ESOPHAGEAL TOPICSESOPHAGEAL TOPICS

Norman M. Simon, M.D., F.A.C.G.Norman M. Simon, M.D., F.A.C.G.

BARRETTBARRETT’’S ESOPHAGUSS ESOPHAGUS A change in the lining of the esophagus A change in the lining of the esophagus

from the normal squamous lining to an from the normal squamous lining to an intestinal type lining called intestinal intestinal type lining called intestinal metaplasia.metaplasia.

Diagnosis suspected on endoscopy but Diagnosis suspected on endoscopy but requires confirmation by pathology requires confirmation by pathology examination of biopsies.examination of biopsies.

Vast majority of cases caused by acid Vast majority of cases caused by acid reflux and secondary injury to the normal reflux and secondary injury to the normal lining.lining.

Incidence appears to have increased Incidence appears to have increased substantially.substantially.

Increased incidence of BarrettIncreased incidence of Barrett’’s s seems responsible for increase in seems responsible for increase in cases of esophageal adenocarcinoma.cases of esophageal adenocarcinoma.

Controversy re. who to screen for Controversy re. who to screen for BarrettBarrett’’s.s.

When BarrettWhen Barrett’’s suspected, biopsies s suspected, biopsies taken to confirm diagnosis and to taken to confirm diagnosis and to check for dysplasia.check for dysplasia.

Monitoring generally being done at Monitoring generally being done at three to five year intervals unless three to five year intervals unless dysplasia is found. Then depends on dysplasia is found. Then depends on whether low or high grade changes.whether low or high grade changes.

Candidates For ScreeningCandidates For Screening

Caucasian MalesCaucasian Males Over 50 years of ageOver 50 years of age Chronic symptoms of GERDChronic symptoms of GERD Nocturnal reflux symptomatologyNocturnal reflux symptomatology Increased BMI with intra-abdominal Increased BMI with intra-abdominal

fat distributionfat distribution Tobacco useTobacco use

BARRETTBARRETT’’S WITHOUT S WITHOUT DYSPLASIADYSPLASIA

BARRETTBARRETT’’S LOW-GRADE S LOW-GRADE DYSPLASIADYSPLASIA

BARRETTBARRETT’’S HIGH-GRADE S HIGH-GRADE DYSPLASIADYSPLASIA

BARRETTBARRETT’’S HIGH GRADE S HIGH GRADE DYSPLASIADYSPLASIA

Some evidence that anti-reflux treatment Some evidence that anti-reflux treatment helps prevent the development of pre-helps prevent the development of pre-cancerous dysplasia and cancer in cancerous dysplasia and cancer in patients with Barrettpatients with Barrett’’s. Role of anti-reflux s. Role of anti-reflux surgery controversial. surgery controversial.

Patients with low-grade dysplasia are Patients with low-grade dysplasia are monitored more frequently than those monitored more frequently than those with no dysplasia. ? Eradicate the with no dysplasia. ? Eradicate the Barrett’s. If not, recheck every 6-12 Barrett’s. If not, recheck every 6-12 months vs. every 3-5 yrs.months vs. every 3-5 yrs.

Options for patients with high-grade Options for patients with high-grade dysplasia include doing nothing, dysplasia include doing nothing, surgical resection, intensive surgical resection, intensive monitoring, photodynamic treatment, monitoring, photodynamic treatment, endoscopic mucosal resection, argon endoscopic mucosal resection, argon plasma coagulation, radio frequency plasma coagulation, radio frequency ablation (HALO), and endoscopic ablation (HALO), and endoscopic spray cryotherapy spray cryotherapy

Barrx 360 RFA Balloon Barrx 360 RFA Balloon CatheterCatheter

26 y/o male with history of recurrent 26 y/o male with history of recurrent dysphagia for solids which seem to dysphagia for solids which seem to catch at midsubsternal level. Drinks catch at midsubsternal level. Drinks fluids to clear the “obstruction.” Has fluids to clear the “obstruction.” Has been going on for about 6 months. been going on for about 6 months. Denies heartburn or other reflux Denies heartburn or other reflux symptoms.symptoms.

