diseases of the esophagus

DISEASES OF THE DISEASES OF THE ESOPHAGUSESOPHAGUS

DISEASES OF THE DISEASES OF THE ESOPHAGUSESOPHAGUS

Prof. Ferenc Szalay MD, PhD

Budapest, 03.02.2003 lecture for students

1st Department of Medicine of Semmelweis University 1st Department of Medicine of Semmelweis University Budapest, HungaryBudapest, Hungary

1st Department of Medicine of Semmelweis University 1st Department of Medicine of Semmelweis University Budapest, HungaryBudapest, Hungary

Diseases of the esophagusDiseases of the esophagusDiseases of the esophagusDiseases of the esophagusGERDGERDMotility disordersMotility disordersEsophagitisEsophagitis (infection, chemicals, pills)(infection, chemicals, pills)Neurological disordersNeurological disordersSkeletal muscle disordersSkeletal muscle disordersVaricesVarices Mallory-Weiss sy.Mallory-Weiss sy.BaBarrrreetttt’s’sTumorsTumors

GERDGERDMotility disordersMotility disordersEsophagitisEsophagitis (infection, chemicals, pills)(infection, chemicals, pills)Neurological disordersNeurological disordersSkeletal muscle disordersSkeletal muscle disordersVaricesVarices Mallory-Weiss sy.Mallory-Weiss sy.BaBarrrreetttt’s’sTumorsTumors

Common complainsCommon complainsWide range of symptomsWide range of symptomsCommon complainsCommon complainsWide range of symptomsWide range of symptoms

SwallowingSwallowingSwallowingSwallowingMany muscleMany muscle5 nerves : V, VII, IX, X, XII5 nerves : V, VII, IX, X, XIIStagesStages

oral oral - - voluntaryvoluntary

pharyngeal pharyngeal - - involuntaryinvoluntary

esophageal esophageal - - LES LES relaxedrelaxed1 second 5 steps1 second 5 steps

Many muscleMany muscle5 nerves : V, VII, IX, X, XII5 nerves : V, VII, IX, X, XIIStagesStages

oral oral - - voluntaryvoluntary

pharyngeal pharyngeal - - involuntaryinvoluntary

esophageal esophageal - - LES LES relaxedrelaxed1 second 5 steps1 second 5 steps

5 steps within 1 second5 steps within 1 second5 steps within 1 second5 steps within 1 second

1. Soft palate is elevated + retracted 1. Soft palate is elevated + retracted

to prevent nasopharingeal refluxto prevent nasopharingeal reflux

2. Vocal cords are closed2. Vocal cords are closed

Epiglottis swings backward Epiglottis swings backward closure the larynxclosure the larynx

3. UES relaxes3. UES relaxes

4. Larynx is pulled upward4. Larynx is pulled upward

streching, opening E and UESstreching, opening E and UES

5. Contractions of pharyngeal muscle5. Contractions of pharyngeal muscle

1. Soft palate is elevated + retracted 1. Soft palate is elevated + retracted

to prevent nasopharingeal refluxto prevent nasopharingeal reflux

2. Vocal cords are closed2. Vocal cords are closed

Epiglottis swings backward Epiglottis swings backward closure the larynxclosure the larynx

3. UES relaxes3. UES relaxes

4. Larynx is pulled upward4. Larynx is pulled upward

streching, opening E and UESstreching, opening E and UES

5. Contractions of pharyngeal muscle5. Contractions of pharyngeal muscle

Anatomy

Motility disorders of oropharynxMotility disorders of oropharynxMotility disorders of oropharynxMotility disorders of oropharynx• Dysfunction of the UES

Zenker’s diverticulum, Cricopharingeal bar

• Neurologic disorders (stroke)Cerebrovascular diseases, PoliomyelitisAmyotrophic lateral sclerosis, Multiple sclerosis, Brain stem tumor

• Skeletal musclular disordersMyastenia gravis, Metabolic myopathy (T4 toxicosis, myxedema, steroid)Muscular dystrophies

• Local structural lesionsNeoplasms, extinsic compression (Thyroid, cervical spur), Surgery

Common problem in the elderly patients and frequently associated with poor prognosis owing to a high incidence of aspiration

Zenker’s diverticulumZenker’s diverticulumZenker’s diverticulumZenker’s diverticulum

Motility disorders of the esophagusMotility disorders of the esophagusMotility disorders of the esophagusMotility disorders of the esophagus

Smooth muscle diseases (scleroderma)Smooth muscle diseases (scleroderma) Intrinsic nervous system Intrinsic nervous system

