heartburn( substernal postprandial burning with upward radiation)• High likelihood they have GERD
• Trail of PPI therapy good response no further testing• Odynophagia, dysphagia
• Need EGD • Alarming symptoms
• Wt loss• FFt• Vomiting • Hematemesis
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Therapy failures• Non compliance• Improper timing• Inadequate dosage• Rapid metabolizer• Nocturnal acid breakthrough• False positive GERD• Another esophageal disorder( achalasia,EoE)• Functional disorder• Z-E syndrome• EoE• Celiac disease• Medication induced• Infection• Delayed gastric emptying