Dysphagia

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Dysphagia

• Dr.Krisana Thaitong

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Dysphagia

• must be distinguished from globus sensation
• Globus is a sensation of a lump in the throat in
  which food transport is not limited
• globus is not related to swallowing and, in fact,
  may improve with swallowing

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Dysphagia

• Oropharyngeal dysphagia
• Esophageal dysphagia

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Dysphagia
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Dysphagia
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Oropharyngeal dysphagia
Esophageal dysphagia
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Neuromuscular dysfunction

• Achalasia
• Nonachalasia Motility
• Disorders
• Strictures
• Rings/Webs
• GERD
• Extraesophageal GERD

?

• Cerebrovascular accidents
• Amyotrophic Lateral
• Sclerosis (AML)
• Parkinson's disease
• Myasthenia gravis
• Tardive dyskinesia.

• Neoplasia
• Esophageal Diverticula
• Foreign Bodies
• Pill-Induced Injury
• Infectious Esophagitis
• Caustic Injury

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Esophageal dysphagia
?
?
Solids only
Solids liquids
?
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Mechanical obstruction
Motility disorder
?
?
?
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Intermittent
Intermittent
progressive
progressive
?
?
?
?

• Rings/Webs

• Strictures

• Achalasia

• Esophageal
• spasm

• Malignancy

• Scleroderma

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Oropharyngeal dysphagia

• abnormality related to the movement of a food
  bolus from the hypopharynx to the esophagus
• arises from disease of the upper esophagus,
  pharynx, or UES.

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• typically present with difficulty initiating a
  swallow and immediately experience coughing,
  choking, gagging, or nasal regurgitation when
  attempting to swallow

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• most common caused by disruptions in swallowing
  secondary to neuromuscular dysfunction
• this setting, the symptoms may be more severe
  when swallowing liquids
• The history and physical examination should
  focus on neurologic signs and symptoms

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Neuromuscular dysfunction

• Cerebrovascular accidents
• Amyotrophic Lateral Sclerosis (AML)
• Parkinson's disease
• Myasthenia gravis
• Tardive dyskinesia.

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• Rarely, structural abnormalities caused such as
• ? cervical osteophytes
• ? hypopharyngeal diverticulum (Zenker's
  diverticulum)
• ? tumors
• ? postcricoid webs
• typically note difficulty with a solid food bolus
  leaving the mouth

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• Oropharyngeal swallow is best assessed by
  videofluoroscopy, also known as the modified
  barium swallow
• Videofluoroscopy not only serves to confirm the
  presence of oropharyngeal dysfunction
• It can also assess the degree of aspiration

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Esophageal dysphagia

• the difficulty in propagating food down the
  esophagus
• arises within the body of the esophagus either
  due to a mechanical or a motility disturbance.

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Esophageal Disease States

• Achalasia
• Nonachalasia Motility Disorders
• Strictures
• Rings/Webs
• Gastroesophageal Reflux Disease
• Extraesophageal GERD

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• Neoplasia
• Esophageal Diverticula
• Foreign Bodies
• Pill-Induced Injury
• Infectious Esophagitis
• Caustic Injury

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1. Achalasia
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Achalasia

• a primary esophageal motility of unknown cause
• characterized by insufficient LES relaxation and
  loss of esophageal peristalsis
• hereditary, degenerative, autoimmune, and
  infectious factors as possible causes

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• Pathologic changes occur in the myenteric plexus
• consist of a patchy inflammatory infiltrate of T
  lymphocytes, eosinophils, and mast cells
• loss of ganglion cells and myenteric neural
  fibrosis

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• selective loss of post-ganglionic inhibitory
  neurons, nitric oxide and vasoactive intestinal
  polypeptide
• The postganglionic cholinergic neurons are
  spared, leading to unopposed cholinergic
  stimulation.

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• This produces high basal LES pressures, and the
  loss of inhibitory input
• results in insufficient LES relaxation
• Aperistalsis along the esophageal bodya process
  mediated by nitric oxide.

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• m/c symptoms of achalasia include
• ? dysphagia for solid liquid
• ? regurgitation
• ? chest pain
• Patients with achalasia localize their dysphagia
  to the cervical or xiphoid areas.

