Esophageal Disorders By George Vagujhelyi MD Cardinal symptoms - - PowerPoint PPT Presentation

Esophageal Disorders

By George Vagujhelyi MD

Cardinal symptoms

• Heartburn
• Bland or sour regurgitation
• Chest Pain
• Dysphagia
• Odynophagia

Atypical Symptoms

• Dyspepsia(epigastric burning and fullness)
• Nausea and Vomiting
• Hematemesis
• Globus
• Coughing
• Throat clearing
• Throat pain
• Hoarseness
• Wheezing/stridor
• Dyspnea
• Apnea
• Halitosis

Esophageal disorders

• Gastroesophageal Reflux Disease
• Barrett’s Esophagus
• Eosinophilic Esophagitis
• Intrinsic Structural disorders
• Systemic Disorders
• Iatrogenic

Gastroesophageal Reflux

• Most common esophageal disorder
• This is where gastric contents refluxes into the esophagus
• TLESR( transient lower esophageal sphincter relaxation)
• <1 min inhibition of the tone LES
• Decrease contraction of circular muscle of esophagus
• Cessation of diaphragmatic
• Contraction of the longitudinal esophageal muscle.
• Requires an intact vagal nerve
• Triggered by abd distension, awake and in postprandial state
• All this is a normal physiological response to venting

GERD

• People with GERD develop more acid reflux during TRLES

and extended further proximally

• Compounding factors:
• Obesity
• Conditions that increase pressure difference between the abd and thoracic cavity
• Delayed emptying
• Delay in clearance of acid contents ( salivary production, peristalsis)

GERD

• Most commonly diagnosed GI disorder
• 9 million o/p visits annually
• Occurs in all ages
• 40 % of adults have an event monthly
• 18% report weekly
• Actual organ damage in fewer then 50% of patients who present with

symptoms

• Of those who have EGD 10 % have esophagitis,3-4% Barrett’s, Adeno CA

GERD risk factors

• Obesity
• Hiatal hernia
• Smoking
• NSAIDS
• Aging
• IBS
• Anxiety/depression
• FHx
• HP and Chronic atrophic gastritis (inverse association)

GERD complications

• Esophagitis and ulceration
• Strictures
• Peptic
• Distal location near GEJ
• Erosions, ulcerations and Barrett’s
• Higher
• Pill
• Neoplasia
• EoE

GERD complications

• Barrett’s Esophagus
• demonstrates salmon-colored mucosa and the biopsy shows intestinal metaplasia

with goblet cells.

• Prevalence is about 1-2 %
• Half don’t report typical GERD symptoms
• Risk factors
• Erosive esophagitis
• Male
• White
• Heavy ETOH
• Hiatal hernia
• Low LES
• Dysfunctional peristalsis

Extra esophageal manifestation of GERD

• These structures are not normal exposed to acid reflux
• Thus no neutralizing mechanism
• No clearance mechanism
• Asthma
• Aspiration pneumontitis/pul fibrosis
• Laryngitis/vocal cord lesions
• Chronic cough
• Dental erosions
• Sinusitis
• Otitis media

Therapy

• Lifestyle changes
• Medical therapy
• PPI once a day prior to the first meal
• Twice a day dosage for those with erosive disease for a period of time only to be titrated

down to control symptoms

• Non erosive reflux disease
• Consider short course therapy to control symptoms
• Surgery
• Initial results are good but then symptoms of dysphagia and gas-bloat may
• ff set
• About half of the patients will require repeat surgery or medical therapy.

Eosinophilic Esophagitis

• Is an esophageal dysfunction accompanied by pathological evidence of

predominantly eosinophilic inflammation in the esophagus

• The eosinophilic infiltration is about 15/high powered field
• Prevalence <1 per 1000
• It seems to be increasing
• Diagnosis is less in the winter months
• More prevalent in Male non-Hispanic whites

20

EoE

• Clinical presentation
• Solid food dysphagia
• Most common diagnosis in young people with food impaction
• May have other atopic conditions ( eczema, allergic rhinitis,food allergy)
• Endoscopic findings
• Corrugated mucosa
• Longitudinal mucosal furrows
• Whites spots/plaques
• Focal rings and strictures
• Diffusely small-caliber esophageal lumen
• Fragile mucosa
• Try to involve an allergist

EoE

• Therapy
• Removal food impactions
• Dilation which may need to be repeated, may results in rents and
• dynophagia
• However unless there is not a dominant stricture driving the dysphagia
• Defer dilation try avoidance of the food
• Medical therapy
• PPI therapy 20-40 mg QD-BID
• Systemic steroids 2mg/kg/d 60 mg max for 4 wks course severe symptoms
• Fluticasone 880-1760 mcg/d risk of candida esophagitis
• Elemental diet great for kids, expensive poorly tolerated do to feeding tube
• Six food elimination( wheat,milk,eggs,soy,peanuts,fish,shell)
• Targeted elimination based on allergy test ( low response rate)

EoE

• Associated conditions
• GERD
• Eosinophilic gastritis
• Celiac disease
• IBD
• Drug reactions
• Hypereosinophilic syndromes
• Infections
• Autoimmune disorders

Systemic Disorders

• Diabetes
• Predispose to GERD
• Type 2 DM
• Obese
• Hyperglycemia increase TLESR response to gastric distension
• Delayed gastric emptying
• Less sensitive to abnormal amounts of reflux
• Reflux esophagitis common finding in DKA
• Candida esophagitis

Systemic disorders

• Connective tissue disorders
• Systemic sclerosis
• Mixed connective tissue
• Reduced LES
• Atrophic smooth muscle
• Delayed gastric emptying
• Sjogrens syndrome
• Reduced saliva
• Risk for iatrogenic causes secondary to immunosuppression, pill injury

and bisphosphonates

Dermatological disorders

• There is squamous epithelial tissue in the esophagus thus

several systemic disease that affect the skin can manifest in the esophagus as well

• Epidermolysis bullosa
• Bullous phemphigoid
• Pemphigus vulgaris
• Steven-Johnson
• Lichen planus

iatrogenic

• Pill induced
• ASA,NSAIDS
• Bisphosphonates
• KCL
• Doxycycline/tetracycline
• Ascorbic acid
• Ferrous sulfate
• They cause symptoms of worsening heartburn, chest pain , dysphagia and/or odynophagia
• Medications
• Inhibit smooth muscle tone and contractility
• Calcium channel blocker
• Theophylline
• Beta-agonist
• Anticholinergic properties
• radiation

Diagnosis

• For patients with classical symptoms
• Heartburn( substernal postprandial burning with upward radiation)
• High likelihood they have GERD
• Trail of PPI therapy good response no further testing
• Odynophagia, dysphagia
• Need EGD
• Alarming symptoms
• Wt loss
• FFt
• Vomiting
• Hematemesis

Therapy failures

• Non compliance
• Improper timing
• Inadequate dosage
• Rapid metabolizer
• Nocturnal acid breakthrough
• False positive GERD
• Another esophageal disorder( achalasia,EoE)
• Functional disorder
• Z-E syndrome
• EoE
• Celiac disease
• Medication induced
• Infection
• Delayed gastric emptying