“Note's & Note's by Ashiq” Disorders of the oesophagus

Gastro-oesophageal reflux disease:-***

♦️ Overview:-
● Gastro-oesophageal reflux resulting in heartburn affects approximately 15% of the
general population.
● Occasional episodes of gastro-oesophageal reflux are common in healthy individuals.
● Reflux is normally followed by oesophageal peristaltic waves.
● Poor correlation between symptoms & endoscopy appearance.
● It occurs during transient relaxation of the lower oesophageal sphincter (LES).
● GORD is the most common non-cardiac cause of chest pain. ( SBA )
● GORD is one of the most common causes of a persistent cough. ***
● Acid reflux in chronic GORD can lead to damage of the enamel layer of teeth.

♦️ Pathophysiology:-

✔️ Gastro-oesophageal reflux disease (GORD) develops when the oesophageal mucosa is

exposed to gastroduodenal contents for prolonged periods of time, resulting in symptoms and,
in proportion of cases oesophagitis.

✔️ Transient lower oesophageal sphincter relaxation is the most common cause. (SBA)
The main stimulus for Transient relaxation of lower oesophageal sphincter is gastric distension,
particularly in the fundus.

♦️ Causes:-
“Note's & Note's by Ashiq” Disorders of the oesophagus

● Pregnancy and obesity ( established predisposing causes ).

● Dietary fat, chocolate, alcohol, tea & coffee ( relax the LES & may provoke symptoms ).
Mnemonics:-
“FACT!!”
F > Dietary Fat.
A > Alcohol.
C > Chocolate & Coffee
T > Tea

● Abnormal lower oesophageal sphincter.

● Hiatus hernia. ( ≥ 90% of patients with severe GORD )
● Defective oesophageal clearance.
● Gastric Acid - pepsin & bile
( Gastric Acid is the most important oesophageal irritant ) ( SBA )

● Delayed gastric emptying ( the reason is unknown )

● Increased intra - abdominal pressure

♦️ Clinical Features:-

● Heartburn & Regurgitation ( major symptoms often provoked by bending,

straining or lying down ).
● Waterbrush ( excessive salivation ).
● Choking at night ( as refluxed fluid irritates the larynx ).
● Odynophagia or dysphagia.
● Atypical chest pain ( may be severe & can mimic angina ) ; it may be due to
reflux- induced oesophageal spasm.
***GORD is the most common non cardiac cause of chest pain. ( SBA ).

⏩
● Extraesophageal symptoms ( eg, chronic cough, hoarseness, wheezing )
The three most common causes of a persistent cough are postnasal drip,
Asthma & GORD.

♠️ SBA Clue For Exam:-

“ Pregnant/ Obese / Overweight / older people along with Dietary factors + Heartburn &
Regurgitation provoked by lying down, bending or straining + Wokes at night by choking
+ Odyno or Dysphagia, atypical chest pain with Extraesophageal symptoms “ >> GORD
“Note's & Note's by Ashiq” Disorders of the oesophagus

♦️ Complications of GORD:- (MCQ)

1 ) Oesophagitis
2 ) Barrett's oesophagus
3 ) Iron deficiency Anemia
4 ) Benign oesophageal structure
5 ) Gastric Volvulus.

🔵 Oesophagitis:-
The hallmark of oesophagitis is odynophagia or pain on swallowing. **** ( SBA )
There is a poor correlation between symptoms & histological & endoscopic findings.

🔵 Consequences of long standing oesophagitis:- (MCQ)

✅ Hiatus hernia
✅ Iron deficiency anemia &
✅ Benign fibrous oesophageal stricture.
🔵 Hiatus hernia:-
- Herniation of the stomach through the diaphragm into the chest.
- Occurs in 30% of the population over the age of 50 years.
- Often asymtomatic.
- Heartburn & Regurgitation can occur.
- Gastric volvulus may complicate large hernias.

- Almost all patients who develop oesophagitis, Barrett's oesophagus or peptic

structures are found to have a hiatus hernia.
“Note's & Note's by Ashiq” Disorders of the oesophagus

- Hiatus hernia is very common & most patients have a large hiatus hernia & bleeding
can stem from subtle erosions in neck of the sac ( Cameron lesions ). Cameron
lesions is found in >> Hiatus hernia*** (SBA)

🔵 Barrett's oesophagus overview:- ( V.V.I for MRCP exam )

● It's a Premalignant Condition.

