LECTURE 2

DISORDERS OF THE ESOPHAGUS

ESOPHAGEAL FUNCTION

INSERTION BY HYPOPHARYNX & INSERTION BY HYPOPHARYNX & RELAXATION OF THE UPPER ESOPHAGEAL SPHINCTER (UES) TRANSPORT BY ESOPHAGEAL PERISTALSIS DELIVERY BY PERISTALSIS AND RELAXATION OF THE LOWER ESOPHAGEAL SPHINCTER (LES)

LES pressure is about 15 mmHg above intragastric pre ssure

59-y.o. male

History of chest pain Intermittent heartburn Intermittent dysphagia Normal exam Labs: normal Normal cardiac evaluation

CASE

UPPER ENDOSCOPY: EROSIVE ESOPHAGITIS ESOPHAGEAL

STRICTURE

TREATMENT ESOPHAGEAL DILATION HEALTH HABITS and

DIETARY PRECAUTIONS PROTON PUMP INHIBITOR

ESOPHAGEAL SYMPTOMS HEARTBURN DYSPHAGIA

OROPHARYNGEAL 32 muscles involved with swallowing

ESOPHAGEAL NEUROMUSCULAR DYSFUNCTION NEUROMUSCULAR DYSFUNCTION MECHANICAL

REGURGITATION CHEST PAIN ODYNOPHAGIA PSEUDOPHAGIA GLOBUS

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

PATHOPHYSIOLOGY: REFLUXATE OVERCOMES THE ANTIREFLUX BARRIERS OF THE

GASTROESOPHAGEAL JUNCTION (LES @ GEJ)

INAPPROPRIATE, PATHOLOGIC, SPONTANEOUS TRANSIENT RELAXATION OF THE LOWER ESOPHAGEAL SPHINCTER

REDUCED LES PRESSURE INCREASED ABDOMINAL PRESSURE

OBESITY PREGNANCY

INCREASED NOCTURNAL HCL (EATING LATE )

GERD PATHOPHYSIOLOGY

INCREASED ESOPHAGEAL:HCL (acid) CONTACT (at night) WITH DECREASED CLEARING OF REFLUXATE

DELAYED GASTRIC EMPTYING HIATAL HERNIA (sliding) HIATAL HERNIA (sliding)

TRANSIENT RELAXATION OF THE LES IMPAIRED LES FUNCTION

SMOKING, ALCOHOL, CAFFEINE, CHOCOLATE NEGATIVE H. PYLORI STATUS

POSITIVE H. pylori STATUS IS PROTECTIVE EMOTIONAL STRESS

INCREASES SUBJECTIVE SEVERITY OF REFLUX SYMPTOMS BUT NOT THE NUMBER OR DURATION OF REFLUX EVENTS

LESP & HIATAL HERNIA GERD

Size of Hiatal Hernia

HIATAL HERNIASLIDING

PROGRESSIVELY INCREASING LAXITY OF THE PHRENOESOPHA GEAL MEMBRANE, , LEADING TO HIATAL HERNIA AND GROSS INCOMPETENCE

HIATAL HERNIA PARAESOPHAGEAL

MOST (SMALL) AREASYMPTOMATIC

LARGER PARAESOPHAGEALHERNIA CAN CAUSE:EPIGASTRIC PAINEPIGASTRIC PAINNAUSEA/VOMITINGGASTRIC OBSTRUCTIONBLEEDINGPERFORATIONGASTRIC VOLVULUS

REQUIRE SURGICALREPAIR

PULMONARYGERD NOT A COMMON CAUSE OF THESE

CONDITIONS

ASTHMA CHRONIC BRONCHITIS ATELECTASIS ATELECTASIS PULMONARY FIBROSIS CHRONIC COUGH

EAR-NOSE-THROATGERD NOT A COMMON CAUSE OF THESE

CONDITIONS:

THROAT CLEARING CHRONIC HOARSENESS DENTAL DISEASE HALITOSIS HALITOSIS NOCTURNAL CHOKING GLOBUS VOCAL CORD ULCERS SUBGLOTTIC STENOSIS PHARYNGITIS NAUSEA

