1. ESOPHAGEAL TOPICS Norman M. Simon, M.D., F.A.C.G.

2. BARRETT ’ S ESOPHAGUS A change in the lining of the esophagus from the normal squamous lining to an intestinal type lining called intestinal metaplasia. A change in the lining of the esophagus from the normal squamous lining to an intestinal type lining called intestinal metaplasia. Diagnosis suspected on endoscopy but requires confirmation by pathology examination of biopsies. Diagnosis suspected on endoscopy but requires confirmation by pathology examination of biopsies. Vast majority of cases caused by acid reflux and secondary injury to the normal lining. Vast majority of cases caused by acid reflux and secondary injury to the normal lining. Incidence appears to have increased substantially. Incidence appears to have increased substantially.

5. Increased incidence of Barrett ’ s seems responsible for increase in cases of esophageal adenocarcinoma. Increased incidence of Barrett ’ s seems responsible for increase in cases of esophageal adenocarcinoma. Controversy re. who to screen for Barrett ’ s. Controversy re. who to screen for Barrett ’ s. When Barrett ’ s suspected, biopsies taken to confirm diagnosis and to check for dysplasia. When Barrett ’ s suspected, biopsies taken to confirm diagnosis and to check for dysplasia. Monitoring generally being done at three to five year intervals unless dysplasia is found. Then depends on whether low or high grade changes. Monitoring generally being done at three to five year intervals unless dysplasia is found. Then depends on whether low or high grade changes.

6. Candidates For Screening Caucasian Males Caucasian Males Over 50 years of age Over 50 years of age Chronic symptoms of GERD Chronic symptoms of GERD Nocturnal reflux symptomatology Nocturnal reflux symptomatology Increased BMI with intra-abdominal fat distribution Increased BMI with intra-abdominal fat distribution Tobacco use Tobacco use

7. BARRETT ’ S WITHOUT DYSPLASIA

8. BARRETT ’ S LOW-GRADE DYSPLASIA

9. BARRETT ’ S HIGH-GRADE DYSPLASIA

10. BARRETT ’ S HIGH GRADE DYSPLASIA

11. Some evidence that anti-reflux treatment helps prevent the development of pre-cancerous dysplasia and cancer in patients with Barrett ’ s. Role of anti-reflux surgery controversial. Some evidence that anti-reflux treatment helps prevent the development of pre-cancerous dysplasia and cancer in patients with Barrett ’ s. Role of anti-reflux surgery controversial. Patients with low-grade dysplasia are monitored more frequently than those with no dysplasia. ? Eradicate the Barrett’s. If not, recheck every 6-12 months vs. every 3-5 yrs. Patients with low-grade dysplasia are monitored more frequently than those with no dysplasia. ? Eradicate the Barrett’s. If not, recheck every 6-12 months vs. every 3-5 yrs.

12. Options for patients with high-grade dysplasia include doing nothing, surgical resection, intensive monitoring, photodynamic treatment, endoscopic mucosal resection, argon plasma coagulation, radio frequency ablation (HALO), and endoscopic spray cryotherapy Options for patients with high-grade dysplasia include doing nothing, surgical resection, intensive monitoring, photodynamic treatment, endoscopic mucosal resection, argon plasma coagulation, radio frequency ablation (HALO), and endoscopic spray cryotherapy

13. Barrx 360 RFA Balloon Catheter

14. 26 y/o male with history of recurrent dysphagia for solids which seem to catch at midsubsternal level. Drinks fluids to clear the “obstruction.” Has been going on for about 6 months. Denies heartburn or other reflux symptoms. 26 y/o male with history of recurrent dysphagia for solids which seem to catch at midsubsternal level. Drinks fluids to clear the “obstruction.” Has been going on for about 6 months. Denies heartburn or other reflux symptoms. Past hx. negative aside from many year hx. of asthma. Past hx. negative aside from many year hx. of asthma. WHAT IS YOUR DIFFERENTIAL DIAGNOSIS? WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

15. EOSINOPHILIC ESOPHAGITIS Also known as “ allergic esophagitis ”. Also known as “ allergic esophagitis ”. Predominant symptom is dysphagia. Predominant symptom is dysphagia. Increasing incidence over past two decades. Increasing incidence over past two decades. Occurs in both children and adults with majority being males. In adults, majority are in their 20 ’ s and 30 ’ s. Occurs in both children and adults with majority being males. In adults, majority are in their 20 ’ s and 30 ’ s. High percentage have allergic issues including asthma, food allergies, hives, hay fever. High percentage have allergic issues including asthma, food allergies, hives, hay fever.

16. EOSINOPHILIC ESPHAGITIS (CONT) Findings can include multiple rings, narrowed esophagus, whitish nodules, furrows, & strictures in upper esophagus. Findings can include multiple rings, narrowed esophagus, whitish nodules, furrows, & strictures in upper esophagus. Some cases have involved several family members. Some cases have involved several family members. Etiology may relate to food allergies, additives, pollen, reflux? Etiology may relate to food allergies, additives, pollen, reflux?

