Swallowing Difficulty & Pain Tim Farrell, MD Assumptions • Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction.
Download ReportTranscript Swallowing Difficulty & Pain Tim Farrell, MD Assumptions • Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction.
Swallowing Difficulty & Pain Tim Farrell, MD Assumptions • Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction. Objectives Students will understand: • Differential diagnosis for a patient with dysphagia. • Symptoms and treatment of GERD. • Pathophysiology and treatment of achalasia and diffuse esophageal spasm. • Etiology and treatment of esophageal diverticula. • Common symptoms and management of hiatal hernias. • Management of adenocarcinoma of the E-G junction. • Presenting symptoms, etiology and treatment of esophageal rupture. Case 1 • An 80-year-old man presents with a trouble swallowing for a year. He regurgitates undigested food after meals, has foul-smelling breath, no pain and is in good health otherwise. • He is thin, without neck mass. His chest is clear and his abdomen is soft and without masses. Case 1 • What is the differential diagnosis? Anatomic Tumor, Stricture, Compression, Foreign Body Functional GERD Motility Disorder (achalasia, scleroderma) Neurologic (Parkinson’s, bulbar paralysis) Psychological Globus Hystericus Case 1 • What test should be done, in what order, and why? Anatomic Assessment Upper GI Series EGD Biopsy Functional Assessment 24-hr pH Esophageal Manometry GES GERD - Definition Protracted exposure of the esophageal lining to stomach juice GERD - Causes • Lower esophageal sphincter – Incompetent valve – Inappropriate relaxations • Hiatal Hernia • Abnormal motility – Impaired esophageal clearing • Delayed gastric emptying • Defective cytoprotection GERD - Symptoms Typical Symptoms Atypical Symptoms Heartburn Asthma Cough Hoarseness Chest Pain Regurgitation Trouble Swallowing GERD - Complications • Peptic Stricture • Esophagitis / Ulcers • Barrett's Esophagus Indications for further Dx-Rx • • • • • • • Persistent or frequent symptoms Dysphagia Frequent vomiting Early satiety Weight loss Significant respiratory complaints Age < 45 GERD - Diagnosis • Barium Swallow • Upper Endoscopy • Esophageal Manometry • 24-Hour Ambulatory Esophageal pH • Gastric Emptying Study GERD - Diagnosis Barium Swallow GERD - Diagnosis Upper Endoscopy GERD - Diagnosis Manometry GERD - Treatment • Environmental • Medical - OTC – Antacids – H2-Blockers • Medical -Prescription – Proton-Pump Inhibitors • Endoscopic • Surgical – Fundoplication Dietary Modifications • Avoid large meals • Limit foods which decrease LES pressure – Fatty foods, chocolate, mints, and alcohol • Avoid irritating foods and beverages – Citrus, tomatoes, pepper, etc. • Limit caffeine and carbonated beverages – Increases acid production – Increased gastric distension • Candy or gum to increase saliva – Alkaline saliva neutralizes acid – Increases motility and clearance Lifestyle Modifications • Weight Loss • Avoid smoking – Decreases LES pressure • Avoid lying down for 2-3 hours after meals – Limits supine reflux • Sleep with elevated head of bed – Improves esophageal clearance Medications Worsening Reflux – Calcium channel blockers – Anticholinergics – Theophylline – Progesterone – β2-antagonists, α-antagonists – Nitrates – Meperidine – Diazepam GERD - Medical Treatment Medications may be used to: • Neutralize acid • Increase LES tone • Improve gastric emptying OTC H2 Blockers • Lower-dose formulations • Acute treatment or prophylaxis • Slower onset than antacids • Longer duration of acid inhibition Proton Pump Inhibitors Endoscopic Treatment Modalities Thermal (Stretta®) Thermal energy Mechanical / Neural Endoscopic Treatment Modalities Endoscopic Suturing • Suturing or plication EndoCinch ® Endoscopic Treatment Modalities Biocompatible Material Enteryx ® GERD - Surgical Treatment GERD - Surgical Treatment Nissen Fundoplication Technique Nissen Fundoplication Technique Nissen Fundoplication Technique Nissen Fundoplication Technique Nissen Fundoplication Technique Nissen Fundoplication Technique Nissen Fundoplication Technique GERD - Surgical Treatment Results • Procedure - 2 Hours • Need to Open <1% • Hospital - 1-2 Days • Need for Blood <1% • Full Activity - 2 weeks • Off Medications - 95% • Full Diet - 3 weeks • Off Steroids - 50% • Need 2nd Procedure - 