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By Dr : RAMY A. SAMY Esophageal Diseases

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Anatomy of Esophagus Hollow tube formed of striated muscle (upper part) and smooth muscle (lower part). Length about 20-30 cm in adults. Fibers of the cricopharyngeus muscle represent the upper esophageal sphincter (UES). In thoracic cavity it lies in posterior mediastinum, posterior to the trachea. Leaves thorax through diaphragmatic hiatus Lower esophageal sphincter (LES) about 3-5 cm long, ?physiological sphincter.

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Esophageal Anatomy Upper Esophageal Sphincter (UES) Lower Esophageal Sphincter (LES) Esophageal Body (cervical & thoracic) 18 to 24 cm

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Microscopic Anatomy of esophagus Mucosa: Lined with stratified squamous epithelium, rich in glycogen. Lamina propria muscularis mucosa : thin layer of smooth muscle Submucosa The outer muscular layers: striated in the upper part and smooth in lower 2/3 No serosal covering.

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Physiology UES: tonically closed, opens 0.2-0.3 sec after a swallow. Peristaltic contractions, duration less than 7 sec and amplitude less than 150 mmHg, velocity less than 8 cm/sec LES: tonically closed at rest, pressure 20 mmHg, cholinergic mediated, relaxes with swallowing. Transient LES relaxation, independent of swallowing is the major cause of reflux.

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Normal Phases of Swallowing Voluntary oropharyngeal phase bolus is voluntarily moved into the pharynx Involuntary UES relaxation peristalsis (aboral movement) LES relaxation Between swallows UES prevents air entering the esophagus during inspiration and prevents esophagopharyngeal reflux LES prevents gastroesophageal reflux peristaltic and non-peristaltic contractions in response to stimuli capacity for retrograde movement (belch, vomiting) and decompression

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Esophageal Disorders Motility Anatomic & Structural Reflux Infectious Neoplastic Miscellaneous

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Motility Disorders upper esophageal UES disorders neuromuscular disorders esophageal body achalasia diffuse esophageal spasm nutcracker esophagus nonspecific esophageal dysmotility LES achalasia hypertensive LES primary disorders achalasia diffuse esophageal spasm nutcracker esophagus nonspecific esophageal dysmotility secondary disorders severe esophagitis scleroderma diabetes Parkinsons stroke

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Upper Esophageal Motility Disorders cause oropharyngeal dysphagia (transfer dysphagia) patients complain of difficulty swallowing tracheal aspiration may cause symptoms pharyngoesophageal neuromuscular disorders stroke Parkinsons Poliomyelitis multiple sclerosis diabetes myasthenia gravis dermatomyositis and polymyositis upper esophageal sphincter (cricopharyngeal) dysfunction

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UES Disorders cricopharyngeal hypertension elevated UES resting tone poorly understood (reflex due to acid reflux or distension) cricopharyngeal achalasia incomplete UES relaxation during swallow may be related to Zenkers diverticula in some patients clinical manifestations localizes as upper (cervical) dysphagia within seconds of swallowing coughing, choking, immediate regurgitation, or nasal regurgitation diagnosis: swallow evaluation & modified barium swallow

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Motility Disorders of the Body & LES symptoms: usually dysphagia (intermittent and occurring with liquids & solids) diagnostic tests barium esophagram endoscopy esophageal manometry disorders achalasia diffuse esophageal spasm (DES) nutcracker esophagus hypertensive LES nonspecific esophageal dysmotility hypomotility hypermotlity

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Achalasia Failure of relaxation of the LES with swallowing and aperistalsis in lower esophagus. Due to decreased or absent intramural esophageal ganglion cells.

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Symptoms of Achalasia Dysphagia to fluids and solids, intermittent, long - standing. Regurgitation of undigested food Chest pain Aspiration Weight loss

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Diagnosis of achalasia Esophageal manometry: Absent peristalsis High LES pressure Failure of relaxation of LES. Radiographic studies Endoscopy to exclude organic disease.

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Normal Barium swallow

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Radiology in Achalasia

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Endoscopy in achalasia

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TREATMENT OF ACHALASIA Medical: Smooth muscle relaxants Balloon Dilatation Surgical myotomy

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Diffuse Esophageal Spasm frequent non-peristaltic contractions simultaneous onset (or too rapid propagation) of contractions in two or more recording leads occur with >30% of wet swallows (up to 10% may be seen in normals)

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Nutcracker Esophagus high pressure peristaltic contractions avg pressure in 10 wet swallows is >180 mm Hg 33% have long duration contractions (>6 sec) may inter-convert with DES

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Hypertensive LES Nonspecific Esophageal Dysmotility high LES pressure >45 mm Hg normal peristalsis often overlaps with other motility disorders abnormal motility pattern fits in no other category non-peristalsis in 20- 30% of wet swallows low pressure waves (