20. FURROWS

23. TREATMENT Trial of anti-reflux medication-PPI. Trial of anti-reflux medication-PPI. Allergy testing and diet changes. Elemental diet Allergy testing and diet changes. Elemental diet Avoidance of six most frequent allergenic foods (eggs, soy, wheat, cow-milk protein, peanuts, and seafood). SFED Avoidance of six most frequent allergenic foods (eggs, soy, wheat, cow-milk protein, peanuts, and seafood). SFED Steroid inhaler- swallowing rather than inhaling the medication. Fluticasone propionate. Steroid inhaler- swallowing rather than inhaling the medication. Fluticasone propionate. Oral Prednisone- higher incidence of side effects. Oral Prednisone- higher incidence of side effects. Dilitation- risks of perforation. Dilitation- risks of perforation.

25. SCHATZKI ’ S RING Occur at the distal end of esophagus at junction of esophagus and stomach. Often are assymptomatic. Occur at the distal end of esophagus at junction of esophagus and stomach. Often are assymptomatic. Probably are a consequence of reflux. Probably are a consequence of reflux. Treatment is dilitation with bougie or balloon- may be best to go directly to large size ( 50 french or larger). Treatment is dilitation with bougie or balloon- may be best to go directly to large size ( 50 french or larger). Data shows decreased rate of recurrence with placing patients on anti-reflux medications. Data shows decreased rate of recurrence with placing patients on anti-reflux medications.

26. SCHATZKI ’ S RING

27. ESOPHAGEAL STRICTURE

28. ESOPHAGEAL STRICTURES Many causes including reflux, malignancy, radiation, toxic ingestions (e.g. lye), surgical anastomoses, sclerotherapy. Many causes including reflux, malignancy, radiation, toxic ingestions (e.g. lye), surgical anastomoses, sclerotherapy. Dilitation generally done gradually stepwise, often no more than three sizes on one day. Dilitation generally done gradually stepwise, often no more than three sizes on one day. Balloons (TTS) and standard dilators seem to produce similar results. Balloons (TTS) and standard dilators seem to produce similar results. Longterm anti-reflux therapy can reduce recurrence rate in many cases. Longterm anti-reflux therapy can reduce recurrence rate in many cases.

31. 69 y/o male with 1 ½ year of dysphagia primarily for solids which sometimes lodge in area of lower neck or upper chest region. Also has experience of coughing up small bits of food he ingested at a previous meal. 69 y/o male with 1 ½ year of dysphagia primarily for solids which sometimes lodge in area of lower neck or upper chest region. Also has experience of coughing up small bits of food he ingested at a previous meal. WHAT DIAGNOSES WOULD YOU CONSIDER? WHAT DIAGNOSES WOULD YOU CONSIDER?

32. ZENKER ’ S DIVERTICULUM Diverticulum occuring at junction of pharynx and upper esophagus. Diverticulum occuring at junction of pharynx and upper esophagus. The “ pocket ” faces posteriorly. The “ pocket ” faces posteriorly. Dysphagia often occurs immediately with swallowing. Dysphagia often occurs immediately with swallowing. Presents with dysphagia and/or spitting up of food eaten earlier. Also may complain of halitosis. Presents with dysphagia and/or spitting up of food eaten earlier. Also may complain of halitosis. Thought to be due to malfunctioning of the upper esophageal sphincter. Thought to be due to malfunctioning of the upper esophageal sphincter.

34. ZENKER ’ S DIVERTICULUM

35. Zenker’s Diverticulum (cont.) Treatment options include surgery through side of the neck with cutting the sphincter along with possible removal of the diverticulum or an endoscopic technique known as endoscopic staple-assisted esophagodiverticulostomy. Treatment options include surgery through side of the neck with cutting the sphincter along with possible removal of the diverticulum or an endoscopic technique known as endoscopic staple-assisted esophagodiverticulostomy.

36. NORMAL ESOPHAGEAL MANOMETRY

37. ACHALASIA Achalasia is well recognized as a cause of swallowing difficulty. Achalasia is well recognized as a cause of swallowing difficulty. Distal esophageal sphincter does not relax with a swallow and the muscle of the lower esophagus does not propel the food or liquid downwards i.e. abnormal peristalsis. Distal esophageal sphincter does not relax with a swallow and the muscle of the lower esophagus does not propel the food or liquid downwards i.e. abnormal peristalsis. Result is dysphagia, occasionally chest pain and regurgitation, and weight loss Result is dysphagia, occasionally chest pain and regurgitation, and weight loss X-rays can reveal a dilated esophagus. X-rays can reveal a dilated esophagus.

