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Diseases of esophagus
Contents
Esophagitis, Barrets esophagus & GERD Esophageal tear & perforation Esophageal web, ring, stricture, atresia Achalasia cardia Esophageal hiatus hernia Esophageal hypermotility disorder Esophageal vascular impression Esophageal neoplasm
Esophagitis
Etiology
Gastro-esophageal reflux disease (commonest) Infective: candidiasis, cytomegalovirus, HIV, herpes simplex, tuberculosis, Crohns disease, actinomycosis Caustic ingestion Medication: Iron, vitamin C, doxycycline, NSAID Iatrogenic: nasogastric tube, radiation Others: graft vs. host disease, uremia, eosinophilic esophagitis, benign pemphigoid, epidermolysis bullosa
Grade 1 esophagitis
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Grade 2 esophagitis
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Grade 3 esophagitis
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Grade 4 esophagitis
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Grade 5 esophagitis
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Predisposing factors
Inefficient lower esophageal sphincter due to: Pregnancy Obesity
Fatty food, large meals Coffee, chocolate Cigarette smoking Alcohol ingestion
Clinical features
Retro-sternal burning pain (heartburn / pyrosis) Dysphagia Chest pain Hoarseness, choking (laryngospasm), Bronchospasm / asthma Hematemesis & melaena Chronic cough due to aspiration pneumonia Symptomatic relief with trial of Pantoprazole
GERD
Burning pain
Angina pectoris
Pain seldom radiates to arms Pain radiates into neck, Produced by bending, drinking hot liquids Relieved by antacids Dyspnea absent
shoulders & both arms Pain produced by exercise Relieved by rest Dyspnea present
Investigations
1. Flexible upper GI endoscopy 2. Ambulatory 24-hour double-probe (esophageal & pharyngeal) pH metry = gold standard
Distal probe = 5 cm above lower esophageal sphincter Proximal probe = 1 cm above upper esophageal sphincter, in hypopharynx behind laryngeal inlet Laryngo-pharyngeal reflux = acidic pH in both probes Gastro-esophageal reflux = acidic pH in distal probe only
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pH metry
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GERD Heartburn Hoarseness & dysphagia Nocturnal (supine) reflux Daytime (upright) reflux ed lower esophageal pH ed pharyngeal pH Pantoprazole treatment ++++ + ++++ + ++++ -
40 mg OD 40 mg BD X 6 X 6 wk mth
Treatment of GERD
A. Life style modifications: 1. Raise head end of bed by 6 inches. Sleep in left lateral position. Maintain optimum weight. 2. Avoid the following: Tight fitting clothes & belts Lifting of heavy weight / straining / stooping Smoking
B. Dietary modifications: 1. Take 6 small meals. Eat slowly & chew thoroughly. 2. Take high protein diet. 3. Avoid the following: Eating / drinking within 3 hours of reclining Fried food / excess fat / large meals Taking large amount of fluids with meals Aerated drinks / alcohol (especially in evening) Coffee / tea / chocolate / mint / citrus fruit juice
C. Avoid following medicines: Tranquilizers & sedatives Muscle relaxants Calcium channel blockers Anti-cholinergic drugs Theophylline N.S.A.I.Ds Doxycycline
Dietary + Life style modifications + avoid reflux producing medicines + Liquid antacid (2 tsp 1 hour before meals & at bed time) no relief after 4 weeks Ranitidine 150 mg BD + Cisapride 10 mg TID before meals no relief after 4 weeks Pantoprazole 40 mg OD before breakfast no relief after 4 weeks
Toupet repair
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Laparoscopic fundoplication
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Transoral fundoplication
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anterior & posterior phreno-esophageal bundles (esophagogastric junction) sutured to pre-aortic fascia after fundoplication
Complications of GERD
Esophageal ulceration Esophageal stricture Iron-deficiency anemia Barrett's esophagus Laryngitis, laryngeal ulcers Bronchial asthma Aspiration pneumonia
Barrets esophagus
Presence of gastric epithelium more than 3 cm above gastro-esophageal junction caused by columnar metaplasia of squamous epithelium due to chronic acid exposure Pre-malignant condition for adenocarcinoma Rx: Pantoprazole + periodic esophagoscopy every 2 years to rule out dysplasia / malignancy
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Barrets esophagus
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Web
Ring
Circumferential Consist of mucosa + muscle Involves distal esophagus E.g. Schatzki's ring of lower esophagus
Schatzkis ring
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Clinical features
Dysphagia: more to solids than liquids. Due to upper esophageal web caused by epithelial fibrosis. Pallor: iron deficiency anemia Koilonychia (spoon nails): iron deficiency anemia Cheilitis + glossitis: vitamin B12 deficiency sub-
Investigations
Barium swallow Esophagoscopy anterior wall web in upper esophagus
Blood smear: microcytic, hypochromic anemia Serum iron: decreased Total iron binding capacity: increased Gastric juice analysis: achlorhydria
10-291 ng /mL
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Treatment
Supplementation: iron + vitamin B12 + vitamin B6 + folic acid Endoscopic dilatation of web with elastic bougie or Hurst mercury pneumatic dilator Electrosurgical incision or surgical resection of web for refractory cases Regular check endoscopy to rule out post-cricoid malignancy (seen in 10% cases)
