1. Swallowing Difficulty & Pain
Tim Farrell, MD
Tom Egan, MD

2. Assumptions
Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction.

3. Objectives Students will understand:
Differential diagnosis for a patient with dysphagia.
Symptoms and treatment of GERD.
Pathophysiology and treatment of achalasia and diffuse esophageal spasm.
Etiology and treatment of esophageal diverticula.
Common symptoms and management of hiatal hernias.
Management of adenocarcinoma of the E-G junction.
Presenting symptoms, etiology and treatment of esophageal rupture.

4. Case 1
An 80-year-old man presents with a trouble swallowing for a year. He regurgitates after meals, has heartburn, but no other pain and is in good health otherwise.
He is thin, without neck mass. His chest is clear and his abdomen is soft and without masses.

5. Case 1 What is the differential diagnosis? Anatomic
Tumor, Stricture, Compression, Foreign Body
Functional
GERD
Motility Disorder (achalasia, scleroderma)
Neurologic (Parkinson’s, bulbar paralysis)
Psychological
Globus Hystericus

6. Case 1 What test should be done, in what order, and why?
Anatomic Assessment Functional Assessment
Upper GI Series 24-hr pH
EGD Esophageal Manometry
Biopsy GES

7. GERD - Definition
Protracted exposure of the esophageal lining to stomach juice

8. GERD - Causes Lower esophageal sphincter Hiatal Hernia
Incompetent valve
Inappropriate relaxations
Hiatal Hernia
Abnormal motility
Impaired esophageal clearing
Delayed gastric emptying
Defective cytoprotection
People will experience heartburn symptoms when excessive amounts of acid reflux into the esophagus.

9. GERD - Symptoms Typical Symptoms Heartburn Regurgitation
Trouble Swallowing
Atypical Symptoms
Asthma
Cough
Hoarseness
Chest Pain
A Throat pharynx and larynx B Windpipe trachea C Esophagus D Lungs E Stomach
GERD can Masquerade as Other Diseases
Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation.
Asthma: Acid reflux may aggravate asthma. Clues that GERD may be worsening your asthma include 1) asthma that appears for the first time during adulthood, 2) asthma that gets worse after meals, lying down or exercise, and 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.
Ear Nose and Throat Problems: Acid reflux may be a cause of chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing, or growths on the vocal cords.

10. GERD - Complications Peptic Stricture Esophagitis / Ulcers
Barrett's Esophagus
Patients with Longstanding GERD Can Experience Severe Complications
Esophagitis Redness to Ulceration
Peptic Stricture: A narrowing of the lower esophagus from an abundance of scar tissue. Patients complain of food sticking in the lower esophagus. Stretching of the esophagus and proton pump inhibitor medication are needed to control and prevent peptic strictures.
Barrett's esophagus:
The most serious complication of chronic GERD.
The lining of the esophagus changes to resemble that found in the intestine.
A pre-cancerous condition: 40-fold increased risk of developing cancer.
Routine surveillance endoscopy by a trained gastroenterologist.

11. Indications for further Dx-Rx
Persistent or frequent symptoms
Dysphagia
Frequent vomiting
Early satiety
Weight loss
Significant respiratory complaints
Age < 45

12. GERD - Diagnosis Barium Swallow Upper Endoscopy Esophageal Manometry
24-Hour Ambulatory Esophageal pH
Gastric Emptying Study

13. GERD - Diagnosis Barium Swallow
During a barium swallow, a patient drinks a liquid barium mixture, and a radiologist watches it travels down the esophagus and into the stomach.

14. GERD - Diagnosis Upper Endoscopy
This test involves passing a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives. It is the best test to identify esophagitis and Barrett's esophagus.

15. GERD - Diagnosis Manometry
24 Hour Ambulatory pH Test
If the diagnosis is still in question, the degree of acid refluxed into the esophagus may be measured by a similar tube left in place for 24 hours.
Esophageal Manometry
This test involves passing a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus.