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• Initially, the dysphagia may be for solids only
• most patients have dysphagia for solids and
  liquids at time of presentation
• Regurgitation occurs in 75 of achalasia and
  becomes a greater problem as the esophagus
  dilates with progression of disease

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• Choking and Coughing may awaken the patient from
  sleep
• Chest pain 40
• Weight loss 60 (minimal loss)
• barium esophagram with fluoroscopy is the best
  initial diagnostic study

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• This test will reveal a loss of primary
  peristalsis in the distal two thirds of the
  esophagus
• In the upright position, there will be poor
  emptying
• with retained food and saliva producing a
  heterogeneous air-fluid level at the top of the
  barium column.

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Achalasia
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• The esophagus may be dilated (Figure 80-18).

esophagus is dilated with a "bird's beak"
tapering of the distal esophagus
Retained secretions form the heteroge-nous
air-fluid level seen at the top of the barium
column.
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• chronic disease be massive with sigmoid-like
  tortuosity

sigmoid-like tortuosity with large amount of
retained debris.
late-stage achalasia
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• smooth tapering of the lower esophagus leading to
  closed LES, resembling a bird's beak
• presence of epiphrenie diverticulum may suggest
  achalasia

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Birds beak deformity at LES
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• Esophageal manometry can be used to diagnosis
• In the body of the esophagus, aperistalsis is
  always present
• all swallows are typically with low
  contraction amplitudes.

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Manometry

• Elevated resting LES pressure (gt35
  mmHg )
• Incomplete LES relaxation
• Absence of peristalsis 

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Manometry
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Manometric findings in achalasia The
aperistalsis is manifested by isobaric
contractions without propagation The LES
pressure, which is elevated, shows minimal
relaxation with swallowing.
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• Abnormal LES relaxation in all achalasia
• 70 - 80 of patients absent/ incomplete LES
  relaxation with swallows
• baseline LES pressure is usually elevated but may
  be normal in up to 45 of patients

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Esophagus is dilated with retained fiuid and
debris.
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• Nonrelaxation of LES
• Asynchronous contraction and Nonperistaltic
• Fibrotic and atrophic
• Retention and stagnation of chronic food
• Retention esophagitis

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• All should upper endoseopy to exclude
  Pseudoaehalasia arising from a tumor at the GEJ
• Pseudoaehalasia may mimic with classic achalasia
  both clinically and manometrically
• suspected in older age with short duration of
  symptoms and more significant weight loss

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Therapy

• 1.Medical therapy
• 2.Pneumatic dilation of the LES
• 3.Surgical myotomy
• 4.Botulinum toxin injection

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• The two most effective treatments
• graded pneumatic dilation and surgical myotomy

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• 1.Medical therapy
• Nitrates, calcium channel blockers (nifedipine)
• Cause smooth muscle relaxation but with limited
  success

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• 2.Pneumatic dilation of the LES
• -good short-term results
• -2 to 5 risk of perforation
• - performed endoscopy uses air pressure to
  dilate and disrupt the
• circular muscle fibers of the LES

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• Balloon dilators, three diameters
• (3, 3.5, and 4 cm) are positioned over a
  guidewire
• After pneumatic dilation
• ? gastrograffin study
• ?by barium swallow to exclude esophageal
  perforation
• relief of symptoms in 50 to 93

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Pneumatic dilation of the LES
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• 3.Surgical myotomy
• -fail repeated pneumatic dilations
• -an anterior myotomy across the LES
• (Heller's myotomy) usually associated with an
  antire-flux procedure
• -laparoscopy

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• good-to-excellent response rate of 80 to 94
• A potential complication of myotomy
• is GERD, which occurs in 10 to 20

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• 4.Botulinum toxin injection
• -Inhibits release of excitatory acetylcholine
  from nerve endings (thus causing lower LES
  pressures)
• -Good short-term results, but long term efficacy
  unknow
• -Effective in about 85 of
• patients

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• However, symptoms recur in more than 50 of
  patients after 6 months
• do not improve LES relaxation or improve
  peristalsis
• do not provide complete symptom relief
• The clinical response is short acting
• efficacy decreases with time.

