BOLILE ESOFAGUL

Diametru intern esofag = 18-20 mm

SIMPTOME
• DISFAGIE
• ODINOFAGIE
• PIROZIS
• REGURGITAȚIE
• “NOD ÎN GÂT”

Disfagia
• Orofaringiană sfincter sup
• Esofagiană corp si sfincter inf

Disfagia oro-faringiana
Tip leziune
1. Diverticul -- d.Zenker
-- d.lateral
2. Intrinsecă -- cancer O.R.L.
-- achalazie
-- sdr. Plummer-Vinson
-- post-iradiere
3. Extrinsecă -- osteofite
-- gusa
4. Tulburări neuromusculare -- accidente vasculare cerebrale
-- boli neurodegenerative

Disfagia esofagiană
1. Lezională a) Mucoasa -- BRGE
-- Esofagite
b) Intrinseci -- stenoza peptica
 -- inel Schatzki
-- cancer
-- hernie hiatala
2. Motorie a) Primitivă -- achalazie
b) Secundară -- sclerodermie
-- alcoolism
-- diabet
Diagnostic diferențial
Simptom Mecanic Motor
Debut insidios/brusc insidios
Progresia regula nu
Tip alimentar solid solid/lichid
Raspuns la deglutitie regurgitare trece cu apa sau deglutitie
Temperatura alimentelor indiferenta rece-agraveaza
Mecanic = leziune, motor = functional

ACHALAZIA = Tulburare idiopatica de motilitate ce produce : achalazia e idiopatica sau secundara

 disfagie progresivă
 regurgitație
 scadere ponderala

FIZIOPATOLOGIE
 absența neuroinhibitorilor VIP și NO
 creșterea presiuni SEI peste 30 mm Hg
 absența sau scăderea contracției esofagului
 relaxare insuficientă a SEI

DIAGNOSTIC
 manometrie
 radiologie
 endoscopie

MANOMETRIE ESOFAGIANA
ASPECT RADIOLOGIC – MODIFICARE IN “CIOC DE PASARE” A ESOFAGULUI INFERIOR

[A 43-year-old woman presented to the surgical clinic with a weight loss of 12 kg in the preceding 8
months and progressive dysphagia for solids and liquids. She also had dyspepsia and depression.
Physical examination revealed her to be pale, without clubbing or lymphadenopathy. On abdominal
examination, there were no palpable masses or organomegaly. Laboratory tests indicated normocytic,
normochromic anemia, with a hemoglobin level of 9.8 g per deciliter. Test results for renal and liver
function were within normal limits. On upper gastrointestinal endoscopy, the scope could not be moved
beyond the gastroesophageal junction. A barium-swallow study showed a dilated esophagus (long
arrow) with tapering at the distal end (short arrow). This tapering is often referred to as “bird's beak
appearance” and is typical of achalasia. The patient underwent a laparoscopic Heller's myotomy, and at
follow-up 6 months later she continued to remain symptomatic, with persistent narrowing at the
gastroesophageal junction seen after a barium swallow. She was then lost to follow-up.]

ESOFAG DILATAT – ASPECTE DE RADIOLOGIE CLASICA SI CT

[A 68-year-old woman presented with fever and dull pleuritic pain in the left chest wall. Chest
radiography revealed a large mass with an air-fluid level in the right hemithorax (Panel A) and a
suggestion of pneumonia in the left lower lobe. Computed tomography using contrast material revealed
a severely dilated esophagus containing food, consolidation in the left lower lobe, and a compressed
right lung (Panels B and C). The patient reported that she had had difficulty in swallowing food since her
20s and had adapted by eating a semiliquid diet for the past four decades. She reported often coughing
when she lay in the left decubitus position. Achalasia was diagnosed by an upper gastrointestinal series
(Panel D). She was successfully treated for aspiration pneumonia and was referred for further treatment
of the achalasia. She declined surgical intervention as a possible means of improving the achalasia.]