16. GERD - Treatment Environmental Medical - OTC Medical -Prescription
Antacids
H2-Blockers
Medical -Prescription
Proton-Pump Inhibitors
Endoscopic
Surgical
Fundoplication

17. Dietary Modifications
Avoid large meals
Limit foods which decrease LES pressure
Fatty foods, chocolate, mints, and alcohol
Avoid irritating foods and beverages
Citrus, tomatoes, pepper, etc.
Limit caffeine and carbonated beverages
Increases acid production
Increased gastric distension
Candy or gum to increase saliva
Alkaline saliva neutralizes acid
Increases motility and clearance
Enhances drug effect
May allow control of symptoms with less aggressive management

18. Lifestyle Modifications
Weight Loss
Avoid smoking
Decreases LES pressure
Avoid lying down for 2-3 hours after meals
Limits supine reflux
Sleep with elevated head of bed
Improves esophageal clearance
Candy or gum to increase saliva c

19. Medications Worsening Reflux
Calcium channel blockers
Anticholinergics
Theophylline
Progesterone
β2-antagonists, α-antagonists
Nitrates
Meperidine
Diazepam

20. GERD - Medical Treatment
Medications may be used to:
Neutralize acid
Increase LES tone
Improve gastric emptying
Over-the-Counter Medications (for occassional symptoms)
Large # of Americans use antacids (Maalox, Mylanta).
Recently, the FDA approved non-prescription strength medicines called H-2 blockers (Zantac, Pepcid).
Prescription Medicines (for more frequent symptoms - >2x/wk)
H-2 Blockers: Symptoms are eliminated in up to 50% of patients with twice a day prescription dosage of the H2 blockers. Healing of esophagitis may require higher dosing. These agents maintain remission in about 25% of patients.
Good firstline treatment and maintenance agent for some patients.
Proton Pump lnhibitors (Prilosec, Prevacid): Provide symptom relief with elimination of symptoms in most cases, even in those with esophageal ulcers.
The best long-term maintenance therapy of esophagitis, particularly for those patients with moderate to severe esophagitis.
Promotility Agents (Reglan, Propulsid): These drugs improvethe movement of food from the stomach.

21. OTC H2 Blockers Lower-dose formulations Acute treatment or prophylaxis
Slower onset than antacids
Longer duration of acid inhibition

22. Proton Pump Inhibitors

23. Endoscopic Treatment Modalities Thermal (Stretta®)
RFA since 1921… Stretta used in GERD
Exclusion: Active esophagitis, Long segment barretts nad HH >3 cm
400 Khz to 1 MHz
Temp set to 85 C, at 65 C collagen contraction
90 sec, muscularis,
two deployments/ring, 6 rings
Mechanical + Neural--> blocks intramural abberant vegal afferent fibres
Thermal energy Mechanical / Neural

24. Endoscopic Treatment Modalities Endoscopic Suturing
Suturing or plication
EndoCinch ®

25. Endoscopic Treatment Modalities Biocompatible Material
Enteryx ®

26. GERD - Surgical Treatment
What are the reasons to consider surgical treatment of reflux disease?
Non-response to medical treatment (persistent regurgitation).
Prevalence of respiratory symptoms.
Paraesophageal Hiatal Hernia.
Excessive cost of medicines.
Concern over the long-term effects of medicines.
Desire not to take medicines for the rest of one’s life.
Complicated GERD (Stricture, Barrett’s)

27. GERD - Surgical Treatment
Antireflux Surgery is done laparoscopically
Requires specialized optics and video systems.

28. Nissen Fundoplication Technique

29. Nissen Fundoplication Technique

30. Nissen Fundoplication Technique

31. Nissen Fundoplication Technique

32. Nissen Fundoplication Technique

33. Nissen Fundoplication Technique

34. Nissen Fundoplication Technique

35. GERD - Surgical Treatment Results
Procedure - 2 Hours
Hospital Days
Full Activity - 2 weeks
Full Diet - 3 weeks
Need to Open <1%
Need for Blood <1%
Off Medications - 95%
Off Steroids - 50%
Need 2nd Procedure - 5%

36. Effects of Fundoplication
augments LES resting pressure
lessens frequency of transient LES relaxations
reestablishes anatomy of the LES and crura
may improve esophageal clearance
may improve gastric emptying
Fundoplication resists reflux by:
1. augmenting LES resting pressure lessening the frequency of transient LES relaxations and 3. reestablishing normal anatomic relationships between the LES and crural diaphragm.
In addition, fundoplication may improve esophageal clearance and gastric emptying.

37. Case 2
A 61-year-old man presents with progressive difficulty swallowing. He has history of indigestion and heartburn. Until 12 months ago, food would come up into his throat when he was supine, with a sour taste and sometimes a cough. About 12 months ago, these symptoms improved but he developed progressive dysphagia.
He smokes 1 PPD and drinks two beers at dinner.
Exam is unremarkable except for barrel chest.