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2.Nonachalasia Motility Disorders
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Nonachalasia Motility Disorders

• Other described primary motility disorders of the
  esophagus
• Defined based on the presence of specific
  manomctrie criteria

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• Most often noted on manometry in
• patients with chest pain or dysphagia
• 2.1 Diffuse esophageal spasm (DES)
• 2.2 Scleroderma or
• progressive systemic sclerosis (PSS)
• 2.3 Other systemic conditions

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Diffuse Esophageal Spasm

• Repetitive, high amplitude contractions of smooth
  muscle portion of the esophagus
• The striated portion and LES relaxation normally.
• Histopathology muscular hypertrophy with
  lymphocytic infiltration of Auerbachplexus

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• SS dysphagia and chest pain (substernal) or
  esophageal colic with may occur with or without
  swallowing.
• Trigger by emotional stress, hot or cold liquids
  and GE reflux

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• DES may present with chest pain if the
  contraction amplitudes are high
• dysphagia if the contraction amplitudes are low.

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• Investigate CXR, cardiac evaluation, barium
  study and manometry
• LES relaxation is also normal in DES
• The classic finding on esophagogram
• is the "corkscrew" esophagus

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Radiographic

• Classic corkscrew
• Beaklike taper
• Increase in esophageal wall thickness

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• Manometrie simultaneous and repetitive
  contractions in the esophageal body
• but in contrast to achalasia, some normal
  peristalsis is maintained

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• Typical corkscrew pattern
• Manometry prolong, high amplitude
  nonperistaltic
• Both UES and LES normal,but elevate LES pressure
  may be found.

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• "Nutcracker" esophagus is another common
  manometrie diagnosis in noncardiac chest pain
• defined by high-amplitude peristalsis

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• distal esophageal contraction amplitude less
  than 30 mmHg in 30 or more of wet swallows
• a food bolus may not be effectively transported
• resulting in dysphagia

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Treatment

• 1.Reassuring the disease is not heart disease.
• 2.Medication nitroglycerine, calcium blocker,
  anticholinergic, PPI (Rx GERD)
• (not completely effective)

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• 3.Surgery
• 3.1 Dilation help only in LES dysfunction,
  improve dysphagia temporarily
• 3.2 Surgical myotomy

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Scleroderma

• progressive systemic sclerosis (PSS)
• Secondary motility disorders arc commonly a
  result of systemic conditions
• The most common condition affecting esophageal
  motility

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• Esophageal motor disturbances occur in several of
  the collagen vascular diseases
• Dermatomyositis
• Polymyositis
• Lupus erythematosus
• Scleroderma (extremely common)

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• Characterized by
• Smooth muscle atrophy and collagen deposition in
  the submucosa
• Decrease peristalsis and LES resting pressure
• Refulx esophagitis, ulceration, bleeding

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Radiography

• Dilate esophagus with decreased motility (unlike
  achalasia, persistent patent GE junction and no
  air fluid level)

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Scleroderma
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• Endoscopy
• Reflux esophagitis

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Other systemic conditions

• results in esophageal hypomotility
• hypothyroidism
• diabetes mellitus
• amy-loidosis

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Investigation

• Esophageal manometry and intraesophageal pH
  readings are the most sensitive means of
  detection
• Diminished contractions in LES and distal two
  thirds of the esophagus

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Treatment

• Standard antireflux medicine
• In patients with intractable symptoms
  gastroesophageal reflux surgery should be
  considered

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3.Strictures

• .

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Strictures

• defined as any loss of lumen area within the
  esophagus
• The normal esophagus measures 20 mm in diameter
• The predominant clinical symptom of strictures is
  dysphagia, which is usually when the lumenal
  diameter is less than 15 mm.

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• Even less severe strictures can cause
  intermittent dysphagia to large food piece meat
  and bread
• There are multiple intrinsic and extrinsic causes
  for esophageal strictures

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• Etiology of Esophageal Strictures
• Intrinsic strictures
• Acid peptic
• Pill-induced
• Chemical/lye
• Post-nasogastric tube
• Infectious esophagitis
• Sclerotherapy
• Radiation-induced
• Esophageal/gastric malignancies
• Surgical anastomotic
• Congenital
• Systemic inflammatory disease
• Epidermolysis bullosa

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• Extrinsic strictures
• Pulmonary/mediastinai malignancies
• Anomalous vessels and aneurysms
• Metastatic submucosal infiltration (breast
  cancer, mesothelioma, adenoeareinoma of gastric
  eardia)

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• Intrinsic strictures are most common, with acid/
  peptic cause accounting for the majority of cases
  (60-70)

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Strictures / Caustic Ingestion
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Treatment

• esophageal dilation.
• There are several different types of dilators,
  including
• (1) mercury-filled, rubber Maloney dilators
  (2) wire-guided rigid Savary-Gilliard dilators
  (3) balloon dilators that can either be
  through-the-scope (TT8) or wire guided

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• Maloney bougies are used in uncomplicated, short,
  straight strictures
• The wire-guided Savary-Gilliard and TTS balloons
  are both best suited for long, tight, or tortuous
  strictures.

