‫بسم هللا الرحمن الرحیم‬

‫مضمون ‪ :‬داخله عمومی‬

‫سمستر ‪۸ :‬‬
‫پو هنځی ‪ :‬طب معالجوی دانشگاه خاتم النبین‬
‫استاد ‪ :‬دوکتورحیم هللا امیرزی متخصص داخله عمومی‬
‫سال ‪ ۱۴۰۲ :‬ه ش‬
‫موضوع ‪ :‬امراض مری‬
Diseases of the Esophagus
ESOPHAGEAL STRUCTURE AND FUNCTION

The esophagus is a, muscular tube coursing through the posterior mediastinum joining the
hypopharynx to the stomach with a sphincter at each end

It functions to transport food and fluid between these ends, otherwise remaining empty.
Esophageal diseases can be manifested by impaired function or pain.

Key functional impairments are swallowing disorders

and excessive gastroesophageal reflux.
Con..
 SYMPTOMS OF ESOPHAGEAL DISEASE

• Heartburn (pyrosis):
• a discomfort or burning sensation behind the sternum that arises from the
epigastrium and may radiate toward the neck.
• most commonly experienced after eating, during exercise,and while lying recumbent.
• The discomfort is relieved with drinking water or antacid but can occur frequently
interfering with normal activities including sleep
 Con…

• Regurgitation
is the effortless return of food or fluid into the pharynx without nausea or retching.
Bending, belching, or maneuvers that increase intraabdominal pressure can provoke
regurgitation.

• Chest pain
 Con….

 Esophageal dysphagia is often described as a feeling

of food “sticking” or even lodging in the chest.
 Odynophagia is pain either caused by or exacerbated by swallowing.
 Globus sensation, is the perception of a lump or fullness in the throat that is felt
irrespective of swallowing
 Water brash is excessive salivation resulting from a vagal reflex triggered by
acidification of the esophageal mucosa.
GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Con…
 con…

 GERD is a condition that develops when the reflux of

stomach contents causes troublesome symptoms or complications.

 The current conception of GERD is to encompass a family of conditions with the

commonality that they are caused by gastroesophageal reflux resulting in either
troublesome symptoms
 potential esophageal and extraesophageal manifestations.
 the spectrum of injury includes esophagitis, stricture, Barrett’s esophagus, and
adenocarcinoma
Epidemiology
 ‫‪PATHOPHYSIOLOGY‬‬
‫پتوجنیرس‪:‬‬
‫‪ GERD‬ازباعث برهم خوردن موازنه بین فکتورهای محافظوی مری وفکتورهای حملوی معده به وجود‬
‫میاید‬
‫فکتورهای محافظوی مری‬
‫‪ ( Low esophageal sphincter‬درتولید ‪ GERD‬استرخا گذری معصره ‪ .‬فشارپاین معصره ‪ .‬تغیرات ساختمانی درین ناحیه‬ ‫‪.1‬‬
‫مانند ‪ hiatal hernia‬رول دارد )‬
‫‪phrenoesophageal ligament‬‬ ‫‪.2‬‬

‫‪diaphragmatic crura‬‬ ‫‪.3‬‬

‫‪angle of his‬‬ ‫‪.4‬‬

‫‪ ( esophageal acid clearance‬که حرکات پرستالتیک ‪ .‬لعاب و تولید بای کاربونات رول دارد )‬ ‫‪.5‬‬

‫‪ tissue resistance‬یا مقاوم نسجی انساج مری‬ ‫‪.6‬‬

‫فکتورهای حملوی معده‬

‫تیزابیت معده‬ ‫‪.7‬‬

‫حجم معده ( مثال در پر خوری )‬ ‫‪.8‬‬

‫تاخیرتخلیه معده ( درحالت های ‪ gastro paresis‬و ‪) partial gastric outlet obstruction‬‬ ‫‪.9‬‬