Spastic Motility Disorders of the Esophagus epidemiology any age (mean age 40) female > male symptoms dysphagia to solids and liquids intermittent and non-progressive present in 30-60%, more prevalent in DES (in most studies) chest pain constant % across the different disorders (80-90%) swallowing is not necessarily impaired can mimic cardiac chest pain pyrosis (20%) and IBS symptoms (>50%) symptoms and manometry correlate poorly

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Spastic Motility Disorders of the Esophagus diagnosis manometry barium esophagram endoscopy pH monitoring treatment reassurance nitrates, anticholinergics, hydralazine - all unproven calcium channel blockers - too few data with negative controlled studies in chest pain psychotropic drugs trazodone, imipramine and setraline effective in controlled studies dilation - anecdotal reports, probable placebo effect

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Hypomotilty Disorders primary (idiopathic) aging produces gradual decrease in contraction strength reflux patients have varying degrees of hypomotility more common in patients with atypical reflux symptoms usually persists after reflux therapy defined as low contraction wave pressures ( of wet swallows

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secondary scleroderma in >75% of patients progressive, resulting in aperistalsis in smooth-muscle region incompetent LES with reflux other connective tissue diseases CREST polymyositis & dermatomyositis diabetes 60% with neuropathy have abnormal motility on testing (most asx) other hypothyroidism, alcoholism, amyloidosis

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Gastroesophageal Reflux

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DEFINITIONS Gasrtoesophageal reflux: Reflux of gastric contents to the esophagus Gastroesophageal reflux disease (GERD): Any significant symptomatic clinical condition or histopathological changes resulting from reflux. Reflux esophagitis: GERD patients with histopathologically demonstrable changes in the esophageal mucosa.

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Epidemiology of GERD Heartburn is a very common condition: 3% of population experience heartburn daily 7% frequently 15% weekly 25% monthly Most common in pregnant women: 80% Common in obese and smokers

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Mechanisms of GERD Transient LES relaxation Hypotensive LES Decreased esophageal acid clearance Hiatus hernia Impaired salivation.

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CLINICAL PICTURE OF GERD ESOPHAGEAL SYMPTOMS EXTRAESOPHAGEAL SYMPTOMS

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ESOPHAGEAL SYMPTOMS OF GERD HEARTBURN REGURGITATION Dysphagia Chest pain Water brash Nausea and vomiting Belching Hicough

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EXTRAESOPHAGEAL SYMPTOMS OF GERD Chronic cough Asthma recurrent pneumonitis nocturnal choking hoarseness of voice posterior laryngitis with ulceration and granuloma formation. sore throat dental disease Earache Globus sensation

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Diagnosis of GERD Clinical picture. UGI endoscopy. 24 hour pH monitoring Radioisotope scanning Bernstein test : esophageal acid perfusion Barium swallow.

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Endoscopy: Normal Junction

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Reflux esophagitis

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Complications of GERD Stricture formation Chronic blood loss Barretts epithelium Adenocarcinoma

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Esophageal stricture

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Barrettes epithelium

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Natural history of GERD May be acute condition in a small percentage Mostly chronic condition with recurrent symptoms Majority can be controlled on drugs Majority may require a sort of acid suppressive therapy at 5 years No clear relation exists between symptoms of reflux, amount of reflux or degree of esophagitis.

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Management of GERD Life- style modification: avoid cigarette smoking dietary manipulation: decrease fatty, spicy and acidic foods decrease weight elevation of the head of the bed avoid tight abdominal binders avoid constipation avoid large meals avoid drugs which decrease LES pressure avoid sleeping after meals for at least 3 hours.

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Pharmacologic therapy of GERD Antacids: Mg trisilicate Aluminium hydroxide Ca carbonate sodium bicarbonate. H2-blockers: Cimetidine ranitidine famotidine nizatidine

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Pharmacologic therapy of GERD Proton pump inhibitors: Omeprazole lansoprazole pantoprazole rabeprazole Esomeprazole Tenatoprazole Prokinetic drugs: metoclopramide domperidone.

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Endoscopic therapy for GERD Sterrata procedure Entyrex Gate keeper anti-reflux repair Gastric plication

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Antireflux surgery Indications: complicated reflux non compliance for medication refractory GERD patients preference severe disease in young person Most popular operation now is laparoscopic fundoplication

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Treatment of Barretts epithelium BE usually occurs in longstanding severe reflux disease BE does not regress after fundoplication or PPI therapy Screening for dysplasia? If high grade dysplasia found: esophagectomy Ablation of BE: Photodynamic therapy Argon plasma coagulation Endoscopic mucosal resection

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