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• Complications of esophageal dilation
• perforation (0.5)
• bleeding (0.3)
• bacteremia (20-50 )
• Those with radiation-induced or malignant
  strictures are at higher risk of perforation.
• To minimize the risk of perforation, the "rule
  of. threes" applies.

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• That is, no more than three sequential dilators
  should be performed per session.
• The goal of esophageal dilation is to obtain an
  objective diameter of greater than 15 mm
• Approximately 90 of patients dilated to 15 mm
  have no recurrence at 24 months

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• Refractory esophageal strictures are defined by
  lack of response to two or more dilations.
• The causes, for refractory strictures can include
  
• ongoing insults from pills or nonsteroida
  antiinfkunmatory drugs(NSAlDs)
• uncontrolled acid reflux
• inadequate lumen diameter with dilations

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• PPIs are superior to H-2 blockers in preventing
  the recurrence of acid-related strictures
• The treatment of refractory strictures includes
  the elimination of the offending agents (pills
  and acid) and gentle dilation to 15 mm.

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• Intralesional steroids injected before dilation
  are safe and probably effective for refractory
  strictures
• Surgery may be considered in those who fail to
  respond to aggressive medical therapy and
  dilation.

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4.Rings/Webs
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Rings/Webs

• common findings on upper endoscopy,
• many are asymptomatic
• Symptoms can include intermittent solid
• food dysphagia, aspiration, and regurgitation.

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• Rings are circumferential, can consist of mucosa
  or muscle, and most commonly occur in the distal
  esophagus
• Esophageal webs occupy only part of the
  esophageal lumen, are always mucosal, and are
  usually located in the proximal esophagus.

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• Esophageal webs can be found as 5 of
  asymptomatic individuals
• When symptomatic, usually dysphagia
• iron deficiency was noted by gas-troenterologists
  
• Plummer and Vinson in the United States, as well
  as otolaryngologists Paterson and Kelly in the
  United Kingdom.

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• Plummer-Vinson or Paterson-Kclly syndrome to the
  triad of proximal esophageal webs, iron
  deficiency anemia, and dysphagia
• Barium radiography is the most sensitive test to
  diagnose esophageal webs

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• endoscopic visualization, web will appear as a
  thin, eccentric lesion with normal-appuaring
  mucosa
• Some webs are located so proximally that routine
  passage of the endoscope through the UES with
  fracture the web

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• Treatment of symptomatic esophageal webs consists
  of mechanical disruption
• This can be accomplished with bougie or balloon
  dilators.

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• Schatzki's ring (B ring) occurs at the GEJ at the
  distal margin of the LES
• most common cause of intermittent solid food
  dysphagia and food impaction
• The presence of symptoms depends on the luminal
  diameter

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• If the ring diameter is less than 13 mm,
  the patient will have symptoms
• If greater than 20 mm the patient will almost
  never have symptoms
• Between 13 and 20 mm, which accounts for the
  majority of Sehatzki's rings, symptoms are
  variable
• The pathogenesis of esophageal rings is
  controversial

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• Recurrent symptoms requiring repeat dilation is
  not uncommon, and some authors recommend
  maintaining the patient on acid suppression given
  the possible association with GERD

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• The second type of esophageal ring is the A
  ring",
• which is a muscular ring most commonly detected
  on barium swallow
• This lower esophageal muscular ring
• rarely symptomatic and occurs at the proximal
  margin of the LES approximately 2 cm proximal to
  SGM.