DIAGNOSIS GERD

HISTORY - SYMPTOMS UGI SERIES (BARIUM)

DEMONSTRATE REFLUX INSENSITIVE INSENSITIVE

UPPER ENDOSCOPY NORMAL (NERD) ESOPHAGITIS BARRETTS ESOPHAGUS EVALUATE AND TREAT

COMPLICATIONS

WHEN TO DO ENDOSCOPY ?ALARM SYMPTOMS

DYSPHAGIA GI BLEEDING ANEMIA WEIGHT LOSS WEIGHT LOSS INADEQUATE THERAPEUTIC

RESPONSE POSSIBLE BARRETTS ESOPHAGUS

with LONG HISTORY OF UNDER TREATED GERD, SYMPTOMS > 5 YRS although there is questionable benefit with routine screening

OTHER DIAGNOSTIC TESTS ESOPHAGEAL MOTILITY

POSITION pH PROBE EVALUATE ESOPHAGEAL FUNCTION

BEFORE SURGERY

24-hour pH STUDY WHEN DIAGNOSIS IS IN DOUBT NON RESPONSE TO THERAPY

ESOPHAGEAL IMPEDANCE MEASURES REFLUX; ACID AND

NONACID REFLUX

ESOPHAGTITIS

ESOPHAGEAL STRICTURE

THERAPY GERD IS CHRONIC & RECURRENT

THERAPY IS LONG TERM IN MODERATE TO SEVERE DISEASE

DIET AND HEALTH HABITS ELEVATION - HEAD OF THE BED

(NIGHTTIME SYMPTOMS)(NIGHTTIME SYMPTOMS) TITRATE TO DISEASE SEVERITY

PPIs when ALARM SYMPTOMS PRESENT STEP UP THERAPY

UNTIL CONTROLLED

STEP DOWN THERAPY UNTIL BREAK-THROUGH

H-2 BLOCKERS

CIMETIDINE (TAGAMET) RANITIDINE (ZANTAC) FAMOTIDINE (PEPCID) FAMOTIDINE (PEPCID) NIZATIDINE (AXID)

PROTON PUMP INHIBITORS

OMEPRAZOLE (PRILOSEC)* LANSOPRAZOLE (PREVACID, DEXILANT) REBEPRAZOLE (ACIPHEX) PANTOPRAZOLE (PROTONIX) PANTOPRAZOLE (PROTONIX) ESOMEPRAZOLE (NEXIUM)** OMEPRAZOLE + Na Bicarb

IMMEDIATE RELEASE (ZEGERID)

LIMITATIONS OF PPI TREATMENT GERD

SPECIFIC GERD Sx ARE NOT EQUALLY RESPONSIVE Heartburn > Regurgitation > Chest pain > Cough

NO SYMPTOM IS 100% SPECIFIC FOR GERD Nonresponsive to treatment make sure there is refl ux

24 hour pH monitoring or Esophageal impedance testi ng 24 hour pH monitoring or Esophageal impedance testi ng

HYPERSENSITIVITY PPIs do not directly treat GERD; it is a neuromuscu lar

dysfunctional disorder that leads to pathological r eflux

TYPICAL GERD SYMPTOMS

ALARM SX / SIGNS PRESENTDYSPHAGIAFOOD IMPACTIONWEIGHT LOSSGI BLEEDINGANEMIAADVANCED AGE (>50)FAMILY HX OF UGI CANCERODYNOPHAGIA

