Transcript ESOPHAGEAL TOPICS

ESOPHAGEAL TOPICS
Norman M. Simon, M.D., F.A.C.G.
BARRETT’S ESOPHAGUS
A change in the lining of the esophagus from
the normal squamous lining to an intestinal
type lining called intestinal metaplasia.
 Diagnosis suspected on endoscopy but requires
confirmation by pathology examination of
biopsies.
 Vast majority of cases caused by acid reflux
and secondary injury to the normal lining.
 Incidence appears to have increased
substantially.

 Increased
incidence of Barrett’s seems
responsible for increase in cases of
esophageal adenocarcinoma.
 Controversy re. who to screen for
Barrett’s.
 When Barrett’s suspected, biopsies taken
to confirm diagnosis and to check for
dysplasia.
 Monitoring generally being done at three
to five year intervals unless dysplasia is
found. Then depends on whether low or
Candidates For Screening
Caucasian Males
 Over 50 years of age
 Chronic symptoms of GERD
 Nocturnal reflux symptomatology
 Increased BMI with intra-abdominal fat
distribution
 Tobacco use

BARRETT’S WITHOUT DYSPLASIA
BARRETT’S LOW-GRADE DYSPLASIA
BARRETT’S HIGH-GRADE DYSPLASIA
BARRETT’S HIGH GRADE DYSPLASIA
Some evidence that anti-reflux treatment helps
prevent the development of pre-cancerous
dysplasia and cancer in patients with Barrett’s.
Role of anti-reflux surgery controversial.
 Patients with low-grade dysplasia are
monitored more frequently than those with no
dysplasia. ? Eradicate the Barrett’s. If not,
recheck every 6-12 months vs. every 3-5 yrs.
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
Options for patients with high-grade
dysplasia include doing nothing, surgical
resection, intensive monitoring,
photodynamic treatment, endoscopic
mucosal resection, argon plasma
coagulation, radio frequency ablation
(HALO), and endoscopic spray cryotherapy
Barrx 360 RFA Balloon Catheter
26 y/o male with history of recurrent
dysphagia for solids which seem to catch at
midsubsternal level. Drinks fluids to clear
the “obstruction.” Has been going on for
about 6 months. Denies heartburn or other
reflux symptoms.
 Past hx. negative aside from many year hx.
of asthma.
WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

EOSINOPHILIC ESOPHAGITIS
Also known as “allergic esophagitis”.
 Predominant symptom is dysphagia.
 Increasing incidence over past two decades.
 Occurs in both children and adults with
majority being males. In adults, majority are
in their 20’s and 30’s.
 High percentage have allergic issues including
asthma, food allergies, hives, hay fever.
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EOSINOPHILIC ESPHAGITIS (CONT)
 Findings
can include multiple rings,
narrowed esophagus, whitish nodules,
furrows, & strictures in upper esophagus.
 Some cases have involved several family
members.
 Etiology may relate to food allergies,
additives, pollen, reflux?
FURROWS
TREATMENT
Trial of anti-reflux medication-PPI.
 Allergy testing and diet changes. Elemental diet
 Avoidance of six most frequent allergenic foods
(eggs, soy, wheat, cow-milk protein, peanuts,
and seafood). SFED
 Steroid inhaler- swallowing rather than inhaling
the medication. Fluticasone propionate.
 Oral Prednisone- higher incidence of side
effects.
 Dilitation- risks of perforation.

