Approach to dysphagia &benign esophageal disease

Done by: Thaer Omar Alqatish

Definitions: • Dysphagia ?

• Aphagia ?

• Odynophagia ?

• Phagophobia ?

Classifications for dysphagia

1- Oral and Pharyngeal (Oropharyngeal) Dysphagia ?

2- Esophageal Dysphagia ?

DDx

• 1- Oropharyngeal Dysphagia: • Iatrogenic causes include surgery and radiation,

• Neurogenic : from cerebrovascular accidents, Parkinson’s disease, and amyotrophic lateral sclerosis

• Structural lesions causing dysphagia include Zenker’s diverticulum, cricopharyngeal bar, and neoplasia.

• 2- Esophageal Dysphagia: • Structural: Schatzki’s rings, eosinophilic esophagitis, and peptic strictures.

• Neuromascular: DES, achalasia, scleroderma

Clinical approach

• History ?

• Physical Examination

• Investigations

• Treatment

History

• 1- localization of dysphagia,

• 2- other symptoms associated with dysphagia,

• 3- The type of food causing dysphagia

• 4- dysphagia progression.

• 5- accompanying odynophagia??,

• 6- A history of ;

* A history of prolonged nasogastric intubation, esophageal or head and neck surgery, ingestion of caustic agents or pills, previous radiation or chemotherapy,

Physical Examination

• 1- Mouth and pharynx ?

• 2- Neck ?

• 3- Changes in the skin ?

• 4- Signs of neuromuscular disease?

Investigations

• 1- start with barium swallow study

• 2- For suspected esophageal dysphagia, upper endoscopy (& mucosal biopsies) is the single most useful test.

• 3- Esophageal manometry

• 4- In specific cases, computed tomography (CT) examination and endoscopic ultrasonography may be useful.

Treatment

• 1- conservative measures: • changing postures or maneuvers

• altering the consistency of ingested food and liquid

• severe and persistent cases may require gastrostomy and enteral feeding.

• 2- medical treatment

• 3- Dilators & Surgical intervention

Zenker’s Diverticulum

• Definition: • is a diverticulum (outpouching) of the mucosa of the pharynx, just above the

cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum (not involving all layers of the esophageal wall).

• Pathophysiology: • If swallowing is Uncoordinated so that the cricopharyngeus does not relax, the week

unsupported area above these fibers bulges out. (Killian’s dehiscence)

• Clinical Features:

• Signs and Symptoms: 1- Dysphagia 2- Halitosis (bad smell) 3- Food regurgitation. 4- Posterior neck mass.

• Diagnosis: • Barium swallow.

** Endoscopy and NG tube are contraindicated (due to the risk of perforation)

• Treatment: • Surgical resection

1. One stage cricopharyngeal myotomy and diverticulectomy

2. Other options are cricopharyngeal myotomy and diverticulopexy

Esophageal Webs

• Definition: Thin protrusion of esophagus mucosa, most often in the upper esophagus (hypopharynx).

• Etiology • ⸎Plummer-vinson syndrome, due to iron deficiency anemia (IDA).

• Clinical Features: • Signs and Symptoms:

Dysphagia: ➢ Intermittent and not progressive. ➢ For solids only.

• Complications: slightly increased risk for esophageal CA.

• Daignosis: 1- Barium swallow. 2- endoscopy

• Treatment: • Esophageal dilatation, using bougie or balloon dilators.

• Treat IDA

Schatzki ring

• Definition: Lower esophageal ring, usually at the squamo-columner junction. { lower esophagus }

• ⸎ almost always associated with esophageal hiatal hernia • Clinical Features:

• 1- Dysphagia: ➢ Intermittent and not progressive. ➢ For solids only, especially meat and fibers.

• Daignosis: 1- Barium swallow (the ring should be >13 mm to cause symptoms) 2- endoscopy

• Treatment: • treat it like esophageal webs, by dilatation.. ➢ The patients are placed on PPI after diltation.

Esophageal stricture ( peptic stricture )

• Definition: Narrowing of the esophagus.

• Etiology: • ➢ Long history of incompletely treated reflux. ➢ Prolonged NG tube placement. ➢ Lye (bleaching agent) ingestion decades ago (alkali is worse than acids)→ erosive esophagitis.

• Pathophysiology: • Prolonged/severe Esophageal irritation→erosion of the mucosa→ fibrosis (stricture).

• Clinical Features: • Signs and Symptoms:

1- Dysphagia: ➢ Constant, slowly progressive. ➢ For solids then liquids.

• Daignosis: • Barium swallow.

• Treatment: • Dilation

Achalasia

• Definition: a failure of smooth muscle fibers to relax, which can cause a sphincter to remain closed and fail to open when needed.

• Etiology: • ⸎Of unknown etiology. ⸎pseudoachalasia/secondary achalasia: 1. Esophageal CA. 2. Lymphoma 3. Chagas disease (trypanosoma cruzi infection). 4. Eosinophilic esophagitis 5. Neurodegenerative diseases.

• Pathophysiology: • Loss of intralumenal neurons → inc. LES tone (failure of relaxation)→Dilation of the Distal

esophagus. • No esophageal peristalsis.