ALARM SX / SIGNS ABSENT

LIFESTYLE CHANGESOTC AA or H2RA prn

PERSISTENT SXSNO

CONTINUE RX

YESUPPER ENDOSCOPY

H2RA BID or PPI QD

YES

PERSISTENT SXS

CONTINUE TX, DECREASING TOLOWEST EFFECTIVE ACID SUPPRESSION TO CONTROL SXS

NO

UPPER ENDOSCOPY

YES

EROSIVE ESOPHAGITISESOPHAGEAL ULCERBARRETTS ESOPHAGUSNORMAL

PPI BID or for NORMAL QD

PERSISTENT SXS

24-HOUR pH or IMPEDANCE STUDY ANTIREFLUX PROCEDURE

NO

YES REFLUX CONFIRMED

CANCERDYSPHAGIAWT LOSS

EOSINOPHILIC ESOPHAGITIS

COMPLICATIONSGERD

STRICTURE - DYSPHAGIA ULCER PAIN, BLEEDING INTRACTABLE

TROUBLESOME SYMPTOMS TROUBLESOME SYMPTOMS MICROASPIRATION BARRETTS ESOPHAGUS

BARRETTS ESOPHAGUSSPECIALIZED INTESTINAL METAPLASIA IN THE

DISTAL ESOPHAGUS1.7% OF ADULT POPULATION IN US

CHRONIC SEVERE REFLUX of both Acid and Bile salts a nd esophageal exposure time

ENDOSCOPY AND BIOPSIES STRICTURE (MID-ESOPHAGUS) STRICTURE (MID-ESOPHAGUS) RISK FOR PROGRESSION TO CANCER

LARGE HIATAL HERNIA LONG BARRETTS SEGMENT DYSPLASIA (high grade) MALES > FEMALES AGE > 70 SMOKING

ADENOCARCINOMA RISK ~ 0.3% /year

1/3 OF PATIENTS ARE ACID INSENSITIVE

BARRETTS ESOPHAGUS

BARRETTS ESOPHAGUS ULCER

ESOPHAGEAL STRICTURE BARRETTS ESOPHAGUS

63-year-old male presents with a history of

progressive dysphagia

Dysphagia associated with a 15 lb weight loss over the last 3 months

Has to eat softer food to get it to go down 40 year history of smoking 1 pack of cigarettes/day Exam: height was 70 inches and he weighed 155 lbs Exam: height was 70 inches and he weighed 155 lbs

(weight 6 months ago 170 lbs) The remainder of the examination was normal except

for reduced breath sounds on chest exam

WHAT IS THE MOST LIKELY CAUSE OF THIS PATIENT S DYSPHAGIA?

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GERD EoE

OBSTRUCTIVE LESIONSDYSPHAGIA

CARCINOMA DYSPHAGIA with WEIGHT LOSS SQUAMOUS CELL CARCINOMA

ALCOHOL AND SMOKING ALCOHOL AND SMOKING

ADENOCARCINOMA GASTROESOPHAGEAL REFLUX DISEASE

ALSOLUTE RISK IS LOW< 10,000 CASES/YEAR IN USINCIDENCE IS INCREASING

ESOPHAGEAL ADENOCARCINOMA PATHOGENESIS

GERD CHRONIC ESOPHAGITIS INTESTINAL METAPLASIA INTESTINAL METAPLASIA

(BARRETTS)* (ALL CASES?)DYSPLASIA ADENOCARCINOMA

Enzinger, PC and Mayer, RJ; Medical Progress: Esop hageal Cancer. NEJM; 2003, 349:2241-2252

TNM STAGING ESOPHAGEAL CANCER

CT CHEST / UPPER ABDOMEN / ENDOSCOPIC ULTRASOUND

PRIMARY TUMOR (T 1 - 4) REGIONAL LYMPH NODES (N0, N1) DISTANT METASTASIS (M0, M1) T1 OR T2, NO, MO - CURATIVE SURGERY T4 OR M1 - CHEMORADIATION T2 OR T3, N1 - CHEMORADIATION +/-

SURGERY

ESOPHAGOGASTRECTOMYCANCER OF THE DISTAL ESOPHAGUS

5-YEAR SURVIVAL: 20-25%

ESOPHAGEAL CANCERADENOCARCINOMA

ESOPHAGEAL CANCER SQUAMOUS CELL

OBSTRUCTIVE DYSPHAGIAALCOHOL & SMOKING

ESOPHAGEAL CANCER SQUAMOUS CELL

RADIOGRAPHIC APPEARANCE

ESOPHAGEAL CANCER ADENOCARCINOMA

26-year-old male dysphagia associated with an

esophageal food impaction

Occurred while eating chicken History of intermittent heartburn and on occasion d ysphagia

over the last 3 years. The heartburn has not been helped with the use of r anitidine The patient was thin otherwise the examination was normal

Labs including a CBC were normal Labs including a CBC were normal

WHAT DOES IMPACTION SUGGEST?

