Esophageal and Swallowing Disorders Brenda Beckett, PA-C UNE PA Program

We’ll Cover Dysphagia GERD Diverticula Mallory Weiss Syndrome Obstructive disorders Schatzki Ring Esophageal Web Motility disorders Achalasia Diffuse Esophageal Spasm GERD Diverticula Mallory Weiss Syndrome Esophageal varices Esophageal rupture

Esophagus Muscular tube about 25 cm long extending from the hypopharynx to the stomach. Lies posterior to the trachea and heart. Passes through the mediastinum and the hiatus in its descent from the thoracic to the abdominal cavity. Terminates at cardia or LES

Symptoms Dysphagia: Difficulty swallowing Odynophagia: Pain with swallowing Heartburn (pyrosis): Substernal burning, can radiate to neck

Diagnostic Studies Upper endoscopy: Study of choice for many esophageal disorders. Visualization and biopsy Barium Esophagography: Differentiate mechanical from motility Esophageal Manometry: Pressure. pH recording: Reflux

Dysphagia Difficulty swallowing. “Food gets stuck” Oropharyngeal dysphagia- abnl function proximal to esophagus Neuro or muscular etiology, ie: Parkinsons, MS, MD, MG Esophageal dysphagia- difficulty passing food down esophagus due to either Mechanical obstruction Motility disorder 2. Muscular or neuro problems.

Obstructive Disorders Dysphagia to solids Bread and meat especially Lower Esophageal Ring Esophageal Web Neoplasms (covered in separate lecture)

Lower Esophageal Ring Schatzki’s Ring 2-4 mm mucosal stricture, usually congenital Causes circumferential narrowing at squamocolumnar junction at distal esophagus Severity of sx based on lumen size

Schatzki Ring Assoc with hiatal hernia Dx: endoscopy or barium esophagography Tx: Chew thoroughly Endoscopic dilation

Esophageal Web Thin mucosal membrane across lumen of upper esophagus Dysphagia to solids Seen with severe iron deficiency anemia (as part of Plummer-Vinson) Dx and tx by endoscopy, also will resolve with tx of Fe-deficiency anemia

Achalasia Neurogenic esophageal motility disorder characterized by: -impaired esophageal peristalsis -lack of lower esophageal sphincter relaxation during swallowing -elevation of lower esophageal sphincter resting pressure Chalasia – relaxation of a ring of muscle.

Achalasia Onset age 20-40 Progressive dysphagia Both liquids and solids Nocturnal regurgitation of undigested foods in 1/3 of patients Chalasia=the relaxation of a ring of muscle (as the cardiac sphincter ofthe esophagus) surrounding a bodily opening

Etiology ? Perhaps viral? Can be secondary to mechanical obstruction or paraneoplastic process Loss of ganglion cells in mesenteric plexus of esophagus Leads to denervation of esophageal musculature

Achalasia Dx Barium studies: Manometry: Absence of progressive peristaltic contractions during swallowing Significant esoph dilation Narrowed “birds beak” distal esoph (at LES) Manometry: Lack of peristalsis, lack of relaxation of LES Birds beak – board question

Achalasia

Complications Nocturnal regurgitation Cough Aspiration pnemonitis

Achalasia Treatment There is no treatment to restore peristalsis Goal: decrease LES pressure Balloon dilation of LES, may repeat Drugs: Nitrates, CCB, Botox Surgery: Heller myotomy 3. Cut outer ring of LES to decrease pressure. Problem is that these Tx can cause GERD – relaxes too much

Diffuse Esophageal Spasm Non-productive esophageal contractions Hyperdynamic contractions Increased LES pressure

Esoph Spasm Sx Substernal squeezing chest pain May occur with exertion With dysphagia for liquids and solids May occur with exertion May occur with esoph temp extremes Sound familiar?? Can be indistinguishable from angina pectoris or myocardial infarction Dysphagia uncommon sx

Esoph Spasm Dx Rule out coronary ischemia Barium swallow: Poor progression of bolus Disordered, simultaneous contractions Esophageal manometry Simultaneous, prolonged, high amplitude contractions “Nutcracker esophagus” – pressure so high it can crack a nut

