esofagcurs

ESOPHAGUSESOPHAGUS

WHAT ABOUT?WHAT ABOUT?

Simptoms and signsSimptoms and signs InvestigationsInvestigations Gastroesophageal RefluxGastroesophageal Reflux EsophagitisEsophagitis Esophageal CancerEsophageal Cancer Motility Disorders: Achalasia and D. SpasmMotility Disorders: Achalasia and D. Spasm Structural Anomalies and Miscellaneous Structural Anomalies and Miscellaneous

Disorders of the EsophagusDisorders of the Esophagus

Simptoms and signsSimptoms and signs1. DYSPHAGIA1. DYSPHAGIA

Sensation of food being hindered in its Sensation of food being hindered in its passage from mouth to stomachpassage from mouth to stomach

Oropharyngeal - odynophagiaOropharyngeal - odynophagia Esophageal dysphagiaEsophageal dysphagia

Simptoms and signsSimptoms and signsDYSPHAGIADYSPHAGIA

Oropharyngeal - (odynophagia-pain at swallowing)

– Neuromuscular disease (Cerebrovascular accident, Parkinson, Wilson, Brain stem tumors, polymyositis, amyloidosis, systemic lupus erytematus)

– Local mechanical lesions: inflammation (pharyngitis), tumours, Zenker diverticulum

Esophageal dysphagia

– Motility disorders (achalasia, scleroderma, diffuse spasm, nutcracher esophagus)

– Intrinsic mecanical lesions (benign stricture, carcinoma, foreign bodie, esophageal diverticulum, Schatzki ring)

– Extrinsic mechanical lesions (mediastinal abnormalities- pulmonary carcinoma, adenopaty, pericarditis, mitral stenosis, cervical osteoarthrities)

Simptoms and signsSimptoms and signsDYSPHAGIADYSPHAGIA

Onset ( acute, chronic);Onset ( acute, chronic); Total or partial;Total or partial; paradoxical (achalasia).paradoxical (achalasia).

2. HEARTBURN (PIROSIS)(most tipical symptom for GE Reflux D)

3. PAIN: Anterior toracic pain (motility 3. PAIN: Anterior toracic pain (motility disorders, cancer)disorders, cancer)

4. Regurgitation: pasage of food from 4. Regurgitation: pasage of food from stomach to the mouth without nausea: stomach to the mouth without nausea: (vomiting)(vomiting)

InvestigationsInvestigations

Endoscopy (visualisation, histology)Endoscopy (visualisation, histology) Radiology Radiology

– Esophageal XREsophageal XR– Computer tomographyComputer tomography– Magnetic ResonanceMagnetic Resonance

Echography (echo-endoscopy)Echography (echo-endoscopy) Esophageal ManometryEsophageal Manometry pH-metrypH-metry

ENDOSCOPYThe normal esophageal body

The lower esophageal sphincter (LES)

RADIOLOGYBarium esophagram

Schatzki's ring on barium esophagra

Schatzki's ring viewed endoscopically

Esophageal stenosis (a)

Esophageal stenosis (b)

ECHOENDOSCOPYECHOENDOSCOPY

ESOPHAGEAL MOTILITYESOPHAGEAL MOTILITY

ESOPHAGEAL PH-METRYESOPHAGEAL PH-METRY

GASTRO-ESOPHAGEAL REFLUX GASTRO-ESOPHAGEAL REFLUX DISEASEDISEASE

Def. Effortless movement of gastric content Def. Effortless movement of gastric content from stomach to esophagusfrom stomach to esophagus

Disease if producing symptoms and signs of Disease if producing symptoms and signs of tissue injury within the esophagus, tissue injury within the esophagus, oropharinx, larynx and/or respiratory tract.oropharinx, larynx and/or respiratory tract.