SCHATZKI’S RING
Occur at the distal end of esophagus at
junction of esophagus and stomach. Often are
assymptomatic.
 Probably are a consequence of reflux.
 Treatment is dilitation with bougie or balloonmay be best to go directly to large size ( 50
french or larger).
 Data shows decreased rate of recurrence with
placing patients on anti-reflux medications.
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SCHATZKI’S RING
ESOPHAGEAL STRICTURE
ESOPHAGEAL STRICTURES
Many causes including reflux, malignancy,
radiation, toxic ingestions (e.g. lye), surgical
anastomoses, sclerotherapy.
 Dilitation generally done gradually stepwise,
often no more than three sizes on one day.
 Balloons (TTS) and standard dilators seem to
produce similar results.
 Longterm anti-reflux therapy can reduce
recurrence rate in many cases.
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69 y/o male with 1 ½ year of dysphagia
primarily for solids which sometimes lodge
in area of lower neck or upper chest region.
Also has experience of coughing up small
bits of food he ingested at a previous meal.
WHAT DIAGNOSES WOULD YOU CONSIDER?
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ZENKER’S DIVERTICULUM
Diverticulum occuring at junction of pharynx
and upper esophagus.
 The “pocket” faces posteriorly.
 Dysphagia often occurs immediately with
swallowing.
 Presents with dysphagia and/or spitting up of
food eaten earlier. Also may complain of
halitosis.
 Thought to be due to malfunctioning of the
upper esophageal sphincter.
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ZENKER’S DIVERTICULUM
Zenker’s Diverticulum (cont.)
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Treatment options include surgery through
side of the neck with cutting the sphincter
along with possible removal of the
diverticulum or an endoscopic technique
known as endoscopic staple-assisted
esophagodiverticulostomy.
NORMAL ESOPHAGEAL MANOMETRY
ACHALASIA
Achalasia is well recognized as a cause of
swallowing difficulty.
 Distal esophageal sphincter does not relax with
a swallow and the muscle of the lower
esophagus does not propel the food or liquid
downwards i.e. abnormal peristalsis.
 Result is dysphagia, occasionally chest pain and
regurgitation, and weight loss
 X-rays can reveal a dilated esophagus.
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ACHALASIA (CONT.)
On endoscopy often see retained food and
secretions in esophagus even though
patient has been NPO.
 Characteristic “yield” of LES to the scope
being advanced.
 “Pseudo-achalasia”
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X-RAYS OF ACHALASIA
ACHALASIA TREATMENT
Three common treatment options
 Pneumatic forceful balloon dilitation with
Rigiflex balloon. May not work; uncomfortable
for patient; 3-5% risk of perforation.
 Botox injection. Not always successful. Tends
to lose effect in 6-12 months requiring
reinjection. Good option for poor surgical
candidates.
 Surgery-laparoscopic myotomy. Cut the
sphincter and add partial fundoplication.
 Rarely, Calcium Channel blockers or Nitrates.
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OTHER MOTILITY PROBLEMS
Nutcracker esophagus, diffuse esophageal
spasm, and hypertensive lower esophageal
sphincter are three patterns often seen.
 Controversy as to whether these conditions can
cause non-cardiac chest pain and/or dysphagia.
 In spite of these uncertainties treatment is
often tried to see if clinical response.
 In some patients, may be related to reflux and
therefore often give trial of anti-reflux
medication first.
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DIFFUSE ESOPHAGEAL SPASM
HYPERTENSIVE LES
NUTCRACKER ESOPHAGUS
Treatment
In many patients improvement can be a
consequence of learning they don’t have a
serious cardiac issue.
 First line therapy often consists of a calcium
channel blocker (diltiazem) or an
antidepressant (imipramine). Can use nitrates
or sildenafil on an as needed basis.
 Other options include trial of hot liquids with
meals, botox injection, bougie.
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Esophageal Varices
All patients with cirrhosis should have EGD
screening for varices.
 No varices- rescope in couple years.
 Small varices- consider NSBB in these patients
 Large varices- low risk group probably use
NSBB. High risk group (red wale signs,
advanced liver disease) can choose between
NSBB and EVL. Add PPI after EVL (ulceration)
 Sclerotherapy not warranted for primary
prevention of bleeding.

Esophageal Varices
Esophageal Varices
Case Presentation
18 y/o female in excellent general health
awakens in the morning with rather severe
substernal chest pain when she swallows
anything even saliva. Has never had similar
problems in the past.
 Her only medication is doxycycline which she
has taken for acne for 2 years.
 WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?
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Medication Ulcers
First reported with KCl. Now known to be
associated with multiple meds including
quinidine, tetracyclines (doxycycline), iron
products, alendronate, and anti-inflamatory
medications most often ASA
 Onset is usual rapid and most often noticable
on awakening in AM. Chest pain, odynophagia.
 Injury caused by direct contact of the caustic
contents of the medication

Treatment of Pill Ulcers
No evidence that any medication speeds
healing. Typically resolves in a few days.
 Pain meds.
 May need parenteral support in rare cases.
 Can try suspension of sucralfate (Carafate)
or topical anesthetic (xylocaine).
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