LE3: DISEASES OF ESOPHAGUS
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Need to know
HEARTBURN (PYROSIS)
• Most common esophageal • Sour/ burning fluid in throat.
symptom • Vomiting: preceded by nausea, radiating to mid-back, arms, or jaws.
• Relieved with drinking
water/ antiacid • Rumination: regurgitation of plexus.
• Interfering sleep
• Associated with GERD.
ENDOSCOPY
• Most useful in evaluation
of esophageal, gastric, &
duodenal lumen.
• Diagnostic and
therapeutic (ability to
dilate strictures)
•
SLIDING HIATAL HERNIA
• gastroesophageal
junction and gastric
cardia translocate
cephalad.
• enlarge with
increased
intraabdominal
pressure, swallowing,
and respiration.
• main significance is
the propensity of
affected individuals
to have GERD
SYMPTOMS OF ESOPHAGEAL DISEASES
REGURGITATION CHEST PAIN ESOPHAGEAL DYSPHAGIA ODYNOPHAGIA GLOBUS SENSATION
• Pressure type sensation in mid-chest • Achalasia (motility disorder): • More common • Relieved by
dysphagia with solid and liquids with Pill or swallowing
accompanied by retching • Esophagus & heart share same nerve • Stricture, ring, or tumor: dysphagia Infectious • Assoc with Anxiety
with solid food. esophagitis or OCD.
swallowed food then • GERD: most common cause of • Symptoms assoc. with oropharyngeal
swallowed repetitively for an esophageal chest pain dysphagia:
hour. • Coronary Artery Disease: always o Aspiration
excluded before the esophagus is o Nasopharyngeal regurgitation
considered as the origin of atypical chest o Cough
pain o Drooling
o Neuromuscular compromise.
DIAGNOSTICS
CONTRAST RADIOGRAPHY ENDOSCOPIC ULTRASOUND (EUS) ESOPHAGEAL MANOMETRY REFLUX TESTING
• Better visualize • Create transmural image. • Motility test, assess peristaltic • Done by ambulatory 24 to 96-hour
hypopharyngeal pathology • Provide greater resolution. integrity. esophageal pH recording
& disorder of • Confirm diagnosis of motility • Outcome expressed as percentage of
cricopharygeus muscle. disorders such as achalasia, the day that the pH was high or low.
scleroderma, diffuse esophageal
spasm.
STRUCTURAL DISORDERS OF THE ESOPAGUS
HIATAL HERNIA LOWER ESOPHAGEAL MUCOSAL RING (B RING) WEBS
PARA-ESOPHAGEAL HERNIA • Thin membranous narrowing at the • originate along the
• esophagogastric junction remains fixed in its normal location squamocolumnar mucosal junction anterior aspect of the
and a pouch of stomach is herniated beside the • Treated with balloon dilatation esophagus.
gastroesophageal junction. • Schatzki rings: present older than 40 years; Plummer-Vinson syndrome: (+)
• type II and III: stomach inverts as it herniates and large para- most common cause of intermittent food symptomatic proximal
esophageal hernias can lead to: “upside down stomach”, impaction → ‘steakhouse syndrome esophageal webs and iron-
gastric volvulus, strangulation of stomach. → need surgical deficiency anemia in middle-
repair. aged women
• Type II - the gastroesophageal junction remains fixed at the
hiatus.
• Type III - combined sliding and para-esophageal hernia.
• Type IV hiatal hernias: viscera herniate into the mediastinum,
most commonly the COLON.

