Diseases of the Esophagus

what is the function of the esophagus?

provides pathway for food boluses from mouth to stomach

what is the average length of an adult esophagus?

25-30 cm

what is the average diameter of an adult esophagus?

2-3 cm

what is the esophagus delimited by?

upper & lower esophageal sphincter(s)

the esophageal sphincters are usually closed. what does this prevent?

entry of air & gastric acid into the esophagus

the proximal 1/3 of the esophagus is __________ muscle

striated

the distal 2/3s of the esophagus is __________ muscle

smooth

is the swallowing reflex voluntary or involuntary?

begins as voluntary & transitions to involuntary

what is the voluntary phase of the swallowing reflex?

oral

- tongue pushes the food bolus into the oropharynx

what are the involuntary phases of the swallowing reflex?

pharyngeal & esophageal phases

what is the pharyngeal involuntary phase of the swallowing reflex?

food bolus stimulates receptors in the pharynx

- breathing is interrupted

- soft palate elevates

- glottis is pulled under the epiglottis

- when bolus reaches esophagus, upper sphincter relaxes & closes behind food bolus

what is the esophageal involuntary phase of the swallowing reflex?

this is when primary & secondary peristalsis occur

what happens during primary peristalsis?

- vagal stretch receptors detect distention & induce wave of contraction

- when wave reaches lower sphincter, it relaxes & allows bolus to enter stomach

what happens during secondary peristalsis?

repetitive waves clear the esophagus of food

what symptoms may indicate a primary esophageal disorder?

- heartburn

- dysphagia (oropharyngeal or esophageal)

- odynophagia

what is heartburn?

substernal burning

- caused by: the reflux of acidic materials into esophagus

- highly specific for GERD

what is oropharyngeal dysphagia?

problem transferring the food bolus from the oropharynx to the upper esophagus

- oral: drooling, spillage of food from mouth, inability to chew or initiate swallowing, dry mouth

- pharyngeal: immediate sense of the bolus catching in the neck, need to swallow repeatedly, coughing or choking during meals

what is esophageal dysphagia?

inability to move food through esophagus

- may be due to: mechanical obstruction or motility disorders

what are the s/s of esophageal dysphasia due to mechanical obstruction?

dysphagia primarily for solid foods

- recurrent

- predictable

- progressive

what are the s/s of esophageal dysphasia due to a motility disorder?

dysphagia for solids & liquids

- episodic

- unpredictable

- progressive

what is odynophagia?

pain with swallowing

what is the study of choice for evaluation of persistent sx &/or suspected mechanical lesion?

upper endoscopy

what does upper endoscopy allow for?

direct visualization

- biopsy

- dilation of strictures

when may videoesophagography be used?

oropharyngeal dysphagia

when may barium esophagography be used?

esophageal dysphagia

- to differentiate between mechanical lesions & motility disorders

what may barium esophagography help differentiate?

- mechanical lesions

- motility disorders

what is barium esophagography more sensitive for?

detecting subtle esophageal narrowing such as:

- rings

- achalasia

- proximal lesions

when is barium esophagography the study of choice?

for a suspected motility disorder

what is esophageal manometry?

measure of esophageal motility

what does esophageal pH recording & impendance testing provide information about?

the amount of esophageal acid reflux & the timing between sx & reflux

- continuous monitoring for 24-48 hrs

what is esophagitis?

inflammation of the esophagus

what may cause GERD?

- gastroesophageal junction dysfunction

- delayed gastric emptying

what does the anti-reflux barrier depend on?

- lower esophageal sphincter (LES) pressure

- intra abdominal location of the sphincter (flap-valve)

- extrinsic compression of the sphincter by the crural diaphragm (L & R crus muscles)

when does most reflux occur?

during transient relaxation of the LES

what are the types of gastroesophageal junction dysfunctions?

- incompetent LES

- hiatal hernia

- truncal obesity

- abnormal esophageal clearance

incompetent LES

- results in: increased acid reflux

- usually occurs when supine or w/ increased intra abdominal pressures

hiatal hernia

- results in: higher amounts of acid reflux & delayed esophageal acid clearance

- caused by: movement of the LES above the diaphragm

how is acid normally cleared?

by esophageal peristalsis

how is acid normally neutralized?

by salivary bicarbonate

what may cause delayed gastric emptying?

- gastroparesis

- partial gastric outlet obstruction

what are the s/s of GERD?