DIAGNOSTIC DIFERENTIAL
• BRGE complicat
• spasmul esofagian
• sclerodermie
• cancere (de cardia)

TRATAMENT
• FARMACOLOGIC SISTEMIC – blocanti Ca
• FARMACOLOGIC LOCAL – botox
• DILATAȚIE PNEUMATICĂ – prin endoscopie
• MIOTOMIE PERORALA ENDOSCOPICĂ (POEM)
• MIOTOMIE CHIRURGICALĂ – clasica / laparoscopica

CAZ EDS: peristaltism esofagian accentuat

Cardie punctiforma la 40cm la AD care se depaseste cu dificultate
TB: esofag ingustat in 2/3 inferioare, intens dischinetic, cu contractii tertiare.
Manometrie de rezolutie inalta: IRP mediu=28mmHg
Peristaltica absenta
>20% WS cu panpresurizare
DIAGNOSTIC: ACHALAZIE TIP II
[Absenta relaxarii SEI (n<15)
Lipsa peristalticii]

* In functie de preferintele pacientului si de pregatirea centrului.

Tehnica dilatarii pneumatice

• Dilatare pneumatica cu balon de 30mm
• Sedare cu Midazolam +/- Propofol
•
ALTE TULBURĂRI MOTORII
• SPASMUL ESOFAGIAN DIFUZ
• ESOFAGUL SPĂRGĂTOR DE NUCI (JACKHAMMER – fost “nutcracker esophagus”)
• CAUZE DE DURERI TORAACICE NON-CARDIACE

[A 74-year-old man presented with a 30-year history of intermittent dysphagia and regurgitation, which
his doctor had initially referred to as a “hysterical reaction.” The patient reported having symptoms of
retrosternal fullness leading to regurgitation every 2 to 3 months; he had no associated chest pain,
weight loss, or change in symptom frequency over this 30-year period. A proton-pump inhibitor had
been prescribed 3 years before presentation and did not provide relief. The patient was referred for
evaluation. A barium-swallow examination showed two diverticula proximal to the marked corkscrew
appearance of the distal esophagus (Panel A). The lumen was identified on endoscopy, but advancement
of the endoscope was not possible owing to esophageal tortuosity (Panel B). Manometry was suggested
to assess for diffuse esophageal spasm, but it could not be performed. The patient's symptoms remain
unchanged, with infrequent dysphagia. He is relatively asymptomatic between episodes and has
declined the use of other therapies, such as smooth-muscle relaxants.]
[An 87-year-old woman with severe retrosternal pain and intermittent dysphagia was referred to the
clinic for further evaluation. She described paroxysms of crampy pain almost exclusively during the
intake of solid foods. In the past several months, she noted a weight loss of 5 kg. Endoscopy revealed a
pronounced helical configuration of the esophageal lumen (Panel A and Video). Strong esophageal
contractions occurred such that any advancement or withdrawal of the endoscope was hindered for
several seconds. A barium swallow revealed a corkscrew appearance (Panel B). High-resolution
manometry of the esophagus showed high-amplitude pressure waves, indicating a hypertensive
peristaltic disorder of the esophagus. Because this patient had normal relaxation of the esophagogastric
junction, no premature contractions, and a mean distal contractile integral (a calculation of the
amplitude, duration, and span of the esophageal contraction) greater than 5000 mm Hg•sec•cm, this
motility disorder can be described as nutcracker esophagus. After a trial of high-dose proton-pump
inhibitors led to no clinical improvement, we initiated treatment with long-acting diltiazem, which had
only a limited clinical benefit and had to be stopped because of severe ankle edema.]
ANOMALII
• DIVERTICULI (ZENKER)
• MEMBRANE (SDR PLUMMER-VINSON)
• INELE (SCHATZKI)

Sdr Plummer Vinson

Inel Schatzki si leziuni de esofagita de reflux la pacient cu disfagie acuta

CORPI STRĂINI
COPII
• PERICULOASE -- BATERII
-- OASE
-- ACE
-- OBIECTE ASCUȚITE
 FRECVENTE -- MONEZI
-- NASTURI
-- PIETRICELE
-- JUCĂRII
ADULȚI
• PERICULOASE -- BATERII
-- OASE
-- DROGURI
 -- SCOBITORI
• FRECVENTE -- BOL ALIMENTE
-- OASE
-- PROTEZE
TRATAMENT
• ENDOSCOPIC
• CHIRURGICAL