● The normal squamous lining of lower oesophagus is replaced by columnar mucosa that
may contain areas of intestinal metaplasia.
● It has been suggested that duodenogastro- oesophageal reflux of bile , pancreatic
enzymes & pepsin, as well as gastric acid, maybe important in the pathogenesis.
● Patients are often asymtomatic until discovered & present with oesophageal cancer.
● It's an adaptive response to chronic gastro esophageal reflux & is found in 10% of
patients undergoing gastroscopy for reflux symptoms.
● The relative risk of oesophageal cancer is increased 40-120 fold. Although the
absolute risk is low (< 1 %).
● Cigarette smoking is a moderate risk factor, while there is a less clear association with
Alcohol.
● Inactivation of the tumor suppressor protein p16 is a key event, followed by somatic
inactivation of TP53.
“Note's & Note's by Ashiq” Disorders of the oesophagus

✅ Risk Factors of Barrett's oesophagus:-

Age > 50 years.
Male gender.
Ethnicity: more common in white populations (especially of European ancestry)
than Hispanic, Black , or Asian.
Central Obesity.
Long duration or frequency of Gastro-oesophageal reflux disease ( GORD )
symptoms. ( Single strongest Risk factor ) ***** ( SBA )
Previous oesophagitis.
Hiatus hernia.

🔵 SBA Clue For Exam:-

“ A male patient aged over 50 years of age + history of Cigarette smoking + Central
Obese + H/O previous oesophagitis + Long duration or frequency of GORD + pink
columnar mucosa seen in lower oesophageal mucosa during endoscopy “ >> Think
about. “Barrett's oesophagus.”

🔵 Diagnosis of “ Barrett's oesophagus “ :-

ENDOSCOPY is the Gold standard for diagnosis. ***** (SBA).
Multiple systematic biopsies are taken, in addition to sampling any visible lesions, to maximise
the chance of detecting intestinal metaplasia and / or dysplasia.
Most Barret's oesophagus is undetected until cancer develops.

🔵 Management of Barrett's oesophagus:- ( Less imp for FCPS but V.V.I for MRCP )
- Treatment is indicated only for symptoms of reflux or complications such as stricture.
- Endoscopic therapies ( such as- radio frequency ablation or photodynamic therapy ) can
induce regression and at present it may be used for those with dysplasia & mucosal
oesophageal adenocarcinoma.
- Management is based on presence or absence of Dysplasia.
“Note's & Note's by Ashiq” Disorders of the oesophagus

01 ) endoscopic surveillance with biopsies:-

✔️ Nondysplastic :-
No dysplasia and <3 cm segment of Barrett's >> endoscopy every three to five
years with biopsies.
NO dysplasia and segment Barrett's >3 cm >> endoscopy every two to three years.

Low grade dysplasia >> repeat endoscopic biopsy in 6 months. If LGD is found >>
Radio frequency ablation.
If ablation is not undertaken, 6 monthly surveillance is recommended.

Moderate To High grade dysplasia or recurrent disease >>

Repeat endoscopic biopsy in 3 months. If a visible lesion is present consider-

✅ 1st line:- Endoscopic ablation therapy with mucosal resection (EMR) or Radio
Frequency ablation (RFA).

✅ 2nd line:- Oesophagectomy.

2 ) High-dose proton pump inhibitor :-

The best next line of management.

whilst this is commonly used in patients with Barrett's the evidence base that this
reduces the change of progression to dysplasia or induces regression of the lesion is
limited.

🔵 Anemia:-
Iron deficiency anemia can occur as a consequence of occult blood loss from long standing
oesophagitis. A post cricoid web is a rare complication of iron deficiency anemia
( Patterson - Kelly or Plummer - Vinson syndrome ), and maybe complicated by the
development of Squamous carcinoma.