‫‪ .10‬ریفلکس محتوای اثناعشر‬

Con..
Con…
Con…
 Con….
• Esophagial acid clearance
• After acid reflux, peristalsis returns the refluxed fluid to the
stomach and acid clearance is completed by titration of the
residual acid by bicarbonate contained in swallowed saliva.
 two causes of prolonged acid clearance are
• impaired peristalsis
Certain medical conditions such as scleroderma are associated
with diminished peristalsis
• and reduced salivation.
Sjögren syndrome, anticholinergic medications, and radiation may
exacerbate GERD due to impaired salivation.
• Tissue resistance
Con..
Con…
Clinical finding
diagnosis
 DIAGNOSIS
 Sign and symptoms +
 Upper endoscopy—is excellent for documenting the type and
extent of tissue damage in gastroesophageal reflux;
• detecting other gastroesophageal lesions that may mimic
GERD;
• detecting GERD complications, including esophageal
stricture, Barrett metaplasia, and esophageal adenocarcinoma
 Barium esophagography—
This study should not be performed to diagnose GERD. In
patients with severe dysphagia, it is sometimes obtained prior to
endoscopy to identify a stricture.
 Con…

 Esophageal pH—Esophageal pH monitoring is unnecessary in most patients but may

be indicated to document abnormal esophageal acid exposure in patients who have
• atypical or extraesophageal symptoms
• or who are being considered for antireflux surgery.
• patients with persistent symptoms despite proton pump inhibitor therapy to
determine whether symptoms
are caused by acid or nonacid reflux (40%) or are unrelated to reflux and indicative
of a functional disorder.
DDX
 Con….
 endoscopic appearance,
• infectious esophagitis is diffuse and tends to involve the
proximal esophagus far more frequently than does reflux
esophagitis.
• The ulcerations seen in peptic esophagitis are usually solitary
and distal,
• whereas infectious ulcerations are punctate and diffuse.
• Eosinophilic esophagitis characteristically exhibits multiple
esophageal rings, linear furrows, or white
punctate exudate.
• pill induced esophagitis are usually singular and deep at
points of luminal narrowing, especially near
the carina
complication
 Complications

 Barrett Esophagus
This is a condition in which the squamous epithelium of the
esophagus is replaced by metaplastic columnar epithelium
• Three types of columnar epithelium may be identified: gastric
cardiac, gastric fundic, and specialized intestinal metaplasia
• The most serious complication of Barrett esophagus is esophageal
adenocarcinoma.
• Barrett esophagus should be treated with long-term
proton pump inhibitors once or twice daily to control
reflux symptoms. Although these medications do not
appear to cause regression of Barrett esophagus, they may
reduce the risk of cancer
 Con…

 Peptic Stricture
Stricture formation occurs in about 5% of patients with
esophagitis.
• It is manifested by the gradual development of solid food dysphagia
progressive over months to years.
• Often there is a reduction in heartburn because the stricture acts as a
barrier to reflux.
• Most strictures are located at the gastroesophageal junction
• Treatement with dilation
• Dilation is continued over one to several sessions. A luminal
diameter of 13–17 mm is usually sufficient to relieve dysphagia.
• Longterm therapy with a proton pump inhibitor is required to
decrease the likelihood of stricture recurrence
 Treatment
• Medical Treatmen
The goal of treatment is to provide symptomatic relief, to
heal esophagitis and to prevent complications.
 1. Mild, intermittent symptoms
 Lifestyle modifications
• avoidance of foods that reduce LES pressure, making them
“refluxogenic” (these commonly include fatty foods, alcohol,
tomato-based foods, chocolate and possibly coffee and tea)
• elimination of acidic foods (citrus, tomatoes, coffee)
• Stop cigarettes may reduce symptoms.
• Weight loss should be recommended for patients who are overweight.
• All patients should be advised to avoid lying down within 3 hours after
meals
• Patients with nocturnal symptoms should also elevate the head of the
bed on 6-inch.
• Patients with infrequent heartburn (less than once
weekly) may be treated on demand with antacids or oral
H2-receptor antagonists.
• Antacids provide rapid relief of heartburn; however, their duration of action is less
than 2 hours
• H2-receptor antagonists
• cimetidine 200 mg,
• Ranitidine and nizatidine 75 mg,
• famotidine 10 mg
 2. Troublesome symptoms
• should be treated with a once-daily oral proton
pump inhibitor
• (omeprazole or rabeprazole, 20 mg; omeprazole, 40 mg with sodium bicarbonate;
lansoprazole, 30 mg; dexlansoprazole, 60 mg; esomeprazole or pantoprazole, 40 mg)
taken 30 minutes before breakfast
• for 4–8 weeks.
• patients with relapse or complications should be maintained on longterm therapy with a
once- or twice-daily proton pump
inhibitor titrated to the lowest effective dose to achieve
satisfactory symptom control.

