1 / 46

Esophageal Diseases

Esophageal Diseases. M. Raza Anees, MD Chief, GI and Hepatology VAMC raza.anees@hotmail.com. Dysphagia Achalasia Diffuse esophageal spasms Lower esophageal rings Esophageal webs Esophageal strictures Malignant Obstruction GERD Barrett ’ s esophagus Esophageal Cancer. Dysphagia.

tahir
Download Presentation

Esophageal Diseases

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Esophageal Diseases M. Raza Anees, MD Chief, GI and Hepatology VAMC raza.anees@hotmail.com

  2. Dysphagia • Achalasia • Diffuse esophageal spasms • Lower esophageal rings • Esophageal webs • Esophageal strictures • Malignant Obstruction • GERD • Barrett’s esophagus • Esophageal Cancer

  3. Dysphagia • Normal Swallowing ( Deglutition)    • Voluntary initiated • Involuntary UES relaxation and epiglottis closure • Peristaltic contraction of smooth muscle of body of esophagus • Relaxation of lower esophageal sphincter • Dysphagia: When swallowing does not proceed normally • Odynophagia: Painful swallowing

  4. Swallowing

  5. Causes of Dysphagia • Transfer Disorders • Neurological disorders that leads to oropharyngeal muscle dysfunction • Difficulty in transferring food from mouth to esophagus • Symptoms: Coughing, gagging and nasal regurgitation • CVA, ALS etc • Anatomical or Structural disorders: Obstruction of esophageal lumen • Schatzki ring, stricture, cancer • Motility disorders: • Failure of effective peristalsis and/ or failure of LES relaxation • Endogenous or exogenous causes • Achalasia, DES , systemic sclerosis

  6. Diagnosis of dysphagia • Always work up dysphagia, no empiric treatment • Barium swallow- first test perform • EGD • Esophageal manometry : if above test negative

  7. Previous healthy pt with new onset dysphagia EGD- unless pill- induce Odynophagia present? Yes No: Dysphagia workup Sx of Neuro dysfunction- cough , gagging Modified BA swallow yes no Ba Swallow LE ring stricture corkscrew Features of achalasia Normal EGD EGD Reassurance Medical rx GED and Manometry Consider EGD

  8. Achalasia • Unknown Pathogenesis • Neuronal denervation and ganglion cell degeneration of myenteric plexus • Loss of organized peristalsis in the esophageal body • Elevated pressure or resting tone of LES • Failure of LES relaxation with swallowing

  9. Features of Achalasia • Dysphagia for solids and liquids • Long-standing symptoms, usually yrs • Regurgitation of food especially at night • No age or gender predilection • Complication: Aspiration pneumonia and wt loss

  10. Diagnosis of Achalasia • First test- Barium swallow • Long dilated esophagus • Bird beak -tight LES • Long time to empty • EGD • 2nd test • confirm  • Exclude tumor • Esophageal Manometry • Last test • Lack of normal peristalsis • non-relaxing LES with swallowing

  11. Treatment of Achalasia • Open LES • Pneumatic dilation • Large balloon ( 3-4cm diameter) • 5% risk of perforation • Surgical Myotomy • Botulinum toxin • effective 65% • repeat- 6-12 months • alternate in high risk pts • Calcium channel blocker and Nitrates • Past • partial response

  12. Diffuse esophageal spasm • Simultaneous, non peristaltic contractions of the esophagus, often precipitated by cold or carbonated liquids • Occult reflux or reflux • Dysphagia or and chest pain (atypical) • Diagnosis: • Barium Swallow: Usually normal, cockscrew • Manometry:  • Confirm • non-peristaltic contractions • LES pressure ,low, normal or high (nonspecific) • 24hr pH recording or emperic trail of PPIs • If reflux is consider cause of spasms

  13. Treatment for DES • Reassurance • Calcium channel blocker- Diltiazem • Nitrates • Botox • Avoid cold beverages • emperic esophageal dilation (no rational)

  14. Anatomic Obstruction: Schatzki ring, cancer or strictures • Progress dysphagia • Solid first then liquids, when sever • Can be constant or intermittent • Younger patients; Schatzki ring • Older patients: Cancer or stricture

  15. Lower Esophageal Ring( Schatzki Ring) • Dysphagia • Younger patient • Intermittent solid food dysphagia esp meat and bread • may regurgitate to relief obstruction • Always associated with Hiatal hernia • Reflux may have a role in pathogenesis • On barium Swallow ring should be 13mm or less in diameter to cause symptoms • Treatment: endoscopic dilation, bougie method or hydrostatic balloon. • PPIs after dilation

  16. Esophageal Web •  Plummer-Vinson Syndrome • Rare •  cervical web • Dysphagia • Iron Def anemia • Female • Slight increase risk of esophageal cancer