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• "Ringed" esophagus is a rare condition that
  occurs in young men
• The syndrome consists of endoscopie findings of
  multiple esophageal rings in patients with
  dysphagia
• The cause is unclear
• GERD. congenital abnormality, and possible
  allergic conditions have been implicated

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Esophageal Webs and Rings
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Treatment

• Treatment consists of dilation with bougienage
  and possibly acid suppression
• Many of these patients require more than one
  treatment session to obtain a desired esophageal
  lumen of 15 mm
• They are also at higher risk of painful deep
  mucosal tears

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5. Gastroesophageal Reflux Disease
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Gastroesophageal Reflux Disease

• chronic symptoms or mucosal damage caused by the
  abnormal reflux of gastric contents into the
  esophagus.
• Reflux esophagitis refers to a subgroup of GERD
  that involves histopathologically characteristic
  changes in the esophageal mucosa

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• Nonerosive reflux disease (NERD) refers to
  endoseopy-negative patients with typical GERD
  symptoms
• NERD accounts for approximately 50 of patients
• Reflux esophagitis for 30 to 40
• Barrett's esophagus in the remaining 10 to 20

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Barretts esophagus
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Barretts esophagus with ulceration
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Barretts esophagus
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Pathophysiology

• Transient relaxation of the GE sphincter
• Esophageal motility disorders
• Delayed gastric emptying
• Hiatal hernia
• Acidic gastric contents
• Bile acids (more severe eophagitis )

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• normal antireflux barrier between the stomach and
  the esophagus is impaired transient /
  permanently
• defects in the esophagogastric barrier such as
  LES incompetence, TLESR, and hiatal hernia in
  the development of GERD

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• TLESRs are short relaxations of the LES that do
  not occur in response to swallow
• TLESRs are the primary mechanism for
  gastroesophageal reflux in healthy persons and in
  those with mild GERD

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• severe GERD and related complications have a
  permanent structural alteration
• low LES pressure
• a large hiatal hernia

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• Symptoms develop when the offensive factors in
  the gastroduodenal contents overcome several
  lines of esophageal defense
• As more components of esophageal defense break
  down, the severity of reflux increases

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• Classic symptoms of GERD are heartburn
• defined as a retrosternal burning discomfort, and
  acid regurgitation
• Symptoms often occur after meals

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• Other in typical reflux are dysphagia,
  odynophagia, and belching
• Atypical GERD symptoms include asthma, chest
  pain, cough, laryngitis, and dental erosions.

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• There is no diagnostic gold .standard for
  detecting GERD
• Classic symptoms of acid regurgitation and
  heartburn are specific but not sensitive for the
  diagnosis of GERD
• as determined by abnormal 24-hour pH monitoring.

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• initial empiric trial of antisecretory therapy in
  a patient with classic GERD symptoms
• Further diagnostic should be done
• if there is a failure to respond to an empiric
  course
• if alarm signs such as dysphagia, odynophagia,
  weight loss, chest pain, or choking are present.

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Atypical symptoms

• Atypical chest pain
• Hoarseness
• Nausea
• Cough
• Odynophagia
• Asthma

• Globus sensation
• Onset after age 45
• Recurrent laryngitis
• Recurrent sore throat
• Subglottic stenosis
• Dental enamel loss

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• Endoscopy is the technique of choice to evaluate
  GERD
• Reflux esophagitis is present when erosions or
  ulcerations are present at SCM
• There are many grading systems to characterize
  the severity of esophagitis,
• the most common of which is the
• Los Angeles classification

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• The presence of esophagitis and the finding of
  Barrett's esophagus are diagnostic of GERD
• 24-hour pH monitoring has long been thought to be
  the gold standard for the diagnosis of GERD
• limitations that remain underappreciated.

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• Results are normal in 25 of patients with
  erosive esophagitis and 33 of patients with
  nonerosive reflux disease

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Radiologic Finding

• Only 1/3 of patients have radiologic findings
• Erosions
• Ulcerations
• Strictures
• Hiatal hernia
• Thickening of mucosal folds
• Not the test of choice for diagnosis

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Esophagogram
Extensive linear superficial ulcerations and
erosions involving the distal 1/3 of the
esophagus.
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Endoscopy

• Useful for diagnosing complications of GERD
• Barretts
• Esophagitis
• Strictures
• Not sensitive for GERD itself
• Only 50 of patients manifest evidence on
  endoscopy

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Gastroesophageal Reflux Disease
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Esophagoscopy
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Ambulatory pH Mornitoring

• Diagnostic gold standard
• pH monitor placed in esophagus above sphincter
• Patient symptom log
• Correlate symptoms with low pH