AAchalasiachalasia, Chagas disease, Chagas disease loss of ganglion cells in Auerbach plexusloss of ganglion cells in Auerbach plexus

LES LES no peristalsis no peristalsis

Diffuse esophagus spasmDiffuse esophagus spasm and its variants and its variants

Smooth muscle diseases (scleroderma)Smooth muscle diseases (scleroderma) Intrinsic nervous system Intrinsic nervous system

AAchalasiachalasia, Chagas disease, Chagas disease loss of ganglion cells in Auerbach plexusloss of ganglion cells in Auerbach plexus

LES LES no peristalsis no peristalsis

Diffuse esophagus spasmDiffuse esophagus spasm and its variants and its variants

Esophagus motility disorder: sclerodermaEsophagus motility disorder: sclerodermaEsophagus motility disorder: sclerodermaEsophagus motility disorder: scleroderma

Achalasia: Chagas’ diseaseAchalasia: Chagas’ diseaseAchalasia: Chagas’ diseaseAchalasia: Chagas’ disease

Cause:

Tripanosoma Cruzi inf.

Diffuse esophageal spasmsDiffuse esophageal spasmsDiffuse esophageal spasmsDiffuse esophageal spasms

Rings and WebsRings and WebsRings and WebsRings and Webs

Schatzki’s ringSchatzki’s ring- proximal or distal- proximal or distal- congenital or secondary to GERD- congenital or secondary to GERD

Plummer Vinson syndromePlummer Vinson syndrome- upper E web- upper E web- dysphagia- dysphagia- irondeficiency anemia- irondeficiency anemia

Symptoms if diameter < 13 mmSymptoms if diameter < 13 mm- intermittent dysphagia for solid food- intermittent dysphagia for solid food- sudden: “steak house syndrome”- sudden: “steak house syndrome”

TreatmentTreatment- mechanical dilators- mechanical dilators

Schatzki’s ringSchatzki’s ring- proximal or distal- proximal or distal- congenital or secondary to GERD- congenital or secondary to GERD

Plummer Vinson syndromePlummer Vinson syndrome- upper E web- upper E web- dysphagia- dysphagia- irondeficiency anemia- irondeficiency anemia

Symptoms if diameter < 13 mmSymptoms if diameter < 13 mm- intermittent dysphagia for solid food- intermittent dysphagia for solid food- sudden: “steak house syndrome”- sudden: “steak house syndrome”

TreatmentTreatment- mechanical dilators- mechanical dilators

Schatzki’s ringSchatzki’s ringSchatzki’s ringSchatzki’s ring

Endoscopic image of the narrow Endoscopic image of the narrow area in mid-esophagusarea in mid-esophagus

Post-mortem specimen from a similar case of esophageal Post-mortem specimen from a similar case of esophageal narrowing in a young boxer.narrowing in a young boxer.

Map of lymph nodes near the oesophagus

Radiographic evaluation in suspected esophageal cancer

Gastroesophageal junction Gastroesophageal junction type II tumorstype II tumors

Esophageal cancer

AJCC Staging of Esophagus: TNM Staging

Regional lymph nodes (N)Nx Regional lymph nodes cannot be assassedN0 No regional lymph node metastasisN1 Regional lymph node metastasis

Distant metastasis (M)Mx Distant metastasis cannot be assassedM0 No distant metastasisM1 Distant metastasis

Tumors of lower or upper esophagusM1a Metastasis in nonregional lymph nodeM1b Distant metastasis (eg: liver, bone, brain)

Tumors of middle esophagusM1a Not applicableM1b Metastasis in nonregional lymph node or distant metastasis (eg: liver, bone, brain)

AJCC Staging of Esophagus: TNM Staging

Stage Tumor Node Metastasis

Stage 0 Tis N0 M0Stage I T1 N0 M0

T2 N0 M0Stage IIA T3 N0 M0

T1 N1 M0Stage IIB T2 N1 M0

T3 N1 M0Stage III T4 Any N M0Stage IV Any T Any N M1Stage IV A Any T Any N M1aStage IV B Any T Any N M1b

Resected esophageal specimen

Other esophageal disorders

Coin in upper oesophagus

INFECTIONS OF THE OESOPHAGUSINFECTIONS OF THE OESOPHAGUSINFECTIONS OF THE OESOPHAGUSINFECTIONS OF THE OESOPHAGUS

Viral herpes, CMVFungal Candida

Most common in immuncompromized patients:AIDSImmunosuppressive treatmentImmune defectsAntibiotic os steroid treatment

Candida oesophagitisCandida oesophagitisCandida oesophagitisCandida oesophagitis

Acid-related Acid-related diseases of the diseases of the

oesophagus oesophagus GERD / GORDGERD / GORD

Talley et al., BMJ 2001; 323: 1294–7.de Caestecker, BMJ 2001; 323: 736–9.

