Diseases of the Esophagus
Lecture 1
Dr. Tatia khachidze
Esophageal Anatomy
Upper Esophageal
Sphincter (UES)
Esophageal Body 18 to 25 cm
(cervical & thoracic)
Lower Esophageal
Sphincter (LES)
Esophageal Disorders
• Motility
• Anatomic &
Structural
• Reflux
• Infectious
• Neoplastic
• Miscellaneous
Diseases of esophagus
clinical manifestations
• Dysphagia, heartburn, and odynophagia are symptoms
with a high degree of specificity for the esophagus
• Chest pain, though common in esophageal disease,
has a much longer differential diagnosis list
Diagnostic Tools
– barium esophagram
– esophageal manometry
– endoscopy
Esophageal Motility
Disorders
Achalasia
• first clinically recognized esophageal
motility disorder
• epidemiology
– 1-2 per 200,000 population
– usually presents between ages 25
to 60
– male=female
– Caucasians > others
– average symptom duration at
diagnosis: 2-5 years
Pathophysiology
• Degeneration of NO producing inhibitory neurons
– loss of ganglionic cells in the myenteric plexus (distal to
proximal)
– vagal fiber degeneration
– underlying cause: unknown
• autoimmune? (antibodies to myenteric neurons in 50%
of patients)
• that affect relaxation of LES
• Basal LES pressure rises
Mechanical End Result
• dual disorder
– LES fails to appropriately relax
• resistance to flow into stomach
• not spasm of LES but an increased basal LES
pressure often seen (55-90%)
– loss of peristalsis in distal 2/3 esophagus
Clinical Presentation
• clinical presentation
– solid dysphagia 90-100% (75% also with dysphagia
to liquids)
– post-prandial regurgitation 60-90%
– chest pain 33-50%
– pyrosis 25-45%
– weight loss
– nocturnal cough and recurrent aspiration
Diagnostic Work Up
– plain film (air-fluid level, wide mediastinum,
absent gastric bubble, pulmonary infiltrates)
– barium esophagram (dilated esophagus with taper
at LES) Bird peak
• good screening test (95% accurate)
– endoscopy (rule out GE junction tumors, esp.
age>60)
– esophageal manometry (absent peristalsis, LES
relaxation, & resting LES >45 mmHg)
Manometric Features
• Incomplete LES
relaxation
• Elevated resting
pressure (>45 mmHg)
• Aperistalsis of
esophageal body
Treatment of Achalasia
Goals
• reduce LES pressure and
• increase emptying
Nitrates and Calcium Channel Blockers
• Isosorbide dinitrate
Reduces LES Pressure 66% for 90 min
• Nifedipine
Reduces LES pressure 30-40% for > 60 minutes
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects
Botulinum Toxin
• prevents ACH release at NM junction
• 90% initial response; 60% at 1 year
• Needs repetitive sessions
Pneumatic Dilatation
• disrupt circular muscle
• 60-95% initial success; 60% at 5 years
• Success increases with repeat dilatations
• risk of perforation 1-3%
Surgical Treatment
– Hellers’s extramucosal
myotomy
– Laparoscopic
myotomy
Diffuse Esophageal Spasm
• frequent non-peristaltic
contractions
• The contraction may have
low, normal, or large
amplitude.
