ESOPHAGEAL DISEASES

Two major functions of the esophagus:
 Transport of the food bolus

from the mouth to the stomach.  Prevention of retrograde flow of gastrointestinal contents.

Upper esophageal sphincter
Striated muscle Consists of the cricopharyngeus and inferior pharyngeal constrictor muscles, striated muscles innervated by excitatory somatic lower motor neurons.

Lower esophageal sphincter
(LES) is composed of smooth muscle. Innervated by parallel sets of parasympathetic excitatory and inhibitory pathways. Supplemented by the striated muscle of the diaphragmatic crura, which surrounds the LES and acts as an external LES.

Fatty meals, smoking, and beverages with a high xanthine content (tea, coffee, cola) cause a reduction in sphincter pressure.
Adrenergic agonists, gastrin, and prostaglandin F2 cause its contraction.

SYMPTOMS

Dysphagia
Sensation of “sticking” or obstruction of the passage of food through the mouth, pharynx, or esophagus.

Odynophagia
painful swallowing.

Atypical chest pain

Heartburn
Is a burning retrosternal discomfort that may move up and down the chest like a wave.

Regurgitation
Is the effortless appearance of gastric or esophageal contents in the mouth. The regurgitated material consists of tasteless mucoid fluid or undigested food.

Diagnostic Tests

Radiologic Studies
Barium swallow with fluoroscopy can be used to evaluate both structural and motor disorders. Double-contrast esophagogram, is particularly useful in demonstrating mucosal ulcers and early cancers.

Esophagoscopy
Esophagoscopy is the direct method of establishing the cause of mechanical dysphagia and of identifying mucosal lesions that may not be identified by the usual barium swallow. Endoscopic ultrasonography permits evaluation of intramural masses and staging of esophageal cancer.

Esophageal Motility
The study of esophageal motility entails simultaneous recording of pressures from different sites in the esophageal lumen with pressure sensors positioned 5 cm apart. The UES and LES appear as zones of high pressure that relax on swallowing.

Motor Disorders

Striated Muscle
Oropharyngeal Paralysis Paralysis of oral muscle leads to difficulty initiating swallowing and drooling of food out of the mouth. Pharyngeal paralysis, characterized by dysphagia, nasal regurgitation, and aspiration during swallowing, occurs in a variety of neuromuscular disorders.

Smooth Muscle
Achalasia
Achalasia is a motor disorder of the esophageal smooth muscle in which the LES does not relax normally with swallowing, and the esophageal body undergoes nonperistaltic contractions.

Pathophysiology of Achalasia
Loss of intramural neurons. Inhibitory neurons are predominantly involved.

Types of Achalasia
Primary idiopathic achalasia accounts for most of the patients. Secondary achalasia:  Gastric carcinoma infiltrating esophagus.  Lymphoma.  Certain viral infections.  Eosinophilic gastroenteritis.  Neurodegenerative disorders.

Clinical features of Achalasia
Dysphagia, chest pain, and regurgitation are the main symptoms. Dysphagia appears early, occurs with both liquids and solids, and is worsened by emotional stress and hurried eating.

Diagnosis of Achalasia
Chest x-ray shows absence of the gastric air
bubble and sometimes a tubular mediastinal mass beside the aorta. Air-fluid level in the mediastinum in the upright position represents retained food in the esophagus.

Barium swallow shows esophageal dilation,
and in advanced cases the esophagus may become sigmoid.

Manometry LES pressure to be normal
or elevated, and swallow-induced relaxation either does not occur or is reduced in degree, duration, and consistency. The esophageal body shows an elevated resting pressure.

Treatment
Nitroglycerin, is used sublingually before meals and as needed for chest pain. Isosorbide dinitrate, sublingually is used before meals. Nifedipine, orally or sublingually before meals, is also effective.

Endoscopic intrasphincteric injection of botulinum toxin is effective over a short period in some patients. Balloon dilatation reduces the basal LES pressure by tearing muscle fibers

Heller's extramucosal myotomy of the LES, in which the circular muscle layer is incised. Laparoscopic myotomy is the procedure of choice.

Diffuse Esophageal Spasm and Related Motor Disorders
Diffuse esophageal spasm is characterized by nonperistaltic contractions, large amplitude and long duration.

Pathophysiology
Nonperistaltic contractions: dysfunction of inhibitory nerves. Diffuse esophageal spasm may progress to achalasia.

Clinical features
Present with chest pain, dysphagia, or both.