Nathoo, Int J Clin Pract 2001; 55: 465–9.Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.

Heartburn:Heartburn: • Burning retrosternal pain radiating upward due to

exposure of the oesophagus to acid

Oesophagitis:Oesophagitis: • Endoscopically demonstrated damage to the

oesophageal mucosa

Gastro-oesophageal reflux disease (GORD):Gastro-oesophageal reflux disease (GORD):• Pathological reflux ranges from simple to erosive to

Barrett’s

Non-erosive reflux disease (NERD):Non-erosive reflux disease (NERD):• Reflux disease in which erosion does not occur

DefinitionsDefinitionsDefinitionsDefinitions

Impaired mucosal defence

de Caestecker, BMJ 2001; 323:736–9.Johanson, Am J Med 2000; 108(Suppl 4A): S99–103.

salivary HCO3

Hiatus herniaImpaired LOS (smoking, fat, alcohol)

– transient LOS relaxations

– basal toneH+

PepsinBile and

pancreatic enzymes

oesophageal clearance of acid (lying flat, alcohol, coffee)

acid output (smoking, coffee)

intragastric pressure (obesity, lying flat)

bile reflux gastric emptying (fat)

Pathophysiology of GORDPathophysiology of GORDPathophysiology of GORDPathophysiology of GORD

Diagnosis of GORDDiagnosis of GORDDiagnosis of GORDDiagnosis of GORD• History

1. Does reflux exist? 2. Is acid R responsible for symptoms? 3. Has R led to esophagus damage?

• Barium swallow• Radionuclide scintigraphy (99mTc sulfur colloid)

• E. manometry• Bernstein test• pH monitoring• Endoscopy

Bernstein testBernstein testBernstein testBernstein test

Retrosternal pain for 0.1 N HCl

One or more mucosal breaks, no longer than 5 mm, that do not extend between the tops of two mucosal folds

Grade AOne or more mucosal breaks, more than 5 mm long, that do not extend between the tops of two mucosal folds

Grade B

One or more mucosal breaks, that are continuous between the tops of two or more mucosal folds, but which involve less than 75% of the circumference

Grade COne or more mucosal breaks, that involve at least 75% ofthe oesophageal circumference

Grade D

Lundell et al., Gut 1999; 45: 172–80.

Los Angeles classification system for oesophagitis

Los Angeles classification system for oesophagitis

Savary & Miller. The Esophagus. In: Handbook & Atlas of Endoscopy. Solothurn, Switzerland: Verlag Gassman AG, 1978: 119–205.

Savary-Miller classification of oesophagitis

Savary-Miller classification of oesophagitis

Grade I One or several erosions in one mucosal fold

Grade II Several erosions in several mucosal folds,

the erosions can merge

Grade III Erosions surrounding the oesophageal circumference

Grade IV Ulcer(s), strictures, shortening of the oesophagus

Grade V Barrett’s epithelium

Grade I - V

Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.

Nathoo, Int J Clin Pract 2001; 55: 465–9.www.gastrolab.net

Savary-Miller classification

One or several erosions in one mucosal fold

Grade I oesophagitisGrade I oesophagitis

www.gastrolab.net


Several erosions in several mucosal folds, the erosions

can merge

Grade II oesophagitisGrade II oesophagitis

Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm


Erosions surrounding the oesophageal circumference

Grade III oesophagitisGrade III oesophagitis



Ulcer(s), shortening of the oesophagus

Grade IV oesophagitisGrade IV oesophagitis

Nadel, UCHC


Stricture

Grade IV oesophagitisGrade IV oesophagitis



Moderate Barrett’s oesophagus

Grade V oesophagitisGrade V oesophagitis



Moderate Barrett’s oesophagus


Chromoendoscopic picture

Barrett’s dysplasiaBarrett’s dysplasiaBarrett’s dysplasiaBarrett’s dysplasia

Columnar cells instead of squamous cells



Severe Barrett’s oesophagus


Nadel/Saint Francis Hospital. In: Gastrointestinal Pathology. Fenoglio-Preiser, New York: Raven Press, 1989: 96–100.