WHAT ARE THE POSSIBLE CAUSES OF THE DYSPHAGIA?

HOW SHOULD THIS PATIENT BE EVALUATED?

MEAT (CHICKEN) IMPACTION IMPACTION REMOVED

EOSINOPHILIC ESOPHAGTITIS

EOSINOPHILIC ESOPHAGITIS (EoE ) AFFECTS ALL AGE GROUPS including children MEN > WOMEN SHARES CLINICAL and HISTOLOGIC FEATURES with GERD

CHILDREN: vomiting, feeding intolerance, failure to thrive ADULTS: chest pain, heartburn, epigastric pain, dysp hagia, food

impactions, refractory GERD

EoE AND GERD ARE NOT MUTUALLY EXCLUSIVE PPI-responsive EoE (do not have GERD) exhibit a clinical PPI-responsive EoE (do not have GERD) exhibit a clinical

response to PPIs PPI may have an anti-inflammatory effect

TREATMENT of SUSPECTED EoE: Trial of PPI for 2 months Swallowed topical steroids Empiric elimination diets Esophageal dilation for dysphagia

EOSINOPHILIC ESOPHAGITISFOOD ALLERGY or AEROALLERGEN

ANTIGEN

ACTIVATED IMMUNE SYSTEM

Th2 (IL-4, IL-5, IL-13)

EOTAXIN-3 secretion from the esophageal

squamous cells

Eosinophilshome to the esophagus

Omeprazole blocks IL-13 Induced Eotaxin-3 secretionIn sq. cells from EoE patients

69-YEAR OLD MALE PRESENTS TO THE EMERGENCY DEPARTMENT AT 11:00 PM WITH THE INABILITY TO

SWALLOW HIS OWN SALIVA

He was eating a steak at 7:00 pm which lodged in his throat

Has been unable to swallow since that time Normally has no difficulty eating, but has noted tha t Normally has no difficulty eating, but has noted tha t

meat has had a tendency to hang-up on occasion. Except for drooling the exam was normal

WHAT IS THE CAUSE OF THIS PATIENT S DYSPHAGIA?HOW SHOULD THIS PROBLEM BE EVALUATED AND TREATED?

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GERDEoE

OBSTRUCTIVE LESIONSRINGS

SCHATZKIS RING 10% OF POPULATION LUMEN < 13 mm: DYSPHAGIA LUMEN < 13 mm: DYSPHAGIA

14-18 mm MAY HAVE DYSPHAGIA

SCHATZKIS RING

FOOD IMPACTION SCHATZKIS RING

RELATED TO GERD

55-YEAR OLD MALE WHO HAS A HISTORY OF PROGRESSIVE DYSPHAGIA TO BOTH

LIQUIDS AND SOLIDS

15 lbs loss over the last 6 months Notes regurgitation but not heartburn. He tried

Prilosec but it was not helpful The patient was somewhat thin but the

examination was otherwise normal Labs including a CBC were normalPOSSIBLE CAUSES OF THIS PATIENT S DYSPHAGIA?