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TREATMENT

• Lifestyle modifications
• Antacids
• Histamine H2 receptor antagonists
• Prokinetic Agents
• Proton Pump inhibitors
• Anti-reflux surgery
• Newer endoscopic treatments

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LIFESTYLE MODIFICATION

• Head of bed elevated six inches
• Decreased fat intake
• Smoking cessation
• Weight loss
• Avoidance of recumbency for 3 hours
  post-prandially
• Avoidance of large meals and trigger foods
• Avoidance of exacerbating medications

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• The goals of treatment in GERD are to
• relieve symptoms
• heal esophagitis
• prevent recurrence of symtoms
• prevent complications
• A variety of lifestyle modifications are
  recommended in the treatment off GERD.

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• These include
• avoidance of precipitating foods(fatty foods,
  alcohol, caffeine)
• avoidance of recumbency for 3 hours
  postprandially
• elevation of the head of the bed
• smoking cessation
• weight loss

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• Histamine receptor antagonists (H2RAs) in
  standard doses achieve complete symptom
  relief in 60 of patients and heal esophagitis
  in bout 50

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• PPIs are superior to H2RAs in both healing rosive
  esophagitis and symptoms relief, with healing 90
• GERD is a chronic relapsing disease with almost
  universal recurence of symptoms after treatment
  withdrawal
• requires maintenance therapy in many patients

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• longterm therapy with PPIs is again
  superior to H2RAs, with remission maintained in
  80 and 50 of patients, respectively

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• "step-down" therapy is recommended
• Antireflux surgery, now laparoscopie approach,
  remains an option for carefully selected patients
  with well documented GERD

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Surgical Treatment

• Nissen fundoplication
• Total or partial
• Their aim is to
• Restore normal anatomy (intra-abdominal segment
  of esophagus)
• Re-creating an appropriate high-pressure sound at
  the esophagogastric junction
• Maintaining this repair in the normal anatomic
  position

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6.Extraesophageal GERD
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Extraesophageal GERD

• Patients with GERD may present with symptoms
  other heartburn and regurgitation
• This includes asthma, chest pain, chronic cough,
  laryngitis, and dental erosions

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• lack of the classic heartburn and regurgitation
  symptoms
• Esophagitis/Barrett's esophagus is usually not
  present
• an empiric trial of bid PPIs is indicated as
  initial treatment because there is no definitive
  diagnostic gold standard for GERD.

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• If treatment fails
• full investigation
• ambulatory pH testing
• Confirm diagnosis of GERD when
• symptoms relieve by specific antireflux therapy

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Extraesophageal GERD

• Laryngitis
• Asthma
• Chest pain
• Chronic cough
• Dental erosions

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7.Neoplasia
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Neoplasia

• uncommon
• when present is typically malignant.
• The two main culprits are
• esophageal squamous cell carcinoma
• esophageal adenocarcinoma.

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Benign Esophageal Tumors and Cysts

• Benign tumors are rare (lt 1 )
• Classified in two groups
• Mucosal
• Extramucosal (intramural)

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• More useful classification
• 60 of benign neoplasms are leiomyomas
• 20 are cysts
• 5 are polyps
• Others (lt 2 percent)

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Leiomyomas

• Most common benign tumor of the esophagus
• Intramural
• Occur between 20-50 years of age with no gender
  preponderance

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• 80 occur in the middle and lower third of the
  esophagus, rare in the cervical region
• Obstruction and regurgitation may occur in large
  lesions
• Bleeding is a more common symptom of the
  malignant form of the tumor leiomyosarcoma

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Cancer
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Malignant Tumors of the Esophagus

• Usually are in advanced stages at the time of
  diagnosis (involving the muscular wall and
  extending into adjacent tissues)
• Alcohol consumption and cigarette smoking seem to
  be the most consistent risk factors

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• Esophageal squamous cell carcinoma
• Esophageal squamous cell carcinoma (95 of all
  esophageal cancers) is a disease of men (5 1)
• most often in the upper and midthoracic segments
• least frequently in the cervical esophagus

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• Adenocarcinoma
• approximate 8 of primary esophageal cancers
• Most often occur in the distal third of the
  esophagus in the 6th decade of life.
• Male to female ratio is 31
• Patients with Barretts metaplasia are 40 times
  more likely to develop adenocarcinoma

