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ESOPHAGUS

WHAT ABOUT?
 Simptoms and signs
 Investigations
 Gastroesophageal Reflux
 Esophagitis
 Esophageal Cancer
 Motility Disorders: Achalasia and D. Spasm
 Structural Anomalies and Miscellaneous
Disorders of the Esophagus
Simptoms and signs
1. DYSPHAGIA
 Sensation of food being hindered in its
passage from mouth to stomach
 Oropharyngeal - odynophagia
 Esophageal dysphagia
Simptoms and signs
DYSPHAGIA
 Oropharyngeal - (odynophagia-pain at swallowing)
– Neuromuscular disease (Cerebrovascular accident, Parkinson,
Wilson, Brain stem tumors, polymyositis, amyloidosis,
systemic lupus erytematus)
– Local mechanical lesions: inflammation (pharyngitis),
tumours, Zenker diverticulum

 Esophageal dysphagia
– Motility disorders (achalasia, scleroderma, diffuse spasm,
nutcracher esophagus)
– Intrinsic mecanical lesions (benign stricture, carcinoma,
foreign bodie, esophageal diverticulum, Schatzki ring)
– Extrinsic mechanical lesions (mediastinal abnormalities-
pulmonary carcinoma, adenopaty, pericarditis, mitral stenosis,
cervical osteoarthrities)
Simptoms and signs
DYSPHAGIA
 Onset ( acute, chronic);
 Total or partial;
 paradoxical (achalasia).
2. HEARTBURN (PIROSIS)
(most tipical symptom for GE Reflux D)
3. PAIN: Anterior toracic pain (motility
disorders, cancer)

4. Regurgitation: pasage of food from


stomach to the mouth without nausea:
(vomiting)
Investigations
 Endoscopy (visualisation, histology)
 Radiology
– Esophageal XR
– Computer tomography
– Magnetic Resonance
 Echography (echo-endoscopy)
 Esophageal Manometry
 pH-metry
ENDOSCOPY
The normal esophageal body
The lower esophageal sphincter (LES)
RADIOLOGY
Barium esophagram
Schatzki's ring on barium esophagra
Schatzki's ring viewed endoscopically
Esophageal stenosis (a)
Esophageal stenosis (b)
ECHOENDOSCOPY
ESOPHAGEAL MOTILITY
ESOPHAGEAL PH-METRY
GASTRO-ESOPHAGEAL REFLUX
DISEASE
 Def. Effortless movement of gastric content
from stomach to esophagus
 Disease if producing symptoms and signs of
tissue injury within the esophagus,
oropharinx, larynx and/or respiratory tract.
Pathophysiology and etiology of reflux
esophagitis
 Inbalance between aggressive forces and
defences forces of esophagus
– aggressive forces: acid, pepsin, bile salts,
pancreatic enzimes
– defence:
» antireflux barries: LES, diaphragmatic crura,
phrenoesophageal ligament, acute angle of His;
» Hiatus Hernia
» luminal acid clearance: gravity, esophageal
peristalsis, salivary and esophageal gland secretions
» tissue resistance
Pathophysiology and etiology of reflux esophagitis
Conditions associeated with GERD

 Gastric acid hypersecretions (gastrinoma)


 pregnancy, diabetes, scleroderma,
 prolong nasogastric intubation
CLINICAL MANIFESTATIONS
CLINICAL MANIFESTATIONS

 TYPICAL
– Heartburn
– regurgitations
– esophageal pain
– dysphagia
 ATYPICAL (respiratory, laryngitis, dental)
When to Perform Diagnostic Tests
 Uncertain diagnosis
 Atypical symptoms
 Symptoms associated with complications
 Inadequate response to therapy
 Recurrent symptoms
 Prior to anti-reflux surgery
INVESTIGATIONS

 Endoscopy (visualisation, histology)


 Radiology
– Gastro-esophageal XR

 Esophageal 24 H pH-metry
 Esophageal Manometry
 Esophageal impedance
ENDOSCOPY

 ESOPHAGITIS/ NO ESOPHAGITIS
 COMPLICATIONS BARRETT
ESOPHAGUS
ENDOSCOPY
ENDOSCOPY
ENDOSCOPY
ENDOSCOPY
Barium Swallow

 Was considered first diagnostic


test for patients with dysphagia
– Stricture (location, length)
– Mass (location, length)
– Bird’s beak
– Hiatal hernia (size, type)
 Limitations
– Detailed mucosal exam for erosive
esophagitis, Barrett’s esophagus
RADIOLOGY

 Gastroesophageal X-Ray
 Trendelenburg position
 Hiatal Hernia
 Stenosis
PH- metry
Wireless, Catheter-Free Esophageal pH Monitoring

Potential Advantages

• Improved patient
comfort and acceptance
• Continued normal work,
activities and diet study
• Longer reporting periods
possible (48 hours)
• Maintain constant probe
position relative to SCJ
Esophageal Manometry

Limited role in GERD

 Assess LES pressure,


location and relaxation
– Assist placement of 24 hr.
pH catheter
 Assess peristalsis
– Prior to antireflux surgery
Impedance Technology Fundamentals
High Impedance Low Impedance

No Reflux Reflux

Impedance falls when reflux is present because the


reflux bolus conducts electricity between the metallic impedance contacts!
Impedance–pH
Catheter 17 cm