- heartburn (pyrosis)

- regurgitation

- dysphagia

- extra esophageal manifestations

are initial diagnostic studies indicated for typical GERD sx of uncomplicated reflux disease?

no

1 multiple choice option

how is GERD treated?

empirically (treatment made based on clinical judgement. no definitive labs were used to confirm dx).
- empirical tx w/ ppi is common

when may further studies be indicated in GERD?

refractory cases or w/ alarm features, such as:

- troublesome dysphagia

- odynophagia

- weight loss

- iron deficiency anemia

if imaging is needed in GERD work-up, what is the test of choice?

upper endoscopy w/ biopsy

ddx for GERD:

- esophageal motility disorders

- peptic ulcer

- angina pectoris

- functional disorders

- pill induced damage

- eosinophilic esophagitis

- Infections (CMV, herpes, candida)

what is the tx for mild or intermittent GERD?

lifestyle modifications

- meds prn

antacids provide ___________________ relief

rapid, short lived

- 2 hrs

OTC oral H2 receptor antagonists provide _______________________ relief

delayed, but longer

- 8 hrs

what is the tx for GERD assoc. w/ troublesome sx or known complications?

once daily PPI for 4-8 wks (may require BID dosing)

- if still inadequate relief, eval w/ upper endoscopy is indicated

what is long-term therapy for GERD?

once daily PPI

- if good symptomatic relief is obtained, discontinue after 8-12 wks

- if relapse occurs, may treat w/ continuous, intermittent 2-4 wk course, or on demand/pt dosed PPIs

esophageal __________ is indicated in pts w/ continued sx after 3 months

pH testing

ddx for refractory esophagitis:

- gastrinoma w/ gastric acid hypersecretion

- pill induced esophagitis

- PPI resistance

- medical non compliance

what is Zollinger-Ellison syndrome?

excess gastric acid

what is surgical fundoplication?

crus muscles are tightened & stomach is wrapped around esophagus

- NOT recommended for pts who are well controlled w/ medical therapy

- new sx can develop: dysphagia, bloating, increased flatulence, dyspepsia, diarrhea

what is barrett esophagus?

normal squamous epithelium of esophagus is replaced by metaplastic columnar epithelium (goblet & columnar cells)

- due to chronic reflux injury

- does NOT present w/ sx

- pt have long hx of reflux sx

how is barrett esophagus treated?

long term PPIs

- does not reverse damage, but slows progression

what is the most serious complication of barrett esophagus?

esophageal adenocarcinoma

do we go looking (screen) for barrett esophagus?

no

1 multiple choice option

in general, guidelines recommend against screening for barrett esophagus, except those w/ multiple risk factors for adenocarcinoma, which includes:

- chronic GERD

- hiatal hernia

- obesity

- white race

- male

- age 50+

patients w/ known barrett esophagus should have endoscopic surveillance every __________ to look for low or high grade dysplasia or adenocarcinoma

3-5 yrs

what is peptic stricture?

narrowing of esophagus, characterized by gradual development of solid food dysphagia over months to years

- complication of GERD

- often decreased heartburn

- dx: endoscopy w/ biopsy (mandatory)

- tx: long term PPIs to decrease recurrence

where are most peptic strictures found?

at the gastroesophageal junction

who does infectious esophagitis most commonly occur in?

immunocompromised patients:

- AIDS

- solid organ transplants

- leukemia

- lymphoma

- immunosuppressive drugs

what are the most common pathogens of infectious esophagitis?

- candida albicans

- herpes simplex

- cytomegalovirus (CMV)

how is infectious esophagitis caused by candida albicans treated?

systemic therapy required

- empiric trial of antifungal (fluconazole)

- if do not respond to med w/i 3-5 days = endoscopy w/ brushings, biopsy & culture

how is infectious esophagitis caused by cytomegalovirus treated?

in HIV pts, HAART is most effective

can most patients w/ infectious esophagitis be effectively treated w/ complete sx resolution?

yes

1 multiple choice option

what are some examples of meds that may injure the esophagus (through direct, prolonged mucosal contact)?

- NSAIDs

- potassium chloride tabs

- quinidine

- alendronate & risendronate

- iron

- Vit C

- abx (-cyclines, clindamycin, bactrim)

when is pill induced esophageal injury most likely?

*if pills are swallowed:

- w/ or w/o water

- while supine

*hospitalized or bed bound patients

how can pill induced esophagitis be prevented?

take pills w/ water & remain upright for 30 mins after ingestion

accidental esophageal injury usually occurs in _________

children

deliberate (suicide) esophageal injury usually occurs in _________

adults

how is caustic esophageal injury treated?

