esophargeal dysphagia - university of texas medical branch · esophargeal dysphagia ... a motility...
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Esophargeal Dysphagia
Jean Paul Font, MD
Faculty Advisor: Michael Underbrink, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
February 6, 2008
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Esophageal Anatomy
Muscular tube connecting the pharynx to the stomach
Esophagus begins where the inferior pharyngeal constrictor merges with the cricopharyngeus
– Upper esophageal sphincter (UES)
18 to 26 cm in length
Lower esophageal sphincter (LES) – Thickened circular smooth muscle
– 40cm from incisors
Extrinsic indentations – Anterior body of C7 (worsen by
osteophytes)
– Arch of the aorta, the left mainstem bronchus
– Diaphragmatic hiatus
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Four layers:
– Mucosa
– Submucosa
– Muscularis propria
– Adventitia; no serosa.
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Esophageal Mucosa
– Nonkeratinized, stratified
squamous epithelium
Gastric lining
– Columnar epithelium
(rugae)
Z-line
– Junction of the squamous
epithelium and columnar
epithelium
Cephalad movement
– Barrett’s esophagus.
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Muscularis propria
Skeletal and smooth muscle
– Skeletal muscle (Proximal 1/3)
– Mixed (Middle 1/3)
– Smooth muscle (Distal 1/3)
Inner circular
Outer longitudinal layers.
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Innervation mainly by Vagus n.
Auerbach’s (myenteric) plexus
– Between the two muscle layers
– Controls esophageal peristalsis
– Acetylcholine mediates contraction
– Nitric oxide relaxation
Meissner's plexus
– Submucosal layer
– Sensory input
– Pain sensation overlap with the heart and respiratory system
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At rest – UES & LES
tonically contracted
Immediately after a swallow – UES pressure falls
transiently
Shortly thereafter – LES pressure falls
and remains low until the peristaltic contraction closes the LES
Esophageal Peristalsis
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Dysphagia
Greek dys (difficulty, disordered) and phagia (to eat)
Sensation that food is hindered in its passage from the mouth to the stomach
Most patients complain that food – “sticks,” “hangs up,” “stops,” or “just won't go down right”
Anatomically classified into two separate clinical categories: – Oropharyngeal and esophageal.
Psychiatric disorders can amplify this symptom.
Dysphagia is a common symptom – Present in 12% of patients admitted to an acute care hospital
and in more than 50% of those in a chronic care facility.
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History
Three questions are crucial:
(1) What type of food or liquid causes symptoms? – Mechanical vs neuromuscular defect
– Primarily solids Structural lesion- peptic stricture, ring, or malignancy
– Both solid and liquid a motility disorder like achalasia or scleroderma
(2) Is the dysphagia intermittent or progressive? – Esophageal rings tend to cause intermittent solid food dysphagia
– Strictures and cancer cause progressive dysphagia
(3) Does the patient have heartburn? – Complication of GERD- Esophagitis, stricture & Barrett’s
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History
Location of dysphagia – Limited value (Referred from any site)
Weight loss – Significance and duration of the disease
Dietary changes – Nature and severity of disease.
Dysphagia must be distinguished from odynophagia – Associated with an inflammatory condition
(esophagitis)
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Diagnostic Tools
Esophagogram
Endoscopy
Esophageal Manometry
pH probe
Esophageal Ultrasound
CT, MRI
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Esophagogram
Double-contrast barium esophagogram
Usually the first specific diagnostic test in
the evaluation of esophageal dysphagia
Detect subtle narrowing or esophageal
webs that may not be appreciated on
endoscopy
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Endoscopy
Procedure of choice to evaluate the mucosa of the esophagus
Detection of structural abnormalities
Flexible esophagoscopy – Used by GI service
– Transorally
– Diameters approaching 1cm
– Allows the insufflation of air to distend the esophagus and more easily see all of the mucosa
– Magnified view, suction, irrigation, and biopsy ports.