Esophageal strictures
Definition: narrowing of esophageal lumen (normal diameter = 20 mm Dysphagia is main symptom (Solids > liquids) Etiology for multiple esophageal strictures: benign pemphigoid, epidermolysis bullosa, caustic ingestion, candidiasis, graft vs. host disease
Benign stricture
Multiple Regular mucosa Proximal esophageal dilation present At sites of normal constrictions
Malignant stricture
Single Irregular mucosa Proximal dilation absent due to cancer invasion Involves any site in esophagus
Caustic stricture
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Benign pemphigoid
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Multiple strictures
Multiple strictures
Hand contractures
Esophageal compression
Extrinsic compression
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Intra-mural compression
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Esophagoscopy
Confirms diagnosis Evaluates position of stricture Evaluates length of stricture Rules out malignancy
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Esophageal atresia
1. Usually occurs with tracheo-esophageal fistula 2. Diagnosed at birth due to: a. failure to pass nasogastric tube b. absence of intestinal gas in X-ray abdomen 3. VACTERL: anomalies of Vertebra, Ano-genital, Cardiac, Trachea, Esophagus, Renal, Limb 4. Rx: immediate repair of esophagus
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X-ray abdomen
NG tube unable to pass into stomach Absence of intestinal gas
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Etiology
1. Instrumentation: involves upper esophagus a. Esophagoscopy b. Dilatation of esophageal stricture 2. Severe vomiting (alcoholic): lower esophagus a. Superficial mucosal tear = Mallory Weiss tear b. esophageal perforation = Boerhaave syndrome 3. ed esophageal lumen pressure: childbirth, forced cough, defecation, seizure, weight lifting
Clinical Features
Esophageal tear: painless hematemesis Esophageal perforation: life threatening condition Severe pain in neck, chest, intra-scapular area Odynophagia, fever, prostration Tachypnea, tachycardia & hypotension Subcutaneous emphysema of neck Pneumo-mediastinum: Hammans mediastinal crunch on auscultation
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Investigation of perforation
Chest X-ray: pneumothorax, pneumomediastinum Gastrograffin esophagogram: shows perforation. Barium increases mediastinitis. Flexible esophagoscopy for difficult cases CT scan chest for mediastinitis Click to edit Master text styles Second level Third level Fourth level Fifth level
Treatment
Conservative: for upper esophageal rupture detected within 12 hours & peptic stricture ruptures Thoracotomy & urgent repair of perforation: for lower esophageal rupture detected within 12 hours Esophageal bypass / resection & anastomosis / indwelling Celestin feeding tube: for perforation detected after 12 hours & stricture perforations of malignancy, caustic ingestion & post-radiotherapy
Conservative treatment
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Nil by mouth Parenteral nutrition IV high dose broad-spectrum antibiotics Endoscopic insertion of nasogastric tube Continuous nasogastric tube suction for 1 week
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Etiology: 1. degeneration of ganglion cells of inhibitory neurons in Auerbachs myenteric plexus 2. Chagas disease (American trypanosomiasis) Pathogenesis: failure of lower esophageal sphincter relaxation + uncoordinated peristalsis food retention dilated + tortuous lower esophagus Clinical features: Dysphagia more to liquids than solids Regurgitation of undigested food
Barium swallow: Smooth fusiform lower esophageal dilation (mega-esophagus) with abrupt tapering of lower end (bird's beak appearance). Absence of fundic gas shadow. Absence of peristalsis.
Esophagoscopy: sudden dilatation of lower esophageal lumen (like entering a dirty cave). Rule out malignancy (0.15% ) causing pseudo-achalasia.
Barium swallow
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Esophagoscopy
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Esophageal manometry
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Treatment
Smooth muscle relaxants (nitrates or calcium channel blockers): afford short-lived relief Endoscopic Botulinum toxin injection into lower esophageal sphincter: gives relief for many weeks Endoscopic dilatation of lower esophageal sphincter: with elastic bougie / pneumatic dilator Hellers laparoscopic cardio-myotomy: surgical division of lower esophageal sphincter + Nissens complete fundoplication to prevent post-op reflux
Hellers cardiomyotomy
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Laparoscopic cardiomyotomy
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Fundoplication
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Atrophy & fibrosis of esophageal smooth muscle + incompetent LES C/F: GERD + Calcinosis + Raynauds phenomenon + Esophageal dysmotility + Sclerodactyly + Telengiectasia Rx: Pantoprazole + Cisapride
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Sliding hiatus hernia: gastro-esophageal junction slides > 2 cm above esophageal hiatus in diaphragm. Esophagoscopy is diagnostic. Para-esophageal or rolling hernia: part of gastric fundus rolls up via esophageal hiatus in diaphragm, alongside esophagus. Gastro-esophageal sphincter remains below diaphragm & is competent . Esophagogram is diagnostic.