Adenocarcinoma of the oesophagus

Adenocarcinoma of the oesophagus

Typical symptoms(Heartburn/regurgitation)

Atypical symptomsAtypical symptoms Complications

With oesophagitis

Without oesophagitis

Chest pain(visceral

hyperalgesia)

Asthma, chronic cough,

wheezing

Hoarseness(‘reflux

laryngitis’)

Oesophageal erosions

and/or ulcers

Stricture

Barrett’s oesophagus

Oesophageal adenocarcinomaDental erosions

Nathoo, Int J Clin Pract 2001; 55: 465–9.

Range of presentations of GORDRange of presentations of GORDRange of presentations of GORDRange of presentations of GORD

Locke et al., Gastroenterology 1997; 112: 1448–56.

Pre

vale

nce

(%

)

25–34 35–44 45–54 55–64 65–74

Age (years)

40

0

Women: at least weekly episodes

Men: at least weekly episodes

Prevalence of heartburn or acid regurgitation

Prevalence of heartburn or acid regurgitation

%

Ast

hm

a p

atie

nts

exp

erie

nci

ng

GO

RD

sy

mp

tom

s (%

)

Perrin-Fayolle et al. (n=150)

O’Connell et al.(n=189)

Field et al. (n=109)

Harding & Sontag, Am J Gastroenterol 2000; 95(Suppl): S23–32.

100

80

60

40

20

0

6572

77

GORD can be a trigger for asthma

GORD can be a trigger for asthma

Wheezing or shortness of breath

Cough

Chest pain

Heartburn

Regurgitation

Nausea

Asthmatic patients with GORD (n=118)

Harding et al., Chest 1999; 115: 654–9.

Respiratory and oesophageal symptoms associated with oesophageal acid events (%)

Correlation of respiratory and oesophageal Correlation of respiratory and oesophageal symptoms with oesophageal acid eventssymptoms with oesophageal acid events

Correlation of respiratory and oesophageal Correlation of respiratory and oesophageal symptoms with oesophageal acid eventssymptoms with oesophageal acid events

65

98

60

83

87

91

0 20 40 60 80 100

Oesophageal acid-induced bronchoconstriction:

vagally mediated oesophageal bronchial reflex

heightened bronchial reactivity microaspiration

Evidence of airway inflammation: Substance P and tachykinin release

Increase: minute ventilation respiratory rate

Harding & Sontag, Am J Gastroenterol 2000; 95(Suppl): S23–32.

Mechanism of asthma symptoms on exposure to oesophageal acid

Mechanism of asthma symptoms on exposure to oesophageal acid

Asthma symptoms plus oesophageal acid

Receptors Cough centreVN Vagus nerveN Cortical input

Irwin & Madison, Am J Med 2000; 108(Suppl 4A): S126–30.

Chronic cough and GORD

Chronic cough and GORD

Kiljander et al., Chest 1999; 16: 1257–64.

Sym

pto

m

sco

re

Effect of PPI on pulmonary and GI symptoms in asthma patients

Effect of PPI on pulmonary and GI symptoms in asthma patients

14

12

10

8

6

4

2

0

Pulmonary symptoms score

Gastric symptom score

Placebo

Weeks PPI

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Oesophageal stricture

Barrett’s oesophagus

Oesophageal adenocarcinoma

Anaemia

Savary-Miller Grade IV and above


Consequences of severe and Consequences of severe and prolonged GORDprolonged GORD

Consequences of severe and Consequences of severe and prolonged GORDprolonged GORD

• Oesophageal stricture

• Barrett’s OE

• OE Adenocarcinoma

• Anemia

Oesophageal cancerOesophageal spasmGORDGlobus hystericusEpiglottitisIngestion of caustic substancesPharyngitisPeritonsillar abscessForeign bodyOesophageal candidiasis

Differential diagnosis of oesophageal stricture

Differential diagnosis of oesophageal stricture

1. Jankowski et al., The Lancet 2000; 356: 2079–85.2. Gore et al., Aliment Pharmacol Ther 1993; 7: 623–8.

3. Spechler. Digestion 1992; 51(Suppl 1): 24–9.4. Peters et al., Gut 1999; 45: 489–94.

Barrett’s found at endoscopy: 0.5–2%1

Barrett’s found while investigating GORD: 10–15%2,3

Barrett’s is common in white males4

Prevalence of adult heartburn: 20–40%3

Barrett’s increases the risk of oesophageal cancer 50–100-fold4

Prevalence and risks of Barrett’s oesophagus in Europe/USA

Prevalence and risks of Barrett’s oesophagus in Europe/USA

0

500

1000

1500

2000

2500

3000

3500

4000

79 84 89 94 97

Mo

rtal

ity

Year

Office of National Statistics, 1999.