Zenker’s Diverticulum
• Obstruction site: stenotic
cricopharyngeus muscle &
hypopharyngeal herniation
(Killian’s triangle)
• Tx: Surgical diverticulectomy and
cricopharyngeal myotomy;
Marsupialization procedure
STRUCTURAL DISORDERS OF THE ESOPAGUS
DIVERTICULA
Epiphrenic Diverticula
• Assoc with: Achalasia, Esophageal
hypercontractile disorders, & Distal
esophageal stricture
Midesophageal Diverticula
• True diverticula (involves ALL
layers)
• caused by: Tuberculosis
TUMORS ESOPHAGEAL ATRESIA
• shift of dominant esophageal cancer type • Most common congenital
from squamous cell to adenocarcinoma. esophageal anomaly.
• linked to reflux disease and Barrett’s
metaplasia.
• Adenocarcinoma: affect the distal
esophagus
• Squamous cell carcinoma: affect more
proximal esophagus.
• SX: progressive solid food dysphagia +
weight loss.
• poor survival because of the abundant
esophageal lymphatics leading to regional
lymph node metastases

ESOPHAGEAL MOTILITY DISORDERS

ACHALASIA
Features • Characterized by: Progressive dilatation,
Sigmoid deformity of the esophagus, &
Hypertrophy of the LES
• Cause of ganglion cell degeneration →
autoimmune process attributable to a
latent infection with human herpes
simplex virus 1 combined with genetic
susceptibility.
• Complications: bronchitis, pneumonia, or
lung abscess
Symptoms • Dysphagia
• Chest pain: described as squeezing,
pressure-like retrosternal pain.
• Regurgitation & Weight loss
Diagnostics • Chest X-ray: (+) Tubular mediastinal mass
beside the aorta, (+) Air fluid level in the
mediastinum in the upright view
, (-) Gastric air bubble
• Barium Swallow: (+) Esophageal dilatation,
esophagus may become sigmoid or S-
shaped. (+) Bird’s beak-like narrowing –
represents non-relaxing LES
• Endoscopy: n to exclude pseudoachalasia
Treatment • Only durable therapy: Pneumatic (balloon)
dilatation & Heller Myotomy
• Endoscopic therapy:
o Botilunum toxin injection
DIFFUSE ESOPHAGEAL SPASM (DES)
• Features exhibits overlap with cardiac • With rising incidence of: Adenocarcinoma of
Pain
• Esophageal “chest” pain mimics angina
pectoris.
• “Corkscrew esophagus”
• Rosary bead esophagus
• Esophageal Manometer:
o Uncoordinated (“spastic”) activity int he
distal esophagus
o Spontaneous and repetitive
contractions
o High amplitude and prolonged
contractions
o indicative of an impairment in the
inhibitory myenteric plexus neurons
• Long myotomy or Esophagectomy – only
indicated with severe weight loss or
unbearable pain
GASTROESOPHAGEAL REFLUX DISEASE (GERD) EOSINOPHILIC ESOPHAGITIS (EoE)
• Atopic history is present
the esophagus
• Mechanisms: Transient LES relaxations, LES
hypotension, & Anatomic distortion of the
esophagogastric junction inclusive of hiatus
hernia.
• Barret’s Metaplasia: Most severe histologic
consequence of GERD
• Heartburn • Dysphagia and esophageal food
• Regurgitation impactions
• Extraesophageal manifestations: Chronic
cough, Laryngitis, Asthma, Dental erosions
• • Endoscopic findings:
o Loss of vascular markings,
o Multiple esophageal rings
o Longitudinally oriented furrows
o Punctate exudate
• Histologic: esophageal mucosal
eosinophilia (peak density of ≥ 15
eosinophils/hpf)
• H2 receptor blocking agents. • Do PPI trial therapy:
• Proton pump inhibitors (PPIs): More effective, o PPI-responsive
does not increase the risk of carcinoid tumors; o PPI-nonresponsive: consider
prolonged use have an increased incidence of elimination of diet & swallowed
topical glucocorticoids.
 o Pneumatic Balloon dilatation: Most hip fractures (because absorption of Vit. B12 & • Esophageal dilation: done if with
popular endoscopic treatment for Calcium are interrupted) risk of perforation.
achalasia • Surgical Treatment: Laparoscopic Nissen
• Surgical: Laparoscopic Heller Myotomy: Fundoplication
most common surgical procedure • Endoscopic Mucosal Ablation Therapy:
o Esophageal resection with gastric pull-up indicated for presence of High-Grade Dysplasia
→ done for refractory cases

