LE3: DISEASES OF ESOPHAGUS

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SYMPTOMS OF ESOPHAGEAL DISEASES

HEARTBURN (PYROSIS) REGURGITATION CHEST PAIN ESOPHAGEAL DYSPHAGIA ODYNOPHAGIA GLOBUS SENSATION
• Most common esophageal • Sour/ burning fluid in throat.
• Pressure type sensation in mid-chest • Achalasia (motility disorder): • More common • Relieved by
symptom • Vomiting: preceded by nausea, radiating to mid-back, arms, or jaws. dysphagia with solid and liquids with Pill or swallowing
• Relieved with drinking accompanied by retching • Esophagus & heart share same nerve • Stricture, ring, or tumor: dysphagia Infectious • Assoc with Anxiety
water/ antiacid • Rumination: regurgitation of plexus. with solid food. esophagitis or OCD.
• Interfering sleep swallowed food then • GERD: most common cause of • Symptoms assoc. with oropharyngeal
• Associated with GERD. swallowed repetitively for an esophageal chest pain dysphagia:
hour. • Coronary Artery Disease: always o Aspiration
excluded before the esophagus is o Nasopharyngeal regurgitation
considered as the origin of atypical chest o Cough
pain o Drooling
o Neuromuscular compromise.
DIAGNOSTICS
ENDOSCOPY CONTRAST RADIOGRAPHY ENDOSCOPIC ULTRASOUND (EUS) ESOPHAGEAL MANOMETRY REFLUX TESTING
• Most useful in evaluation • Better visualize • Create transmural image. • Motility test, assess peristaltic • Done by ambulatory 24 to 96-hour
of esophageal, gastric, & hypopharyngeal pathology • Provide greater resolution. integrity. esophageal pH recording
duodenal lumen. & disorder of • Confirm diagnosis of motility • Outcome expressed as percentage of
• Diagnostic and cricopharygeus muscle. disorders such as achalasia, the day that the pH was high or low.
therapeutic (ability to scleroderma, diffuse esophageal
dilate strictures) spasm.
•

STRUCTURAL DISORDERS OF THE ESOPAGUS

HIATAL HERNIA LOWER ESOPHAGEAL MUCOSAL RING (B RING) WEBS
SLIDING HIATAL HERNIA PARA-ESOPHAGEAL HERNIA • Thin membranous narrowing at the • originate along the
• gastroesophageal • esophagogastric junction remains fixed in its normal location squamocolumnar mucosal junction anterior aspect of the
junction and gastric and a pouch of stomach is herniated beside the • Treated with balloon dilatation esophagus.
cardia translocate gastroesophageal junction. • Schatzki rings: present older than 40 years; Plummer-Vinson syndrome: (+)
cephalad. • type II and III: stomach inverts as it herniates and large para- most common cause of intermittent food symptomatic proximal
• enlarge with esophageal hernias can lead to: “upside down stomach”, impaction → ‘steakhouse syndrome esophageal webs and iron-
increased gastric volvulus, strangulation of stomach. → need surgical deficiency anemia in middle-
intraabdominal repair. aged women
pressure, swallowing, • Type II - the gastroesophageal junction remains fixed at the
and respiration. hiatus.
• main significance is • Type III - combined sliding and para-esophageal hernia.
the propensity of • Type IV hiatal hernias: viscera herniate into the mediastinum,
affected individuals most commonly the COLON.
to have GERD
 STRUCTURAL DISORDERS OF THE ESOPAGUS
DIVERTICULA TUMORS ESOPHAGEAL ATRESIA
Zenker’s Diverticulum Epiphrenic Diverticula Midesophageal Diverticula • shift of dominant esophageal cancer type • Most common congenital
• Obstruction site: stenotic • Assoc with: Achalasia, Esophageal • True diverticula (involves ALL from squamous cell to adenocarcinoma. esophageal anomaly.
cricopharyngeus muscle & hypercontractile disorders, & Distal layers) • linked to reflux disease and Barrett’s
hypopharyngeal herniation esophageal stricture • caused by: Tuberculosis metaplasia.
(Killian’s triangle) • Adenocarcinoma: affect the distal
• Tx: Surgical diverticulectomy and esophagus
cricopharyngeal myotomy; • Squamous cell carcinoma: affect more
Marsupialization procedure proximal esophagus.
• SX: progressive solid food dysphagia +
weight loss.
• poor survival because of the abundant
esophageal lymphatics leading to regional
lymph node metastases