38. Case 2 What is the differential diagnosis? Anatomic
Tumor, Stricture, Compression, Foreign Body
Functional
GERD,
Motility Disorder (achalasia, scleroderma)
Neurologic (Parkinson’s, bulbar paralysis)
Psychological
Globus Hystericus

39. Case 2 How would you evaluate this patient?
Anatomic Assessment Functional Assessment
Upper GI Series 24-hr pH
EGD Esophageal Manometry
Biopsy GES

40. Case 2 What are the treatment options for benign esophageal stricture?
Medications
Endoscopic Dilation
Surgery

41. Case 2 What are the treatment options for carcinoma of the esophagus?
Esophagogastectomy
Ivor-Lewis
Transhiatal

42. Barrett’s Esophagus Epidemiology
Affects 10% of patients with severe GER
40-fold increased risk of cancer
Patients require endoscopic surveillance
Esophagectomy for severe dysplasia/cancer

43. Barrett’s Esophagus Endoscopic Appearance

44. Barrett’s Esophagus Pathologic Diagnosis
Normal squamous epithelium transforms to intestinal-type (columnar) epithelium
40x increased cancer risk
No increased cancer risk

45. PPI-Induced Regression?
Peters FT, et al., Gut 1999;45:

46. Surgery-Induced Regression?
56 Barrett’s patients had antireflux surgery
Annual flexible endoscopy
24 Barrett’s regressed
8 cm 4 cm
9 Barrett’s progressed
6 cm cm
23 No change
Sagar: Br J Surg 1995;82:

47. Barrett’s Esophagus Development of Cancer Based on Grade
No dysplasia %
Low-grade dysplasia 18%
High-grade dysplasia 28%
Morales and Sampliner, Arch Int Med 1999;159:

48. Barrett’s Esophagus Following Patients Without Dysplasia
Studies of cost-effectiveness are mixed
Few cancers found during surveillance are node-positive, versus >50% otherwise
Optimal surveillance interval debated, but data suggest q2-3 years

49. Barrett’s Esophagus Patients With Low-Grade Dysplasia
Repeat endoscopy to avoid sampling error
Surveillance q6 mo. x 1 year then q12 mo.
May regress allowing increased interval

50. Barrett’s Esophagus Patients With High-Grade Dysplasia
Must confirm the diagnosis
Treatment is controversial
Some advocate aggressive biopsy protocol
Some advocate esophagectomy

51. Barrett’s Esophagus Patients With High-Grade Dysplasia
Case for Aggressive Surveillance (q3-6 mos.):
Regression may occur (25%)
Most patients will not progress to cancer
Cancers remain surgically curable
Esophagectomy carries morbidity (up to 40%) and mortality (3-6%)

52. Barrett’s Esophagus Patients With High-Grade Dysplasia
Case for Esophagectomy:
40% may already have cancer
Surveillance delays definitive treatment
Risk of esophagectomy low in high-volume centers

53. Barrett’s Esophagus Specific Treatment
Ablative Techniques
laser
electrocautery
photodynamic therapy (PDT)
Resective Techniques
Endoscopic mucosal resection (EMR)

54. Barrett’s Esophagus Take-Home Points
Barrett’s esophagus is not a contraindication to antireflux operation
Medical or surgical therapy does not eliminate need for Barrett’s surveillance
Management of high-grade dysplasia is evolving away from esophagectomy

55. Case 3
A 53-year-old patient presents with a history of difficulty swallowing for years. More recently she is having increasing trouble swallowing, and has been regurgitating undigested food. Exam is unrevealing, but on chest film there is an air fluid level seen behind the heart in the mid chest.

56. Case 3
Describe a differential diagnosis and diagnostic evaluation.

57. Case 3
Discuss the management options for a patient with achalasia.

58. Achalasia Incidence 0.5 new cases / 100,000 population / year
Dysphagia, regurgitation, cough, wheezing, aspiration, pulmonary infections
50% initially misdiagnosed

59. Achalasia Pathophysiology
Involves degeneration of Auerbach’s plexus and elevated LES resting pressure
Poor LES relaxation results in esophageal dilation with progressive loss of peristalsis

60. Achalasia Diagnosis Ba swallow: EGD: Esophageal manometry:
esophageal dilation / narrowing at GE junction
EGD:
patulous esophagus, retained food, thickening
Esophageal manometry:
LES resting pressure
LES relaxation on swallowing
primary peristalsis

61. Achalasia Treatment Options
Non-Surgical options:
Nitrates and Ca++-channel blockers
Endoscopic injection of Botox
Pneumatic balloon dilatation
Surgical options:
Heller myotomy (laparoscopic, thoracoscopic)
Meds: response is short-lived and associated with side effects.
botulinum toxin provides two-thirds of patients short-term symptom relief (mean 1.3 years.
Both Dilation and surgery have high initial success in overcoming dysphagia, although dilatation carries four times greater risk for esophageal perforation.
Surgery provides more durable symptom relief according to retrospective (94 vs. 81 percent) and prospective (95 vs. 65 percent) studies of late outcomes.
Most gastroenterologists attempt dilatation(s) initially, reserving surgical referral for treatment failures. Dissemination of minimally invasive methods may broaden the appeal of operative strategies for achalasia.

