Lower Esophagus and Related Disorders

Reflux Testing

  • Purpose: To determine if a patient's symptoms, such as burning, are due to acid reflux.

  • Method:

    • Ambulatory 24-hour pH monitoring: Previously involved a nasal tube, but now uses an endoscopically placed capsule in the esophagus long-term monitoring.

    • Operation: Capsule transmits data regarding pH changes to a portable recorder worn by the patient, allowing correlation of pH levels with symptoms and condition of the patient during monitoring (e.g., food intake, sleep).

    • Reflux Event Identification: Any time the pH drops below a specific level indicates a reflux episode.

Hiatal Hernias

  • Definition: Abnormal structural changes at the gastroesophageal (GE) junction affecting reflux events.

  • Anatomy: Involves the diaphragm and the lower esophageal sphincter (LES).

  • Types of Hiatal Hernia:

    • Type I (Sliding) Hiatal Hernia: Protrusion of the stomach through the diaphragm without fixed anatomical separation; can cause issues with the LES.

    • Type II (Paraesophageal) Hiatal Hernia: Specific sections of the stomach push through the LES, often leading to complications.

    • Type III (Mixed): Combination of Type I and Type II features.

    • Type IV: Additional organs besides the stomach attempt to enter through the diaphragm.

  • Etiology & Symptoms:

    • Hiatal hernias can be small with minimal symptoms; however, larger ones can complicate GERD. Associated with obesity and pregnancy but not definitively caused by genetics.

Complications of Hiatal Hernia

  • Gastroesophageal Reflux Disease (GERD): A result of the anatomical alterations affecting the closure of the GE junction.

  • Volvulus: A critical emergency condition where the stomach twists, leading to potentially necrotizing effects due to blood vessel obstruction.

    • Symptoms: Severe nausea, inability to vomit, X-ray signs such as a large bubble in the chest.

    • Diagnostic Measures: CT scan for confirmation, surgical intervention required if volvulus is suspected.

Esophageal Structural Disorders

  • Rings and Webs:

    • Occur in ~15% of the population, visible on endoscopy.

    • Schatzki Ring: Distal and can cause food impaction; treated using dilation.

    • Plummer-Vinson Syndrome: Associated with esophageal webs and iron deficiency anemia; more common in middle-aged women.

  • Esophageal Strictures: Resulting from chronic acid exposure leading to scar tissue formation.

    • Treatment: Endoscopic balloon dilation to expand narrowed areas.

  • Diverticula:

    • False diverticula (e.g., Zenker's diverticulum): Occur due to muscular exertion causing outpouching.

    • True diverticula (e.g., traction diverticula): Involve all esophageal layers, often linked with pulmonary diseases.

Esophageal Cancers

  • Prevalence: About 4 per 100,000 people.

    • Squamous Cell Carcinoma: High incidence in African American males, smokers, and alcohol consumers.

    • Adenocarcinoma: Strongly associated with Barrett’s esophagus, typically seen in obese white males.

  • Symptoms: Progressive dysphagia from solids to liquids, weight loss signals potential malignancy.

Achalasia

  • Definition: A motility disorder where the lower esophageal sphincter fails to relax, leading to esophageal dilation.

  • Diagnosis: Endoscopy will show a dilated esophagus with retained food debris; radiographically, can resemble a colon.

  • Types:

    • Type I: Classic achalasia with minimal pressure.

    • Type II: Some random prescriptive pressure noted but still with no relaxation.

    • Type III: Esophageal spasm noted with high pressures and pain during swallowing.

  • Treatment Options:

    • Pneumatic dilation: High-pressure balloon to disrupt esophageal muscle; risk of perforation.

    • Surgical myotomy: Preferred method where the sphincter is surgically opened; now done laparoscopically.

    • Peroral endoscopic myotomy (POEM): Newer technique, less invasive, with good outcomes.

GERD Management

  • Common Symptoms: Heartburn, regurgitation, dysphagia.

  • Lifestyle Recommendations: Avoid triggers like fatty foods, alcohol, and smoking.

    • Keep the head of the bed elevated, no food intake two hours before bed.

  • Medications:

    • Proton Pump Inhibitors (PPIs): Effective but must be timed correctly.

    • H2 Blockers: Work faster for symptom relief; less effective in long-term acid suppression.

Eosinophilic Esophagitis

  • Diagnosis involves >15 eosinophils per high-powered field noted in biopsy.

    • Treatments: Topical steroids or dietary modifications.

Infectious Esophagitis

  • Seen in immunosuppressed patients; may be attributed to fungi (Candida), viruses (CMV), or can be due to corrosive agents.