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Esophageal MotilityEsophageal Motility

David Markowitz, MDColumbia University, College ofColumbia University, College of

Physicians and Surgeons

Alimentary Tract Motility

• Propulsion– Movement of food and endogenousMovement of food and endogenous

secretions• MixingMixing

– Allows for greater contact of food with digestive enzymes and absorptive surfacedigestive enzymes and absorptive surface

• Reservoir

Determinants of GI TractDeterminants of GI Tract Motility

• Myogenic controlMyogenic control

• Neurogenic controlg

• Endocrine factors

Myogenic Control

• Basic Electrical Rythym:– intrinsic rhythmic fluctuation of smoothintrinsic rhythmic fluctuation of smooth

muscle membrane potential• Pacemaker Cells:Pacemaker Cells:

– set BER for the entire organ• Slow waves:• Slow waves:

– spread from cell to cell via gap junctions

Enteric Nervous System

• Afferent and efferent arms• Numerous interneurons in the ENS are highly g y

integrated and receive input from:– CNS– efferent arm of ENS

• Afferent neurons receive input from ENS i t d th ff tinterneurons and these affect:– smooth muscle

blood vessels– blood vessels– secretory cells

Swallowing

• Oropharyngeal Phase– Involuntary & Voluntary PhasesInvoluntary & Voluntary Phases– Extremely rapid– Dx test: Video esophagramDx test: Video esophagram

• Esophageal PhaseSlow– Slow

– StereotypedD t t E h l M t– Dx test: Esophageal Manometry

Oropharyngeal Phase ofOropharyngeal Phase of Swallowing

• Moves ingested food and fluid into upper esophaguspp p g

• Prevents aspiration or regurgitation of the bolusthe bolus

• Voluntary movement by the tongue of the bolus into the pharynx triggers thethe bolus into the pharynx triggers the involuntary phase of swallowing

Esophageal DiseaseEsophageal Disease Symtpoms

• Dysphagia– Oropharyngeal DysphagiaOropharyngeal Dysphagia– Esophageal Dysphagia

• Pain• Pain– Odynophagia

Atypical Chest pain– Atypical Chest pain• GE Reflux disease (GERD)

Dyspahgia

• Oropharyngeal– Difficulty transferring bolus out of mouthDifficulty transferring bolus out of mouth– Associated w/ coughing & aspiration

• Esophageal• Esophageal– Sense of bolus “sticking in chest”

Mechanical causes– Mechanical causes– Motility disorders

Esophageal DysphagiaEsophageal DysphagiaMechanical Causes

• Typically occurs with solid foods• Frequently progressive especially withFrequently progressive, especially with

malignancy• Food impaction (w/ forced regurgitation)• Food impaction (w/ forced regurgitation)

commonP i t i ht l l /• Prominent weight loss only w/ malignancy

Schiatzki Ringg

Schiatzki RingSchiatzki Ring

Esophageal Strictures

Esophageal StrictureEsophageal Stricture

Esophageal Dilators

TTS Ballons

Esophageal Carcinoma

Esophageal CarcinomaEsophageal Carcinoma

Esophageal CarcinomaEsophageal Carcinoma

Esophageal Stents

Esophageal StentsEsophageal Stents

Barrett’s Esophagus

Barrett’s esophagus –d fi itidefinition

• “A change in the esophageal epithelium of any length that can g p g p y gbe recognized at endoscopy and is confirmed to have intestinal

metaplasia by biopsy”

Sampliner. Am J Gastroenterol 1998

Barrett’s EsophagusBarrett s Esophagus

Barrett’s esophagus is a premalignant l i f h l d i

Normal

lesion for esophageal adenocarcinoma

Endoscopy-negative reflux disease

Erosive esophagitis

?

Barrett’s esophagus

?

?

Dysplasia

?

Esophageal adenocarcinoma

Esophageal DysphagiaEsophageal Dysphagia

Motor Disorders

Esophageal ManometryNormal Study

Achalasia

Achalasia

Achalasia

AchalasiaAchalasia

Achalasia

Achalasia

SclerodermaScleroderma

S l dScleroderma

SclerodermaScleroderma

Esophageal DysphagiaEsophageal Dysphagia

E h l D h iEsophageal Dysphagia

Mechanical Motor

Benign Malignant AchalasiaScleroderma

WebsRings

Adeno ca.Sq cell caRings

StricturesSq. cell ca.

Spastic Motility Disorders

Diffuse Esophageal Spasmp g p

Atypical Chest Pain

Candida Esophagitis

GE RefluxNormal PhysiologyNormal Physiology

GERDGERD

The sequellae of prolonged exposure of esophageal mucosa g

to caustic gastric refluxate

GERD: PathogenesisGERD: Pathogenesis

Defective Esophageal ClearanceDefective Esophageal Clearance

• Ineffective peristalsis

• Reduced salivary secretionsecretion

• Reduced secretion from esophageal submucosal glands

LES ‘dysfunction’

• Inappropriate and prolongedand prolonged transient relaxationsrelaxations

• Reduction in basal LES pressure/tone

Hiatal hernia

• May trap a reservoir of gastric contentsof gastric contents above the diaphragm, increasing refluxincreasing reflux

M i• May compromise LES function

Delayed gastric emptying• May result in an

y g p y g

increase in the volume of gastric contents available for reflux into the esophagus

• Exact role in GERD remains toGERD remains to be clarified

Bravo Capsule

Bravo CapsuleBravo Capsule

Nissen FundoplicationNissen Fundoplication

Stretta procedureStretta procedure

St 1Step 1

Step 2

Step 3

Mechanism of action of refluxate in GERD

Acid-peptic attack weakens cell junctions

leading to a widening of cell gaps

and thus allowing acid penetration

GERD

weakens cell junctions cell gaps penetration

AcidTight cell WidenedPepsinBicarbonate

Nerve endingTight celljunction

Widened cell

junctionOrlando. Am J Gastroenterol 1996

Mechanism of action of refluxate in GERD

Penetration of acid and pepsin allows contact of acid with nerve

endings

and disrupts intracellular mechanisms leading to cell rupture

and damage

refluxate in GERDg g

Acidc dPepsinBicarbonate

Nerveending

Orlando. Am J Gastroenterol 1996