INFECTIOUS ESOPHAGITIS
Disease CANDIDA ESOPHAGITIS HERPETIC ESOPHAGITIS VIRAL ESOPHAGITIS CYTOMEGALOVIRUS ESOPHAGITIS
Features • Etiologic agents: Herpes simplex • Occurs in immunocompromised patients,
virus type 1 or 2 particularly with organ transplant recipients
• Limited to squamous epithelium.
Symptoms • (+) Oral thrush • Vesicles on the nose and lips. • Serpiginous ulcers (snake-like)
• Vesicles and small, punched-out
ulcerations.
Diagnostics • Prompt endoscopy with biopsy: most useful • Histologic findings: ground-glass nuclei, • Histologic findings: pathognomonic large
diagnostic evaluation eosinophilic Cowdry’s Type A inclusion nuclear or cytoplasmic inclusion bodies
• Endoscopic findings: white plaques with friability bodies and giant cells
Treatment • Oral fluconazole - preferred treatment • Acyclovir • Ganciclovir take 3-6 weeks
• Voriconazole or Posaconazole
- if refractory to fluconazole
• Intravenous Echinocandin – cannot tolerate oral
drug intake.

MECHANICAL TRAUMA AND IATROGENIC INJURY

Disease
ESOPHAGEAL PERFORATION
Features • Boerhaave’s Syndrome:
Forceful vomiting or retching
→ spontaneous rupture at
CORROSIVE FOREIGN BODY/ FOOD
MALLORY-WEISS TEAR RADIATION ESOPHAGITIS PILL ESOPHAGITIS
ESOPHAGITIS IMPACTION
• Non-transmural tear at • complicate treatment • Caustic esophageal • Mid-Esophagus: Most common • Causes: Peptic
the GEJ for thoracic cancers, injury location for the pill to lodge in. stricture, carcinoma,
• Common cause of upper with the risk • Absence of oral • Most common pills: Schatzki ring, EoE,
GI bleeding. injury does not doxycycline, tetracycline, Inattentive eating
 the gastroesophageal
junction.
• Mediastinitis: major
complication of esophageal
perforation
Symptoms
Diagnostics • CT of the chest: most
sensitive in detecting
mediastinal air.
• Confirmed by: Contrast
swallow (Gastrografin)
followed by thin barium
Treatment • Nasogastric suction and
parenteral broad-spectrum
antibiotics with prompt
surgical drainage and repair
• Caused by: vomiting, proportional to exclude possible quinidine, phenytoin,
retching or vigorous radiation dosage esophageal potassium chloride, ferrous
coughing followed by involvement sulfate, bisphosphonates,
hematemesis NSAIDS
• Sudden onset of chest pain & • Inability to handle
odynophagia. secretions (foaming at
• Develops over a period of hours the mouth) and severe
or will awaken the individual chest pain
from sleep.
• Esophageal mucosa • Endoscopic • •
becomes erythematous, evaluation
edematous, & friable
• Endoscopic clipping: done • Supportive • Upper GI endoscopy • No specific therapy • Glucagon (1mg) IV:
to stop bleeding • Esophageal dilation: for with repeated tried before
Chronic strictures dilatation endoscopic
dislodgement.
• Endoscopic
dislodgement

ESOPHAGEAL MANIFESTATIONS OF SYSTEMIC DISEASE

Disease SCLERODERMA ESOPHAGUS DERMATOLOGIC DISEASES
Features • Hypotensive LES and absence of esophageal peristalsis • Pemphigus vulgaris
• Predispose patients to severe GERD • Bullous pemphigoid
• Cicatricial pemphigoid
• Behcet’s syndrome
• Epidermolysis bullosa
Diagnostics • Histopathologic findings:
o Infiltration and destruction of the esophageal muscularis propria
o Collagen deposition
o Fibrosis
Treatment • Glucocorticoid treatment
• Esophageal dilatation - treat strictures