Mortality due to oesophageal adenocarcinoma in England and Wales

Mortality due to oesophageal adenocarcinoma in England and Wales

Lagergren et al., N Engl J Med 1999; 340: 825–31.

Od

ds

rat

io

20

0None 1 2–3 >3 0 <12 12–20 >20

Frequency

Chronicity

1

5.1

6.3

16.7

1

5.2

16.4

7.5

Heartburn episodes/week Duration of symptoms (years)

Frequency and duration of symptoms

Heartburn as a risk factor for oesophageal adenocarcinomaHeartburn as a risk factor for oesophageal adenocarcinoma

Management of upper GI symptoms Management of upper GI symptoms in primary carein primary care

Management of upper GI symptoms Management of upper GI symptoms in primary carein primary care

Appropriate treatment

Age >45

Test-and-treat for H. pylori

Treat empirically

Clinical history

Heartburn (GORD)

Manage with antisecretory

agents

Upper abdominal pain/dyspepsia

Early endoscopy

Alarm features

Odynophagia

Dysphagia

Vomiting

Bleeding

Weight loss

Alarm Alarm featuresfeatures


Alarm features for GORDAlarm features for GORDAlarm features for GORDAlarm features for GORD

Careful analysis of symptoms and history is key to diagnosis

Diagnosis based on symptoms can be aided by a trial of treatment

Clear endoscopic abnormalities are found in <50% of patients

Treatment should start with a proton pump inhibitor (PPI)

Most patients will require long-term treatment; anti-reflux surgery may be as effective as PPIs, but is less predictable

Summary of conclusions from a multidisciplinary workshop held in Genval, Belgium in 1999.Dent et al., BMJ 2001; 322: 344–7.

European practice guidelines: European practice guidelines: GORDGORD

European practice guidelines: European practice guidelines: GORDGORD

Alarm symptoms (e.g. dysphagia, weight loss, bleeding, abdominal mass)

Diagnostic problems (e.g. atypical symptoms)

Heartburn for 5 years or longer

Failure to respond to initial treatment

Pre-operative assessment

Dent et al., BMJ 2001; 322: 344–7.

When should endoscopy be considered in patients with GORD?

When should endoscopy be considered in patients with GORD?

Hiatus hernia

Oesophageal stricture

Oesophageal cancer

Chest pain of cardiac origin

Functional dyspepsia


Differential diagnosis of GORDDifferential diagnosis of GORDDifferential diagnosis of GORDDifferential diagnosis of GORD

Treatment options in GORDTreatment options in GORD• Simple (lifestyle) measures• Medical treatment

antacidsacid secretion suppressors -

PPI, H2RAs, H.p. erad. prokinetics

• Surgery (laparascopic)

Reduce weight

Stop smoking

Avoid reflux-promoting agents (e.g. alcohol, coffee, some foods) (not evidence based)

Elevate headof bed

Consider alternatives to

reflux-promoting drugs (e.g. theophylline, anticholinergics)

ModificationsModifications

Eat small meals,no late meals, reduce

fat

Lifestyle modificationsLifestyle modifications for the management of GORDfor the management of GORD

Lifestyle modificationsLifestyle modifications for the management of GORDfor the management of GORD

Increase the pH of gastric refluxate Reduce the erosive effect and hence reduce symptoms

Suitable for quick relief of mild symptoms

Most antacids are not suitable therapies for established GORD or oesophagitis

Less effective than H2RAs or PPIs for treatment of GORD

Adverse effects include: Accumulation in patients with renal impairment Milk-alkali syndrome with high doses Constipation Diarrhoea

Sonnenberg A, Pharmacoeconomics 2000; 17: 391–401.de Caestecker, BMJ 2001; 323: 736–9.

Hatlebakk & Berstad, Clin Pharmacokinet 1996; 31: 386–406.Scott & Gelhot, Am Fam Physic 1999; 59: 1161–9.

AntacidsAntacids

AntacidsAntacids

Inhibit histamine stimulation of gastric parietal cell, resulting in reduced gastric acid secretion

Slower onset but longer duration of action than antacids

Cimetidine is associated with more drug interactions than other H2RAs, such as ranitidine

H2RAs are generally not as effective as PPIs for symptom relief or healing

de Caestecker, BMJ 2001; 323: 736–9.Sonnenberg, Pharmacoeconomics 2000; 17: 391–401.