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Clinical Presentation

• Dysphagia is the presenting complaint in 80-90
  of patients with esophageal carcinoma
• Early symptoms are sometimes nonspecific
  retrosternal discomfort or indigestion

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• As the tumor enlarges, dysphagia becomes more
  progressive.
• Later symptoms include weight loss, odynophagia,
  chest pain and hematemesis

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Diagnosis

• Barium swallow
• Esophagoscopy
• Esophageal biopsy
• Brushings for cytologic evaluation

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Barium
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Barium
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Cancer apple core appearance
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Current AJCC 2002 staging
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Treatment

• Surgical resection is the standard treatment for
  early esophageal cancer in Stages I, II and most
  cases of III

164

• During the past decade, outcomes with surgery
  have improved resulting in a better 5 year
  survival due to
• Better staging techniques
• Increased rate of curative resection
• A decreased rate of postoperative death
• Palliative endoscopic measures

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• Palliative endoscopic measures include
• repeated dilation,
• laser/photo dynamic therapy ablation
• esophageal stent placement
• percutaneous gastrostomy tube placement

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Neoadjuvant /adjuvant therapy

• Neo-adjuvant Chemotherapy
• Neo-adjuvant Radiation
• Neo-adjuvant Chemo-Radiation
• Adjuvant Chemotherapy
• Adjuvant Radiation
• Adjuvant chemoradiation

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• 8.Esophageal Diverticula

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Esophageal Diverticula

• is a sac that protrudes from the esophageal wall
• As in the rest of the Gl tract
• a true diverticulum is one that contains all
  layers of the wall.

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• Esophageal diverticula are most practically
  classified, based on anatomy, into four
  categories
• Zenker's diverticula
• midesophageal diverticula
• epiphrenic diverticula
• intramural pseudodiverticulosis.

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• Zenker's divertieulum referred to as an
  esophageal diverticulum
• its location is proximal to the esophagus, above
  the UES, and it should be considered a
  hypopharyngeal diverticulum.

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• believed to form as a result of an area of
  weakness
• Killian's triangle, which exists between the
  cricopharyngeal sphincter and the inferior
  pharyngeal constrictor muscle

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Zenkers diverticulum

• Occurs in Killians area.
• Associated with failure of cricopharyngeal
  dilatation.
• Symptoms regurgitation, dysphagia, weight loss.

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• Symptoms include
• oropharyngeal dysphagia
• regurgitation
• halitosis
• cough
• aspiration pneumonia

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• Barium swallow is an excellent test
• Many small diverticula are asymptomatic
• patients with large diverticula should be offered
  treatment

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• The classic treatment
• open surgical resection of the diverticulum with
  division of the cricopharyngcus muscles
• Another option for extremely large diverticula
• diverticulopexy
• suspension of the diverticulum in a cranial
  direction.

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• Midesophageal diverticula are most commonly
  asymptomatic, occur in the midesophagus
• Traction diverticuli form as a result of external
  pulling of the esophageal wall
• from neighboring inflammatory or
• fibrotic tissue, such as adjacent tuberculous
  mediastinitis

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• Traction diverticuli are located in the middle
  third of the esophagus.
• Midesophageal traction diverticula are the only
  true diverticula in the esophagus

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• Epiphrenic diverticula, located near the
  diaphragmatic hiatus, occur in the distal
  esophagus near the LES
• These diverticula are often the result of a
  motility disorder such as achalasia or DES

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• manometric studies in patients with epiphrenic
  diverticulum to rule out an associated motility
  disorder
• Most diverticula are asymptomatic, but
  occasionally chest pain or regurgitation can be
  prominent symptoms

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Midesophageal Diverticula
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Epiphrenic Diverticula
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Treatment

• Treatment consists of
• managing the underlying motility disorder
• diverticulotomy with/without myotomy for
  symptomatic diverticula

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9.Foreign Bodies
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Foreign Bodies
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Foreign Bodies

• The esophagus is one of the locations where
  intervention is often required
• Underlying alterations in the lumen of the
  esophagus play an important role in the risk of a
  swallowed object becoming lodged

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• The esophagus has several areas of physiologic
  narrowing
• the upper esophageal sphincter
• the level of the aortic arch
• the diaphragmatic hiatus/LES where a foreign body
  can become impacted.

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• The key to the management of foreign bodies is
  understanding that different foreign bodies
  require different interventions
• It is important to distinguish a true foreign
  body from a food impaction.