Pathophysiology and etiology of reflux esophagitis

Inbalance between aggressive forces and Inbalance between aggressive forces and defences forces of esophagusdefences forces of esophagus– aggressive forces: acid, pepsin, bile salts, pancreatic aggressive forces: acid, pepsin, bile salts, pancreatic

enzimesenzimes– defence: defence:

» antireflux barries: LES, diaphragmatic crura, antireflux barries: LES, diaphragmatic crura, phrenoesophageal ligament, acute angle of His;phrenoesophageal ligament, acute angle of His;

» Hiatus Hernia Hiatus Hernia » luminal acid clearance: gravity, esophageal peristalsis, luminal acid clearance: gravity, esophageal peristalsis,

salivary and esophageal gland secretionssalivary and esophageal gland secretions» tissue resistancetissue resistance

Pathophysiology and etiology of reflux esophagitis

Conditions associeated with GERD

Gastric acid hypersecretions (gastrinoma)Gastric acid hypersecretions (gastrinoma) pregnancy, diabetes, scleroderma, pregnancy, diabetes, scleroderma, prolong nasogastric intubationprolong nasogastric intubation

CLINICAL MANIFESTATIONS

CLINICAL MANIFESTATIONS

TYPICALTYPICAL– HeartburnHeartburn– regurgitationsregurgitations– esophageal painesophageal pain– dysphagiadysphagia

ATYPICAL (respiratory, laryngitis, dental)ATYPICAL (respiratory, laryngitis, dental)

When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests

Uncertain diagnosisUncertain diagnosis Atypical symptomsAtypical symptoms Symptoms associated with complicationsSymptoms associated with complications Inadequate response to therapy Inadequate response to therapy Recurrent symptomsRecurrent symptoms Prior to anti-reflux surgeryPrior to anti-reflux surgery

INVESTIGATIONS

Endoscopy (visualisation, histology)Endoscopy (visualisation, histology) Radiology Radiology

– Gastro-esophageal XRGastro-esophageal XR

Esophageal 24 H pH-metryEsophageal 24 H pH-metry Esophageal ManometryEsophageal Manometry Esophageal impedanceEsophageal impedance

ENDOSCOPY

ESOPHAGITIS/ NO ESOPHAGITISESOPHAGITIS/ NO ESOPHAGITIS COMPLICATIONS BARRETT COMPLICATIONS BARRETT

ESOPHAGUSESOPHAGUS

ENDOSCOPYENDOSCOPY

ENDOSCOPYENDOSCOPY

ENDOSCOPYENDOSCOPY

ENDOSCOPYENDOSCOPY

Barium SwallowBarium Swallow

Was considered first diagnostic Was considered first diagnostic test for patients with dysphagiatest for patients with dysphagia– Stricture (location, length)Stricture (location, length)– Mass (location, length)Mass (location, length)– Bird’s beakBird’s beak– Hiatal hernia (size, type)Hiatal hernia (size, type)

LimitationsLimitations– Detailed mucosal exam for erosive Detailed mucosal exam for erosive

esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus

RADIOLOGY

Gastroesophageal X-Ray Gastroesophageal X-Ray Trendelenburg positionTrendelenburg position Hiatal HerniaHiatal Hernia StenosisStenosis

PH- metry

Wireless, Catheter-Free Esophageal pH Monitoring

• Improved patient Improved patient comfort and acceptancecomfort and acceptance

• Continued normal work, Continued normal work, activities and diet studyactivities and diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages

Esophageal ManometryEsophageal Manometry

Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation– Assist placement of 24 hr. Assist placement of 24 hr.

pH catheterpH catheter

Assess peristalsisAssess peristalsis– Prior to antireflux surgery Prior to antireflux surgery

Limited role in GERDLimited role in GERD

Impedance Technology FundamentalsImpedance Technology Fundamentals

High Impedance

No Reflux

Low Impedance

Reflux

Impedance falls when reflux is present because the

reflux bolus conducts electricity between the metallic impedance contacts!