🔵 Benign oesophageal stricture:-

- It is usually a consequence of GORD.
- Occurs specially in older people & those with poor oesophageal peristaltic activity.
- The typical presentation is with dysphagia that is worse for solids than for liquids.
“Note's & Note's by Ashiq” Disorders of the oesophagus

- Bolus obstruction following ingestion of meal causes absolute dysphagia.

- Schatzki ring is found in Benign oesophageal stricture*** ( SBA ) & cause intermittent
dysphagia, often starting in middle age.
- A history of heartburn is common but not invariable.

🔵 SBA Clue For Exam:-

“ Older people presents with dysphagia ( solids > liquids ) + bolus obstruction following
ingestion of meal causes dysphagia + H/O Heartburn + Schatzki ring is found by Barium
studies >> Benign oesophageal stricture **

✅ Diagnosis of benign oesophageal stricture:-

Diagnosis is by Endoscopy ( SBA ) *** when biopsies of the structure can be taken to exclude
malignancy.

✅ Management of benign oesophageal stricture:-

- long-term therapy with a PPI at full dose should be started to reduce the risk of recurrent
oesophagitis and stricture formation.
- The patient should be advised to chew food thoroughly and it is important to ensure
adequate dentition.
- Endoscopic balloon dilatation or bouginage is helpful.
“Note's & Note's by Ashiq” Disorders of the oesophagus

🔵 Gastric Volvulus:-
Occasionally, a massive intrathoracic hiatus hernia may twist on itself, lead-
ing to a gastric volvulus.
This gives rise to complete oesophageal or gastric obstruction and the patient presents
with severe chest pain, vomiting and dysphagia.

✅ Diagnosis:- The diagnosis is made by chest X-ray (air bubble in the

chest) and barium swallow ).

✅ Management:- A nasogastric tube is normally

inserted in the acute phase to facilitate decompression, with surgery usually
advised after the acute episode. Endoscopic decompression may be an
alternative option in selected patients in old age.

🔵 SBA Clue For Exam:-

“ Patient usually aged over 50 years+ presents with severe chest pain, vomiting &
dysphagia + H/O Oesophagitis, Heartburn & Regurgitation + air bubble founds in the
chest X-ray >> Gastric Volvulus “

♦️ Investigations Of GORD:-

Young patients who present with typical symptoms of gastro- oesophageal reflux,
without worrying features such as dysphagia, weight loss or anemia, can be treated
empirically without investigation.
" Investigation is advisable if patients present over the age of 50-55 years, if
symptoms are atypical or if a complication is suspected.

Endoscopy is the investigation of choice. ( SBA )****

24hr oesophageal pH monitoring is gold standard investigation in GORD ( SBA ) ****
Oesophageal pH monitoring is indicated if the diagnosis is unclear or surgical
intervention is under consideration. An oesophageal pH of less than 4 for more than 6%
of the study time is considered diagnostic for reflux disease.
“Note's & Note's by Ashiq” Disorders of the oesophagus

🔵 What are the indications for Upper GI Endoscopy ❓❓

✅ No symptomatic improvement after PPI trial ( symptoms> 4 weeks or persistent symptoms
despite treatment)

✅ Alarm features -
1. Age > 55 years.
2. Relapsing symptoms.
3. Weight loss.
4. Dysphagia.
5. Odynophagia.
6. Early satiety.
7. Persistent vomiting.
8. Aspiration pneumonia.
9. Evidence of gastrointestinal bleeding (haematemesis, melena, hematochezia, occult
blood in stool).
10. Iron deficiency anemia.
11. Anorexia.
12. Gastrointestinal cancer in a first degree relative.

There's poor correlation between symptoms and histological & endoscopic findings.

🔵 Demo Qué:-
A 25 year's old alcoholic man comes to you with the complaints of burning sensation of
chest during bed time. He also notes that he wakes up at night few times for this

❓❓
problem. His appetite is good & no swallowing difficulties. What's the next possible
investigation in this case

A Chest X-ray
B Endoscopy
C 24th hour osophageal pH

✅
D Oesophageal manometry
E No investigation is needed.