 3. Extraesophageal reflux manifestations

Current guidelines recommend that a trial of a
twice-daily proton pump inhibitor be administered for 2–3
months in patients with suspected extraesophageal GERD syndromes who also have
typical GERD symptoms.
 4. Unresponsive disease—Approximately 5% do not
respond to twice-daily proton pump inhibitors.
• These patients should undergo endoscopy for detection of severe, inadequately
treated reflux esophagitis and for other gastroesophageal lesions (including
eosinophilic esophagitis) that may mimic GERD.

 Laparoscopic Nissen fundoplication wherein the proximal stomach is wrapped

around the distal esophagus to create an antireflux barrier, is a surgical alternative to
the management of chronic GERD.
Con…
 Inflammatory esophageal disorder
 infectious esophagitis
 viral
 bacterial
 fungal
 other type of esophageal disorder
 radiation induced esophagitis ( radiation , chemotherapy )
 corrosive esophagitis
 pill induced esophagitis
Infectious esophagitis
Con…
Clinical finding
 Con…

• odynophagia is a characteristic symptom of infectious esophagitis;

• dysphagia,
• chest pain,
• hemorrhage are also common.
• Odynophagia is uncommon with reflux esophagitis
Candida Esophagitis
Con…
Con...
Con…
Con…
 HERPETIC ESOPHAGITIS

• Herpes simplex virus type 1 or 2 may cause esophagitis.

• CMV and HZV also cause esophagitis
• Acyclovir (200 mg orally five times a day for 7–10 days) can be used for
immunocompetent hosts,

• Immunocompromised patients are treated with acyclovir

(400 mg orally five times a day for 14–21 days),
Eosinophilic Esophagitis
Con…
Con..
Con…
Con..
Con…
Con…
Con..
 PILL ESOPHAGITIS

• Pill-induced esophagitis occurs when a swallowed pill fails to traverses the entire
esophagus and lodges within the lumen.
• Generally, this is attributed to poor “pill taking habits”:
• inadequate liquid with the pill
• lying down immediately after taking a pill.
•
The most common location for the pill to lodge is in the mid-esophagus near the
crossing of the aorta or carina.
Pill induce esophagitis
Con..
 esophageal diverticula
‫عبارت از بیرون زدگی جدار مری است‬
‫ درناحیه خلفی هیپوفارنگس به وجود امده‬: Zenkers diverticula .1
‫ در مریضان اکالزیا دیده میشود‬: Epiphrenic diverticula .2
‫ اسبب توسع غدوات عمیق مری بوده‬Defuse intramural diverticula .3
diverticulectomy , distal myotomy ‫تداوی‬
 ‫‪Web and ring‬‬

‫تضیقات پرده مانند مری به نام ‪ web‬یا ‪ ring‬مری یاد میشود که منشایی جنتیکی والتهابی دارد‬
‫‪ Web‬قسمت علوی مری که در سندروم پالمروینسون دیده میشود‬ ‫‪.1‬‬
‫‪ Web‬قسمت متوسط مری در مریضان ‪ eosinophilic esophagitis‬دیده میشود‬ ‫‪.2‬‬
‫‪ web‬قسمت پاین مری یا ‪ schatzki ring‬در مریضان ‪ GERD‬دیده میشود یا هم منشا والدی دارد‬ ‫‪.3‬‬
‫رنگ سبب عسرت بلع میشود‬
 ESOPHAGEAL MOTILITY DISORDERS

• Esophageal motility disorders are diseases attributable to esophageal neuromuscular

dysfunction commonly associated with dysphagia, chest pain, or heartburn.
• The major entities are achalasia,
• Diffuse esophageal spasm (DES),
• Motility disorders can also be secondary to broader disease processes as is the case
with pseudoachalasia, Chagas’ disease, and scleroderma.
Oesophageal motility disorder
Con…
 ACHALASIA

• Achalasia is a rare disease caused by loss of ganglion cells within the esophageal
myenteric plexus with a population incidence of about 1:100,000 and usually
presenting between age 25 and 60.