- admit to ICU (chest & abdominal XRs)

- initial tx = supportive (IV fluids, PPIs, analgesics)

if an endoscopy is done w/i 12-24 hrs of ingestion of a substance that has caused esophageal injury, what will it show?

no injury

caustic esophageal injury w/ mild damage =

- edema

- erythema

- exudates

- superficial ulcers

- recover quickly w/ low risk of developing strictures

caustic esophageal injury w/ severe damage =

- deep, circumferential, necrotic ulcers

- high risk of acute complications

should corticosteroids or antibiotics be used in caustic esophageal injury pts w/ severe damage?

NO

1 multiple choice option

who should the diagnosis of eosinophilic esophagitis (EoE) be considered in?

- adults w/ hx of food impaction, persistent dysphagia, or w/ GERD that fails to respond to medical therapy

- young males or boys, & in those w/ hx of allergies, asthma, or atopy

- those w/ hx of esophageal perforation or severe pain after dilation of stricture

what does the diagnosis of EoE require?

sx & histological findings

- upper endoscopy w/ esophageal biopsies (2-4)

possible endoscopic features in EoE:

- stacked circular rings ("feline" esophagus)

- strictures (proximal)

- attenuation of subepithelial vascular pattern

- linear furrowing that may extend the entire length of esophagus

- whitish papules (eosinophil microabscesses)

- small cabiler esophagus

possible histologic features in EoE:

- peak eosinophil count of >/= 15 eosinophils per high power field

- eosinophil microabscesses

- superficial layering of eosinophils

- sheets of eosinophils

- extracellular eosiniphil granules

- subepithelial & lamina propia fibrosis & inflammation

- basal cell hyperplasia

- papillary lengthening

why should patients w/ EoE undergo evaluation by an allergist?

bc of the strong assoc. of EoE w/ allergies

esophageal web

thin (<2 mm) eccentric membrane that protrudes into the esophageal lumen

- covered w/ squamous epithelium

- most commonly occur anteriorly in the cervical esophagus, causing a focal narrowing in the postcricoid area

esophageal ring

concentric (2-5 mm) diaphragm of tissue that protrudes into the esophageal lumen

- usually mucosal, but in rare cases may be due to hypertrophy of an A ring

- typically located in distal esophagus, but can occur in other parts

A ring

caused by normal smooth muscle contraction in esophagus

- located in distal esophagus just proximal to SCJ, corresponding to strongest part of LES

B ring

mucosal stricture precisely at the SCJ

- smooth & thin (

what is the most common type of esophageal ring?

schatzki ring

- narrow mucosal B ring (< 12.5 mm in diameter)

schatzki rings are almost always associated w/ a _______________

hiatal hernia

schatzki rings have also been associated w/ EoE; however, more often pts w/ EoE have:

- multiple proximal esophageal rings

- long strictured segments

- linear furrows in the mucosa

- linear abscesses that appear as white papules

what are the s/s of esophageal webs & rings?

most are asymptomatic

- usually present w/ intermittent dysphagia to solids

how are esophageal webs/rings usually diagnosed?

barium swallow &/or upper endoscopy

how are esophageal webs/rings treated?

dilation &/or indefinite PPI therapy

esophageal _____ have been associated w/ zenker's diverticulum; however, the role is unknown

webs

1 multiple choice option

what is zinkers diverticulum (ZD)?

a sac-like outpouching of mucosa & submucosa through killian's triangle

- posterior, "false" diverticulum that has a neck proximal to the cricopharyngeal muscle

- s/s: transient oropharyngeal dysphagia, halitosis, gurgling in throat, appearance of mass in neck, regurgitation

- dx: barium swallow & upper endoscopy

what is killians triangle?

an area of weakness between transverse fibers of the cricopharyngeus muscle & oblique fibers of the lower inferior constrictor (thyropharyngeus)

when should the dx of ZD be considered?

in middle aged or older adults w/ progressive oropharyngeal dysphagia (usually to solids & liquids) or regurgitation of undigested food debris

what is the definitive tx of ZD?

surgical

- zenker peroral endoscopic myotomy

what are the motility disorders?

- achalasia

- scleroderma

- mallory weiss tear

- varices

what is achalasia?

idiopathic loss of peristalsis in the distal 2/3 of the esophagus w/ impaired relaxation of the LES

- due to degeneration of myenteric neurons of the esophagus