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

2. 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

3. 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

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

5. 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

6. 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.

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

8. 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

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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. Achalasia

16. Complications
Nocturnal regurgitation
Cough
Aspiration
pnemonitis

17. 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

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

19. 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

20. 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

21. Treatment
CCBs
Botox
Nitrates
Others

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

23. 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

24. Zenker’s Diverticulum

25. 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)

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

28. 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

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

30. 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.

31. Complications Esophagitis Peptic esophageal ulcer Esophageal stricture
Barrett’s esophagus

32. 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

33. 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

34. Nissen Fundoplication

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

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

37. 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

40. 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

41. 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

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

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

44. 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

45. 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