Ans :- E
“Note's & Note's by Ashiq” Disorders of the oesophagus

♦️ Management:-

01 ) Lifestyle changes’-

- Weight loss.
- Avoidance of dietary items that worsen symptoms.
- Elevation of the bed head in those who experience nocturnal symptoms.
- Don't lie down after eating.
- Eat small servings.
- Avoidance of late meals.
- Avoid spicy foods.
- Cessation of smoking.
- Avoid nicotine, alcohol, coffee, and certain drugs ( e.g: Calcium channel blockers,
diazepam).

02 ) Pharmacological:- If lifestyle changes are ineffective

should be offered PPIs ( (omeprazole, lansoprazole) which are usually effective in

resolving symptoms and healing oesophagitis.Recurrence of symptoms is common
when therapy is stopped and some patients require life-long treatment at the lowest
acceptable dose. The risks described with PPIs are relatively modest, but patients
should receive the lowest dose of PPIs to manage their symptoms.

H2 receptor antagonist ( cimetidine, ranitidine ) drugs relieve symptoms without

healing oesophagitis.
Proprietary antacids and alginates can also provide symptomatic benefit.

There is no evidence that H.pylori eradication has any therapeutic value but H. pylori
eradication is advised in patients requiring PPIs for more than 1 year.

Consequences of Long-term PPI therapy:-

Long-term PPI therapy can lead to-

● the development of parietal cell hyperplasia and hypertrophy, leading to acid rebound on
withdrawal of PPIs after long-term usage.

● PPI therapy is also associated with reduced absorption of iron, B12and magnesium.
(MCQ)*** mnemonics; “ BMI” (B12, magnesium & iron !!)

● may also predispose to enteric infections with Salmonella, Campylobacter and

possibly Clostridioides difficile. *** (MCQ).
mnemonics; “ CSD “ (Campylo, Salmonella & Difficile).
“Note's & Note's by Ashiq” Disorders of the oesophagus

● They may have an undesirable impact on the composition of the gut microbiota,
although the clinical importance of this is unclear
.
● An association between microscopic colitis and PPIs has also been suggested, as well
as with acute interstitial nephritis.

● Long-term therapy increases the risk of Helicobacter-associated progression of

gastric mucosal atrophy.

03 ) Surgical:-

Patients who fail to respond to medical therapy, those who are unwilling to take long-term PPIs
and those whose major symptom is severe regurgitation should be considered for laparoscopic
fundoplication.

The treatment of choice for patients with GORD refractory to or intolerant of

proton pump inhibitor therapy is Laparoscopic Nissen fundoplication. ( SBA ) ****

♦️Other causes of oesophagitis:-

🔵 Infection:-
✅ Oesophageal candidiasis:-
● It occurs in debilitated patients and those taking broad-spectrum antibiotics or cytotoxic
drugs.
● It is a particular problem in patients with HIV/AIDS.
● Oesophageal candidiasis (Fig. 14.7) is the most common cause of pain on
swallowing (odynophagia), dysphagia and regurgitation in advanced HIV infection.
(SBA)
“Note's & Note's by Ashiq” Disorders of the oesophagus

✅ Diagnosis:-
• Endoscopy with a biopsy ( SBA ) ***

✅ Treatment:-
Systemic azole therapy, e.g. fluconazole 200 mg daily for 14 days, is usually effective
but relapses are common.

Patients whose oesophageal symptoms fail to respond to azoles should be investigated

with oesophagoscopy.

🔵 Corrosives:-
Suicide attempt by ingestion of caustic acid (e.g. vinegar) or alkaline agents (e.g. bleach) is
followed by painful burns of the mouth and pharynx and by extensive erosive oesophagitis. Late
complications include oesophageal strictures.
“Note's & Note's by Ashiq” Disorders of the oesophagus

🔵 Drugs:-
Drugs causing oesophagitis - ( MCQ )**
Potassium supplements & NSAIDS.
Bisphosphonates
Tetracyclines such as doxycycline.

🔵 Eosinophilic oesophagitis:-
✔️ OVERVIEW:-
- It affects both children & adults, and is more common in males.
- It occurs more often in atopic individuals & is characterised by eosinophilic infiltration of
the oesophageal mucosa.

➡️
- Should be considered in adults with-

➡️
H/O food impaction, with persistent dysphagia, or
GORD that fails to respond to medical therapy.

