Transcript Diseases of esophagus

Diseases of
Esophagus &
Dysphagia
Dr. Vishal Sharma
Diseases of
esophagus
Contents
• Esophagitis, Barret’s 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, Crohn’s 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
Savary Monnier classification
of esophageal erosion
• Grade 1: Single erosion over single mucosal fold
• Grade 2: Erosions over multiple folds
• Grade 3: Circumferential mucosal erosions
• Grade 4: Erosion with definitive ulcer or stricture
• Grade 5: Columnar metaplasia (Barret’s esophagus)
Grade 1 esophagitis
Grade 2 esophagitis
Grade 3 esophagitis
Grade 4 esophagitis
Grade 5 esophagitis
Los Angeles Classification
• Grade A: Mucosal break < 5 mm in length over
single mucosal fold
• Grade B: Mucosal break > 5mm over single
mucosal fold
• Grade C: Continuous mucosal break b/w > 2
mucosal folds but < 75% of esophageal
circumference
• Grade D: Mucosal break >75% of esophageal
circumference
Los Angeles Classification
Gastro- Esophageal
Reflux Disease
Predisposing factors
Inefficient lower esophageal sphincter due to:
Pregnancy
 Obesity
 Fatty food, large meals  Coffee, chocolate
 Cigarette smoking
 Alcohol ingestion
 Reflux promoting drugs (see under treatment)
 Scleroderma
 Hiatus hernia
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
• Gripping / crushing pain
• Pain seldom radiates to • Pain radiates into neck,
arms
• Produced by bending,
drinking hot liquids
shoulders & both arms
• Pain produced by
exercise
• Relieved by antacids
• Relieved by rest
• Dyspnea absent
• 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
24 hour ambulatory double-probe
pH monitoing
pH metry
GERD
LPRD
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
X 6 wk
6 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
Nissen’s fundoplication + Hill’s posterior gastropexy
Nissen’s complete fundoplication
Nissen’s complete fundoplication
Belsey Mark IV partial
fundoplication
Toupet repair
Laparoscopic fundoplication
Transoral fundoplication
Hill’s fundoplication + posterior gastropexy
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
Barret’s 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
Barret’s esophagus
Barret’s esophagus with
adenocarcinoma
Esophageal ring, web,
stricture & atresia
Web
Ring
• Only part of lumen
• Circumferential
• Consists of mucosa
• Consist of mucosa +
only
• Involves proximal
esophagus
• E.g. web of Plummer
Vinson Syndrome
muscle
• Involves distal
esophagus
• E.g. Schatzki's ring of
lower esophagus
Schatzki’s ring
Plummer Vinson Syndrome
• Synonym: 1. Patterson Brown Kelly syndrome
2. Sideropenic dysphagia
• Seen in middle-aged females due to iron
deficiency caused by atrophic gastritis or vitamin
B12 deficiency (pernicious anemia)
• Classical Triad: upper esophageal web
iron deficiency anemia (sideropenia)
cheilitis / glossitis
Clinical features
• Dysphagia: more to solids than liquids. Due to
upper esophageal web caused by
sub-epithelial fibrosis.