  17. Esophageal stricture • Constant not intermittent dysphagia for solid food • Long history of reflux • Other • Prolong NG tube placement • Lye injury • rare now • increase risk of esophageal cancer • Diagnosis • Barium Swallow: • Narrowing at EG junction • Treatment • Dilation • PPI

  18. Malignant Obstruction • Squamous cell carcinoma • Adenocarcinoma • extrinsic compression from non esophageal cancer • Rapid progression of symptoms • Solid to Soft solid to liquid

  19. GE- Reflux Disease (GERD):Overview: • Result of inappropriate, transient relaxation of the LES • transient relaxation  • Overdistention of stomach • reflex sec to presence of fatty food in duodenum • Hiatal hernia facilitate reflux • LES pressure is increased by • Motilin • Acetylcholine • Gastrin • LES pressure is decrease by • Progesterone ( pregnancy increases reflux) • Chocolate • smooking • Meds ( eg anticholinergic)

  20. Extra-esophageal manifestations of GERD • Nonproductive cough which is worse at night, hoarseness, continual clearing of the throat. • Fullness in the throat • Frequent Sore throat • Loss of dental enemal • Non- Cardiac chest pain: • 70% are casued by GERD • Usually not associated with heartburn or dysphagia

  21. Extra-esophageal manifestations of GERD • Two respiratory disorders • Excerbation of Asthma • Some asthma patient show improvement with GERD treatment (even without GERD symptoms) • Always ask for Asthma symptoms with GERD pts, esp night time asthma • VCD( vocal cord dysfunction) • Night time wheezing • Usually among younger pts in competitive sports • Stress reaction • Inspiratory stridor (pts can not differentiate it from wheezing) • Can be associated with GERD, so emperic rx help

  22. Complications • Esophageal ulcers • Stricture • Bleeding • Barrett esophagus • Both asthma and GERD are associated with increase BMI

  23. Diagnosis of GERD • Hearburn only • Therapeutic Trial of PPIs • EGD only if trial fails • Alarm symptoms - Start with EGD • Nausea/ emesis • Blood in the stool • Family history of PUD • Weight loss • Anorexia • Anemia • Abnormal physical exam • Long duration of frequent symptoms, especially in while males >45yrs old • Failure to respond to full doses of a PPI • Dysphagia/Odynophagia

  24. Diagnosis of GERD • 24 -hr esophageal pH monitor for atypical causes • refractory symtoms and normal egd • hoarseness, coughing, or atypical chest pain,but no classic symptoms of gerd • failure to responds to PPIs

  25. Treatment of GERD • General Measures • Raise head of bed  • encourage wt loss of >10lb if overweight or recent weight gain • Small meals • No fatty meals in the evening • Eat dinner at least 3 hrs before bed time • No sweets at bedtime • Stop smoking • Antacid PRN • Avoid acidic beverages (e.g;. colas, orange juice, wine) • excessive alcohol

  26. If unsuccessful try antisecretory drugs • PPI or H2 receptor blockers • PPIs before breakfast after a nocturnal fast • Antireflux surgery : Fundoplication in sever GERD • young patient with sever GERD • Refractory to medication • alternative to long term medical therapy • 60% of patient will require PPIs after surgery

  27. Barrett esophagus • Change in cell type from esophageal squamous to specialized intestinal metaplasia- caused by chronic GE reflux • 10-20% of men with chronic reflux • 2% of women with chronic reflux • Screening is controversial • BE is associated with adenocarcinoma • Incidence of adeno in BE patient is 30x then normal rate • Linked to  • Length of BE segment • Hiatal hernia • Degree of dysplasia • Smooking • Risk of adeno in pts with BE is 0.4% per yr • Neither medication or reflux surgery reverse the epithelial changes or eliminate cancer risk

  28. BE follow up • 2 EGDs with biopsies within a yr if no dysplasia repeat in 3 yrs • Low grade dysplasia, repeat in 6months then yearly egd till two consecutive egds are negative for dysplasia • High grade dysplasia, repeat in 3 months • mucosal resection • esophgectomy • repeat q 3 months

  29. Esophageal Cancer • Two types • Squamous cell cancer • Location : Midesophagus • Incidence: 2.2/100,000(white) 15/100000 (blk) • M:F: males >female • Risk factors: • Alcohol • Tobacco • Strictures • Fanconi's anemia • Plummer-vinson syndrome • tylosis  • Scleroderma

  30. Esophageal cancer • Adenocarcinoma • Incidence: 3/100000 (white males), 0.5/100,000(bm) • M:F: 8:1 • Location: Distal esophagus • Risk Factors: • Barrett's metaplasia • GERD • Obesity • Tobacco

  31. Symptom: Progressive dysphagia • Diagnosis:  • Barium Swallow • EGD with biopsy • CT scan and Ultrasound for staging • Treatment • Small or Localized • Surgery • Large or metastasized • Combination chemo plus radiation

More Related