esophageal diseases (1)

8/7/2019 Esophageal Diseases (1)

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Prof. Mutti Ullah KhanMedical Unit III

Services Hospital


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Anatomy of Esophagusy Hollow tube formed of striated muscle (upperpart) and smooth muscle (lower part).y Length about 20-30 cm in adults.y Fibers of the cricopharyngeus muscle

represent the upper esophageal sphincter(UES).y In thoracic cavity it lies in posterior

mediastinum, posterior to the trachea.y Leaves thorax through diaphragmatic hiatus

y Lower esophageal sphincter (LES) about 3-5 cmlong, ?physiological sphincter.


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Phys

iologyy UES: tonically closed, opens 0.2-0.3 sec after

a swallow.

y Peristaltic contractions, duration less than

7 sec and amplitude less than 150 mmHg,velocity less than 8 cm/sec

y LES: tonically closed at rest, pressure 20mmHg, cholinergic mediated, relaxes with

swallowing.y Transient LES relaxation, independent of

swallowing is the major cause of reflux.


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Motor disorders of the esophagusy Achalasia

y Localized esophageal spasm

y Diffuse esophageal spasmy Nutcracker esophagus

y Non-specific motor abnormalities


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Achalasia

yFailure of relaxation of the LESwith swallowing and aperistalsisin lower esophagus.

y

Due to decreased or absentintramural esophageal ganglioncells.


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Symptoms of Achalasiay Dysphagia to fluids and solids, intermittent, long -

standing.

y

Regurgitation of undigested foody Chest pain

y Aspiration

y Weight loss


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Normal esophageal manometry


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Manomet

ryin a

chalas

ia


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Barium swallow

Normal Achalasia


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Endoscopy in achalasia


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TREATMENT OF ACHALASIAy Drug therapy

y Smooth muscle relaxantsy Botulinum toxin injection

y 1 to 2 years reliefy Symptomatic relief

y Semisoft bland diety Eating slowlyy Drinking with mealsy Sleeping with Head end elevated

y Endoscopic pneumatic dilationy Outpatient procedurey LES disrupted using balloons of progressively larger diametersy Repeat dilations are often required

y Surgical myotomy


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Gastroesophageal Reflux


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DEFINITIONSy G

asrtoesophageal reflux:

Reflux of gastriccontents to the esophagus

y Gastroesophageal reflux disease (GERD): Anysignificant symptomatic clinical condition or

histopathological changes resulting fromreflux.

y Reflux esophagitis: GERD patients withhistopathologically demonstrable changes in

the esophageal mucosa.


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Epidemiology ofGERDy Heartburn is a very common condition:

y 3% of population experience heartburn daily

y 7% frequentlyy 15% weekly

y 25% monthly

y Most common in pregnant women: 80%

y Common in obese and smokers


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Mechanisms ofGERDyTransient LES relaxationy Hypotensive LES

y Decreased esophageal acid clearance

y Hiatus hernia

y Impaired salivation.


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CLINICAL PICTURE OF GERDy ESOPHAGEAL SYMPTOMS

y EXTRAESOPHAGEAL SYMPTOMS


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ESOPHAGEAL SYMPTOMS OF

GERDy HEARTBURN

y REGURGITATION

y Bad Breathy Dysphagia

y Chest pain

y

Water brashy Nausea and vomiting

y Belching

y Hiccup


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EXTRAESOPHAGEAL SYMPTOMS OF

GERDy Chronic coughy Asthmay recurrent pneumonitisy nocturnal chokingy

hoarseness of voicey posterior laryngitis with ulceration and granuloma

formation.y sore throaty dental disease

y Earachey Globus sensation


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Diagnosis ofGERDy Clinical picture.

y UGI endoscopy.

y 24 hour pH monitoringy Radioisotope scanning

y Barium swallow.


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Endosc

opy:N

or

mal Junc

ti

on


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Reflux esophagitis


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Reflux esophagitis


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Complications of GERDy Stricture formation

y Chronic blood loss

y Barretts epitheliumy Narrow band imaging & chromoendoscopy with

methylene blue are used as diagnostic tool.

y Adenocarcinoma


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Esophageal stricture

Savary Gillard dilator used for

dilatation of esophageal strictures


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Barretts epithelium


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Barretts epithelium

y Narrow Band Imaging used for diagnosis of barretts epthelium


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Barretts epithelium

y Chromoendoscopy using methylene blue used for diagnosis of Barretts


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Adenocarcinoma


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Adenocarcinoma


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Natural history ofGERDy May be acute condition in a small percentage

y Mostly chronic condition with recurrentsymptoms

y Majority can be controlled on drugs

y Majority may require a sort of acid suppressivetherapy at 5 years

y No clear relation exists between symptoms of

reflux, amount of reflux or degree ofesophagitis.


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Management ofGERDy Life- style modification:

y avoid cigarette smokingy dietary manipulation: decrease fatty, spicy and

acidic foods

y decrease weight

y elevation of the head of the bed

y avoid tight abdominal bindersy avoid constipation

y avoid large meals

y avoid drugs which decrease LES pressure

y

avoid sleeping after meals for at least 3 hours.


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Pharmacologic therapy ofGERDy Antacids:

y Mg trisilicate

y Aluminium hydroxide

y Ca carbonate

y sodium bicarbonate.

y H2-blockers:y Cimetidine

y ranitidine

y famotidiney nizatidine


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Pharmacologic therapy ofGERDy Proton pump inhibitors:

y Omeprazole

y lansoprazole

y pantoprazole

y rabeprazoley Esomeprazole

y Tenatoprazole

y Prokinetic drugs:y

metoclopramidey domperidone.


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Endoscopic therapy forGERDy Sterrata procedure

y Entyrex

y Gate keeper anti-reflux repairy Gastric plication


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Antireflux surgeryy Indications:

y complicated reflux

y non compliance for medication

y refractoryGERD

y patients preference

y severe disease in young person

y Most popular operation now is laparoscopic

fundoplication


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Treatment ofBarretts epithelium

y BE usually occurs in longstanding severereflux disease

y BE does not regress after fundoplication orPPI therapy

y

Screening for dysplasia?y If high grade dysplasia found:

esophagectomyy Ablation of BE:

y Photodynamic therapy

y Argon plasma coagulationy Endoscopic mucosal resection

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