1. DISORDERS OF ESOPHAGUS
DR.LATHADEVI
PROFESSOR ENT

2. Dysphagia, GERD, Barrett's Esophagus, Hiatal Hernia, foreign bodies, Esophageal cancer

3. Anatomy Mucosa, submucosa, muscularis propria, and adventitia
Lack serosa vs. other GI tract
Mucosa innermost (4 layers)
contains squamous epithelium

4. Muscularis Propria Continuation of inferior constrictor of the pharynx
Two muscle bundles
inner circular
outer longitudinal
Striated upper 1/3
-vagus and its recurrent
laryngeal branches
Smooth lower 2/3
-visceral nerve plexus derived
from neural crest cells
Left vagus anterior-liver/biliary tree
Right vagus posterior-celiac plexus

5. Esophageal Lymphatics
Lymphatics: upper 2/3 cephalad, lower 1/3 caudad

6. Anatomy

7. Anatomic Areas of Narrowing
Cricopharyngeal muscle
Left mainstem bronchus and aortic arch
Diaphragm

8. Anatomic Areas of Narrowing

9. UES
15 cm from incisors
Cricophayrngeus muscle, recurrent laryngeal nerve
Site of perforation is cricopharyngeus muscle (with EGD), aspiration if UES fail

10. LES 40 cm from incisors No anatomic landmarks
rise in pressure when transducer is pulled from the stomach
Increased Pressure: Alpha-adrenergics, BBs, gastrin, motilin, antacids, cholinergics, metoclopramide
Decreased Pressure: Alpha blockers, Beta andrenergics, CCK, estrogen, glucagon, progesterone, somatostatin, secretin, barbiturates, CCBs, caffeine, diazepam, dopamine, meperidine, ethanol, coffee, fat

11. Gastroesophageal Reflux Disease
1/3 Western population experience symptoms at least once a month
4-7% daily
Most patients with mild symptoms carry out self-medication
The prevalence and severity of GERD is increasing

12. Typical GERD Symptoms Heartburn Regurgitation Dysphagia
substernal burning or chest pain
worse with spicy foods, tomato sauce, citrus juices, chocolate, coffee, and alcohol
1 to 2 hours after eating, often at night, relieved by antacids and OTC H2 blockers
Regurgitation
sensation that fluid or food is returning into the esophagus
worse at night or when lying down after a meal
Dysphagia
up to 40% of pts with GERD have sensation of food hanging up in the lower esophagus--esophageal dysphagia
typically limited to only solid food, with normal passage of liquids, suggesting mechanical disorder
develops slowly enough that the patient may adjust eating habits unknowingly

13. Atypical GERD Symptoms
Cough, asthma, hoarseness, and noncardiac chest pain
primary complaint in 20-25%
more difficult to prove a cause-and-effect relationship
trial of high-dose PPIs is helpful
make sure patient doesn’t have another cause for pain

14. Pathophysiology of GERD
Fundic distention because of overeating
LES is taken up by the expanding fundus, exposing the squamous epithelium/LES to gastric juice
Worsened by delayed gastric emptying with high-fat diet and hiatal hernia
continued epigastic pain and possibly epithelial columnarization
Extension of the inflammatory process into
the muscularis propria
leading to a permanently defective sphincter

15. Diagnosis of GERD Based on symptoms alone?
Correct in only 2/3 of patients
these symptoms are not specific for GE reflux
achalasia, diffuse spasm, esophageal carcinoma, pyloric stenosis, cholelithiasis, gastritis, gastric or duodenal ulcer, and coronary artery disease
need objective diagnosis before the decision is made for surgical treatment

16. Diagnosis of GERD First episode
Initial therapy with H2 blockers or PPI for 12 weeks
Failure of H2 blockers or PPI to control the symptoms suggests that either the diagnosis is incorrect or the patient has severe disease
EGD
Opportunity for assessing the severity of mucosal damage
24-hour pH and bilirubin monitoring
Measurement degree and pattern of esophageal exposure to gastric and duodenal juice
Manometry
Assess the status and function of the LES and esophageal body
These studies identify features that predict a poor response to medical therapy, frequent relapses, and the development of complications

17. Complications of GERD Mucosal complications-esophagitis and stricture
Extraesophageal or Respiratory complications, such as laryngitis, recurrent pneumonia, and progressive pulmonary fibrosis
Reflux (aspiration) vs reflex (vagal bronchoconstriction)
Metaplastic and Neoplastic complications, Barrett's and esophageal adenocarcinoma
Prevalence/severity of complications related to the degree of loss of the GE barrier and content of refluxed gastric juice, not symptoms

18. Barrett’s Esophagus
Squamous epithelium metaplasia  columnar epithelium
7-10% of patients with GERD
Presence of any columnar mucosa extending at least 3 cm into the esophagus (goblet cells)=Barrett’s
predisposed to malignant degeneration
Increased risk of adenocarcinoma x50

19. Classification and Management of Barrett’s Esophagus with Dysplasia
Indefinite for Dysplasia: Aggressive antireflux therapy (60 mg PPI per day) and repeated biopsy in 3 months
Low Grade: Aggressive antireflux therapy vs. surgical treatment
High Grade-Esophagectomy and PPI