15 cm
6 impedance channels

2 pH channels
9 cm

7 cm

5 cm pH - 5 cm

3 cm

pH at tip
Adult with Gastric pH
Model ZAN-S62C01E
COMPICATIONS
Esophageal stricture
BENIGN ESOPHAGEAL STENOSIS
ENDOSCOPY
COMPLICATIONS
Barrett's esophagus
Esophageal Cancer

Barium Swallow Endoscopy


Extraesophageal Manifestations
of GERD
Pulmonary ENT
Asthma Hoarseness
Aspiration pneumonia Laryngitis
Chronic bronchitis Pharyngitis
Pulmonary fibrosis Chronic cough
Globus sensation
Dysphonia
Other Sinusitis
Chest pain Subglottic stenosis
Dental erosion Laryngeal cancer
Potential Oral and Laryngopharyngeal Signs
Associated with GERD
• Edema and hyperemia of
larynx
• Vocal cord erythema,
polyps, granulomas,
ulcers
• Hyperemia and lymphoid
hyperplasia of posterior
pharynx
• Interarytenyoid changes
• Dental erosion
• Subglottic stenosis
• Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-
Pathophysiology of Extraesophageal
GERD
HIATAL HERNIATION
Axial hiatus hernia
Paraesophageal hernia
ESOPHAGITIS
Reflux esophagitis
Esophagitis with candida
Esofagitis with eosinophils
 Citomegal virus herpes
Caustic esophagitis
 Drug alcool
ESOPHAGEAL CANCER
 Pathology: squamous cell carcinoma (S), adenocarcinoma
(A).
 Epidemiology: (S): 2.5-5 in men and 1.5-2.5 women; High
: North China, India, nort Iran, South Africa; (A) lower but
increasing
 Causes: risc factors (S) tabacco, alcohol (Calvados); diet
with low contents in vitamins (A,C,folic A, E, B12) green,
yelow vegetable; achalasia, Head and Nech Squamous Cell
Carcinoma; tylosis; (A) Barrett esophagus
 Symptoms: disphagea (chronic, first to liquid than for solid
too)

ESOPHAGEAL CANCER
 Symptoms: disphagia (chronic, first to liquid than
for solid too);
– anorexia, cought, retrosternal pain, hematemesis,
hoarseness
 Signs: weigh loss, anemia, lymphadenopaty,
hepatomegaly
ESOPHAGEAL CANCER-
INVESTIGATIONS
 GASTROINTESTINAL ENDOSCOPY
– INCLUDING HISTOLOGY
 ESOPHAGEAL Xray
– EXCENTRIC STENOSIS
 LOCAL+DISTAL EXTENSION OF THE
DISEASE
– COMPUTER TOMOGRAPHY
– ECHOENDOSCPY
– LAPAROSCOPY
ENDOSCOPY
Endoscopy
Histopathology

Adenocarcinoma on Barrett esophagus

Adenocarcinoma
X-Ray
Ecoendoscopy

Cancer limited to the esophageal wall

Esophageal cancer invading aorta


Esophageal cancer
Surviving rate at 5 years– 5%
Complictions
Eso-bronchial fistula
Pneumonia
Perforation
Bleeding
Total stenosis

Eso-bronchial fistula
Motility disorders
 Achalasia
 Difuse spasm

ACHALASIA
Def. Motility disorder characterized by increased
lower esophageal sphincter pressure and failure to
relax during swalowing. Peristalsis of body is
absent
Et: degeneration of myenteric plexus of unknown
cause
Achalasia- clinical features-
 Occours at any age
 Dysphagia -all patients;slowly progressive
+paradoxical dysphagia
 Weight loss- quite common
 Regurgitations - 30%; undigested food with
aspirations
 pain- substernal cramps may be severe and
precede dysphagia
INVESTIGATIONS

 Radiology: Chest Xray + Gastroesophageal


Xray:
– esophageal fluid level at the aortic knuckle
– gastric air bubble absent
– dilated esophagus ; barium and food mixing in
the dilated esphagus;
– tapered distal narrowing;
– aperistaltic contractions
INVESTIGATIONS

 Radiology:
INVESTIGATIONS

 Esophageal manometry:
– absence of LOS relaxation with swallowing
– hipertensieve LOS
– absence of peristaltic contractions
Manometric LES tracing of pull through in patient with achalasia
Manometric tracing of a patient with achalasia
Manometric tracing of a patient with achalasia
INVESTIGATIONS

 Endoscopy:
– dilated esophagus with
food debrie
– endoscope is passing
easily in the stomach
TREATMENT
Motility disorders
 Achalasia
 Difuse spasm

Difuse esophageal spasm


Def. Motility disorder characterized by high
amplitude aperistaltic esophageal contractions
without demonstrable organic lesions
Simptoms:
Disphagia intermittent but associated with pain
Chest pain may mimic cardiac pain and be
provoked by stress
Contracţii terţiare,
aperistaltice
Manometric tracing of patient with diffuse esophageal spasm
(DES)
Structural disorders and
Miscelaneous disorders
Mid-esophageal diverticulum as seen on barium swallow
Midesophageal diverticulum
Epiphrenic diverticulum as seen on barium swallow
Lower esophageal mucosal ring
Schatzki's ring viewed endoscopically
Schatzki's ring on barium esophagra
Esophageal stenosis (b)