Past hx. negative aside from many Past hx. negative aside from many year hx. of asthma. year hx. of asthma.

WHAT IS YOUR DIFFERENTIAL WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?DIAGNOSIS?

EOSINOPHILIC ESOPHAGITISEOSINOPHILIC ESOPHAGITIS

Also known as Also known as ““allergic esophagitisallergic esophagitis””.. Predominant symptom is dysphagia.Predominant symptom is dysphagia. Increasing incidence over past two Increasing incidence over past two

decades.decades. Occurs in both children and adults with Occurs in both children and adults with

majority being males. In adults, majority majority being males. In adults, majority are in their 20are in their 20’’s and 30s and 30’’s.s.

High percentage have allergic issues High percentage have allergic issues including asthma, food allergies, hives, including asthma, food allergies, hives, hay fever.hay fever.

EOSINOPHILIC ESPHAGITIS (CONT)EOSINOPHILIC ESPHAGITIS (CONT) Findings can include multiple rings, Findings can include multiple rings,

narrowed esophagus, whitish narrowed esophagus, whitish nodules, furrows, & strictures in nodules, furrows, & strictures in upper esophagus.upper esophagus.

Some cases have involved several Some cases have involved several family members.family members.

Etiology may relate to food allergies, Etiology may relate to food allergies, additives, pollen, reflux?additives, pollen, reflux?

FURROWSFURROWS

TREATMENTTREATMENT Trial of anti-reflux medication-PPI.Trial of anti-reflux medication-PPI. Allergy testing and diet changes. Allergy testing and diet changes.

Elemental dietElemental diet Avoidance of six most frequent allergenic Avoidance of six most frequent allergenic

foods (eggs, soy, wheat, cow-milk protein, foods (eggs, soy, wheat, cow-milk protein, peanuts, and seafood). SFEDpeanuts, and seafood). SFED

Steroid inhaler- swallowing rather than Steroid inhaler- swallowing rather than inhaling the medication. Fluticasone inhaling the medication. Fluticasone propionate.propionate.

Oral Prednisone- higher incidence of side Oral Prednisone- higher incidence of side effects.effects.

Dilitation- risks of perforation.Dilitation- risks of perforation.

SCHATZKISCHATZKI’’S RINGS RING Occur at the distal end of esophagus at Occur at the distal end of esophagus at

junction of esophagus and stomach. junction of esophagus and stomach. Often are assymptomatic.Often are assymptomatic.

Probably are a consequence of reflux.Probably are a consequence of reflux. Treatment is dilitation with bougie or Treatment is dilitation with bougie or

balloon- may be best to go directly to balloon- may be best to go directly to large size ( 50 french or larger).large size ( 50 french or larger).

Data shows decreased rate of recurrence Data shows decreased rate of recurrence with placing patients on anti-reflux with placing patients on anti-reflux medications.medications.

SCHATZKISCHATZKI’’S RINGS RING

ESOPHAGEAL STRICTUREESOPHAGEAL STRICTURE

ESOPHAGEAL STRICTURESESOPHAGEAL STRICTURES Many causes including reflux, Many causes including reflux,

malignancy, radiation, toxic ingestions malignancy, radiation, toxic ingestions (e.g. lye), surgical anastomoses, (e.g. lye), surgical anastomoses, sclerotherapy.sclerotherapy.

Dilitation generally done gradually Dilitation generally done gradually stepwise, often no more than three sizes stepwise, often no more than three sizes on one day.on one day.

Balloons (TTS) and standard dilators Balloons (TTS) and standard dilators seem to produce similar results.seem to produce similar results.

Longterm anti-reflux therapy can reduce Longterm anti-reflux therapy can reduce recurrence rate in many cases.recurrence rate in many cases.