H2-receptor antagonists (H2RAs)H2-receptor antagonists (H2RAs)HH22-receptor antagonists (H-receptor antagonists (H22RAs)RAs)

Omeprazole

Lansoprazole

Pantoprazole

Rabeprazole

Esomeprazole

But are they all the same?

Available PPIs in Europe in 2002Available PPIs in Europe in 2002

Available Available PPIsPPIs in Europe in 2002 in Europe in 2002

Bio

avai

lab

ilit

y (%

)

Tolman et al, J Clin Gastroenterol 1997; 24: 65–70.Fitton & Wiseman, Drugs 1996; 51: 460–82.

Hassan-Alin et al, Gastroenterology 2000; 118: A16.Swan et al., Aliment Pharmacol Ther 1999; 13(Suppl 3): 11–7.

Howden, Clin Pharmacokinet 1991; 20: 38–49.

PPI bioavailability after the first dosePPI bioavailability after the first dose

8090

80

70

60

50

40

30

20

10

0

Lansoprazole Pantoprazole Esomeprazole Rabeprazole Omeprazole

77

64

52

40

LANSOPRAZOLE

CYP2C19

Hydroxy lansoprazole

CYP3A4

Lansoprazole sulphone

Liver Liver enzymes enzymes

unaffectedunaffected

LAN LAN

Tolman et al., J Clin Gastroenterol 1997; 24: 65–70.Welage & Berardi, J Am Pharm Assoc 2000; 40: 52–62.

Lansoprazole metabolism is unaltered with repeated dosingLansoprazole metabolism is

unaltered with repeated dosing

LAN

L = lansoprazole P = pantoprazole O = omeprazole R = rabeprazole

Healing rates for various PPIs in GORD

Healing rates for various PPIs in GORD

Thomson, Curr Gastroenterol Rep 2000; 2: 482–93.

Petite et al. L30/O20

Castell et al. L30/O20

Mee et al. L30/O20

Mulder et al. L30/O40

Mossneret al. P40/O20

Corinaldesi et al. P40/O20

Hotz et al. P40/O20

Vicari et al. P40/O20

Thjodleifsson et al. R20/O20

Dekkers et al. R20/O20

Patients healed at 8 weeks (%)

30 = 30 mg/day, 20 = 20 mg/day, 40 = 40 mg/day

0 20 40 60 80 100

Nissen’s fundoplication for GORDNissen’s fundoplication for GORDNissen’s fundoplication for GORDNissen’s fundoplication for GORD

Acid suppression therapy with PPIs1

Surveillance endoscopy with biopsies

Mucosal ablation (electrocautery, laser or photodynamic therapy) combined with high-dose acid suppression

Oesophageal resection

1. de Caestecker, BMJ 2001; 323: 736–9.

Clinical management of Barrett’s oesophagus

Clinical management of Barrett’s oesophagus

Reflux symptoms are frequent throughout lifeReflux symptoms are frequent throughout life

Incidence of oesophageal adenocarcinoma Incidence of oesophageal adenocarcinoma

is rising:is rising: Associated with increasing incidence of reflux

and decreasing incidence of H. pylori

Heartburn is a risk factor for oesophageal Heartburn is a risk factor for oesophageal adenocarcinoma:adenocarcinoma:

Frequency Duration Severity

Hennessy, Postgrad Med J 1996; 72: 458–63.Malfertheiner & Gerards, Baillière’s Clin Gastroenterol 2000; 14: 731–41.

ConclusionsConclusions

Long-term GORD can result in serious complications, which may prove fatal

Early treatment of GORD is associated with excellent outcomes

Late treatment is associated with an increased risk of complications and potentially poor outcomes

Early intervention relieves symptoms and helps prevent serious complications

Key pointsKey pointsKey pointsKey points

Mallory-Weiss syndromeMallory-Weiss syndromeMallory-Weiss syndromeMallory-Weiss syndrome

Bleeding from rupture of esophageal mucosa

Pill induced esophageal mucosal lesionPill induced esophageal mucosal lesionPill induced esophageal mucosal lesionPill induced esophageal mucosal lesion

Portal hypertension – Esophageal varicesPortal hypertension – Esophageal varicesPortal hypertension – Esophageal varicesPortal hypertension – Esophageal varices

Esophageal varicesEsophageal varicesEsophageal varicesEsophageal varices

diseases of the esophagus

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