Esophagus small group

2021
  To get food from the mouth to
Job of the stomach and keep it there.
It is essentially a propulsive
Esophagus tube with 2 values, one on
either end.
 Salivary
secretion

Physiology of
tLESR
GERD Peristalsis
LES pressure
Diaphragm
Gastric Gravity
pressure
 CC: 30 yo woman hx of “heartburn” and regurgitation of sour material in her
mouth which has worsened

HPI: Started 2 years ago, worse after large meal and when lying down. She has
awakened with chest tightness, coughing and wheezing. She denies vomiting
or difficulty swallowing.

PMH: none, weight increase of 10 kg in 2 years

SHx: drinks 3-4 drinks most evenings, smokes 10-15 cigarettes/day, no other
Case 1 drugs or meds. Works as a food server. Lives with supportive partner.
Meds: none
NKDA

PE: Afeb, nl VS, BMI=32

Normal exam, except oral

Lab tests all normal

Oral
Examination
 Anatomically, what does it mean that she has occasional sour taste in her
mouth?
The acidic stomach contents are retrogradely passing up to her mouth,
breaching both the LES and her UES.

What does the coughing while sleeping mean?

Case 1 She is aspirating into her bronchial tree her stomach contents that are
traveling up the esophagus.

What do you see on the oral exam?

Loss of tooth structure (specifically enamel first) on the lingual side by the
gastric acid that is refluxed.
 What mechanisms operate to decrease exposure of the lower esophagus to
gastric acid?

The resting tone of the lower esophageal sphincter (LES) and the squeeze of the
cuff of diaphragmatic muscle surrounding the LES provide a barrier to the reflux
of gastric contents into the esophagus. The normal LES muscle and
diaphragmatic cuff maintain a high resting tone between swallows to prevent
reflux when intra-abdominal pressure increases.

Case 1 When reflux of acid occurs, either normally due to tLESRs (transient Lower
Esophageal Sphincter Relaxations), or pathologically due to impaired LES tone,
two mechanisms promote clearance of the acid from the esophagus:
1) Peristalsis propels ingested food and refluxed material downward into the
stomach. Primary peristalsis is induced by swallowing and proceeds distally
from the hypopharynx; secondary peristalsis is induced by local distension of
the esophagus and proceeds distally from the site of distension. Main
mechanism for returning refluxed contents to the stomach.
2) Neutralization of the refluxed acid by swallowed salivary bicarbonate.

She is referred for endoscopy…

Normal
Endoscopy

Body of Esophago-Gastric
Esophagus Junction
 Case 1

Case 1
Endoscopy

Normal GE
Junction
  Decreased LES Pressure:
 Alcohol, coffee, smoking, obesity, sleep
 Fatty foods, onions, garlic, hot spices
 Transient LES relaxations reflux episodes:
 Gastric distension

What factors  Impaired gastric emptying:

 Vagotomy, diabetic neuropathy, pyloric obstruction
contribute to  Decreased esophageal peristalsis:
GERD  Sleep, scleroderma
 Decreased gradient across LES:
 Recumbency, increased intra-abdominal pressure-valsalva
 Decreased flow of saliva:
 Smoking, Sjøgren’s
 Compared to patients without heartburn, does she have increased,
decreased, or the same number of tLESRs?
She has the same number of tLESRs as a normal patient but more of
her tLESRs are associated with actual reflux of acid when they occur.

What are the differences between vomiting and regurgitation?

Vomiting is a CNS reflex-mediated process in which gastric contents
are discharged retrograde from the stomach through the mouth. It
involves forceful contraction of the stomach, diaphragm and
GERD abdominal wall muscles as well as relaxation of the LES and UES.

Regurgitation is the retrograde passage of esophageal contents into

the oropharynx, permitted by relaxation of the UES without central
vomiting coordination

Aspiration is passage of oropharyngeal contents into the bronchial

tree.
 • Smoking cessation
• Alcohol cessation or limited use
• Avoid spicy and fatty foods and other dietary triggers
• Weight loss
• Avoid large meals, especially in the evening
• Do not ingest food or liquids for at least two hours before lying
down
• Elevate the head of the bed to gradually achieve a tilt of 30
Treatments for degrees above the horizontal
• Use a PPI (proton pump inhibitor) or H2 blocker to maintain
GERD decreased gastric acidity
• Oral antacids may provide immediate symptom relief

If the GERD is mild then lifestyle changes and antacids may be

enough to treat. Otherwise PPIs are used to treat the symptoms
 How does heartburn (pyrosis) differ from odynophagia?
Heartburn is a vague substernal feeling of burning pain and pressure. Odynophagia
is painful swallowing that generally resolves quickly. Odynophagia is often
associated with ulceration of the esophageal mucosa.

What pathophysiology might you think of when a patient complains of

odynophagia?
Esophageal Ulceration and painful inflammation can be secondary to many things including
candida, herpes, Coxsachie virus (herpangina) and other infections.
Symptoms
How is dysphagia different from heartburn and odynophagia?
Dysphagia is often felt as food sticking on the way down.
 CC: 60 yo man reports food “sticks” on the way down.

HPI: He has noticed increasingly that food has been harder to swallow
over the past 6 months. He now avoids all chunky foods, chews more
thoroughly, and washes bites down with water. He has lost 5 kg in 2
months.