– Requires intravenous sedation setting
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Rigid esophagoscopy
– Used by otolaryngologists
– Requires general anesthesia
– Examine the full extent of the esophagus
– View is not magnified
– Esophagus is not distended
– Allows use of instrumentation
– The risks of general anesthesia and the rigid
esophagoscopy
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Transnasal Esophagoscopy
Flexible esophagoscopy – Smaller size (5mm) allows their passage through the
nasal cavity
Topical anesthesia
“Easily” performed clinic procedure
Patient can returned to work after the appointment
Allows the insufflation of air to distend the esophagus and more easily see all of the mucosa.
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Transnasal Esophagoscopy
Patient is asked to swallow as scope is gently advanced through the UES
Air is insufflated into esophagus
If mucosal lesions or irregularities are found multiple biopsies are taken with biopsy forceps passed through the biopsy port
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Postma et al in 2005
– Review of 711 consecutive patients examined with transnasal esophagoscopy
– They used a spray combination of 0.05% oxymetazoline and 4% lidocaine in the nasal cavity
– If biopsy or a longer procedure is required, one Tessalon Perle is used
– Seventeen of 711 procedures (3%) were terminated due to a tight nasal vault and 2 due to a self-limited vasovagal response
– 50% incidence of significant findings
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Esophageal Manometry
Measures intraluminal pressures – LES, esophageal body & UES
With each swallow – Strength
– Timing
– Sequencing of pressure events
Indicated for patients who need recurrent intraluminal pressure assessment – Achalasia
– Diffuse esophageal spasm
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Achalasia
Primary esophageal motility disorder – Insufficient LES relaxation
– Loss of esophageal peristalsis
Pathologic – Loss of ganglion cell in the myenteric plexus
– Infiltrate of T lymphocytes, eosinophils, and mast cells
– Selective loss of postganglionic inhibitory neurons, which contain both nitric oxide and vasoactive intestinal polypeptide
Symptoms – Dysphagia to solids and liquid
– Regurgitation
– Chest pain
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Achalasia Diagnosis
Best initial diagnostic study
– Barium esophagram with fluoroscopy
Esophageal dilation
Closed LES
Loss peristalsis
Bird's beak
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Esophageal manometry
– Establish the diagnosis
Absent or incomplete LES relaxation
Loss peristalsis
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Endoscopy
– Exclusion of
pseudoachalasia
by carcinoma at
the GE junction
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Treatment
Pneumatic dilation – Should be a surgical candidates
2% to 5% risk of perforation
– After dilation need a gastrograffin study followed by barium swallow to exclude esophageal perforation
– Good to excellent relief of symptoms in 50% to 93% of patients
Surgical myotomy – Myotomy across the LES
– Laparoscopy with a response rate of 80% to 94%
– Complication- GERD in 10% to 20%
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High risk for pneumatic dilation or surgery
– Botox
Effective in about 85% of patients
Symptoms recur in more than 50% of patients after
6 months
– Pharmacologic treatment with nitrates or
calcium-channel blockers
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Non-achalasia Motility Disorders
Diffuse esophageal spasm (DES)
– Simultaneous and repetitive contractions in
the esophageal body
– Normal LES relaxation
– Dysphagia if the contraction amplitudes are
low
– Chest pain if the contraction amplitudes are
high
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Diffuse esophageal spasm
Diagnosis – Esophagogram
"corkscrew" esophagus
– Manometry Simultaneous and repetitive contractions in the esophageal body
Treatment – Medications that relax
the esophagus Nitrates and calcium-channel blockers
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Scleroderma
Connective tissue disease
Peristalsis is absent in the distal two-thirds
Mild dilation of the distal esophagus
LES becomes incompetent
Associated – Aspiration pneumonia
– Reflux esophagitis with Barrett's esophagus
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Esophageal Strictures
Loss of lumen area
– Normal 20 mm in diameter
Dysphagia main symptom
– Less than 15 mm
Worse with large food
pieces such as meat and
bread
Acid/peptic stricture
accounting for the
majority of cases (60%–
70%).