• Any age (mean 40 yrs)
• Female > Male
Clinical Presentation
• Dysphagia to solids and liquids
• intermittent and non-progressive
• present in 30-60%, more prevalent in DES (in most studies)
• Chest Pain
• constant % across the different disorders (80-90%)
• swallowing is not necessarily impaired
• can mimic cardiac chest pain
• Heartburn (20%)
Diagnosis
• Manometry
• Barium Esophagram
• Endoscopy
• PH monitoring
Treatment
reassurance
nitrates, anticholinergics, hydralazine - all
unproven
calcium channel blockers - too few data with
negative controlled studies in chest pain
psychotropic drugs – trazodone, imipramine and
setraline effective in controlled studies
dilation - anecdotal reports, probable placebo
effect
GERD
– 7% have daily GERD symptoms
– 14-20% weekly symptoms
– 15-50% monthly
Symptoms include: heartburn, acid
regurgitation, water brash, dysphagia,
atypical symptoms (asthma, globus,
laryngitis, cough,)
Pathophysiology
• Lower esophageal sphincter dysfunction
• Delayed gastric emptying
• Esophageal dysmotility
• +/- hiatal hernia
• Repetitive mucosal injury / esophagitis
• Barrett’s Esophagus
Symptoms of
GERD
• Extraesophageal
• Esophageal – Cough
- Heartburn – Wheezing
– Dysphagia – Hoarseness
– Odynophagia – Sore throat
– Regurgitation – Globus sensation
– Belching – Epigastric pain
– Non-cardiac chest
pain(NCCP)
Factors That Can Aggravate
GERD
• Diet – Caffeine, fatty/spicy
foods, chocolate, coffee, peppermint
, citrus, alcohol
• Position/Activity – Bending,
straining
• External Pressure – pregnancy, tight
clothing
Diagnostic
Evaluation
-If classic symptoms of heartburn and
regurgitation exist in the absence of
“alarm symptoms” the diagnosis of GERD
can be made clinically and treatment can
be initiated
Alarming Signs & Symptoms
• Dysphagia
• Early satiety
• GI bleeding
• Odynophagia
• Vomiting
• Weight loss
• Iron deficiency anemia
Diagnostic Tests for
GERD
• Barium swallow
• Endoscopy
• Ambulatory pH monitoring
• Impedance-pH monitoring
• Esophageal manometry
Barium Swallow
• Useful first diagnostic test for
patients with dysphagia
– Stricture (location, length)
– Mass (location, length)
– Hiatal hernia (size, type)
• Limitations
– Detailed mucosal exam for
erosive esophagitis,
Barrett’s esophagus
Endoscopy
• Indications
– Alarm symptoms
– Empiric therapy
failure
– Preoperative
evaluation
– Detection of
Barrett’s esophagus
pH
-24-hour pH monitoring-----Physiologic study
– Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
– Trans-nasal catheter or a wireless, capsule
shaped device
Treatment
–Symptomatic relief
–Heal esophagitis
–Prevent & Treat
complications
–Maintain remission
Medical Treatment
• Lifestyle modifications
– avoid coffee, fatty foods, smoking; lose
weight, raise head of bed, eliminate late
night meals
• Acid suppressin via PPI’s
Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Esomeprazole 40mg daily 20-40mg daily
Omeprazole 20mg daily 20mg daily
Lansoprazole 30mg daily 15-30mg daily
Pantoprazole 40mg daily 40mg daily
Rabeprazole 20mg daily 20mg daily
Indications for Surgery
• Failed medical management
• Need for lifelong medical therapy
• Hiatal hernia
• Complications
• – Barrett’s esophagus (5-15% develop BE)
• – Erosive esophagitis
Surgical Treatment
• Laparoscopic Nissen Fundoplication
Infectious Esophagitis
• most commonly found in patients who are
immunocompromised:
• Candida albicans
• herpes simplex virus type 1 (HSV-1)
• CMV
Symptoms
• Odynophagia is characteristic and may be severe.
• Dysphagia,
• weight loss,
• and gastrointestinal bleeding are common.
• Complications are infrequent but may include
tracheobronchial fistula, perforation, and hemorrhage.
Candida esophagitis
• Multiple biopsies of ulcerated areas with routine
histologic evaluation provide a definitive diagnosis.
Candida esophagitis is characterized on endoscopy by
• numerous small white-yellow mucosal plaques
containing microorganisms, inflammatory cells,
and necrotic mucosa
• biopsy demonstrate
Candida pseudohyphae
Tx Candida esophagitis
• In non-AIDS patients, Candida esophagitis may be
treated with
• oral nystatin, 1 to 3 million units four times a day,
• or clotrimazole (Mycelex troches), 100- mg tablets
dissolved in the mouth three to five times a day,
• but patients with AIDS require an azole antifungal such
as
• oral or intravenous fluconazole (Diflucan), 100 to 200
mg/day for 10 to 14 days
HSV esophagitis
HSV esophagitis on endoscopy
• begins as numerous vesicles that ulcerate to yield small
(<2 cm), shallow, volcano-shaped ulcers
• A positive biopsy specimen from the ulcer edge
demonstrates the characteristic cytopathic effect of HSV
within squamous epithelial cells—eosinophilicintranuclear
occlusions.