PMH: Heartburn that he has treated with OTC meds for 20 years,
Case 2 otherwise unremarkable
SHx: Never tobacco use. Rare EtOH (<2/month); works in construction,
lives alone
Meds: OTC antacids
NKDA

PE: unremarkable
Labs: Hct = 30% (normal is 45%)
 What is the significance of solid food dysphagia in this man?
New onset solid food dysphagia in anyone over 40 (especially with a long
history of heartburn) should be considered esophageal cancer until proven
otherwise. The solid food dysphagia may result from a stricture or mass which
is impeding the passage of food from the mouth to the stomach.
 
What are the implications of the compensatory changes he made in his
diet?
He has found that chewing his food extra carefully and washing it down with
Case 2 water helps. This behavior is evidence of a physical stricture or mass lesion. It is
less likely that he has a motor disorder which usually presents with liquid
dysphagia.
 
What do you want to know about his weight loss?
Was he trying to lose weight? People who lose significant amounts of weight
unintentionally is a sign of a potentially serious illness.
 
Use the dysphagia algorithm on Slide 16 to arrive at a likely diagnosis.
 Trouble chewing or Likely transfer dysphagia
YES
clearing bolus from (check for dental , neurologic ,
mouth? or muscle disease)

NO

Is the patient YES Consider fungal

immune-suppressed? or viral infection

NO
DYSPHAGIA
ALGORITHM Do only liquids arrest?
YES Consider motor disorder
(achalasia, diffuse spasm, etc.)

for a patient who NO

complains of Likely lumen obstructed

difficulty Must bolus be
regurgitated?
YES (cancer, stricture,
Schatzki ring)
swallowing NO

Is dysphagia rapidly Consider cancer

YES (peptic stricture less common)
progressive?

NO

Consider GERD,
Motor Disorders
Case 2
Barium
Esophagogram

Carcinoma is narrowing and distorting a short segment of

the distal esophagus. The multiple filling defects in the
lumen above the cancer are probably retained food, rather
than other tumor masses.
 Normal

Case 2
Esophagoscopy

Esophagoscopic view of fungating

carcinoma in the distal esophagus
Barett’s
esophagus can
develop from
chronic GERD
Normal gastro-
esophageal junction
for comparison Barrett’s Esophagus
predisposes the patient
to esophageal cancer!
 CC: 34 yo presents to ER complaining of painful swallowing and severe
stabbing substernal pain that has been going on for 5 days, but worse
today.

HPI: This stabbing substernal pain at first was episodic when she
swallowed, but now she has a lasting uncomfortable sensation, much
worse when she swallows. She has soreness throughout her mouth and
throat. She is so uncomfortable that she is not eating or drinking, and
she has lost 3 pounds in 5 days.

PMH: moderate asthma since age 24

Case 3 SHx: No tobacco use, drinks EtOH 4/week, computer programmer
who lives with husband and 1 child
Meds: Tapering off a 3-week course of oral prednisone (steroid) for
recent asthma exacerbation, inhaled steroid BID, and beta-agonist
(Albuterol) prn
ALL: NSAIDS stimulate her asthma
PE Afeb, 100 bpm, 90/60
Lungs: clear
Oral: white exudate throughout which is removable and overlies a
hyperemic (red) mucosa
 What are the most likely causes of her symptoms? Why?
The acute onset of odynophagia, without prior esophageal symptoms,
suggests ulcerative esophagitis. Her exam suggests opportunistic infection
from Candida sp. (yeast). Candida can be found in the mouth of >50% of
the general population. Her recent use of systemic steroids puts her at
increased risk of overgrowth because steroids suppress immune function.
Other opportunistic infections that can occur during immunocompromise
include Herpes and CMV as well as increased risk of the standard
community-acquired infections.
Case 3 Other causes of odynophagia include esophagitis from medications,
anything that can desquamate or ulcerate the posterior pharynx and
esophagus.

What studies would you recommend to confirm the diagnosis? (Slides 22-
24).
Oral candidiasis is typically diagnosed clinically. However, samples can be
viewed under the microscope (using a KOH solution to see the buds,
hyphae and pseudohyphae).
Usually esophagoscopy would be necessary to biopsy and culture the
lesions if the diagnosis was not clear.
Case 3
Oral Exam
 Normal Case 3

Case 3
Esophagoscopy
 Low Power, High Power, Silver-
H&E Stain Methenamine Stain

Case 3
Esophageal
Biopsy
  Infections
 Candida, Herpes, Cytomegalovirus (CMV)
Odynophagia:
 Idiopathic esophageal ulcer
Diff DX
 seen in severe immunodeficiency states
 Acute dysphagia and
Interesting hearing loss in an 87 year
Case A old man
 Patient suffered
acute onset of
Interesting dysphagia and
Case B odynophagia
during a day trip
to Walla Walla.
 Disease List (from the Path Medication List
Pearls lecture) • Proton Pump
• Zenker’s Diverticulum (and Inhibitors
know what a diverticulum is) • H2 blockers
• Achalasia • Antacids
Esophageal • Barrett’s Esophagus
• Esophageal Adenocarcinoma
diseases and • Squamous Cell Carcinoma
Medications • Scleroderma/CREST
• Varices
to know • Mallory-Weiss tears