ESOPHAGEAL MOTILITY DISORDERS

ACHALASIA DIFFUSE ESOPHAGEAL SPASM (DES) GASTROESOPHAGEAL REFLUX DISEASE (GERD) EOSINOPHILIC ESOPHAGITIS (EoE)
Features • Characterized by: Progressive dilatation, • Features exhibits overlap with cardiac • With rising incidence of: Adenocarcinoma of • Atopic history is present
Sigmoid deformity of the esophagus, & Pain the esophagus
Hypertrophy of the LES • Mechanisms: Transient LES relaxations, LES
• Cause of ganglion cell degeneration → hypotension, & Anatomic distortion of the
autoimmune process attributable to a esophagogastric junction inclusive of hiatus
latent infection with human herpes hernia.
simplex virus 1 combined with genetic • Barret’s Metaplasia: Most severe histologic
susceptibility. consequence of GERD
• Complications: bronchitis, pneumonia, or
lung abscess
Symptoms • Dysphagia • Esophageal “chest” pain mimics angina • Heartburn • Dysphagia and esophageal food
• Chest pain: described as squeezing, pectoris. • Regurgitation impactions
pressure-like retrosternal pain. • Extraesophageal manifestations: Chronic
• Regurgitation & Weight loss cough, Laryngitis, Asthma, Dental erosions
Diagnostics • Chest X-ray: (+) Tubular mediastinal mass • “Corkscrew esophagus” • • Endoscopic findings:
beside the aorta, (+) Air fluid level in the • Rosary bead esophagus o Loss of vascular markings,
mediastinum in the upright view • Esophageal Manometer: o Multiple esophageal rings
, (-) Gastric air bubble o Uncoordinated (“spastic”) activity int he o Longitudinally oriented furrows
• Barium Swallow: (+) Esophageal dilatation, distal esophagus o Punctate exudate
esophagus may become sigmoid or S- o Spontaneous and repetitive • Histologic: esophageal mucosal
shaped. (+) Bird’s beak-like narrowing – contractions eosinophilia (peak density of ≥ 15
represents non-relaxing LES o High amplitude and prolonged eosinophils/hpf)
• Endoscopy: n to exclude pseudoachalasia contractions
o indicative of an impairment in the
inhibitory myenteric plexus neurons
Treatment • Only durable therapy: Pneumatic (balloon) • Long myotomy or Esophagectomy – only • H2 receptor blocking agents. • Do PPI trial therapy:
dilatation & Heller Myotomy indicated with severe weight loss or • Proton pump inhibitors (PPIs): More effective, o PPI-responsive
• Endoscopic therapy: unbearable pain does not increase the risk of carcinoid tumors; o PPI-nonresponsive: consider
o Botilunum toxin injection prolonged use have an increased incidence of elimination of diet & swallowed
topical glucocorticoids.
 o Pneumatic Balloon dilatation: Most hip fractures (because absorption of Vit. B12 & • Esophageal dilation: done if with
popular endoscopic treatment for Calcium are interrupted) risk of perforation.
achalasia • Surgical Treatment: Laparoscopic Nissen
• Surgical: Laparoscopic Heller Myotomy: Fundoplication
most common surgical procedure • Endoscopic Mucosal Ablation Therapy:
o Esophageal resection with gastric pull-up indicated for presence of High-Grade Dysplasia
→ done for refractory cases