38. ACHALASIA (CONT.) On endoscopy often see retained food and secretions in esophagus even though patient has been NPO. On endoscopy often see retained food and secretions in esophagus even though patient has been NPO. Characteristic “yield” of LES to the scope being advanced. Characteristic “yield” of LES to the scope being advanced. “ Pseudo-achalasia ” “ Pseudo-achalasia ”

39. X-RAYS OF ACHALASIA

41. ACHALASIA TREATMENT Three common treatment options Three common treatment options Pneumatic forceful balloon dilitation with Rigiflex balloon. May not work; uncomfortable for patient; 3-5% risk of perforation. Pneumatic forceful balloon dilitation with Rigiflex balloon. May not work; uncomfortable for patient; 3-5% risk of perforation. Botox injection. Not always successful. Tends to lose effect in 6-12 months requiring reinjection. Good option for poor surgical candidates. Botox injection. Not always successful. Tends to lose effect in 6-12 months requiring reinjection. Good option for poor surgical candidates. Surgery-laparoscopic myotomy. Cut the sphincter and add partial fundoplication. Surgery-laparoscopic myotomy. Cut the sphincter and add partial fundoplication. Rarely, Calcium Channel blockers or Nitrates. Rarely, Calcium Channel blockers or Nitrates.

42. OTHER MOTILITY PROBLEMS Nutcracker esophagus, diffuse esophageal spasm, and hypertensive lower esophageal sphincter are three patterns often seen. Nutcracker esophagus, diffuse esophageal spasm, and hypertensive lower esophageal sphincter are three patterns often seen. Controversy as to whether these conditions can cause non-cardiac chest pain and/or dysphagia. Controversy as to whether these conditions can cause non-cardiac chest pain and/or dysphagia. In spite of these uncertainties treatment is often tried to see if clinical response. In spite of these uncertainties treatment is often tried to see if clinical response. In some patients, may be related to reflux and therefore often give trial of anti-reflux medication first. In some patients, may be related to reflux and therefore often give trial of anti-reflux medication first.

43. DIFFUSE ESOPHAGEAL SPASM

44. HYPERTENSIVE LES

45. NUTCRACKER ESOPHAGUS

46. Treatment In many patients improvement can be a consequence of learning they don ’ t have a serious cardiac issue. In many patients improvement can be a consequence of learning they don ’ t have a serious cardiac issue. First line therapy often consists of a calcium channel blocker (diltiazem) or an antidepressant (imipramine). Can use nitrates or sildenafil on an as needed basis. First line therapy often consists of a calcium channel blocker (diltiazem) or an antidepressant (imipramine). Can use nitrates or sildenafil on an as needed basis. Other options include trial of hot liquids with meals, botox injection, bougie. Other options include trial of hot liquids with meals, botox injection, bougie.

47. Esophageal Varices All patients with cirrhosis should have EGD screening for varices. All patients with cirrhosis should have EGD screening for varices. No varices- rescope in couple years. No varices- rescope in couple years. Small varices- consider NSBB in these patients Small varices- consider NSBB in these patients Large varices- low risk group probably use NSBB. High risk group (red wale signs, advanced liver disease) can choose between NSBB and EVL. Add PPI after EVL (ulceration) Large varices- low risk group probably use NSBB. High risk group (red wale signs, advanced liver disease) can choose between NSBB and EVL. Add PPI after EVL (ulceration) Sclerotherapy not warranted for primary prevention of bleeding. Sclerotherapy not warranted for primary prevention of bleeding.

48. Esophageal Varices

51. Case Presentation 18 y/o female in excellent general health awakens in the morning with rather severe substernal chest pain when she swallows anything even saliva. Has never had similar problems in the past. 18 y/o female in excellent general health awakens in the morning with rather severe substernal chest pain when she swallows anything even saliva. Has never had similar problems in the past. Her only medication is doxycycline which she has taken for acne for 2 years. Her only medication is doxycycline which she has taken for acne for 2 years. WHAT IS YOUR DIFFERENTIAL DIAGNOSIS? WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

52. Medication Ulcers First reported with KCl. Now known to be associated with multiple meds including quinidine, tetracyclines (doxycycline), iron products, alendronate, and anti-inflamatory medications most often ASA First reported with KCl. Now known to be associated with multiple meds including quinidine, tetracyclines (doxycycline), iron products, alendronate, and anti-inflamatory medications most often ASA Onset is usual rapid and most often noticable on awakening in AM. Chest pain, odynophagia. Onset is usual rapid and most often noticable on awakening in AM. Chest pain, odynophagia. Injury caused by direct contact of the caustic contents of the medication Injury caused by direct contact of the caustic contents of the medication

54. Treatment of Pill Ulcers No evidence that any medication speeds healing. Typically resolves in a few days. No evidence that any medication speeds healing. Typically resolves in a few days. Pain meds. Pain meds. May need parenteral support in rare cases. May need parenteral support in rare cases. Can try suspension of sucralfate (Carafate) or topical anesthetic (xylocaine). Can try suspension of sucralfate (Carafate) or topical anesthetic (xylocaine).