Treatment CCBs Botox Nitrates Others

Esophageal Diverticula Outpouching of mucosa through the muscular layer of the esophagus Asymptomatic or dysphagia and regurgitation

Zenker’s diverticulum Posterior outpouchings of mucosa and submucosa through the crico-pharyngeal muscle Likely results from an incoordination between pharyngeal propulsion and cricopharyngeal relaxation SX: Regurg, choking, protrusion in neck TRT: surgery, stapling

Zenker’s Diverticulum

GERD Gastroesophageal reflux disease Incompetent LES from: Reflux of stomach contents causing symptoms Incompetent LES from: General loss of intrinsic sphincter tone Recurrent inappropriate relaxations triggered by gastric stretch Allows reflux of gastric contents into esophagus Frequent in infants (also GER)

Factors contributing to LES Competence Angle of cardioesophageal junction Action of diaphragm Gravity

GERD & Hiatal Hernia Hiatal hernia occurs when the LES, upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragmatic hiatus acts as an additional sphincter around the lower end of the esophagus Greater risk for GERD

Factors Contributing to Reflux Weight gain Fatty foods Caffeine Carbonated beverages EtoH Tobacco Increased intrabdominal pressure Drugs: anticholinergics, antihistamines, TCAs, CCBs, nitrates, progesterone

Symptoms Heartburn Hypersalivation (from smoking as well) Substernal burning Regurgitation (I think I just threw up in my mouth…) Hypersalivation (from smoking as well) Belching, nausea Dysphagia, odynophagia *Cough, wheezing, hoarseness, asthma *atypical sx.

Complications Esophagitis Peptic esophageal ulcer Esophageal stricture Barrett’s esophagus

GERD Dx Detailed history Typical symptoms get trial treatment Work-up reserved for: Longstanding sx Symptoms of complications Pts who fail empiric tx Endoscopy with biopsy

GERD Tx  HOB 6 inches (not just pillows) NO: Eating within 3 hours of bedtime, large meals Acidic foods(coffee, citrus, tomatoes, etc) Drugs (see list of contributors to sx) Smoking (hyposalivation) Foods that weaken LES (fatty foods, alcohol, chocolate, peppermint) Meds: PPI x 8-12 weeks (better than H2 blockers, antacids or pro-motility meds) Weight loss Surgical: Fundoplication DOC = PPI

Nissen Fundoplication

Esophagitis GERD (Most common) Pill esophagitis Radiation esophagitis Direct erosive effects Radiation esophagitis Infectious esophagitis Usually in immunocompromised pts Candida, CMV, HSV

Esophagitis Symptoms Odynophagia. Pain on swallowing Dysphagia Chest pain: substernal Signs of infection

Barrett’s Esophagitis Normal stratified squamous epithelium of distal esophagus replaced by: Metaplastic, columnar, glandular intestine-like mucosa Can give rise to adenocarcinoma Warrants frequent surveillance by endoscopy

Esophageal varices Usually caused by portal hypertension secondary to cirrhosis Can cause painless, sometimes massive upper GI bleed Bright red hematemesis NOT coffee-ground emesis First, stabilize the pt: fluid resuscitation, blood transfusion, etc Then endoscopic/surgical repair

Mallory-Weiss Syndrome Non-penetrating mucosal laceration of distal esoph/proximal stomach Caused by vomiting, retching, hiccupping Often seen in alcoholics, but any forceful vomiting will do Can cause significant bleeds Most stop spontaneously 10% require transfusion May need cauterization

Esophageal Rupture Iatrogenic Spontaneous ie: during endoscopy Boerhaave Syndrome (usu vomiting, so not truly spontaneous, but differentiates from iatro) Severe bleed.

Esoph Rupture MC site distal esophagus, L side Acid and stomach contents cause fulminant medistinitis, pneumomediastinum, shock. Bad. MC – main cause

Esoph rupture S/S Sx: chest, abd, thoracic pain, hematemesis, shock Did I say BAD? Subcutaneous emphysema palpable in 30% Hamman’s sign- mediastinal crunch Crackling synchronous with heartbeat. Cool

Rupture Dx & Tx Imaging Mediastinal air & widening, pleural effusion Confirm with esophagography with water soluble contrast dye Broad spectrum abx, fluid resuscitation, surgical repair. High mortality