Tx HSV esophagitis
• HSV esophagitisis treated with a nucleoside analogue such
as
• Acyclovir (Zovirax), 200 to 400 mg orally five times a
day or 250 mg/m2 intravenously every 8 hours for 2
weeks.
• Valacyclovir (Valtrex) and famciclovir (Famvir) are
alternatives;
• for resistant cases, intravenous foscarnet, 60 mg/kg
every 8 hours for 2 to 4 weeks, is effective
CMV esophagitis
• CMV esophagitis is characterized by large (>2 cm), deep, often linear
ulcers;
• a positive biopsy specimen from the ulcer base demonstrates the
characteristic cytopathic effect of CMV within fibroblasts and
endothelial cells—basophilic intranuclear inclusions
Tx CMV esophagitis
CMV esophagitisis treated with
• intravenous ganciclovir, 5 mg/kg every
• 12 hours for 2 to 4 weeks;
• for resistant cases, foscarnet is administered
intravenously at 60 mg/kg every 8 hours for 2 to 4
weeks.
Eosinophilic esophagitis
Structural abnormalities of the
esophagus
Zenker's Diverticulum
• A Zenker's Diverticulum is an esophageal
pouch that develops in the upper esophagus
which causes difficulty swallowing and
regurgitation of food.
Symtoms
• halitosis
• regurgitation of saliva and food
• When it becomes large and filled with food, it
can compress the esophagus and cause
dysphagia or complete obstruction
Diagnosis:
Barium Swallow
Upper Endoscopy
Treatment
• Cricopharyngeal Myotomy - cutting or
opening of the muscle
• Diverticulectomy - removal of the
diverticulum or pouch
Esophageal cancer
Risk Factors : Squamous Cell Carcinoma
• Smoking and alcohol (80% - 90%)
• Dietary factors
• N-nitroso compounds (animal carcinogens)
• Pickled vegetables and other food-products
• Toxin-producing fungi
• Betel nut chewing
• Ingestion of very hot foods and beverages (such as tea)
Risk Factors: Adenocarcinoma
• Associated with Barretts’s esophagus, GERD &
hiatal hernia.
• Obesity (3 to 4 fold risk)
• Smoking (2 to 3 fold risk)
• Increased esophageal acid exposure such as
Zollinger-Ellison syndrome.
Barrett’s esophagus is a metaplasia of the
esophageal epithelial lining. The squamous
epithelium is replaced
by columnar epithelium,with
0.5% annual rate of neoplastic
transformation.
Clinical Features
• Dysphagia, the most common presenting
symptom of esophageal cancer, is initially
experienced for solids but eventually progresses to
include liquids.
• Weight loss - This is the second most common
symptom,occurs in more than 50% of dx cases.
• Bleeding - Patients may experience bleeding from
the tumor
• Pain - Pain may be felt in the epigastric or
retrosternal area; pain over bony structures
indicates metastatic disease
• Hoarseness - This is caused by invasion of the
recurrent laryngeal nerve
• Respiratory symptoms - These can be caused by
aspiration of undigested food or by direct invasion
the tracheobronchial tree by the tumor; the latter
is also a sign of unresectability
Pathology diagnosis - Upper
endoscopy
18
Early, Circumferential ulceration Malignant stricture
superficial esophageal cancer of esophagus
cancer
Barium swallow:
Barium swallow demonstrating an Barium swallow demonstrating
endoluminal mass in the mid
esophagus stricture
Endoscopic
Ultrasonography
• Endoscopic ultrasonography (EUS) is the most sensitive test
for determining the depth of tumor penetration (T staging)
and the presence of enlarged periesophageal lymph nodes
Treatment
• Endoscopic Mucosal Resection(EMR)
• Surgery
• Chemotherapy
• Radiotherapy
• Combined-modality therapy
• Palliative Therapy