- Associated with Allergies: ( asthma, rhinitis, atopic - dermatitis, alimentary allergies )

✔️ Features:-
Episodic oesophageal spasm and intermittent dysphagia.

Children commonly present with vomiting, difficulty feeding or failure to thrive.

In contrast, adults present with dysphagia or food bolus obstruction more often than
heartburn. Chest pain maybe present.

🔵 SBA Clue For Exam:-

“ patient presents with food impaction + dysphagia + chest pain + H/O atopy” >>
Eosinophilic Oesophagitis ( SBA ) *****

🔵 Diagnosis:-
● Upper endoscopy with esophageal biopsy >> presence of epithelial infiltrate of ≥ 15
eosinophils per high- power microscopy field.
“Note's & Note's by Ashiq” Disorders of the oesophagus

🔵 Treatment:-
First line treatment is dietary modifications that include elemental & elimination diets.
Refer for allergy testing (Eosinophilic esophagitis commonly associated with allergies).
Once an antigen is identified, avoidance can improve symptoms.

Pharmacological management, an empiric 8- week trail of high dose PPI can be used
in the first instance.

In patients who do not respond, 8-12 weeks therapy with topical glucocorticoids
( such as fluticasone & budesonide ) can be used.

♦️ Tumors of the oesophagus:-

🔵 Benign tumors:-
The most common benign tumor of the oesophagus is “Leiomyoma” **** ( SBA )
“Note's & Note's by Ashiq” Disorders of the oesophagus

🔵 Carcinoma of the oesophagus:-

Overview:-

● Squamous oesophageal cancer accounts for 90% of oesophageal cancers globally.

● Squamous cell carcinoma ( SCC ) is the most common type of oesophageal cancer
worldwide. **** ( SBA )
● Adenocarcinoma, most common type of oesophageal cancer in the UK & US.
● H. pylori infection associated with DECREASE incidence of oesophageal cancer.
● Helicobacter pylori may actually be protective against oesophageal cancer

Types:-

Squamous cell carcinoma ( SCC ):-

✅ Squamous cancer can occur in any part of the oesophagus, Although almost all tumors in
✅ The most prevalent oesophageal cancer worldwide. **** ( SBA )
the upper oesophagus are squamous cancers. *** ( SBA )

✅ Occurs most often in the upper two-thirds of the esophagus. **** ( SBA )

✅ The primary risk factors for squamous cell esophageal cancer are alcohol consumption,
smoking, and dietary factors ( e.g; diet low in fruits & vegetables )

✅ Dermatological conditions associated with esophageal carcinoma >> Tylosis ( 95% will
✅ Tylosis is a rare autosomal dominant disorder characterized by hyperkeratosis of the
get squamous cell carcer. *** ( SBA )

palms and soles, with thickening and fissuring of the skin.

✅ Prognosis:- Poor long - term prognosis after resection

✅ Treatment:- More sensitive to chemo-radiotherapy than adenocarcinoma.
“Note's & Note's by Ashiq” Disorders of the oesophagus

Adenocarcinoma:-

✅ Affects primarily white men

✅ Occurs most often in the lower ⅓ rd portion of the esophagus ( near the
gastro-oesophageal junction ) from Barrett's oesophagus or from the cardia of the stomach.

✅ Alcohol is NOT a risk factor for Adenocarcinoma.

✅ The most important risk factors for esophageal adenocarcinoma are gastro-oesophageal
✅ Prognosis:- Better long- term prognosis after resection than that of SCC.
reflux & associated Barrett esophagus.

✅ Risk factors for adenocarcinoma:-

● Gastroesophageal reflux (GORD) → the most common predisposing factor. (SBA)
● Barrett esophagus.
● Smoking (twofold risk).
● Obesity.
● Male sex.
● Older age (50–60 years).

Clinical Features:-

Early stages - Often asymtomatic. Physical signs maybe absent but, even at initial
presentation cachexia, cervical lymphadenopathy or other evidence of metastatic spread
is common.
“Note's & Note's by Ashiq” Disorders of the oesophagus

Late stages - most patients have a H/O progressive, painless dysphagia for solid
foods. Others present acutely because of food bolus obstruction. In the late stages,
weight loss is often extreme.