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• A trial of pharmacologic therapy with .1 to 2 mg
  of glucagon given intravenously, which relaxes
  the LES, can be given but is rarely successful in
  relieving a food' impaction.

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10.Pill-Induced Injury
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Pill-Induced Injury

• Pill-induced injury to the esophagus is an
  underappreciated entity.
• over 70 drugs are capable of producing injury to
  the esophagus
• Drugs commonly associated with pill-induced
  injury include potassium chloride tablets,
  doxycycline, quuudine, NSAIDs. iron, and
  alendronate

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• Pills can damage the esophagus by various
  mechanisms such as acidity, size, and contact
  time with esophageal mucosa
• There is a wide spectrum of injury
• from acute self-limited esophagitis to
  refractory strictures

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• The typical sites of pill-induced injury are at
  the level of the aortic arch and the distal
  esophagus, where there is anatomic narrowing.

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11.Infectious Esophagitis
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Infectious Esophagitis

• Infectious esophagitis is common, especially in
  immunosuppressed hosts such as patients with
  human immunodeficiency virus (HIV), transplant
  patients, and chemotherapy patients.

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• The cardinal symptom of infectious esophagitis is
  
• odynophagia
• pain
• swallowing
• immunodeficient patients can present with a
  variety of symptoms including heartburn, nausea,
  fever, or bleeding.

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• The three most common causes of infectious
  esophagitis are
• Candida albicans
• cytomegalo virus (CMV)
• herpes simplex virus (HSV)

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• Treatment consists of antifungal therapy, most
  commonly with fluconazole100 to 200 mg/day for10
  to 14 days
• In patients with only mild immunologic
  deficiencies, the topical antifungal agents
  clotrimazole and nystatm are reasonable
  alternatives

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12.Caustic Injury
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Caustic Injury

• Caustic ingestion can result in severe injury to
  the esophagus and stomach.
• Most ingestions occur accidentally in the
  pediatric population and the remainder in
  suicidal, psychotic, and alcoholic adults

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Caustic Ingestion

• Esophagus, pharynx, larynx
• Bases ( most severe injuries )
• Drain cleaners
• Electric dishwasher soap
• Hair relaxant
• Acids
• Bleaches

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Mechanism of injury

• Alkalis pH gt 7
• Liquefaction necrosis
• Acids pH lt 7
• Coagulation necrosis
• Bleaches pH 7
• Irritants

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Severity of burn

• Type
• Amount
• Concentration
• Time of contact
• Stricture formation

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Signs and symptoms

• Pharyngeal or laryngeal
• Odynophagia
• Mucosal erythema, ulceration
• Drooling
• Tongue edema
• Stridor
• Hoarseness

• Esophageal
• Dysphagia
• Odynophagia
• Chest or back pain
• Gastric
• Epigastric pain or tenderness
• Vomiting
• Hematemesis

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Radiography

• Radiologic exam
• Chest neck radiographs
• Barium swallow
• Will not reveal 1st and 2nd degree injuries

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Esophagoscopy

• Esophagoscopy in virtually all patients at 24-48
  hours post-ingestion
• lt 24 hours underestimation of injury
• gt 48-72 hours with risk of iatrogenic perforation
  barium swallow
• Rigid vs. flexible debatable
• Endoscopy to upper limit of severe burn

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Management

• 1. Stable airway
• dexamethasone (adult 20 to 30 mg intravenous
  bolus, pediatric 0.5 to 1 mg/kg) can help prevent
  further deterioration

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• 2. Acute airway obstruction
• Blind nasotracheal intubation should be avoided
• If direct visualization of the larynx for
  intubation is not possible because of edema and
  exudate, emergent cricothyrotomy or tracheotomy
  is a safer choice

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Therapy

• Choice of therapy depends on the degree of
  injury.
• 1. First-degree burns of the esophageal mucosa
  require no further therapy

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• 2. Second- and localized third-degree injuries
  without transmural necrosis
• pharmacologic reduction or prevention of
  stricture formation and to maintain a conduit
  from the hypopharynx to the stomach by esophageal
  dilation, stenting, or reconstruction

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• 3. Fourth-degree and even selected extensive
  third-degree esophageal burns
• thoracotomy for direct examination of the
  esophageal wall ?esophagectomy

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Thank You