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Sliding hernia
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Para-esophageal hernia
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Para-esophageal hernia
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Cricopharyngeal spasm
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Cricopharyngeal myotomy
Barium esophagogram
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Esophageal manometry
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Esophageal manometry
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Esophageal manometry
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Vascular impressions
A. Intrinsic esophageal varices Uphill: in portal hypertension Downhill: in superior vena cava obstruction B. Extrinsic (dysphagia lusoria) Aberrant right subclavian artery Right aortic arch Double aortic arch Aberrant left pulmonary artery
Esophageal varices
Etiology: portal hypertension & SVC obstruction Clinical presentation: hematemesis Endoscopy: bluish esophageal varices Barium swallow: string of black pearls appearance Treatment: a. Cure of etiology b. Endoscopic variceal sclerotherapy c. Endoscopic variceal ligation (banding) d. Porto-systemic vascular shunt e. Devascularization of lower 5 cm of esophagus
Esophagoscopy
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Uphill varices
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Downhill varices
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Forrestiers disease
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Rx: Osteophytectomy
Esophagogram
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Esophageal neoplasm
Rare condition Types: Leiomyoma (commonest) Fibro-vascular polyp Squamous papilloma > 50% are asymptomatic Endoscopic / thoracotomy excision for dysphagia
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Esophageal malignancy
Squamous cell carcinoma (upper 2/3rd) Adenocarcinoma (lower 1/3rd) Spindle cell carcinoma Leiomyosarcoma Lymphoma Metastasis
Clinical features
progressive, painless dysphagia for solid foods acute food bolus obstruction weight loss in late stages chest pain or hoarseness: mediastinal invasion coughing after swallowing, pneumonia & pleural effusion: tracheo-esophageal fistula cervical lymphadenopathy: node metastasis
Risk factors
Smoking Alcohol consumption Tobacco chewing Vitamin C deficiency Betel nut chewing Vitamin A deficiency
Investigations
1. Barium swallow: a. shouldering: malignant ulcer with everted margin b. rat tail appearance: narrow lower 1/3rd with no proximal dilatation c. apple core appearance: narrow middle 1/3rd only 2. Esophagoscopy & biopsy from growth 3. CT scan chest: for staging of malignancy
Shouldering
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Palliative treatment
70% patients have advanced disease at presentation & require palliative treatment
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Endoscopic tumour ablation using laser Low dose intra-cavitary radiotherapy Indwelling feeding tube (Mousseau-Barbin, Celestin) Feeding jejunostomy Chemotherapy (5 Fluorouracil) Nutritional support & analgesia with morphine
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Definitive Treatment
Upper 1/3rd: early: radical radiotherapy (5500 cGy) advanced: chemo-radiation Middle 1/3rd: early: radical RT or radical surgery advanced: radical surgery + CT Lower 1/3rd: early: radical surgery advanced: radical surgery + CT Radical surgery: esophagectomy + gastrectomy + reconstruction with gastric / jejunal flap Chemotherapy (CT): Cisplatin + 5-fluorouracil
Evaluation of dysphagia
Extra-esophageal causes
Neoplasm: jaw / oral cavity / oropharynx / hypopharynx / supraglottis Inflammation: TM joint arthritis / aphthous ulcer /
History taking
Level of dyphagia: oral cavity / pharynx / esophagus Acute onset: foreign body / trauma / inflammation Intermittent: hypermotility disorder Progressive: malignancy / stricture More for liquids: neuromuscular disorder Difficulty in initiation of swallow or after swallow Fever + odynophagia: inflammation
History taking
Hoarseness / stridor: laryngo-tracheal invasion Hemoptysis: Ca bronchus Heartburn: GERD Hematemesis: esophageal varices Regurgitation: pharyngo-esophageal obstruction Neck mass: metastatic lymph node / goitre Neurological disorder Smoking & alcohol consumption
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Examination
General: pallor + koilonychia = Plummer Vinson synd Oral cavity, oropharynx Indirect laryngoscopy: larynx, pyriform sinus, posterior pharyngeal wall, post cricoid area Laryngeal crepitus: absent in post-cricoid malignancy, retropharyngeal abscess Neck node & cranial nerve examination
Investigations
Barium swallow with or without air contrast Video-fluoroscopic (modified) Barium swallow Esophagoscopy: flexible & rigid Esophageal manometry: achalasia, esophageal spasm 24 hour double probe ambulatory pH monitoring Fibreoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)
Investigations
Bolus scintigraphy Chest X-ray: mediastinal mass / cardiomegaly CT scan chest: mediastinal or pulmonary tumor Bronchoscopy: Ca bronchus Thyroid scan: thyroid malignancy Angiography: vascular rings (dysphagia lusoria)
Barium Swallow
Plain
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Air-contrast
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Rigid Esophagoscopy
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Esophageal manometry
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Bravo capsule
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Minimal aspiration
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Normal swallowing
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Bolus scintigraphy
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Thank You
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