5% Effects of Fundoplication Fundoplication – augments LES resting pressure – lessens frequency of transient LES relaxations – reestablishes anatomy of the LES and crura – may improve esophageal clearance – may improve gastric emptying Case 2 • A 61-year-old man presents with progressive difficulty swallowing. He has history of indigestion and heartburn. Until 12 months ago, food would come up into his throat when he was supine, with a sour taste and sometimes a cough. About 12 months ago, these symptoms improved but he developed progressive dysphagia. • He smokes 1 PPD and drinks two beers at dinner. • Exam is unremarkable except for barrel chest. Case 2 • What is the differential diagnosis? Anatomic Tumor, Stricture, Compression, Foreign Body Functional GERD, Motility Disorder (achalasia, scleroderma) Neurologic (Parkinson’s, bulbar paralysis) Psychological Globus Hystericus Case 2 • How would you evaluate this patient? Anatomic Assessment Upper GI Series EGD Biopsy Functional Assessment 24-hr pH Esophageal Manometry GES Case 2 • What are the treatment options for benign esophageal stricture? • Medications • Endoscopic Dilation • Surgery Case 2 • What are the treatment options for carcinoma of the esophagus? – Esophagogastectomy • Ivor-Lewis • Transhiatal Barrett’s Esophagus Epidemiology • Affects 10% of patients with severe GER • 40-fold increased risk of cancer • Patients require endoscopic surveillance • Esophagectomy for severe dysplasia/cancer Barrett’s Esophagus Endoscopic Appearance Barrett’s Esophagus Pathologic Diagnosis • Normal squamous epithelium transforms to intestinal-type (columnar) epithelium 40x increased cancer risk No increased cancer risk PPI-Induced Regression? Peters FT, et al., Gut 1999;45:489-94. Surgery-Induced Regression? • 56 Barrett’s patients had antireflux surgery • Annual flexible endoscopy 24 Barrett’s regressed 8 cm 4 cm 9 Barrett’s progressed 6 cm 10 cm 23 No change Sagar: Br J Surg 1995;82:806-10. Barrett’s Esophagus Development of Cancer Based on Grade • No dysplasia 3% • Low-grade dysplasia 18% • High-grade dysplasia 28% Morales and Sampliner, Arch Int Med 1999;159:1411-16. Barrett’s Esophagus Following Patients Without Dysplasia • Studies of cost-effectiveness are mixed • Few cancers found during surveillance are node-positive, versus >50% otherwise • Optimal surveillance interval debated, but data suggest q2-3 years Barrett’s Esophagus Patients With Low-Grade Dysplasia • Repeat endoscopy to avoid sampling error • Surveillance q6 mo. x 1 year then q12 mo. • May regress allowing increased interval Barrett’s Esophagus Patients With High-Grade Dysplasia • Must confirm the diagnosis • Treatment is controversial • Some advocate aggressive biopsy protocol • Some advocate esophagectomy Barrett’s Esophagus Patients With High-Grade Dysplasia Case for Aggressive Surveillance (q3-6 mos.): • Regression may occur (25%) • Most patients will not progress to cancer • Cancers remain surgically curable • Esophagectomy carries morbidity (up to 40%) and mortality (3-6%) Barrett’s Esophagus Patients With High-Grade Dysplasia Case for Esophagectomy: • 40% may already have cancer • Surveillance delays definitive treatment • Risk of esophagectomy low in highvolume centers Barrett’s Esophagus Specific Treatment Ablative Techniques • laser • electrocautery • photodynamic therapy (PDT) Resective Techniques • Endoscopic mucosal resection (EMR) Barrett’s Esophagus Take-Home Points • Barrett’s esophagus is not a contraindication to antireflux operation • Medical or surgical therapy does not eliminate need for Barrett’s surveillance • Management of high-grade dysplasia is evolving away from esophagectomy Case 3 • A 53-year-old patient presents with a history of difficulty swallowing for years. More recently she is having increasing trouble swallowing, and has been regurgitating undigested food. Exam is unrevealing, but on chest film there is an air fluid level seen behind the heart in the mid chest. Case 3 • Describe a differential diagnosis and diagnostic evaluation. Case 3 • Discuss the management options for a patient with achalasia. Achalasia Incidence • 0.5 new cases / 100,000 population / year • Dysphagia, regurgitation, cough, wheezing, aspiration, pulmonary infections • 50% initially misdiagnosed Achalasia Pathophysiology • Involves degeneration of Auerbach’s plexus and elevated