• Pallor: iron deficiency anemia
• Koilonychia (spoon nails): iron deficiency anemia
• Cheilitis + glossitis: vitamin B12 deficiency
Investigations
• Barium swallow
anterior wall web in
• Esophagoscopy
upper esophagus
• Blood smear: microcytic, hypochromic anemia
• Serum iron: decreased
• Total iron binding capacity: increased
• Gastric juice analysis: achlorhydria
Normal Iron levels
Male
Female
Total Iron
45-160 g / dL
30-160 g / dL
Total iron binding
capacity
220-420 g / dL
220-420 g / dL
Serum ferritin
20-323 ng /mL
10-291 ng /mL
Upper esophageal web
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
Causes of single stricture
• GERD, esophagitis, Barret’s esophagus
• Caustic ingestion: corrosives, hot fluid
• Trauma: foreign body, external injury
• Medication capsules & tablets
• Radiotherapy, sclerotherapy
• Surgical anastomosis of esophagus
• Malignancy
• Congenital: involves lower 1/3rd
Benign stricture
Malignant stricture
• Multiple
• Single
• Regular mucosa
• Irregular mucosa
• Proximal esophageal
• Proximal dilation absent
dilation present
• At sites of normal
constrictions
due to cancer invasion
• Involves any site in
esophagus
Caustic stricture
Benign pemphigoid
Multiple strictures
Benign epidermolysis bullosa
Multiple strictures
Hand contractures
Asymmetric malignant stricture
Esophageal compression
Extrinsic compression
Intra-mural compression
Esophagoscopy
• Confirms diagnosis
• Evaluates position of
stricture
• Evaluates length of
stricture
• Rules out malignancy
Treatment of corrosive ingestion
Acid = superficial coagulative necrosis (better)
Alkali = penetrating liquefaction necrosis (worse)
1. Hospitalize + treatment of shock & acid-base balance
2. Stricture prevention by:
• Steroid given within 48 hours for 6 weeks
• Careful nasogastric tube insertion for 3 weeks
• N-acetyl cysteine / Penicillamine: es collagen bonding
3. IV antibiotics + antacids + analgesics
4. Neutralize corrosive with weak acid / alkali within 6 hr
5. Discharge after 6 wk; life long follow up to r/o cancer
Surgical treatment of stricture
1. Progressive stricture dilatation over months
a. Prograde: oral route with elastic bougie
b. Retrograde: gastrostomy route
2. Stent insertion
3. Stricture excision + reconstruction with colon
4. Esophageal bypass with jejunum / colon segment
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
X-ray
abdomen
• NG tube
unable to
pass into
stomach
• Absence of
intestinal gas
Esophageal tear &
perforation
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: Hamman’s mediastinal
crunch on auscultation
Mallory Weiss syndrome
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
Boerhaave
syndrome
Mallory
Weiss tear
Onset
Vomiting
Vomiting
Alcoholism
Yes
Yes
Tear
Trans-Mural
Mucosal
Hematemesis
Absent
Present
Pain
Present
Absent
Investigation
Gastrograffin
esophagogram
Endoscopy
Treatment
Emergency repair
Self limiting,
Cauterization
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
1. Nil by mouth
2. Parenteral nutrition
3. IV high dose broad-spectrum antibiotics
4. Endoscopic insertion of nasogastric tube
5. Continuous nasogastric tube suction for 1 week
• Most perforations heal within 2 weeks
Achalasia Cardia
(Cardiospasm)
Etiology: 1. degeneration of ganglion cells of inhibitory
neurons in Auerbach’s 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
– Weight loss, aspiration pneumonia
• Chest X-ray: mediastinal widening + air-fluid level
• 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.
• Esophageal manometry:  pressure in esophageal
body;  pressure at lower esophageal sphincter
Barium swallow
Fluoroscopic barium swallow
Esophagoscopy
Esophageal manometry
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
• Heller’s laparoscopic cardio-myotomy: surgical
division of lower esophageal sphincter + Nissen’s
complete fundoplication to prevent post-op reflux
Heller’s cardiomyotomy
Laparoscopic cardiomyotomy
Fundoplication
Scleroderma (CREST syndrome)
• Atrophy & fibrosis of
esophageal smooth muscle
+ incompetent LES
• C/F: GERD + Calcinosis +
Raynaud’s phenomenon +
Esophageal dysmotility +
Sclerodactyly + Telengiectasia
• Rx: Pantoprazole + Cisapride
Esophageal hiatus
hernia
• Definition: herniation of part of stomach above esophageal
hiatus in diaphragm
• 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.
• Rx: Reduction of hernia + Nissen’s fundoplication
Sliding hernia
Para-esophageal hernia
Para-esophageal hernia
Mixed hiatus hernia
Esophageal
Hypermotility
disorders
Cricopharyngeal spasm
• Cricopharyngeous muscle
remains contracted
between swallows
• Smooth posterior
impression in hypopharynx
seen at C6 level
• Cricopharyngeal myotomy
Diffuse esophageal spasm
• Dysphagia & chest pain mimicking myocardial
infarction especially on drinking cold liquids
• Barium swallow: simultaneous, uncoordinated,
non-peristaltic contractions in esophagus body
(cork-screw esophagus). Normal LES relaxation.