Impedance–pH Catheter

3 cm

5 cm

7 cm

9 cm

15 cm

17 cm

pH - 5 cm

6 impedance channels

2 pH channels

pH at tip

Adult with Gastric pH

Model ZAN-S62C01E

COMPICATIONSEsophageal stricture

BENIGN ESOPHAGEAL STENOSISBENIGN ESOPHAGEAL STENOSIS

ENDOSCOPYENDOSCOPY

COMPLICATIONSBarrett's esophagus

Esophageal CancerEsophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy

Extraesophageal Manifestations Extraesophageal Manifestations of GERDof GERD

PulmonaryPulmonaryAsthmaAsthmaAspiration pneumoniaAspiration pneumoniaChronic bronchitisChronic bronchitisPulmonary fibrosisPulmonary fibrosis

OtherOther Chest painChest pain Dental erosionDental erosion

ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationDysphoniaDysphoniaSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer

Potential Oral and Laryngopharyngeal Signs Potential Oral and Laryngopharyngeal Signs Associated with GERDAssociated with GERD

• Edema and hyperemia of Edema and hyperemia of larynxlarynx

• Vocal cord erythema, Vocal cord erythema, polyps, granulomas, polyps, granulomas, ulcersulcers

• Hyperemia and lymphoid Hyperemia and lymphoid hyperplasia of posterior hyperplasia of posterior pharynx pharynx

• Interarytenyoid changesInterarytenyoid changes

• Dental erosionDental erosion

• Subglottic stenosisSubglottic stenosis

• Laryngeal cancerLaryngeal cancer

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.344.

Pathophysiology of Extraesophageal Pathophysiology of Extraesophageal GERDGERD

HIATAL HERNIATIONHIATAL HERNIATION

Axial hiatus hernia

Paraesophageal hernia

ESOPHAGITIS

Reflux esophagitisReflux esophagitis

Esophagitis with candidaEsophagitis with candida

Esofagitis with eosinophilsEsofagitis with eosinophils

Citomegal virusCitomegal virus herpesherpes

Caustic esophagitisCaustic esophagitis

DrugDrug alcoolalcool

ESOPHAGEAL CANCERESOPHAGEAL CANCER Pathology: squamous cell carcinoma (S), adenocarcinoma (A).Pathology: squamous cell carcinoma (S), adenocarcinoma (A). Epidemiology: (S): 2.5-5 in men and 1.5-2.5 women; High : Epidemiology: (S): 2.5-5 in men and 1.5-2.5 women; High :

North China, India, nort Iran, South Africa; (A) lower but North China, India, nort Iran, South Africa; (A) lower but increasingincreasing

Causes: risc factors (S) tabacco, alcohol (Calvados); diet with Causes: risc factors (S) tabacco, alcohol (Calvados); diet with low contents in vitamins (A,C,folic A, E, B12) green, yelow low contents in vitamins (A,C,folic A, E, B12) green, yelow vegetable; achalasia, Head and Nech Squamous Cell vegetable; achalasia, Head and Nech Squamous Cell Carcinoma; tylosis; (A) Barrett esophagusCarcinoma; tylosis; (A) Barrett esophagus

Symptoms: disphagea (chronic, first to liquid than for solid Symptoms: disphagea (chronic, first to liquid than for solid too)too)

Signs: weigh loss, anemiaSigns: weigh loss, anemia

ESOPHAGEAL CANCERESOPHAGEAL CANCER

Symptoms: disphagia (chronic, first to liquid than Symptoms: disphagia (chronic, first to liquid than for solid too);for solid too);– anorexia, cought, retrosternal pain, hematemesis, anorexia, cought, retrosternal pain, hematemesis,

hoarsenesshoarseness

Signs: weigh loss, anemia, lymphadenopaty, Signs: weigh loss, anemia, lymphadenopaty, hepatomegalyhepatomegaly

