Lecture 2: The Esophagus

muscular propriawhat layer of the esophagus is made of: -striated upper third -smooth lower third -mixed mid thirdadventitiawhat layer of the esophagus is made of: helps with anchoring the esophagus-mucus secretion -transport -no enzyme production or nutrient absorption3 physiologic roles of the esophagus?atrial blood: from small branches from aorta and other organsarterial blood of the esophagus?venous networks: drain into other larger venous systemsvenous networks of the esophagus?common esophageal complaints-pyrosis -dysphagia -odynophagiapyrosis-aka heartburn -intermittent, substernal burning pain -due to reflux of stomach contentsoropharyngeal esophagealwhat are the 2 types of *dysphagia*?oropharyngeal (dysphagia)-difficulty transferring oral contents from oropharynx to upper esophagus -multiple etiologies -results in drooling / spilling of oral contents, inability to chew / swallow, and dry mouthobstructive and motorwhat are the 2 types of esophageal dysphagias?obstructive esophageal (dysphagia)-physical obstruction narrows lumen to less than 1.3cm -worse for solids the liquids but can progressmotor esophageal (dysphagia)-associated with a motility disorder -impaired peristalsis down the esophagus -intermittent -can occur equally with solids or liquidsglobus pharyngeus / globus sensation-sensation of "lump in the throat" -not true dysphagia -no organic cause -all testing normal, pt needs reassuranceodynophagia-pain triggered by swallowing -commonly seen with esophageal inflammation (Candida, HSV) -multiple other common etiologies such as tooth and gum disease, pharyngitis, etcendoscopy (EGD)what type of diagnostic study? -procedure of choice -direct visualizationbarium swallow upper GI (UGI)what type of diagnostic study? -can show: esophagus -can show: esophagus, stomach, duodenummanometrywhat type of diagnostic study? -pressure measurementesophageal pH monitoringwhat type of diagnostic study? -useful in diagnosing reflux -can monitor for 24-48hrs -transnasal catheter connected to a recording devicetracheoesphageal fistula (TE fistula)-congenital or acquired communication that forms between the esophagus and tracheatracheoesphageal fistula (TE fistula)what anatomical abnormality of the esophagus? -congenital occurs in 2,000-4,000 live births; associated with other anomalies in 20-70% of cases; diagnoses short after birth -acquired = rare; associated with malignancy, mechanical ventilation, tracheostomy; complicationstracheoesphageal fistula (TE fistula)what anatomical abnormality of the esophagus? sx: those of respiratory infection; common: cough, choking, fever PE: fever pulmonary: cracklesUGI or endoscopy to diagnose the fistula CxR to look for pulmonary infectionworkup for tracheoesphageal fistula (TE fistula)?surgical repair of fistula -individualized treatment of pulmonary complicationstreatment for tracheoesphageal fistula (TE fistula)? complications: pneumonia, ARDS, abscess, respiratory figure, death prognosis: overall survival >90%hiatal hernia-portion of stomach protrude through diaphragm into thoracic cavity -often incidental finding on chest x ray -2 types: sliding & paraesophageal / rollingsliding hiatal hernia-most common type off hiatal hernia (95%) -LES and stomach slide through diaphragmatic hiatusparaesophageal or rolling hiatal hernia-portion of stomach rolls up alongside lower esophagus -GE junction remains fixedhiatal herniawhat anatomical abnormality of the esophagus? -sliding type very common especially in western countries; found in 10% of those under 40yrs, @ 70% of those over 70yrs -more common in women, elderly, and obese ptssliding hiatal herniasymptoms for which type of hiatal hernia? -asymptomatic if LES competent, otherwise reflux occurs with associated heart burn physical findings: typically noneparaesophageal or rolling hiatal herniasymptoms for which type of hiatal hernia? -portion of the stomach can be obstructed and strangulated with associated pain and vomiting physical finings: possible epigastric tendernesstypically none required often incidental finding on CxR can be confirmed by UGIworkup for sliding hernia?UGIworkup for paraesophageal or rolling hiatal hernia?none if asymptomatic treat reflux if present rarely requires surgerytreatment for sliding hernia?surgical repairtreatment for paraesophageal or rolling hiatal hernia?sliding: GERD, reflux esophagitis rolling: acute obstruction, strangulation, Volvoscomplications for: -sliding hiatal hernia? -paraesophageal or rolling hiatal hernia?sliding: excellent rolling: risk with acute surgical complicationsprognosis for: -sliding? -rolling?Zenker's or Pharyngoesophageal Diverticula-outpouching above the UES due to decreased elasticity of the UES -improper relaxation of UESmore common