• The disease involves both excitatory and inhibitory ganglionic neurons.

• Their absence leads to impaired deglutitive LES relaxation and absent peristalsis.
 Con…

• ganglion cell degeneration in achalasia is an autoimmune process attributable to a

latent infection with human herpes simplex virus 1 combined with genetic
susceptibility.
Con…
Con…
 Clinical manifestations

• dysphagia, report solid and liquid food dysphagia.

• regurgitation occurs when food, fluid, and secretions are retained in the dilated
esophagus.
• chest pain is frequent early in the course of
achalasia, thought to result from esophageal spasm
radiating to the neck, arms, jaw, and back.
• weight loss.
• Most patients with advanced achalasia are at risk for bronchitis, pneumonia, or
lung abscess from chronic regurgitation and aspiration.
Con…
 diagnosed

• Achalasia is diagnosed by barium swallow x-ray and/or esophageal manometry

• The barium swallow x-ray appearance is of a
• dilated esophagus with poor emptying
• an air-fluid level
• tapering at the LES giving it a beak-like appearance
Con...
 Con…

• The diagnostic criteria for achalasia with esophageal manometry are impaired LES
relaxation and absent peristalsis.
• endoscopy has a relatively minor role other than to
exclude pseudoachalasia.
Con…
 Treatment
• There is no known way of preventing or reversing achalasia.
• Therapy is directed at reducing LES pressure
• pharmacologic therapy
• Pharmacologic therapies
• Nitrates
• calcium channel blockers are administered before eating.
• Botulinum toxin, injected into the LES under endoscopic
guidance, inhibits acetylcholine release from nerve endings
and improves dysphagia in about 66% of cases for at least 6
months.
• Sildenafil and alternative phosphodiesterase inhibitors
effectively decrease LES pressure
 Con…

• pneumatic balloon dilatation

• Pneumatic dilatation, with a reported efficacy ranging from 32–98%, is an
endoscopic technique using a noncompliant
• The major complication is perforation with a reported incidence of 0.5–5%
• surgical procedure for achalasia is laparoscopic Heller myotomy,
• conjunction with an antireflux procedure (partial fundoplication)
• good to excellent results are reported in 62–100% of cases.
 DIFFUSE ESOPHAGEAL SPASM (DES)

• DES is manifested by episodes of dysphagia and chest pain attributable to abnormal

esophageal contractions with normal deglutitive LES relaxation
• The pathophysiology and natural history of DES are ill defined.
• Radiographically DES has been characterized by tertiary contractions or a
“corkscrew esophagus”
Con..
 Con…

• Manometrically a variety of defining features

have uncoordinated (“spastic”) activity in the distal esophagus
• spontaneous and repetitive contractions, or high-amplitude and prolonged
contractions.
Con…
Con…
Con..
 Clinical feature

• Esophageal chest pain closely mimics angina pectoris. Features suggesting

esophageal pain include
• pain that is nonexertional, prolonged, interrupts sleep, meal-related, relieved with
antacids, and accompanied by
• heartburn,
• dysphagia,
• regurgitation.
 diagnosis

• DES is diagnosed by manometry.

• Endoscopy is useful to identify alternative structural and inflammatory lesions that

may cause chest pain.

• Radiographically, a “corkscrew esophagus,” “rosary bead esophagus,”

pseudodiverticula
Con..
Treatment
Nitrates
calcium channel blockers
Hydralazine
botulinum toxin
anxiolytics. The only controlled trial showing
efficacy was with an anxiolytic
Surgical therapy (long myotomy or even
esophagectomy) should be considered only with severe weight loss or unbearable
pain.
‫‪Con..‬‬

‫مننه‬