Diseases of Esophagus & Dysphagia

1. Diseases of Esophagus & Dysphagia Dr. Vishal Sharma

2. Diseases ofesophagus

3. 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

4. Esophagitis

5. 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

6. SavaryMonnier 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)

7. Grade 1 esophagitis

8. Grade 2 esophagitis

9. Grade 3 esophagitis

10. Grade 4 esophagitis

11. Grade 5 esophagitis

12. 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

13. Los Angeles Classification

14. Gastro- Esophageal Reflux Disease

15. 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

16. 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

17. GERD Angina pectoris Gripping / crushing pain Pain radiates into neck, shoulders & both arms Pain produced by exercise Relieved by rest Dyspnea present • Burning pain • Pain seldom radiates to arms • Produced by bending, drinking hot liquids • Relieved by antacids • Dyspnea absent

18. Investigations 1. 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 esophagealsphincter, in hypopharynx behind laryngeal inlet • Laryngo-pharyngeal reflux = acidic pH in both probes • Gastro-esophagealreflux = acidic pH in distal probe only

19. 24 hour ambulatory double-probe pH monitoing

21. pH metry

23. 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

24. 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

25. C. Avoid following medicines: • Tranquilizers & sedatives • Muscle relaxants • Calcium channel blockers • Anti-cholinergic drugs • Theophylline • N.S.A.I.Ds • Doxycycline

26. 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’sfundoplication+ Hill’s posterior gastropexy

27. Nissen’s complete fundoplication

28. Nissen’s complete fundoplication

29. Belsey Mark IV partial fundoplication

30. Toupet repair

31. Laparoscopic fundoplication

32. Transoralfundoplication

33. Hill’s fundoplication + posterior gastropexy anterior & posterior phreno-esophageal bundles (esophagogastric junction) sutured to pre-aortic fascia after fundoplication

34. Complications of GERD • Esophageal ulceration • Esophageal stricture • Iron-deficiency anemia • Barrett's esophagus • Laryngitis, laryngeal ulcers • Bronchial asthma • Aspiration pneumonia

35. 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

38. Barret’s esophagus

39. Barret’s esophagus with adenocarcinoma

40. Esophageal ring, web, stricture & atresia

41. 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

42. Schatzki’s ring

43. 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

44. 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

45. 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

46. Normal Iron levels

47. Upper esophageal web

48. 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)

49. Esophageal strictures • Definition: narrowing of esophageal lumen (normal diameter = 20 mm • Dysphagia is main symptom (Solids > liquids) • Etiology for multiple esophageal strictures: benign pemphigoid, epidermolysisbullosa, caustic ingestion, candidiasis, graft vs. host disease

50. 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