20. Dysphagia
Difficulty in transferring a food from the mouth to the stomach
Regurgitation, chest pain, heartburn, and coughing or choking spells
Oropharyngeal
functional disturbance in the swallowing mechanism
Esophageal
mechanical obstruction or esophageal motility disorder

21. Dysphagia
Evaluation of a patient with dysphagia must be performed in a systematic manner
Barium swallow
Additional diagnostic tests
EGScopy, manometry, 24-hour pH study, and possibly bronchoscopy and endoscopic ultrasonography (EUS).
Diagnostic imaging by CT and PET in assessing patients with esophageal cancer

22. Oropharyngeal Dysphagia
inability to chew food, drooling, coughing during a meal, and nasal regurgitation of solids or liquids
dysphagia within 1 second of swallowing
The common causes can be grouped into three broad categories:
1) generalized systemic conditions: CVA, Myasthenia gravis
2) intrinsic functional disturbances: Zenker's diverticulum
3) fixed mechanical obstruction: Neoplasm, webs, previous surgical treatment, previous radiation therapy

23. Esophageal Dysphagia Dysphagia with solids? =Mechanical Obstruction
Intermittent? Esophageal Ring or Esophagitis
Progressive with GERD? Peptic Stricture
Progressive with weight loss and anorexia? Esophageal Cancer
Dysphagia for both liquids and solids?
=Motility Disorder
Intermittent? Spasm (DES)
Progressive with GERD? Scleroderma
Progressive? Achalasia

24. Schatzki's Ring symmetrical narrowing at SCJ, small hiatal hernia
correlation with GERD
barium swallow and esophagoscopy to confirm
Asymptomatic? no specific treatment is needed
Definitive treatment? dilatation of the ring with medical therapy for GERD. If refractory, dilatation plus antireflux surgery

25. Peptic Stricture greater length and more tapered than Schatzki’s
H/o GERD
worsening dysphagia for years without weight loss
End stage of ulcerative esophagitis, healing ulcer causes annular fibrosis
Dx: barium swallow followed by upper GI endoscopy
greater length and more tapered than Schatzki’s

26. Esophageal Webs
localized narrowing of the esophagus caused by intraluminal extension of the mucosa and part of the submucosa
congenital or acquired (mc), usually secondary to conditions such as iron deficiency anemia/Plummer-Vinson syndrome and ulcerative colitis.
Tx: endoscopic dilatation

27. Achalasia Dysphagia for liquids and solids and possibly weight loss.
Barium swallow shows absent peristalsis and a dilated esophagus, possibly tapered narrowing in distal esophagus=bird's beak
Achalasia risk factor for squamous cell cancer
Tx: Pneumatic dilatation or surgery

28. Diffuse esophageal spasm
unknown etiology
Nonprogressive dysphagia with solids and liquids and nonexertional chest pain that responds to nitroglycerin
corkscrew on barium
The diagnosis by manometry
periodic occurrence of simultaneous high-amplitude contractions with intervening periods of normal peristalsis.
Tx: r/o CAD, then medical management of reassurance, nitrates, and CCBs
Botulinum toxin injection, surgery does not have an established role

29. Nutcracker Esophagus unknown etiology women>men
Manometry: peristaltic waves with significantly elevated amplitude (> 180 mm Hg).
Treatment is primarily medical

30. Esophageal Diverticula
< 5% of all cases of dysphagia.
False diverticula (pulsion) include only the mucosal layer
underlying motor dysfunction
True diverticula (traction) include all layers of the esophageal wall
inflammatory process
Esophageal diverticula may also be classified into three categories on the basis of the anatomic level at which they occur

31. Pharyngoesophageal/Zenker’s Diverticula
from muscle incoordination that leads to herniation of the mucosa in prox esophagus
Dysphagia symptom, halitosis, regurgitation, throat discomfort, palpable neck mass, recurrent aspiration pneumonia
The best initial diagnostic tool is a barium swallow
perforation in EGD

32. Chemical Ingestion Alkali household cleaning agents
Most occur accidentally in children, but suicide in adults
Magnitude and site of the injury?
Related to the length of the contact time
Injury at any level, MC is distal esophagaus
lead to submucosal scar formationstricture and dysphagia
Endoscopic exam is first step
A barium swallow should be done in the first month after injury to detect any stricture and then serial swallows

33. Hiatal Hernia
I-Sliding, dilation of hiatus, most commonly associated with GERD -most with reflux have sliding, most with sliding don’t have reflux II-Paraesophageal, defect in diaphragm alongside esophagus with normal GE junction --chest pain, dysphagia, early satiety III-Combined I and II IV-entire stomach in chest plus another organ (colon, spleen)

34. Laparoscopic Antireflux Procedure
Most commonly performed procedure is a fundoplication
Nissen Fundoplication: 360 degree fundoplication
Laparoscopic approach reduces postoperative pain and shortens length of hospital stay
Rapid increase in surgical treatment of GERD

35. GERD
Gastroesophageal reflux disease increases risk developing of: A) Adenocarcinoma of the esophagus B) Squamous cell carcinoma of the esophagus C) Both D) Neither -SCC related to lye ingestion, achalasia and EtOH and tobacco -Adenocarcinoma now esophageal cancer, related to GERD

36. CANCER PREMALIGNANT CONDITIONS Etiology of esophageal cancer
P-V SYNDROME
BARRETT’S
HIATUS HERNIA
Etiology of esophageal cancer
Clinical features
Management