• Diagnosis: • 1. Barium swallow: (best initial test) → bird’s beak appearance ?

2. Upper endoscopy+ biopsy: why ? 3. Esophageal manometry: (the definitive diagnosis) ?

• Treatment: 1- Pneumodilatation: (BEST initial therapy) ➢ 3-4 diameter ballon is inflated in the LES→ produce higher pressure. ➢ Effective in 85% of patients. ➢ 5% risk of perforation. ** Pneumodilatation effective only for short duration of weeks , best to mix it with botox 2- Botox (botulinum toxin injection) ➢ Effective in 65% of patients. ➢ Requires repeating therapy within 6-12 months. 3- Surgical myotomy. ➢ ”Heller” myotomy. ➢ Incision of circular muscle layer of LES. (cut through the muscle to relief the tension ) ➢ High risk of GERD 4- Medical treatment (CCB and nitrates) is not that effective.

Diffuse esophageal spasm

• Definition: Idiopathic abnormality in neuromuscular activity of the esophagus, resulting in non-peristaltic contractions with high amplitudes causing pain and dysphagia. { sphincter function is usually normal }

• Etiology: • Idiopathic.

• Clinical Features: • 1. Dysphagia: ➢ For both solids and liquids.

• 2. Atypical chest pain. • ➢ May mimic MI. ➢ Inc. With cold liquids.

• Diagnosis: • 1- ECG to role out MI.

• 2- Barium swallow : ➢ Corkscrew appearance (see picture).

• 3- Manometry (most accurate test): ➢ High intensity, intermittent, disorganized contractions.

• Treatment: • Medical (antireflux measures, calcium channel blockers, nitrates)

• Long esophagomyotomy in refractory cases (a cut through the muscle )

• Nutcracker Esophagus ???

Gastroesophageal reflux disease (GERD)

• Definition: also known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications.

• Pathophysiology: • ⸎Loss of anti-reflux mechanisms:

• 1. Loss of LES tone &/or peristalsis; due to smoking, alcohol, peppermint, Chocolate, CCB & nitrates. Or hiatal hernia

• 2. Inc. Gastric volume; due Diabetic gastroparesis or pyloric stenosis.

• 3. Inc. Gastric pressure; due to Ascites or pregnancy.

• Signs and Symptoms: • 1. Heartburn/ sore throat.

2. Water brush. 3. Epigastric/substernal pain (the most common cause of non-cardiac chest pain is GERD). 4. Bad, metal-like taste in mouth. 5. Cough, wheezing or hoarseness (it may exacerbate asthma).

• Alarming signs: 1. Dysphagia/odynophagia 2. Wight loss/ anorexia/ anemia/ blood in stool. 3. Family history of peptic ulcer disease. 4. Failure to respond to PPI. 5. Long duration of symptoms.

• Complications: • 1. Exacerbation of asthma.

2. Esophageal ulcers 3. Strictures, 4. bleeding 5. Barrett esophagus ?

• Treatment: • 1. Life style modification. ?? • 2. Antacids • 3. H2 blockers or PPI

• ⸎Surgical: ( indications ?? ) 1. Lap Nissen 2. Belsey Mark IV 3. Hill 4. Toupet

•➢ Indications for surgery: 1. Failure of medical treatment. 2. Respiratory problems. 3. Severe esophageal injury

•1. Lap Nissen • It’s 360 fundoplication – 2 cm Laparoscopically. ** how does it work ?? • It works through improving lower esophageal sphincter function; Increasing LES tone, Elongates LES by 3 Cm, Returning LES into abdominal cavity. • Effective in 85% (70% to 95%)

• Post-op complications: • 1. Gas-bloating syndrome (Inability to burp or vomit)

2. Strictures • 3. Esophageal perforation. • 4. Pneumothorax. • 5. Spleen injury requiring splenectomy.

Other surgical options

• 2. Belsey Mark IV: 240 to 270 fundoplication through thoracic approach.

• 3. Hill: Arcuate ligament repair (close large esophageal hiatus) + gastropexy (suture stomach to diaphragm).

• 4. Toupet: laparoscopic Incomplete Wrap (200)

Barrett esophagus

• Definition: It’s an intestinal metaplasia of lower esophageal mucosa (change from stratified squamous epithelium into simple columnar epithelium with goblet cells).

•➢ Risk factors are smoking and GERD • 10% patients with GERD develops Barrett’s esophagus.

• 7% (5% to 10%) of patients with Barrett’s esophagus will develop adenocarcinoma.

• Diagnosed: by edoscopy & Bx.

• Management is by PPI, resection and follow up: • i. No dysplasia → 3-5 years

ii. Low-grade dysplasia→ 6-12 months iii. High-grade dysplasia → 3 months

** from Dr. Mansour : (in high grade dysplasia we don’t wait and follow the pt instead of that, we go and remove the esophagus as if it was a case of esophageal CA)

• Resection options: • endoscopic mucosal resection and photodynamic therapy, radiofrequency

ablation, and cryoablation

Other medical disorders

• 1- Scleroderma esophagus

• 2- Pill-induced esophagitis

• 3- Infective esophagitis

• 4- Eosinophilic (allergic) esophagitis