69 y/o male with 1 ½ year of 69 y/o male with 1 ½ year of dysphagia primarily for solids which dysphagia primarily for solids which sometimes lodge in area of lower neck sometimes lodge in area of lower neck or upper chest region. Also has or upper chest region. Also has experience of coughing up small bits experience of coughing up small bits of food he ingested at a previous meal. of food he ingested at a previous meal.

WHAT DIAGNOSES WOULD YOU WHAT DIAGNOSES WOULD YOU CONSIDER?CONSIDER?

ZENKERZENKER’’S DIVERTICULUMS DIVERTICULUM Diverticulum occuring at junction of Diverticulum occuring at junction of

pharynx and upper esophagus.pharynx and upper esophagus. The The ““pocketpocket”” faces posteriorly. faces posteriorly. Dysphagia often occurs immediately with Dysphagia often occurs immediately with

swallowing.swallowing. Presents with dysphagia and/or spitting Presents with dysphagia and/or spitting

up of food eaten earlier. Also may up of food eaten earlier. Also may complain of halitosis.complain of halitosis.

Thought to be due to malfunctioning of Thought to be due to malfunctioning of the upper esophageal sphincter. the upper esophageal sphincter.

ZENKERZENKER’’S DIVERTICULUMS DIVERTICULUM

Zenker’s Diverticulum Zenker’s Diverticulum (cont.)(cont.)

Treatment options include surgery Treatment options include surgery through side of the neck with cutting through side of the neck with cutting the sphincter along with possible the sphincter along with possible removal of the diverticulum or an removal of the diverticulum or an endoscopic technique known as endoscopic technique known as endoscopic staple-assisted endoscopic staple-assisted esophagodiverticulostomy. esophagodiverticulostomy.

NORMAL ESOPHAGEAL NORMAL ESOPHAGEAL MANOMETRYMANOMETRY

ACHALASIAACHALASIA Achalasia is well recognized as a cause of Achalasia is well recognized as a cause of

swallowing difficulty. swallowing difficulty. Distal esophageal sphincter does not Distal esophageal sphincter does not

relax with a swallow and the muscle of relax with a swallow and the muscle of the lower esophagus does not propel the the lower esophagus does not propel the food or liquid downwards i.e. abnormal food or liquid downwards i.e. abnormal peristalsis.peristalsis.

Result is dysphagia, occasionally chest Result is dysphagia, occasionally chest pain and regurgitation, and weight losspain and regurgitation, and weight loss

X-rays can reveal a dilated esophagus.X-rays can reveal a dilated esophagus.

ACHALASIA (CONT.)ACHALASIA (CONT.)

On endoscopy often see retained On endoscopy often see retained food and secretions in esophagus food and secretions in esophagus even though patient has been NPO.even though patient has been NPO.

Characteristic “yield” of LES to the Characteristic “yield” of LES to the scope being advanced.scope being advanced.

““Pseudo-achalasiaPseudo-achalasia””

X-RAYS OF ACHALASIAX-RAYS OF ACHALASIA

ACHALASIA TREATMENTACHALASIA TREATMENT Three common treatment optionsThree common treatment options Pneumatic forceful balloon dilitation with Pneumatic forceful balloon dilitation with

Rigiflex balloon. May not work; Rigiflex balloon. May not work; uncomfortable for patient; 3-5% risk of uncomfortable for patient; 3-5% risk of perforation.perforation.

Botox injection. Not always successful. Tends Botox injection. Not always successful. Tends to lose effect in 6-12 months requiring to lose effect in 6-12 months requiring reinjection. Good option for poor surgical reinjection. Good option for poor surgical candidates.candidates.

Surgery-laparoscopic myotomy. Cut the Surgery-laparoscopic myotomy. Cut the sphincter and add partial fundoplication. sphincter and add partial fundoplication.

Rarely, Calcium Channel blockers or Nitrates.Rarely, Calcium Channel blockers or Nitrates.