62. Heller Myotomy Technique

63. Heller Myotomy Technique

64. Heller Myotomy Technique

65. Heller Myotomy Outcomes
40 laparoscopic Heller myotomies
No conversions, mean op time min
Median hospital stay - 2 days
One intraop mucosal injuriey repaired
Dysphagia alleviated in > 95%

66. Case 3
Discuss the management of a patient with paraesophageal hernia.

67. Epidemiology Hiatal Hernias
Herniation of the stomach through the esophageal hiatus
Para-esophageal type - 5%
Occurs in elderly patients (~ 65 years)
Frequent co-morbid conditions

68. Classification Hiatal Hernias
Classification depends on location of GEJ
Type I- “sliding” hiatal hernia
Type II- true paraesophageal hernia
Type III- “mixed” hernia- sliding hernia and true paraesophageal hernia
Type IV- intra-abdominal organ involvement

69. Sliding Hiatal Hernia Type I GE junction “slides” into the mediastinum
Most HH
May be associated with symptomatic GERD
Surgery not indicated

70. True Paraesophageal Hernia
Type II
GEJ in the abdominal cavity, fundus in the mediastinum
5% of all HH
Risk of incarceration and strangulation

71. Mixed Paraesophageal Hernia
Type III
GE junction and gastric fundus are located in mediastinum
5% of all HH
Risk of incarceration and strangulation

72. Paraesophageal Hernia Volvulus
Mesoaxial Volvulus
Organoaxial Volvulus

73. Paraesophageal Hernia X-ray

74. Paraesophageal Hernia Upper GI series
Type II
Type III

75. Paraesophageal Hernia EGD

76. Paraesophageal Hernia Treatment Options
Observation
Medical Therapy
Surgery

77. Paraesophageal Hernia Observation
Assumes a low rate of gastric strangulation
Allen et al.
23 of 147 patients followed for mos (median 78 mos).
Only 4 pts had progressive symptoms and 2 had elective repair
Estimate prevalence of one gastric strangulation per 245 pts
J Thorac Cardiovasc Surg 1993;105:253

78. Paraesophageal Hernia Medical Therapy
One-third of patients have heartburn alone
Acid inhibition
Patient clearly informed of risk of gastric strangulation and consequences
Excessive (10-50%) mortality for surgical repair of gastric strangulation

79. Paraesophageal Hernia Principles of Operative Repair
Hernia Reduction
Hernia sac excision
Crural repair
Gastric fixation
Fundoplication controversial

80. Paraesophageal Hernia Hernia Reduction
Entire stomach and at least 2 cm of esophagus must be intra-abdominal

81. Paraesophageal Hernia Sac Excision
Entire sac must be excised to decrease risk of recurrence
Remnants of sac along inferior border of left crus lead to recurrence

82. Paraesophageal Hernia Crural Repair
Primary repair alone
Primary repair with relaxing incision
Mesh repair

83. Paraesophageal Hernia Fundoplication
Recent series report high rate of GERD without fundoplication
Wrap provides bulk to create “plug” at site of crural repair

84. Paraesophageal Hernia Surgical Outcomes
Luketich et al.: 100 pts lap PH repair
12% intraop complications; technically demanding
3 conversions to open procedures
28% postop complication rate; 0% mortality
3% reoperation rate
91% satisfied, 2-day hospital stay
Ann Surg 2000;232:608

85. Paraesophageal Hernia Take-Home Points
Uncommon, rarely present with strangulation
Repair advised for non-GER symptoms
Repair is technically demanding
Laparoscopic vs. open remains controversial
Prospective study to determine recurrence

86. Case 4
A 47-year-old woman has chest pain after eating dinner at home 4 hours following upper GI endoscopy for dilatation of her achalasia.
What is the presumed diagnosis?

87. Case 4
What is the best means of making the diagnosis?

88. Case 4
What is the appropriate management? Under what circumstances might you manage this non-operatively?
What might be an appropriate management for a small perforation at the GE junction with minimal soiling?