ESOPHAGEAL CANCER-ESOPHAGEAL CANCER-INVESTIGATIONSINVESTIGATIONS

GASTROINTESTINAL ENDOSCOPYGASTROINTESTINAL ENDOSCOPY– INCLUDING HISTOLOGYINCLUDING HISTOLOGY

ESOPHAGEAL XrayESOPHAGEAL Xray– EXCENTRIC STENOSISEXCENTRIC STENOSIS

LOCAL+DISTAL EXTENSION OF THE LOCAL+DISTAL EXTENSION OF THE DISEASEDISEASE– COMPUTER TOMOGRAPHYCOMPUTER TOMOGRAPHY

– ECHOENDOSCPYECHOENDOSCPY

– LAPAROSCOPYLAPAROSCOPY

ENDOSCOPYENDOSCOPY

EndoscopyEndoscopy

HistopathologyHistopathology

Adenocarcinoma on Barrett esophagus

Adenocarcinoma

X-RayX-Ray

EcoendoscopyEcoendoscopy

Cancer limited to the esophageal wall

Esophageal cancer invading aorta

Esophageal cancerEsophageal cancerSurviving rate atSurviving rate at 5 5 yearsyears– 5%– 5%

ComplicComplictionstionsEso-bronchial fEso-bronchial fistula istula PneuPneumoniamoniaPerfPerforationorationBleedingBleedingTotal stenosisTotal stenosis

Eso-bronchial fistula

Motility disordersMotility disorders AchalasiaAchalasia Difuse spasmDifuse spasm

ACHALASIAACHALASIADef. Motility disorder characterized by increased

lower esophageal sphincter pressure and failure to relax during swalowing. Peristalsis of body is absent

Et: degeneration of myenteric plexus of unknown cause

Achalasia- clinical features-Achalasia- clinical features-

Occours at any ageOccours at any age Dysphagia -all patients;slowly progressive Dysphagia -all patients;slowly progressive

+paradoxical dysphagia+paradoxical dysphagia Weight loss- quite commonWeight loss- quite common Regurgitations - 30%; undigested food with Regurgitations - 30%; undigested food with

aspirationsaspirations pain- substernal cramps may be severe and pain- substernal cramps may be severe and

precede dysphagiaprecede dysphagia

Radiology:Radiology: Chest Xray + Gastroesophageal Chest Xray + Gastroesophageal Xray: Xray: – esophageal fluid level at the aortic knuckle esophageal fluid level at the aortic knuckle – gastric air bubble absentgastric air bubble absent– dilated esophagus ; barium and food mixing in dilated esophagus ; barium and food mixing in

the dilated esphagus;the dilated esphagus;– tapered distal narrowing;tapered distal narrowing;– aperistaltic contractionsaperistaltic contractions

INVESTIGATIONSINVESTIGATIONS

INVESTIGATIONSINVESTIGATIONS

Radiology:Radiology:

Esophageal manometry:Esophageal manometry:– absence of LOS relaxation with swallowingabsence of LOS relaxation with swallowing– hipertensieve LOShipertensieve LOS– absence of peristaltic contractionsabsence of peristaltic contractions

INVESTIGATIONSINVESTIGATIONS

Manometric LES tracing of pull through in patient with achalasia

Manometric tracing of a patient with achalasia

Manometric tracing of a patient with achalasia

INVESTIGATIONSINVESTIGATIONS

Endoscopy:Endoscopy:– dilated esophagus with dilated esophagus with

food debriefood debrie

– endoscope is passing endoscope is passing easily in the stomacheasily in the stomach

TREATMENTTREATMENT

Motility disordersMotility disorders AchalasiaAchalasia Difuse spasmDifuse spasm

Difuse esophageal spasmDifuse esophageal spasmDef. Motility disorder characterized by high

amplitude aperistaltic esophageal contractions without demonstrable organic lesions

Simptoms:

Disphagia intermittent but associated with pain

Chest pain may mimic cardiac pain and be provoked by stress

Contracţii terţiare, aperistaltice

Manometric tracing of patient with diffuse esophageal spasm (DES)

Structural disorders and Structural disorders and Miscelaneous disordersMiscelaneous disorders

Mid-esophageal diverticulum as seen on barium swallow

Midesophageal diverticulum

Epiphrenic diverticulum as seen on barium swallow

Lower esophageal mucosal ring

Schatzki's ring viewed endoscopically

Schatzki's ring on barium esophagra

Esophageal stenosis (b)