ESOFAGITE
Clasificare etiologică
• Microbiene
• Virale
• Micotice
• Chimice
• Fizice
• Medicamentoase
• Secundare tulburărilor de motilitate -- BRGE
-- achalazie
CLINICA
 Asimptomatice – majoritatea cazurilor
• Pirozis
• Disfagie
• Odinofagie

CANDIDA ALBICANS
Component normal al florei bucale.
 Antibiotice
 Corticosteroizi
 Tratament antiacid
 Diabet
 Alcolism
 Radioterapie
 Tulburări de motilitate
 HIV CD4 < 200/mmc

TRATAMENT
 ketoconazol 2-400 mg (nizoral)
 fluconazol 100 mg (diflucan)
 itraconazol 200 mg (sporanix)
 amfotericin B 10-20 mg

[Figure 1. A 48-year-old man infected with the human immunodeficiency virus had had recurrent painful
ulcers in his mouth and esophagus for several years. Biopsies of the lesions were nondiagnostic.
Odynophagia and substernal chest pain responded to repeated courses of prednisone for presumed
idiopathic esophageal ulcers. A subsequent recurrence led to a weight loss of 14 kg. The CD4+ cell count
was 9 per cubic millimeter. Esophagoscopy revealed extremely large coalescing ulcers of the distal
esophagus, effectively resulting in a "double-barreled" lumen (Panel A), as well as evidence of Barrett's
esophagus. A barium swallow (Panel B) confirmed the presence of at least four distal esophageal ulcers
and revealed spontaneous reflux of gastric contents into the true lumen (arrowheads in Panels A and B)
and false lumen (arrows in Panels A and B) of the esophagus. Biopsies of the ulcers showed viral
cytopathic effects, and cultures were positive for cytomegalovirus. After six weeks of intravenous
ganciclovir and oral omeprazole therapy, the patient had regained 6 kg and had no odynophagia or chest
pain. Repeated esophagoscopy revealed less active, shallower areas of ulceration, but the overall
anatomy remained grossly abnormal.]

ESOFAGITA HERPETICA – leziuni cu contur bine delimitat, esofag sup, biopsie superficiala (virus in cel
epiteliale), aciclovir
ESOFAGITA CMV – ulceratii mari cu contur geografic, esofag inf, biopsie profunda (virus in endoteliu
vascular), ganciclovir
Necroza de esofag – BLACK ESOPHAGUS

ESOFAGITE MEDICAMENTOASE
Se exclud:
• Scleroterapia
• Radioterapia
• Causticele
• Drogurile ce afectează SEI

LOCALIZARE – de elecție 1/3 medie: esofagita “suspendată”

– 20% 1/3 inferioară

FIZIOPATOLOGIE/TIMP DE TRANZIT:
- Mărime
- Formă
- Forma galenică
- Poziția
- Apă
- Tulburării motorii
- Compresii extrinseci
[acid acetil salicilic intra in celule, scade pH, precipita proteine sii mor celulele]

EVOLUȚIE - cicatrizare 3-6 săptămâni

COMPLICAȚII - stenoze (rar)
TRATAMENT: -- oprirea drogului
-- sucralfat, antiacide
-- dilatare
-- chirurgie

ESOFAGITE CAUSTICE
 • Substante ce sunt capabile sa distruga tesuturile la nivelul locului de aplicare
• Varste: 2-7 ani/40-45
• Istoria naturala -- natura produsului
-- concentratie
-- cantitate
-- durata contactului
acizii => necroza de condensare (precipita proteine), mai putin nociva decat cea data de baze
bazele => necroza de lichefactie (dizolva membranele celulare)
SIMPTOME
• Dureri orofaringiene
• Durerei retrosternale
• Dureri epigastrice
• Hipersalivație
• Vărsături
• H.D.S
• Semne de perforație