in men most cases seen in 70-90 year rangewho is Zenker's or Pharyngoesophageal Diverticula more common in, age?dysphagia feeling food sticking in throat regurgitating of undigested food especially when supine coughing with eating halitosis nocturnal chokingsymptoms of Zenker's or Pharyngoesophageal Diverticula? physical finings: often none, can have bad breathbarium swallow, UGI, endoscopyworkup for Zenker's or Pharyngoesophageal Diverticula?none if small UES myotomy with diverticulectomytreatment of Zenker's or Pharyngoesophageal Diverticula? prognosis: risks with procedures, age, and concurrent medical conditionsZenker's or Pharyngoesophageal Diverticulacomplications of...? -aspiration pneumonia, lung abscess -compression of esophagus (if abnormality too large) -erosion with bleedingEpigastric Diverticula-outpouching just above the LES -spastic (tonic) LES -can be seen with achalasia and DES -rare; incidence similar to Zenker's -typically found in adults over the age of 50 -no gender associationdysphagia supine regurgitation of undigested food symptoms usually mildsymptoms of Epigastric Diverticula? physical findings: usually normalUGI, endoscopyworkup for Epigastric Diverticula?none if asymptomatic surgical diverticulectomy with possible LES myotomy treat underlying disease (achalasia, DES)treatment for Epigastric Diverticula? complications: risk with procedure prognosis: goodrings and webs-thin band of mucosa and or submucosa that narrow lumen of the esophagus 1. Schatzki's Ring 2. Esophagus WebSchatzki's Ring-lower esophageal ring; occurs at Z lineSchatzki's Ring-found in 6-14% of al routine UGI barium studies -associated with sliding hiatal hernia -broad age of presentation: 20-70 years -etiology: unknown symptoms: -usually asymptomatic -occasionally causes solid food dysphagia -can obstruct acutely with large food bolus -do not cause reflux although reflux may occur due to a coinciding hiatal hernia physical findings: usually nonemany found incidentally on UGI -if any doubt of diagnosis, endoscopy should be performed to r/o cancerworkup for Schatzki's Ring?many require none since asymptomatic -pt ed: chew thoroughly, increase fluids wit meals -esophageal dilation occasionally needed -endoscopy with removal of food bolus occasionally neededtreatment for Schatzki's Ring? complications: typically none prognosis: excellentEsophageal Web-fold of mucosa commonly found in upper esophagusEsophageal Web-found inn 6-14% of all routine UGI barium studies -more common in females -age of presentation: 20-70 -etiology: unknown or associated with Plummer-Vinson Syndrome symptoms: -usually asymptomatic -occasionally dysphagia for solids, especially large bolus physical findings: usually noneUGI and endoscopy can both demonstrate the web -endoscopy required to rule out cancerworkup for Esophageal Web?often none since asymptomatic -dilation if necessarytreatment for Esophageal Web? complications: associated with an increased risk of squamous cell carcinoma prognosis: typically goodPlummer Vinson Syndrometriad of: upper esophageal web, dysphagia, and iron deficiency anemiaPlummer Vinson Syndrome-typical pt is a middle aged white female (autoimmune disorder) -these pts have increased risk of squamous cell cancer of pharynx / esophagus symptoms: -solid food dysphagia along with weakness, fatigue, and dyspnea secondary to anemia physical findings: findings secondary to anemia (cheilits, glossitis, pallor, koilonychias)CBC, iron studies, UGI, endoscopy (EGD)workup for Plummer Vinson Syndrome?find cause of anemia and treat anemia -treatment of anemia resolves the web -annual EGD to surveil for cancertreatment and Pt ed for Plummer Vinson Syndrome?scleroderma and CREST syndromewhat 2 diseases? -both are autoimmune disorders that affect smooth muscle -absence of LES tone -usually occurs in mid aged females -3-4x more common in femalesscleroderma_____ is aka systemic sclerosis; collagen is deposited in the skin and visceraCREST_____ stands for calcinosis cutis, Raynaud's phenomenon, esophageal dysmotility, scleroderma, telangiectasisscleroderma and CREST syndrome-atrophy and fibrosis of smooth muscle results in loss of peristalsis and absence of LES tone symptoms: -severe reflux -motor dysphagia -structures develop over time resulting in increasing dysphagia and decreasing heartburn physical findings: -may have other findings related to autoimmune disease, but GI negativeUGI can demonstrate reflux manometry demonstrates loss of peristalsis and decreased LES pressureworkup for scleroderma and CREST syndrome?control reflux with lifestyle changes and PPP to decrease acid secretionstreatment for scleroderma and CREST syndrome?uncontrolled reflux can lead to esophagitis, Barrett's esophagus, strictures, and adenocarcinoma of