Esophageal and Swallowing Disorders

Brenda Beckett, PA-C

UNE PA Program

We’ll Cover Dysphagia

– Obstructive disorders• Schatzki Ring• Esophageal Web

– Motility disorders• Achalasia• Diffuse Esophageal Spasm

GERD Diverticula Mallory Weiss Syndrome Esophageal varices Esophageal rupture

Esophagus Muscular tube about 25 cm long

extending from the hypopharynx to the stomach.

Lies posterior to the trachea and heart. Passes through the mediastinum and

the hiatus in its descent from the thoracic to the abdominal cavity.

Terminates at cardia or LES

Symptoms

Dysphagia: Difficulty swallowing Odynophagia: Pain with swallowing Heartburn (pyrosis): Substernal burning,

can radiate to neck

Diagnostic Studies

Upper endoscopy: Study of choice for many esophageal disorders. Visualization and biopsy

Barium Esophagography: Differentiate mechanical from motility

Esophageal Manometry: Pressure. pH recording: Reflux

Dysphagia

Difficulty swallowing. “Food gets stuck” Oropharyngeal dysphagia- abnl function

proximal to esophagus– Neuro or muscular etiology, ie: Parkinsons, MS,

MD, MG

Esophageal dysphagia- difficulty passing food down esophagus due to either– Mechanical obstruction– Motility disorder

Obstructive Disorders

Dysphagia to solids– Bread and meat especially

Lower Esophageal Ring Esophageal Web Neoplasms (covered in separate

lecture)

Lower Esophageal Ring Schatzki’s Ring 2-4 mm mucosal stricture, usually

congenital Causes circumferential narrowing at

squamocolumnar junction at distal esophagus

Severity of sx based on lumen size

Schatzki Ring Assoc with hiatal hernia Dx: endoscopy or barium

esophagography Tx:

– Chew thoroughly– Endoscopic dilation

Esophageal Web Thin mucosal membrane across lumen

of upper esophagus Dysphagia to solids Seen with severe iron deficiency

anemia (as part of Plummer-Vinson) Dx and tx by endoscopy, also will

resolve with tx of Fe-deficiency anemia

Achalasia Neurogenic esophageal motility disorder

characterized by:

-impaired esophageal peristalsis

-lack of lower esophageal sphincter relaxation during swallowing

-elevation of lower esophageal sphincter resting pressure

Achalasia

Onset age 20-40 Progressive dysphagia

– Both liquids and solids Nocturnal regurgitation of undigested

foods in 1/3 of patients

Etiology ? Perhaps viral? Can be secondary to mechanical

obstruction or paraneoplastic process Loss of ganglion cells in mesenteric

plexus of esophagus Leads to denervation of esophageal

musculature

Achalasia Dx Barium studies:

– Absence of progressive peristaltic contractions during swallowing

– Significant esoph dilation– Narrowed “birds beak” distal esoph (at LES)

Manometry: – Lack of peristalsis, lack of relaxation of LES

Achalasia

Complications

Nocturnal regurgitation Cough Aspiration

– pnemonitis

Achalasia Treatment There is no treatment to restore

peristalsis Goal: decrease LES pressure

– Balloon dilation of LES, may repeat– Drugs: Nitrates, CCB, Botox

Surgery: Heller myotomy

Diffuse Esophageal Spasm

Non-productive esophageal contractions

Hyperdynamic contractions Increased LES pressure

Esoph Spasm Sx Substernal squeezing chest pain

– With dysphagia for liquids and solids May occur with exertion May occur with esoph temp extremes Sound familiar?? Can be

indistinguishable from angina pectoris or myocardial infarction

Dysphagia uncommon sx

Esoph Spasm Dx Rule out coronary ischemia Barium swallow:

– Poor progression of bolus– Disordered, simultaneous contractions

Esophageal manometry– Simultaneous, prolonged, high amplitude

contractions– “Nutcracker esophagus” – pressure so high

it can crack a nut

Treatment

CCBs Botox Nitrates Others

Esophageal Diverticula Outpouching of mucosa through the

muscular layer of the esophagus Asymptomatic or dysphagia and

regurgitation

Zenker’s diverticulum Posterior outpouchings of mucosa and

submucosa through the crico-pharyngeal muscle

Likely results from an incoordination between pharyngeal propulsion and cricopharyngeal relaxation