Diagnostic - Endoscopie
Grad Endoscopic Extindere leziuni
0 fara leziuni
I eritem
Iia pseudomembrane
Iib ulceratie si/sau necroza
IIIa pseudomembrane circumferential
IIIb ulceratie si/sau necroza circumferential

URGENȚĂ MEDICALĂ
• Poziția sezând
• Abstinența alimentară
• Antiemetice
• Curățarea cavității bucale
• Linie venoasă
• Oxigen
• Antibioterapie sistemica
• Terapie suportiva

ESOFAGITA EOZINOFILICA = Boală cronică imună, mediată prin antigene, caracterizată prin disfuncție
esofagiană și prin inflamație cu eozinofile.

Asocierea cu boli alergice

• Sunt menţionate următoarele asocieri :
- alergia alimentară
- eczeme
- rinita alergică
 - astm

MANIFESTĂRI CLINICE
 Copiii -- refuză hrana
-- nu cresc
-- dureri epigastrice
-- pirozis
 Adulţii -- Evoluţie indolentă 4-5 ani
-- Dureri epigastrice
-- Pirozis rezistent la IPP
-- Disfagie
-- Impactarea bolului
-- H.D.S.
Aspecte endoscopice in EE

TRATAMENT
• DIETĂ DE EXCLUDERE
• DIETĂ GHIDATĂ DE TESTE
• DIETĂ ELEMENTARĂ
• I.P.P
• CORTICOIZI GENERAL/INHALATORI/GEL

BOALA DE REFLUX GASTRO-ESOFAGIAN = Mișcarea retrogradă a conținutului gastric prin sfincterul

esofagian inferior → reflux
1. Reflux fiziologic
2. Reflux patologic
a) des, lung
b) diurn, nocturn
c) simptomatic/lezional

Cresc Scad
alimente proteine lipide
ciocolata
alcool
hormoni vasopresina progesteron
gastrina glucagon
 motilina secretina
CCK
droguri prokinetice blocanti Ca
benzodiazepine
teofilina

MANIFESTĂRI ESOFAGIENE
SIMPTOMATICE
• S. REFLUX TIPIC
• DURERE TORACICĂ LEGATĂ DE REFLUX
LEZIONALE
• ESOFAGITA
• STENOZĂ BENIGNĂ
• ESOFAGUL BARRETT
• ADENOCARCINOM ESOFAGIAN

MANIFESTĂRI EXTRAESOFAGIENE
CERTE
• TUSE CRONICĂ
• BRONȘITĂ
• ASTM BRONȘIC
• LEZIUNI DENTARE
PREZUMATE/POSIBILE
• FARINGITĂ
• SINUZITĂ
• OTITĂ MEDIE RECURENTĂ
• FIBROZĂ PULMONARĂ IDIOPATICĂ

TRATAMENT
I. Schimbarea modului de viață
1. Scadere ponderala
2. Orarul meselor
3. Calitatea alimentelor
4. Fumatul
5. Poziția de somn (capul discret ridicat)
II. Farmacologic
1. Prokinetice :
a) antidopaminergice
-- central: metoclopramid
-- periferic: domperidon
b) colinergice
-- central; betanechol
-- periferic: cisaprid scos din uz
 c) antisecretorii:
-- blocanți receptori H2
-- IPP gold standard
d) antirefluat:
-- sucralfatul
-- alginați
III. Tratament endoscopic
• Procedura STRETTA
• EndoCINCH
• Injectarea de polimeri
• Montarea de LYNCH
• Anti-reflux mucosectomy (ARMS)

Procedura endoscopica antireflux (poza)

Chirurgie
a) gastropexia
b) fundoplicarea Nissen/ Toupet
Procedura Stretta
INJECTARE POLIMERI
Sistemul LYNCH
OPERAȚIA NISSEN
OPERAȚIA TOUPET
PROCEDEUL NISSEN ENDOSCOPIC