Diagnosis
In diffuse esophageal spasm, barium swallow shows that normal sequential peristalsis is replaced by uncoordinated simultaneous contractions. Manometry:hypertensive, "nutcracker esophagus."

Treatment
Sublingual nitroglycerin Isosorbide dinitrate Nifedipine. Tranquilizers are helpful in allaying apprehension.

Scleroderma Esophagus
The esophageal lesions in systemic sclerosis consist of atrophy of smooth muscle, manifested by weakness in the lower two-thirds of the esophageal body and incompetence of the LES. The esophageal wall is thin and atrophic and may exhibit areas of patchy fibrosis.

Symptoms
These patients usually also complain of heartburn, regurgitation, and other symptoms of gastroesophageal reflux disease (GERD).

Diagnostic
Barium swallow shows dilation and loss of peristaltic contractions in the middle and distal portions of the esophagus

GASTROESOPHAGEAL REFLUX DISEASE

GERD

Gastroesophageal Reflux Disease (GERD)
Any symptoms or esophageal mucosal damage that results from reflux of gastric acid into the esophagus. Classic GERD symptoms
– Heartburn . – Regurgitation.

Important Reasons to Diagnose and Treat GERD
Negative impact on health-related quality of life. Risk factor for esophageal adenocarcinoma.

Clinical Presentations of GERD
Classic GERD. Extraesophageal/Atypical GERD. Complicated GERD.

Extraesophageal Manifestations of GERD
Pulmonary Asthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis ENT Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Dysphonia Sinusitis Subglottic stenosis Laryngeal cancer

Other Chest pain Dental erosion

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

Pathophysiology of Extraesophageal GERD

Symptoms of Complicated GERD
Dysphagia
– Difficulty swallowing: food sticks or hangs up

Odynophagia
– Retrosternal pain with swallowing

Bleeding

When to Perform Diagnostic Tests??
Uncertain diagnosis. Atypical symptoms. Symptoms associated with complications. Inadequate response to therapy. Recurrent symptoms. Prior to anti-reflux surgery.

Diagnostic Tests for GERD
Barium swallow. Endoscopy. Ambulatory pH monitoring. Esophageal manometry.

Barium Swallow
Useful first diagnostic test for patients with dysphagia
– Stricture (location, length). – Mass (location, length). – Hiatal hernia (size, type).

Limitations
– Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus

Endoscopy
Indications for endoscopy
– Alarm symptoms – Empiric therapy failure – Preoperative evaluation – Detection of Barrett’s esophagus

Ambulatory 24 hr. pH Monitoring
Physiologic study Quantify reflux in proximal/distal esophagus
– % time pH < 4

Symptom correlation

Ambulatory 24 hr. pH Monitoring

Normal

GERD

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

Treatment Goals for GERD
Eliminate symptoms. Heal esophagitis. Manage or prevent complications. Maintain remission.

Lifestyle Modifications are Cornerstone of GERD Therapy
Elevate head of bed 4-6 inches. Avoid eating within 2-3 hours of bedtime. Lose weight if overweight. Stop smoking. Modify diet:
– Eat more frequent but smaller meals. – Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea.

Acid Suppression Therapy for GERD
H2-Receptor Antagonists Cimetidine. Ranitidine. Famotidine. Nizatidine. Proton Pump Inhibitors (PPIs) Omeprazole. Lansoprazole. Rabeprazole. Pantoprazole. Esomeprazole.

Effectiveness of Medical Therapies for GERD
Treatment Lifestyle modifications/antacids H2-receptor antagonists Single-dose PPI Increased-dose PPI Response 20 % 50 % 80 % up to 100 %

Treatment Modifications for Persistent Symptoms
Improve compliance. Optimize pharmacokinetics
– Adjust timing of medication to 15 – 30 minutes before meals. – Allows for high blood level.

Consider switching to a different PPI.

Complications of GERD
Erosive/ulcerative esophagitis. Esophageal (peptic) stricture. Barrett’s esophagus. Adenocarcinoma.

Erosive Esophagitis

When to Discuss Anti-Reflux Surgery with Patients
Intractable GERD (rare):
– Difficult to manage strictures. – Severe bleeding from esophagitis. – Non-healing ulcers.

GERD requiring long-term PPI in a healthy young patient. Persistent regurgitation/aspiration symptoms.

Endoscopic GERD Therapy
Radiofrequency energy delivered to the LES → (Stretta procedure) Suture ligation of the cardia → (Endoscopic plication) Submucosal implantation of inert material in the region of the lower esophageal sphincter.

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