An Overview of Esophageal

Disorders

.Omar M. Abdul Shafi, FRCS Glasg

Al Quds University, 2012
Esophageal Function Tests
 Cineradiology: Video-esophagogram,
Dysphagia
 Esophagoscopy:
 Endoscopic ultrasound:
 Endoscopic mucosal resection:
 Esophageal manometry:
 Esophageal pH monitoring:
 Bilitec monitoring:
 Impedence testing:
Esophageal Perforation
 Introduction and Etiology: Boerhaave 1724
 Pathophysiology: Negative intrathoracic pressure,
severe sepsis
 Clinical Features:
 Symptoms depend on three factors:
 Location:
 Cervical: Neck tenderness, odynophagia & surgical emphysema
 Intrathoracic: Dysphagia pain, tachycardia & fever
 Spontaneous perforation: Emesis, chest pain, Shortness of breath
 Intra-abdominal: Peritonitis, tachycardia
 Degree of containment
 Time elapsed since injury
Esophageal Perforation2
 Investigation:
 CXR: Pneumomediastinum, air under diaphragm
 Contrast swallow: Water soluble, thin Barium
 CT Scan: Immediately after contrast ingestion
 Esophagoscopy: In suspected perforations distal to the
cervical esophagus, look for a slight bruise, fluttering of
mucosa
 Threrapy:
 Initial resuscitation:
 Intravenous fluids
 Broad spectrum antibiotics: gm +ve, gm –ve and anaerobes
 Antifungals
 Nasogastric tube
 Chest tube
Esophageal Perforation3
 Resection and repair of the esophagus:
 Careful history, therapy depends on the original pathology
 Techniques differ with intrathoracic or intra-abdominal
perforations
 Endoscopic clipping, stenting
 Conservative therapy: Intramural, transmural draining back into the
esophagus, no distal obstruction, no abdominal perforation, no evidence
of systemic sepsis
 Operative principles:
 Debridement
 Two layer closure with buttressing with healthy tissue
 Drainage
 Establishment of enteral access
Achalasia of the Esophagus
 A 1ry esophageal motility disorder of an unknown etiology
 Achalaisa is characterized by:
 A non relaxing lower esophageal sphincter (LES)
 Esophageal body aperistalsis
 Etiology: Thought to be due to loss of ganglion cells from the
myenteric plexus of the esophagus
 Uncommon 1:10000 individuals / year
 M=F, occurs between 20 – 50 years of age but no age is
exempt
 Slow and progressive disease, therefore, patients present late
in the disease
 Earlier diagnosis is possible with conscientious attention to the
pt’s esophageal complaints and a high index of suspicion
Achalasia of the Esophagus 2

:Clinical Symptoms
 Progressive dysphagia for both solids and liquids
 Regurgitation of bland undigested food
 Chest pain
 Weight loss
 History suggestive of aspiration including recurrent pneumonia and
chronic cough
Achalasia of the Esophagus 3

:Diagnosis
 Plain CXR:
 Absent gastric gas bubble
 Dilated fluid filled esophagus seen a right-sided posterior mediastinal
shadow
 Esophagoscopy: (in all patients to exclude tumors or strictures)
 Dilated esophagus with retention of saliva and undigested food
 Barium Swallow: (Diagnostic)
 Air fluid level with a “bird’s beak “ appearance by a non-relaxing LES
 Careful examination of the video will reveal a flaccid aperistaltic
esophagus
 Manometry: 4 characterisitics
 Hypertensive LES in approx. 50% of pts.
 Non relaxing LES
 Esophageal aperistalsis
 An elevated esophageal baseline pressure
Achalasia of the Esophagus 4

:Treatment
 Incurable disease
 Aim of therapy is relief of symptoms
 Non Surgical treatment:
 Calcium channel blockers, nitrates
 Botulinum toxin (Botox)
 Pneumatic dilatation
 Surgical treatment:
 Laparoscopic esophageal (Heller) myotomy and partial fundoplication (Standard of
Care)
 Open Heller myotomy
Disorders of Esophageal Motility