OTHER MOTILITY PROBLEMSOTHER MOTILITY PROBLEMS Nutcracker esophagus, diffuse esophageal Nutcracker esophagus, diffuse esophageal

spasm, and hypertensive lower esophageal spasm, and hypertensive lower esophageal sphincter are three patterns often seen.sphincter are three patterns often seen.

Controversy as to whether these Controversy as to whether these conditions can cause non-cardiac chest conditions can cause non-cardiac chest pain and/or dysphagia.pain and/or dysphagia.

In spite of these uncertainties treatment is In spite of these uncertainties treatment is often tried to see if clinical response.often tried to see if clinical response.

In some patients, may be related to reflux In some patients, may be related to reflux and therefore often give trial of anti-reflux and therefore often give trial of anti-reflux medication first.medication first.

DIFFUSE ESOPHAGEAL SPASMDIFFUSE ESOPHAGEAL SPASM

HYPERTENSIVE LESHYPERTENSIVE LES

NUTCRACKER ESOPHAGUSNUTCRACKER ESOPHAGUS

Treatment Treatment In many patients improvement can be a In many patients improvement can be a

consequence of learning they donconsequence of learning they don’’t have t have a serious cardiac issue.a serious cardiac issue.

First line therapy often consists of a First line therapy often consists of a calcium channel blocker (diltiazem) or an calcium channel blocker (diltiazem) or an antidepressant (imipramine). Can use antidepressant (imipramine). Can use nitrates or sildenafil on an as needed nitrates or sildenafil on an as needed basis.basis.

Other options include trial of hot liquids Other options include trial of hot liquids with meals, botox injection, bougie.with meals, botox injection, bougie.

Esophageal VaricesEsophageal Varices

All patients with cirrhosis should have EGD All patients with cirrhosis should have EGD screening for varices.screening for varices.

No varices- rescope in couple years.No varices- rescope in couple years. Small varices- consider NSBB in these Small varices- consider NSBB in these

patientspatients Large varices- low risk group probably use Large varices- low risk group probably use

NSBB. High risk group (red wale signs, NSBB. High risk group (red wale signs, advanced liver disease) can choose between advanced liver disease) can choose between NSBB and EVL. Add PPI after EVL (ulceration)NSBB and EVL. Add PPI after EVL (ulceration)

Sclerotherapy not warranted for primary Sclerotherapy not warranted for primary prevention of bleeding.prevention of bleeding.

Esophageal VaricesEsophageal Varices

Esophageal VaricesEsophageal Varices

Case PresentationCase Presentation

18 y/o female in excellent general health 18 y/o female in excellent general health awakens in the morning with rather awakens in the morning with rather severe substernal chest pain when she severe substernal chest pain when she swallows anything even saliva. Has never swallows anything even saliva. Has never had similar problems in the past. had similar problems in the past.

Her only medication is doxycycline which Her only medication is doxycycline which she has taken for acne for 2 years.she has taken for acne for 2 years.

WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

Medication UlcersMedication Ulcers

First reported with KCl. Now known to be First reported with KCl. Now known to be associated with multiple meds including associated with multiple meds including quinidine, tetracyclines (doxycycline), quinidine, tetracyclines (doxycycline), iron products, alendronate, and anti-iron products, alendronate, and anti-inflamatory medications most often ASAinflamatory medications most often ASA

Onset is usual rapid and most often Onset is usual rapid and most often noticable on awakening in AM. Chest noticable on awakening in AM. Chest pain, odynophagia.pain, odynophagia.

Injury caused by direct contact of the Injury caused by direct contact of the caustic contents of the medicationcaustic contents of the medication

Treatment of Pill UlcersTreatment of Pill Ulcers

No evidence that any medication No evidence that any medication speeds healing. Typically resolves in a speeds healing. Typically resolves in a few days.few days.

Pain meds.Pain meds. May need parenteral support in rare May need parenteral support in rare

cases.cases. Can try suspension of sucralfate Can try suspension of sucralfate

(Carafate) or topical anesthetic (Carafate) or topical anesthetic (xylocaine).(xylocaine).