• Esophageal manometry: simultaneous repetitive
contractions in esophageal body
• Treatment: Nitrates, Nifedipine, Amytriptilline
Barium esophagogram
Esophageal manometry
Coordinated, normal amplitude contractions in
normal esophagus
Esophageal manometry
simultaneous, uncoordinated, non-peristaltic
contractions in esophagus body in diffuse
esophageal spasm
Esophageal manometry
High amplitude contractions in nutcracker esophagus
Esophageal vascular
impressions
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
String of black pearls
These filling
defects change
shape during
respiration due to
venous emptying
Uphill varices
Downhill varices
Aberrant Rt subclavian artery
Aberrant Rt subclavian artery
Fluoroscopic barium
swallow shows
esophageal
compression at level
of third & fourth
thoracic vertebrae
Double aortic arch
Aberrant left pulmonary artery
Forrestier’s disease
• Dysphagia caused by
cervical esophageal
compression by vertebral
column osteophyte
• Inv: a. X-ray neck lateral
b. Esophagogram
• Rx: Osteophytectomy
Esophagogram
Esophageal neoplasm
Benign esophageal tumors
• Rare condition
• Types:
• Leiomyoma (commonest)
• Fibro-vascular polyp
• Squamous papilloma
• > 50% are asymptomatic
• Endoscopic / thoracotomy
excision for dysphagia
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
 Betel nut chewing
 Tobacco chewing
 Vitamin A deficiency
 Vitamin C deficiency
 Barret’s esophagus
 Achalasia cardia
 Corrosive stricture
 Human Papilloma Virus
 Plummer Vinson syndrome
 Tylosis (familial hyperkeratosis of palms & soles)
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
Rat tail appearance
Also seen in
advanced
cases of
achalasia
cardia
Palliative treatment
70% patients have advanced disease at
presentation & require palliative treatment
1. Endoscopic tumour ablation using laser
2. Low dose intra-cavitary radiotherapy
3. Indwelling feeding tube (Mousseau-Barbin, Celestin)
4. Feeding jejunostomy
5. Chemotherapy (5 Fluorouracil)
6. Nutritional support & analgesia with morphine
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 /
Ludwig’s angina / tonsillitis / quinsy / epiglottitis /
retropharyngeal abscess / parapharyngeal abscess
• Paralysis: tongue / soft palate
Esophageal intra-luminal causes
• Impacted foreign body / food bolus
• Esophageal atresia
• Esophageal web (Plummer Vinson Syndrome)
• Esophageal ring (Schatzki’s ring)
• Esophageal stricture: benign / malignant
• Esophageal neoplasm: benign / malignant
Esophageal intra-mural causes
• Inflammation: esophagitis (GERD commonest)
• Hypomotility disorders: Achalasia / scleroderma
• Hypermotility disorders: cricopharyngeal spasm /
diffuse esophageal spasm / nutcracker esophagus
• Other neuro-muscular disorders: Myasthenia
gravis / Multiple sclerosis / Motor neuron disease
Esophageal extra-mural causes
• Pharyngeal pouch
• Hiatus hernia
• Thyroid enlargement: benign / malignant
• Mediastinal: Ca left bronchus / lymphadenopathy /
cardiomegaly / aortic aneurysm / neoplasm
• Vascular ring: dysphagia lusoria
• Cervical spine osteophyte: Forrestier’s disease
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
• Esophageal trauma / caustic ingestion
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
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)
Peripheral blood smear: Plummer Vinson syndrome
Barium Swallow
Plain
Air-contrast
Video-fluoroscopic swallow study
Video-fluoroscopic swallow study
Rigid Esophagoscopy
Flexible (oral) esophagoscopy
Esophageal manometry
24 hour ambulatory double-probe
pH monitoing
Bravo capsule
Capsule has
no catheter.
Transmits
radio signals.
Fibreoptic Endoscopic Evaluation of
Swallowing with Sensory Testing
• Air-pulse stimuli delivered to ary-epiglottic fold
mucosa innervated by superior laryngeal nerve to
elicit laryngeal adductor reflex for airway
protection
• Swallowing evaluation performed with variety of
food consistencies containing green food dye
• Look for aspiration into larynx
Sensory Testing with air pulse
Fibreoptic Endoscopic
Evaluation of Swallowing
Complete aspiration
Minimal aspiration
Normal swallowing
Bolus scintigraphy
Uses food bolus with radio-isotope to quantify
amount of reflux
Thank You