esophagus review 1 nir hus md., phd

Esophagus

Nir Hus MD, PhD.

ABSITE Review

Department of Surgery

Mount Sinai Medical Center

Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital

Esophagus: Anatomy

Esophageal Studies• Anatomic

– Esophagogram– CT-Scan– Endoscopy(Biopsy/Ultrasound)

• Functional– Esophageal manometry– 24 hour pH probe

Esophagus: Physiology

Esophageal Manometry

Esophageal Manometry: Swallowing

Characteristics of Lower Esophageal Sphincter

• Intramural pressure• Length of LES• Abdominal length LES

Manometry LES: Pressure/Length Relationship

24-Hour pH Monitoring

Esophageal Motility Disorders• Esophageal Diverticula

– Zenker’s (pulsion)– Epiphrenic– Traction (pulsion)

• Functional Disorders– Achalasia– Diffuse esophageal spasm– Nutcracker esophagus

Zenker’s Diverticulum

• Dysphagia• Regurgitation undigested food• Aspiration• Unyielding cricopharingeous• Dx: barium swallow• No endoscopy• Tx: diverticulectomy/myotomy• Left cervical incision

Achalasia• Dysphagia and regurgitation undigested food• Substernal/epigastric pain• Diagnosis and work-up: CXR, UGIS• endoscopy/bx: esophagitis, r/o Ca• Manometry:

– aperistalsis – incomplete relaxation of LES– High resting pressure LES (>30 mmHg)

Achalasia

Achalasia: Treatment• Esophageal dilations, success rate: 70%• Botulinum toxin injections: short lived• Surgery: Heller myotomy, success rate: 95%• Indications:

– children– vigorous achalasia– medical failures

Achalasia: Heller Operation

Diffuse Esophageal Spasm and Nutcracker Esophagus

• Intermittent chest pain and dysphagia• Negative cardiac work-up• Manometry: normal LES, tertiary peristalsis• Treatment:

– Medical: reduce stress and precipitating factors– NTG, Isosorbide, Nifedipine– Surgery: Full length myotomy, success rate 65%

Nutcracker Esophagus

• Abnormal exposure of distal esophagus to refluxed gastric juice• Etiology

– Mechanically defective LES (60%)– Poor esophageal clearance– Gastric outlet obstruction– Functional delayed gastric emptying– Increased gastric acid secretion– inappropriate relaxation of LES

• Symptoms– Substernal/epigastric burning pain– Regurgitation– Effortless emesis– Dysphagia– Flatulence– Atypical symptoms

• Complications (20%)– Esophagitis– Stricture– Barrett’s esophagus– Ulceration– Esophageal shortening

GERD: Work-up• UGIS and EGD• Manometry: characterizes LES and motility

– LES pressure < 6 mm Hg– Overall length < 2 cm– Abdominal length < 1 cm

• Esophageal pH testing (sens/specif - 90%)– pH < 4 more than 1 hour and a half/24 hours (6%)– Composite score derived from: total time pH <4, upright time pH <4, supine time pH <4, # episodes, episodes >5 min, longest episode.

GERD: Treatment• Medical

– Postural alterations– Dietary alterations– Pharmacologic

• Surgery– Symptomatic reflux, manometric evidence of incompetent LES, and failure of medical therapy– Development of complications

Nissen Fundoplication

Belsey-Mark IV

Collis Gastroplasty

Barrett’s Esophagus• Columnar metaplasia of the distal esophagus at least 3-cm above GE junction or any length with intestinal metaplasia• Incidence

– 2% of all endoscopies– 15% of all esophagitis

• Types– Fundic– Junctional– Intestinal

Barrett’s Esophagus• Dx; endoscopy/bx• Complications

– Ulceration (50%)– Stricture (30%)– Low grade dysplasia (5-10%)– High grade dysplasia/ Ca in situ– Adenocarcinoma (2%)

Barrett’s Esophagus• Asymptomatic uncomplicated Barret’s

– Surveillance and yearly biopsies

• Symptomatic uncomplicated Barret’s– treat as GERD

• Barret’s Ulcers– aggressive medical therapy, recurrence or failure to heal - surgery

• Barret’s Strictures– medical management and esophageal dilation– recurrence or persistence - surgery

esophagus review 1 nir hus md., phd

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