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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
Extrinsic strictures
Pulmonary/mediastinal malignancies
Anomalous vessels and aneurysms
Metastatic submucosal infiltration (breast
cancer, mesothelioma, adenocarcinoma of
gastric cardia)
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Diagnosis
Esophagogram
– Initial diagnostic study
– Delineate the stricture
Endoscopy
– Evaluate the mucosa
Distal stricture Caustic ingestion
normal mucosa Barrett's metaplasia
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Treatment
Esophageal dilation – Depends on the length and diameter
– Tight or complex strictures
Less than 10 mm in diameter
Greater than 2 cm in length
Best managed with wire-guided bougies under fluoroscopic and endoscopic control
– Simple strictures can be dilated with Maloney dilators
– Progressively over weeks to months with a gradual increase in the diameters of the dilators
– Most patients have relief of dysphagia after dilation to a diameter of 40 to 54 French with no requirement for maintenance dilations
– Radiation-induced or malignant strictures are at higher risk of perforation
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Treatment
To minimize the risk of perforation, the "rule of
threes" applies
– No more than three sequential dilators should be
performed per session
– Refractory strictures can be treated endoscopically
with injection of triamcinolone into the stricture in all
four quadrants prior to dilation
– More recently, endoscopically placed temporary
nonmetallic expandable stents (Polyflex)
Effective in refractory benign strictures
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Esophageal Rings & Webs
Symptoms – Intermittent solid food dysphagia,
aspiration, and regurgitation
Rings – Circumferential
– Mucosa or muscle
– Most commonly occur in the distal esophagus
– Schatzki's ring occurs at the GEJ
Webs – Only part of the esophageal lumen
– Always mucosal
– Located in the proximal esophagus
– Association with iron deficiency (Plummer and Vinson)
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Diagnosis
Barium Esophagogram – Most sensitive test
Endoscopic visualization – Normal-appearing mucosal
– Cervical webs are associated with carcinoma
Treatment – Endoscopic dilation
– Large bougie or balloon (15 to 20 mm) so as to fracture the ring
– Refractory rings Pneumatic dilation (large balloon)
Electrosurgical incision
Surgical resection
Treat GERD
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Dysphagia lusoria
Aberrant right subclavian artery – Arises from the left side of the aortic arch
– Compress the posterior esophagus
– 20% of cases anterior
Barium esophagogram – Indentation at the level of the third and fourth thoracic vertebrae
Confirmation – CT, MRI, arteriography, or EUS
Endoscopy – Right radial pulse may diminish with compression of the right subclavian artery
Esophageal manometry – High-pressure zone at the location of the aberrant artery
Symptoms usually respond to changes in diet to soft consistency and small size
When necessary, surgery relieves the obstruction by reanastomosing the aberrant artery to the ascending aorta
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Gastroesophageal Reflux
Disease
GERD is recognized in about 10-15% of the population
Reflux esophagitis – Changes in the esophageal mucosa
– Present in 30% to 40%
Barrett's esophagus – 10% to 20%
Defects in the esophagogastric barrier such as – LES incompetence
– Transient relaxation of LES
– Hiatal hernia
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GERD Diagnosis
Classic symptom is heartburn
– Retrosternal burning discomfort and acid
regurgitation
– Other symptoms are dysphagia, odynophagia,
and belching
Laryngopharyngeal reflux (LPR)
– Hoarseness, throat clearing, dysphagia,
increased phlegm and globus sensation
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Management
Treatment
– Initial empiric trial in the absence of alarm
signs
– Diagnostic testing
if there is a failure to respond to an empiric course
of antisecretory therapy
if alarm signs such as dysphagia, odynophagia,
weight loss, chest pain, or choking are present.
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pH probe
Ambulatory 24-hour
esophageal pH monitoring
– Gold standard for the diagnosis
of GERD
– Detect and quantify
gastroesophageal reflux
– Correlate symptoms temporally
with reflux
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Bravo pH probe
Size of a capsule
Placed endoscopically
– 6 cm above the GEJ
Transmits to a recording device
48 hours of pH data
Falls off after 4 to 10 days
Patients prefer this device over the catheter-based system due to reduced discomfort
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Endoscopy
– Reflux esophagitis
Erosions or ulcerations
– pH probe results are
normal in 25% of
patients with erosive
esophagitis
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Barrett's esophagus
Potentially serious complication of long-standing GERD
Stratified squamous epithelium of the distal esophagus is replaced by intestinal columnar metaplasia
It is the most significant outcome of chronic GERD and predisposes patients to the development of esophageal adenocarcinoma.