 Inadequate LES relaxation

 Achalasia
 Epiphrenic diverticulum with spasm
 Uncoordinated esophageal contraction
 Diffuse esophageal spasm
 Hypercontraction
 High amplitude peristaltic contraction (Nutcracker Esophagus)
 Hypertensive LES
 Hypocontraction
 Ineffective esophageal motility
Pharyngoesophageal (Zenker’s) Diverticula

 The most common esophageal diverticulum occurs at the

junction of the hypopharynx and the cervical esophagus and is
due to a natural weakness and is due to a natural weakness
between the inferior pharyngeal constrictor and the
cricopharyngeus muscle.
 Symptoms:
 Difficulty of swallowing and weight loss
 Regurgitation of the sac contents; cough, microaspiration and
throat clearing
 Diagnosis:
 Modified Barium swallow
 Treatment:
 Principle: Cricopharyngeal myotomy, excision of the diverticulum
Gastroesophageal Reflux Disease
 Gastroesophageal reflux disease (GERD) is a disorder in which
gastric contents reflux into the esophagus causing heartburn
and other symptoms.
 In the U.S. it affects 40% of the population once a month,
20% once a week and 7% daily
 Symptoms:
Heartburn – Regurgitation – Waterbrash – Dysphagia
 Complications:
Esophagitis & ulcers – Esophageal strictures – Barrett’s Disease - Anemia
 Extraesophageal manifestations of gastroesophageal
reflux disease:
Dental: Erosions – Laryngeal: Laryngitis, polyps, cancer, hoarseness & stenosis
Pulmonary: Chronic cough, asthma, bronchitis & fibrosis
Gastroesophageal Reflux Disease2
 Diagnosis:
 Anatomic Tests:
 Esophagogastroduodenoscopy (± biopsy), Barrett's, mitoses
 Upper gastrointestinal series: H.H., GE junction, stenosis
 Physiologic Tests:
 24 hour pH test: (Gold Standard) Quantifies the number and
duration of reflux events, differentiates upright & supine reflux
events and correlates them with subjective symptoms
 Esophageal manometry: LES data, 1ry motility disorder
 Impedence monitoring: Directional bolus transit
Gastroesophageal Reflux Disease3
 Treatment:
 Symptoms control: PPI
 Surgery:
 Partial fundoplication: Belsey Mark IV, Dor or Toupet
 Total fundoplicationNissen or Nissen-Rosetti
The primary operation now is Laparoscopic Nissen Fundoplication
 Endoluminal Therapy of GERD
Other Esophageal Disorders
 Barrett’s Disease (BE): Premalignant
 Paraesophgeal Hiatal Hernia
 Chemical Esophageal injury:
 Ingestion of caustic agents:
 Alkkaline: Bleaches, toilet bowl and glass cleaners,
hair dyes, button batteries, detergents, dishwasher
detergents, water softeners
 Acidic: Swimming pool cleaners, metal & toilet bowl
cleaners, anti-rust products and car battery fluids
 Chronic strictures and repeated dilatations
Presentation of Esophageal Malignancies
 On the rise in the U.S. – 4% of cancers diagnosed each year
 Frequently presents as advanced disease and is associated with
poor prognosis
 Adenocarcinoma 55% of all diagnoses in the U.S.
 Smoking & alcohol abuse  Squamous cell carcinoma
 GERD  Adenocarcinoma
 Presentation: Dysphagia is the most common presentation 50%,
25% are discovered by endoscopy for chronic GERD or BE surveilance,
bleeing, anemia, chest or abdominal pain
 Investigation:
Upper GI endoscopy – Chest and Abdomen CT – PET CT
Endoscopic Ultrasound (EUS): Gaining acceptance as the modality of choice
for staging, giving information about depth of invasion and nodal status
Endoscopic mucosal resection (EMR): Lesions 2cm in diameter. Depth of
invasion