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GERDEoE

ESOPHAGEAL NEUROMUSCULAR (MOTILITY)

DISORDERS

ACHALASIA SCLERODERMA SCLERODERMA MOTILITY DISORDERS

DISTAL (DIFFUSE) ESOPHAGEAL SPASM

HYPOMOTILITY

ACHALASIAFAILURE TO RELAX

DEGENERATION OF NEURONS (MYENTERIC PLEXUS) NITRIC OXIDE NEURONS

(INHIBITION)(INHIBITION) VIP NEURONS

REDUCED RELAXATION of the LES WITH SWALLOWING INCREASED LES PRESSURE

LOSS OF PERISTALSIS IN THE LOWER 2/3 OF THE ESOPHAGUS

ACHALASIA

DYSPHAGIA TO BOTH LIQUIDS AND SOLIDS

WEIGHT LOSS ASPIRATION ASPIRATION INCREASED RISK OF SQUAMOUS

CARCINOMA AFTER AGE 50 IF UNTREATED

ACHALASIA DIAGNOSIS

UPPER ENDOSCOPY ESOPHAGEAL MOTILITY STUDY

TREATMENT PNEUMATIC BALLOON DILATION PNEUMATIC BALLOON DILATION SURGICAL MYOTOMY BOTOX INJECTION MEDICATION NOT VERY USEFUL

NITRATES CALCIUM CHANNEL BLOCKER VIAGRA

ACHALASIA

BIRDS BEAK ENDOSCOPIC VIEW

ACHALASIA PNEUMATIC BALLOON DILATION

19-YEAR OLD FEMALE COMPLAINS OF

ODYNOPHAGIA

She has a history of acne for which she takes doxycycline which she typically takes at night

She woke up in the morning with severe odynophagia when she drank a glass of orange juice. juice.

Examination was normal. Labs including a CBC were normal

WHAT IS THE MOST LIKELY CAUSE OF THIS PATIENT S ODYNOPHAGIA?

PILL ESOPHAGITIS ODYNOPHAGIA

ESOPHAGEAL INFLAMMATORY LESIONS

EOSINOPHILIC ESOPHAGITIS PILL ESOPHAGITIS CANDIDA ESOPHAGITIS HERPETIC ESOPHAGITIS HERPETIC ESOPHAGITIS IDIOPATHIC ULCER - AIDS

CANDIDA CMV HERPES

CANDIDA ESOPHAGITIS ODYNOPHAGIA

HERPETIC ESOPHAGITIS ODYNOPHAGIA

IDIOPATHIC ULCER - AIDS ODYNOPHAGIA

ESOPHAGEAL DISORDERS KEY POINTS

GERD COMMON, RECURRENT, CHRONIC WIDE SPECTRUM OF SYMPTOMS TAILOR THERAPY TO SEVERITY STRICTURES 10%

EXCLUDE CARDIAC CAUSES OF CHEST PAIN PRIOR TO CONSI DERING THE DIAGNOSIS OF NON-CARDIAC CHEST PAIN

ALARM SYMPTOMS WARRANT UPPER ENDOSCOPY PPIs ARE EFFECTIVE AND SAFE FOR APPROPRIATE INDICAT IONS AND USING

LOWEST EFFECTIVE DOSELOWEST EFFECTIVE DOSE ESOPHAGEAL ADENOCARCINOMA IS ON THE RISE (OBESITY, LONG HISTORY OF

GERD, BARRETTS ESOPHAGUS) SQUAMOUS CELL CARCINOMA RELATED TO TOBACCO AND ALCO HOL USE

(DECREASING) ACUTE ODYNOPHAGIA - PILL ESOPHAGITIS INFLAMMATORY ESOPHAGITIS

EOSINOPHILIC ESOPHAGITIS (CHILDREN, ADULTS MALE > FEMALE) SHARES SYMPTOMS WITH GERD ENDOSCOPY WITH BIOPSIES PPI, TOPICAL STEROID, ELIMINATION DIET

HEALTHY PEOPLE: HSV AIDS, DM, CHEMO: CANDIDA, CMV, HSV, IEU (AIDS)

SCHATZKIS RINGS INTERMITTENT DYSPHAGIA

LARGE ESOPHAGEAL ULCER WITH TRACHEOESOPHAGEAL FISTU LA

ESOPHAGEAL STENT PLACED

TRACHEOESOPHAGEAL FISTULA