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MALIGNANT STRICTURES
12,000 new cases each year in the United States
Squamous cell carcinoma (SCC) – Black males
– Alcohol and tobacco abuse
– History of caustic esophageal injury
– Other conditions including achalasia, Plummer-Vinson syndrome, and a history of head and neck SCC
– Have also been associated with human papillomavirus.
Adenocarcinoma – white males
– well-documented association with GERD
– Barrett's esophagus
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MALIGNANT STRICTURES
Malignant obstruction – Late presentation and carries a poor prognosis
– Dysphagia is rapidly progressive
– Diagnosis Endoscopy with mucosal biopsy
Evaluation includes staging – CT and Endoscopic US
– Staging is based on the TNM classification
– T1 or T2 without nodal or metastatic disease, can be treated with surgery alone
– Patients with more advanced disease Neoadjuvant chemotherapy/radiation before surgical resection
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Cricopharyngeal Dysfunction
The cricopharyngeus remains contracted between swallows
Cricopharyngeal achalasia – Muscle fails to
completely relax
– smooth posterior impression on the hypopharynx
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Zenker’s Diverticulum
Esophageal diverticula are classified based on:
– Anatomic location
– Mechanism of origin (pulsion or traction).
Zenker's diverticulum (ZD)
– Pulsion type diverticulum
Herniation of esophageal mucosa and submucosa through
an area of weakened esophageal musculature
– Annual incidence of 2 per 100,000 people per year
– Males predominance (2 to 3 times)
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Zenker’s Diverticulum
Killian's dehiscence or triangle – Between the
cricopharyngeal muscle and inferior constrictor muscle
Killian-Jamieson's area – between the oblique and
transverse fibers of the cricopharyngeal muscle
Laimer's triangle – Between the
cricopharyngeal muscle and the most superior esophageal wall circular muscles
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Diagnosis
History
– Progressive dysphagia
90% of patients
presenting with ZD
– Regurgitation of food
– Unprovoked aspiration
– Noisy deglutition
Barium
Esophagogram
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Treatment
Surgery
– Cricopharyngeal
myotomy
External
– cricopharyngeal
myotomy
– Diverticulum is excised
and the defect closed
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Endoscopic
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References
Bechi P: Long-term ambulatory enterogastric reflux monitoring: validation of a new fiberoptic technique. Dig Dis Sci 1993; 38:1297-1306.
Devault KR, Castell DO: Updated guideline for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 1999; 94:1434-1442.
Elluru RG, Willging JP. Endoscopy of the Pharynx and Esophagus. Cummings
CW, ed. Otolaryngology Head & Neck Surgery. Philadelphia: Elsevier Mosby; 2005, 1825-1834.
Mittal RK: Transient lower esophageal sphincter relaxation. Gastroenterology 1995; 109:601-610
Postma GN, Cohen JT, Belafsky PC, et al. Transnasal Esophagoscopy: Revisited (over 700 Consecutive Cases). Laryngoscope 2005;115:321-323.
Postma GN, Bach KK, et al. The Role of Transnasal Esophagoscopy in Head and Neck Oncology. Laryngoscope 2002;112:2242-2243.
Tobin RW: Esophageal rings, webs, and diverticula. J Clin Gastroenterol 1998; 27:285.
Vaezi MF, Richter JE: Diagnosis and management of achalasia. Am J Gastroenterol 1999; 12:3406-3413.
Vollweiller JF, Vaezi MF. The Esophagus: Anatomy, Physiology, and Diseases. Cummings CW, ed. Otolaryngology Head & Neck Surgery. Phaladelphia: Elsevier Mosby, 2005, 1835-1998.