Dysphagia is the most common presenting symptom*** ( SBA )

Chest pain or hoarseness suggests mediastinal invasion.

Sudden onset of hiccups is common when tumor spreads to diaphragm.

🔵 SBA Clue For Exam:-

“ elderly cachectic alcoholic male presents with progressive, painless dysphagia for
solid foods + H/O smoking & weight loss >> think about Oesophageal cancer “

Investigations:-

✅ The investigation of choice is Upper gastrointestinal endoscopy with biopsy**** (SBA)

It is the first line test.*** (SBA)

Once a diagnosis has been made, investigations should be performed to stage the tumour
and define operability.

✅ Staging:-
● For local tumor extent ( mural invasion or tumor depth ) :- Endoscopic ultrasound
( EUS )
● For distant metastases:-
CT of the Chest, abdomen and pelvis.
PET/CT scan is more sensitive than CT for detecting metastatic disease and are
now widely used for detecting occult metastases if metastases are not seen
on the initial staging CT scans.

Management:-

✅ The treatment Of choice is Surgery if the patient presents at a point at which resection is
possible. *** ( SBA ). Nevertheless most oesophageal cancers are not resectable at
presentation.
“Note's & Note's by Ashiq” Disorders of the oesophagus

✅ Superficial intramucosal oesophageal cancer is best managed by endoscopic mucosal

resection or endoscopic submucosal dissection with or without radio frequency ablation (RFA).
( have become established for Barrett's oesophagus and in particular, adenocarcinoma.

✅ Oesophagectomy is the treatment of choice for limited and locally advanced tumours
where resection is possible.

✅ For locally advanced tumours, neoadjuvant and perioperative chemotherapy or

chemoradiotherapy (e.g. cisplatin and capecitabine) can reduce the tumour bulk and increase
the chances of complete (R0) surgical resection.

*** Chemo-radiotherapy then surgery is preferred to surgery alone.

*** Squamous cell carcinoma is more sensitive to chemo-radiotherapy than
adenocarcinoma.

✅ Palliative:- Approximately 70% of patients have extensive disease at presentation;

in these, treatment is palliative and should focus on relief of dysphagia and pain.

♦️ Perforation Of The Oesophagus:-

Overview:-

● Oesophageal perforation is a rare but potentially life threatening clinical condition.

● The most common cause is iatrogenic endoscopic perforation complicating
dilatation or intubation. *** ( SBA ), symptoms usually within 24 hours of endoscopy.
● Malignant, corrosive or post-radiotherapy strictures are more likely to be perforated than
peptic strictures.
● Boerhaave syndrome is accounting for 15% cases of oesophageal perforation.
● Most perforations occur in the left posterior aspect of the oesophagus.

Boerhaave syndrome:-

Spontaneous oesophageal perforation results from forceful vomiting & retching is

called Boerhaave syndrome. *** ( SBA )
It is relatively uncommon but serious & potentially fatal
It is more common in men than women & typically present in those between 50-70
years old.
“Note's & Note's by Ashiq” Disorders of the oesophagus

May be associated with excessive intake of alcohol or food in the recent past.
It is a complete transmural laceration of the lower part of the oesophagus with
gastric contents entering the mediastinum & pleural cavity.

Features:-

● Severe chest pain & shock occur as oesophago-gastric contents enter the
mediastinum & thoracic cavity.
● Subcutaneous emphysema ( crepitus in the suprasternal notch ) , pleural effusions &
pneumothorax develop.
● The most relevant finding on examination is the crepitus over the chest. ***

🔵 SBA Clue For Exam:-

“ 50-70 years old men presents with Repeated vomiting followed by severe epigastric
pain with respiratory distress + H/O excessive food or alcohol consumption + O/E
crepitus is found over the chest >> Boerhaave syndrome”

Diagnosis:-

✅ The diagnosis is made using a water-soluble contrast swallow ( Gastrografin swallow )

& Is recommended first - line investigation (diagnostic).

✅ If a gastrografin swallow is not possible or negative or in difficult cases A CT scan should be

done.