INFECTIOUS ESOPHAGITIS
Disease CANDIDA ESOPHAGITIS HERPETIC ESOPHAGITIS VIRAL ESOPHAGITIS CYTOMEGALOVIRUS ESOPHAGITIS
Features • Etiologic agents: Herpes simplex • Occurs in immunocompromised patients,
virus type 1 or 2 particularly with organ transplant recipients
• Limited to squamous epithelium.
Symptoms • (+) Oral thrush • Vesicles on the nose and lips. • Serpiginous ulcers (snake-like)
• Vesicles and small, punched-out
ulcerations.
Diagnostics • Prompt endoscopy with biopsy: most useful • Histologic findings: ground-glass nuclei, • Histologic findings: pathognomonic large
diagnostic evaluation eosinophilic Cowdry’s Type A inclusion nuclear or cytoplasmic inclusion bodies
• Endoscopic findings: white plaques with friability bodies and giant cells
Treatment • Oral fluconazole - preferred treatment • Acyclovir • Ganciclovir take 3-6 weeks
• Voriconazole or Posaconazole
- if refractory to fluconazole
• Intravenous Echinocandin – cannot tolerate oral
drug intake.

MECHANICAL TRAUMA AND IATROGENIC INJURY

Disease CORROSIVE FOREIGN BODY/ FOOD
ESOPHAGEAL PERFORATION MALLORY-WEISS TEAR RADIATION ESOPHAGITIS PILL ESOPHAGITIS
ESOPHAGITIS IMPACTION
Features • Boerhaave’s Syndrome: • Non-transmural tear at • complicate treatment • Caustic esophageal • Mid-Esophagus: Most common • Causes: Peptic
Forceful vomiting or retching the GEJ for thoracic cancers, injury location for the pill to lodge in. stricture, carcinoma,
→ spontaneous rupture at • Common cause of upper with the risk • Absence of oral • Most common pills: Schatzki ring, EoE,
GI bleeding. injury does not doxycycline, tetracycline, Inattentive eating
 the gastroesophageal • Caused by: vomiting, proportional to exclude possible quinidine, phenytoin,
junction. retching or vigorous radiation dosage esophageal potassium chloride, ferrous
• Mediastinitis: major coughing followed by involvement sulfate, bisphosphonates,
complication of esophageal hematemesis NSAIDS
perforation
Symptoms • Sudden onset of chest pain & • Inability to handle
odynophagia. secretions (foaming at
• Develops over a period of hours the mouth) and severe
or will awaken the individual chest pain
from sleep.
Diagnostics • CT of the chest: most • Esophageal mucosa • Endoscopic • •
sensitive in detecting becomes erythematous, evaluation
mediastinal air. edematous, & friable
• Confirmed by: Contrast
swallow (Gastrografin)
followed by thin barium
Treatment • Nasogastric suction and • Endoscopic clipping: done • Supportive • Upper GI endoscopy • No specific therapy • Glucagon (1mg) IV:
parenteral broad-spectrum to stop bleeding • Esophageal dilation: for with repeated tried before
antibiotics with prompt Chronic strictures dilatation endoscopic
surgical drainage and repair dislodgement.
• Endoscopic
dislodgement

ESOPHAGEAL MANIFESTATIONS OF SYSTEMIC DISEASE

Disease SCLERODERMA ESOPHAGUS DERMATOLOGIC DISEASES
Features • Hypotensive LES and absence of esophageal peristalsis • Pemphigus vulgaris
• Predispose patients to severe GERD • Bullous pemphigoid
• Cicatricial pemphigoid
• Behcet’s syndrome
• Epidermolysis bullosa
Diagnostics • Histopathologic findings:
o Infiltration and destruction of the esophageal muscularis propria
o Collagen deposition
o Fibrosis
Treatment • Glucocorticoid treatment
• Esophageal dilatation - treat strictures