SX: Regurg, choking, protrusion in neck TRT: surgery, stapling

Zenker’s Diverticulum

GERD Gastroesophageal reflux disease

– Reflux of stomach contents causing symptoms Incompetent LES from:

– General loss of intrinsic sphincter tone– Recurrent inappropriate relaxations triggered

by gastric stretch Allows reflux of gastric contents into

esophagus Frequent in infants (also GER)

Factors contributing to LES Competence Angle of cardioesophageal junction Action of diaphragm Gravity

GERD & Hiatal Hernia Hiatal hernia occurs when the LES,

upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus).

The diaphragmatic hiatusacts as an additional sphincter around the lowerend of the esophagus

Factors Contributing to Reflux

Weight gain Fatty foods Caffeine Carbonated beverages EtoH Tobacco Increased intrabdominal pressure Drugs: anticholinergics, antihistamines,

TCAs, CCBs, nitrates, progesterone

Symptoms Heartburn

– Substernal burning– Regurgitation (I think I just threw up in my

mouth…) Hypersalivation (from smoking as well) Belching, nausea Dysphagia, odynophagia *Cough, wheezing, hoarseness, asthma

Complications

Esophagitis Peptic esophageal ulcer Esophageal stricture Barrett’s esophagus

GERD Dx

Detailed history Typical symptoms get trial treatment Work-up reserved for:

– Longstanding sx – Symptoms of complications– Pts who fail empiric tx

Endoscopy with biopsy

GERD Tx HOB 6 inches (not just pillows) NO:

– Eating within 3 hours of bedtime, large meals– Acidic foods(coffee, citrus, tomatoes, etc)– Drugs (see list of contributors to sx)– Smoking (hyposalivation)– Foods that weaken LES (fatty foods, alcohol,

chocolate, peppermint) Meds: PPI x 8-12 weeks (better than H2

blockers, antacids or pro-motility meds) Weight loss Surgical: Fundoplication

Nissen Fundoplication

Esophagitis

GERD (Most common) Pill esophagitis

– Direct erosive effects Radiation esophagitis Infectious esophagitis

– Usually in immunocompromised pts– Candida, CMV, HSV

Esophagitis

Symptoms– Odynophagia. Pain on swallowing– Dysphagia– Chest pain: substernal– Signs of infection

Barrett’s Esophagitis

Normal stratified squamous epithelium of distal esophagus replaced by:– Metaplastic, columnar, glandular intestine-

like mucosa Can give rise to adenocarcinoma Warrants frequent surveillance by

endoscopy

Esophageal varices

Usually caused by portal hypertension secondary to cirrhosis

Can cause painless, sometimes massive upper GI bleed

Bright red hematemesis– NOT coffee-ground emesis

First, stabilize the pt: fluid resuscitation, blood transfusion, etc

Then endoscopic/surgical repair

Mallory-Weiss Syndrome Non-penetrating mucosal laceration of

distal esoph/proximal stomach Caused by vomiting, retching,

hiccupping Often seen in alcoholics, but

any forceful vomiting will do Can cause significant bleeds

– Most stop spontaneously– 10% require transfusion– May need cauterization

Esophageal Rupture

Iatrogenic– ie: during endoscopy

Spontaneous– Boerhaave Syndrome (usu vomiting, so not

truly spontaneous, but differentiates from iatro)

Esoph Rupture

MC site distal esophagus, L side Acid and stomach contents cause

fulminant medistinitis, pneumomediastinum, shock.

Bad.

Esoph rupture S/S

Sx: chest, abd, thoracic pain, hematemesis, shock

Did I say BAD? Subcutaneous emphysema palpable in

30% Hamman’s sign- mediastinal crunch

– Crackling synchronous with heartbeat.– Cool

Rupture Dx & Tx Imaging

– Mediastinal air & widening, pleural effusion Confirm with esophagography with

water soluble contrast dye Broad spectrum abx, fluid resuscitation,

surgical repair.

High mortality