LES resting pressure • Poor LES relaxation results in esophageal dilation with progressive loss of peristalsis Achalasia Diagnosis • Ba swallow: – esophageal dilation / narrowing at GE junction • EGD: – patulous esophagus, retained food, thickening • Esophageal manometry: – – – LES resting pressure LES relaxation on swallowing primary peristalsis Achalasia Treatment Options • Non-Surgical options: – Nitrates and Ca++-channel blockers – Endoscopic injection of Botox – Pneumatic balloon dilatation • Surgical options: – Heller myotomy (laparoscopic, thoracoscopic) Heller Myotomy Technique Heller Myotomy Technique Heller Myotomy Technique Heller Myotomy Outcomes • 40 laparoscopic Heller myotomies • No conversions, mean op time - 180 min • Median hospital stay - 2 days • One intraop mucosal injuriey repaired • Dysphagia alleviated in > 95% Case 3 • Discuss the management of a patient with paraesophageal hernia. Epidemiology Hiatal Hernias • Herniation of the stomach through the esophageal hiatus • Para-esophageal type - 5% – Occurs in elderly patients (~ 65 years) – Frequent co-morbid conditions Classification Hiatal Hernias • Classification depends on location of GEJ – Type I- “sliding” hiatal hernia – Type II- true paraesophageal hernia – Type III- “mixed” hernia- sliding hernia and true paraesophageal hernia – Type IV- intra-abdominal organ involvement Sliding Hiatal Hernia • Type I • GE junction “slides” into the mediastinum • Most HH • May be associated with symptomatic GERD • Surgery not indicated True Paraesophageal Hernia • Type II • GEJ in the abdominal cavity, fundus in the mediastinum • 5% of all HH • Risk of incarceration and strangulation Mixed Paraesophageal Hernia • Type III • GE junction and gastric fundus are located in mediastinum • 5% of all HH • Risk of incarceration and strangulation Paraesophageal Hernia Volvulus Mesoaxial Volvulus Organoaxial Volvulus Paraesophageal Hernia X-ray Paraesophageal Hernia Upper GI series Type II Type III Paraesophageal Hernia EGD Paraesophageal Hernia Treatment Options • Observation • Medical Therapy • Surgery Paraesophageal Hernia Observation • Assumes a low rate of gastric strangulation • Allen et al. – 23 of 147 patients followed for 12-268 mos (median 78 mos). – Only 4 pts had progressive symptoms and 2 had elective repair – Estimate prevalence of one gastric strangulation per 245 pts J Thorac Cardiovasc Surg 1993;105:253 Paraesophageal Hernia Medical Therapy • One-third of patients have heartburn alone – Acid inhibition – Patient clearly informed of risk of gastric strangulation and consequences • Excessive (10-50%) mortality for surgical repair of gastric strangulation Paraesophageal Hernia Principles of Operative Repair • Hernia Reduction • Hernia sac excision • Crural repair • Gastric fixation • Fundoplication controversial Paraesophageal Hernia Hernia Reduction • Entire stomach and at least 2 cm of esophagus must be intra-abdominal Paraesophageal Hernia Sac Excision • Entire sac must be excised to decrease risk of recurrence • Remnants of sac along inferior border of left crus lead to recurrence Paraesophageal Hernia Crural Repair • Primary repair alone • Primary repair with relaxing incision • Mesh repair Paraesophageal Hernia Fundoplication • Recent series report high rate of GERD without fundoplication • Wrap provides bulk to create “plug” at site of crural repair Paraesophageal Hernia Surgical Outcomes • Luketich et al.: 100 pts lap PH repair – 12% intraop complications; technically demanding – 3 conversions to open procedures – 28% postop complication rate; 0% mortality – 3% reoperation rate – 91% satisfied, 2-day hospital stay Ann Surg 2000;232:608 Paraesophageal Hernia Take-Home Points • Uncommon, rarely present with strangulation • Repair advised for non-GER symptoms • Repair is technically demanding • Laparoscopic vs. open remains controversial • Prospective study to determine recurrence Case 4 • A 47-year-old woman has chest pain after eating dinner at home 4 hours following upper GI endoscopy for dilatation of her achalasia. • What is the presumed diagnosis? Case 4 • What is the best means of making the diagnosis? Case 4 • What is the appropriate management? Under what circumstances might you manage this non-operatively? • What might be an appropriate management for a small perforation at the GE junction with minimal soiling?