the esophaguscomplications seen in scleroderma and CREST due to uncontrolled reflux? prognosis: dependent on other, non-GI complications of the autoimmune diseaseachalasia_____ is a slowly progressive degeneration of neurons that innervate the smooth muscle of the esophagus results in: -spasticity of the LES -loss of peristalsis of distal 2/3 of esophagus -dilation of the esophagusachalasia-average age of presentation is 25-60 years -occurs in males and females equally -etiology: unknown symptoms -motor dysphagia -chest pain: often described as substernal discomfort and or fullness after eating -positional regurgitation of undigested food -weight loss physical findings: nonspecific, weight loss, halitosischest x ray may show air / fluid filled level in the esophagus UGI can demonstrate "birds beak" taper of the distal esophagus endoscopy should be performed to r/o cancer at the distal esophagus / GE junction manometry demonstrates a hypertonic LES tat fails to relax with swallowingworkup for achalasia?goal is to weaken the LESwhat is the goal for achalasia tx?medication: smooth muscle relaxer (CCB) injection: botulinum toxin pneumatic dilation*** myotomytreatments for achalasia?medication: smooth muscle relaxer, CCBwhat type of achalasia treatment? -only 10% effective so reserved for those who cannot tolerate other forms of tx -Nifedipine 10mg orally, 3 times daily, before meals (sublingual form not recommended due to SE) -Isosorbide sublingual (nitrate); no longer available in the US -Nitroglycerine 0.4mg sl is an alternateBotulinum Toxin Injectionwhat type of achalasia treatment? -botulinum toxin injected endoscopically into the LES -50% relapse in 6-9 months -all relapse by 2 years -most appropriate for those who cannot have more invasive procedurespneumatic dilationwhat type of achalasia treatment? -best treatment option -ballon is inflated across the GE junction to disrupt the LES -1-3 sessions required -perforation rate <3% -up to 90% get relief -up to 35% recur within 10 years but do well with repeated dilationmyotomywhat type of achalasia treatment? -cutting some of the fibers of the LES -performed laparoscopically or peroral /POEM - >90% effective -@20% incidence of reflux after procedure -fundoplication at time of _____ to prevent reflux; can only be done if laparoscopic -pts placed on PPI post operatively ->25% recur within 10 years but these pts do well with dilationprognosis: good prognosis with myotomy and pneumatic dilation complications: occasionally leads to squamous cell carcinoma of the distal esophagusprognosis and complications with achalasia?Distal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophaguswhat are the 2 types of esophageal spasm?Disal Esophageal Spasm (DES)which type of esophageal spam? -uncoordinated contractions of he esophagus -waves do not progress correctlyJackhammer (Nutcracker) Esophaguswhich type of esophageal spasm? -coordinated contractions of the esophagus -excessive amplitudeDistal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophagusincidence: true incidence unknown as many are mild and go undiagnosed -more common in women and in Caucasian population -incidence increases with age etiology: cause of abnormal esophageal contractions unknownDistal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophagussymptoms: -dysphagia: due to intermittent episodes of abnormal esophageal motility, can occur with solids and or liquids -noncardiac chest pain: unpredicted, cab be confused with angina -regurgitation -heartburn due to reflux physical findings: normal PEmay need to rue out cardiac origin UGI and manometry are the best tests for making the diagnosisworkup for Distal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophagus?Distal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophagusdiagnosis for...? -episodes of chest pain with dysphagia -spontaneous non peristaltic contractions on UGI -repetitive contractions on manometry in 50% or more of the esophagusPPI: to control heartburn Pepermint Oil: 2 Altoids (relaxes esophageal smooth muscle) CCB: Dilitazem TCA: Imipramine Botulinum Toxin Injection extreme cases... myotomy or esophagectomytreatment for Distal Esophageal Spasm (DES) and Jackhammer (Nutcracker) Esophagus? complications: possible SE with medications, surgical complications prognosis: moderate, mortality low but morbidity high; some ptsd do not respond well to txCCBtreatment for esophageal spams that *decreases amplitude of contractions*, *Dilitazem* 60-90mg QID x 3 months if improving then decrease BID, if symptoms resolve discontinue and use 60mg prnBotulinum Toxin Injectiontreatment for esophageal spams that helps *dysphagia only*, injection performed 2 and 7 cm above the GE junction; *temporary relief, no greater than 6 months*