✅ Chest X-ray:- The most common finding is a unilateral effusion usually on the left. It
may confirm the surgical emphysema.

Management:-

Surgery remains the mainstay of treatment for oesophageal perforation. *** ( SBA )
Early operation after appropriate resuscitation offers the best chance of survival.
“Note's & Note's by Ashiq” Disorders of the oesophagus

♦️ Oesophageal motility disorders:-

Pharyngeal pouch ( Oesophageal diverticulae )

Overview:-

● This occurs because of incoordination of swallowing within the pharynx, which leads to
herniation through the cricopharyngeus muscle and formation of a pouch.
● Zenker's diverticulum is the most common type of oesophageal diverticula.
● It is more common in older patients.
● Is most common in the seventh & eighth decades of life.
● 5 times more common in men.

Features:- Most patients have no symptoms others may have -

Dysphagia to solids & liquids ( most common ) ***

Regurgitation of undigested food.
Aspiration >> pneumonia.
Nocturnal chronic cough.
Retrostenal pressure sensation & pain.
Halitosis ( a bad breath )
Neck swelling which gurgles on palpation (Boyce’s sign).
Weight loss.

🔵 SBA Clue For Exam:-

“ Older men aged 70-80 years + dysphagia to both solids & liquids + gurgling sound
during swallowing or palpitation + Halitosis + a sensation of lump in the throat + chronic
nocturnal cough + regurgitation >> Pharyngeal pouch “

Diagnosis:- Investigation of choice is Barium swallow *** ( SBA )

Management:-
Treatment is indicated in symptomatic patients, and can be via a surgical approach,
such as cricopharyngeus myotomy (diverticulotomy), with or without resection of the pouch.
“Note's & Note's by Ashiq” Disorders of the oesophagus

Achalasia of the oesophagus:-

Epidemiology:-

● can present at any age but typically presents in middle age ( most often in the 3rd to 5th
decades )
● equally common in men & women

Pathophysiology:-

a hypertonic lower oesophageal sphincter which fails to relax in response to the

swallowing wave.
failure of propagated oesophageal contraction, leading to progressive dilatation of the
gullet. ( LOS contracted, oesophagus above dilated ).
defective release of nitric oxide by inhibitory neurons in the lower oesophageal
sphincter has been reported and there is degeneration of ganglion cells within the
sphincter & the body of the oesophagus.

Disease association:-

- It is associated with autoimmune diseases such as type 1’diabetes mellitus, systemic

lupus erythematosus, rheumatoid arthritis & sjögren's syndrome.

Causes:-
● Primary achalasia (most common): cause is unknown.
● Secondary achalasia (pseudoachalasia):
- mechanical obstruction e.g; a malignancy (ca of cardia).
- chagas disease ( infection with Trypanosoma cruzi in chagas disease causes
a syndrome that clinically indistinguishable from achalasia.

Clinical features:-

- Dysphagia of BOTH liquids & solids (as the disease progresses, dysphagia worsens).
Dysphagia affecting both solids & liquids from the start - think achalasia*** (SBA)

- Regurgitation to saliva & food.

- heartburn, aspiration pneumonia, cough (30% have a nocturnal cough due to aspiration
of esophageal contents).
“Note's & Note's by Ashiq” Disorders of the oesophagus

- episodes of chest pain due to oesophageal spasm.

- weight loss ( around one-third of patients )

🔵 SBA Clue For Exam:-

“ middle aged (30-40 years old) + dysphagia, typically to solids & liquids + regurgitation
to saliva & food + episodic chest pain + h/o weight loss + h/o any autoimmune diseases
such as type 1 DM” >> Achalasia ( SBA ) ****

Predispositions:-
● Achalasia predisposes to squamous carcinoma of the oesophagus.

Investigations:-

✅ Upper endoscopy
- to rule out pseudoachalasia (because ca of cardia can mimic the presentation &
radiological & manometric features of achalasia.

✅ Barium swallow
- Initial investigation (SBA) *** It shows tapered narrowing of the lower oesophagus.
- The most appropriate initial investigation of a high dysphagia is a barium swallow.
- Bird's beak/ rat’s tail appearance/ dilated tapering end found in barium swallow.
“Note's & Note's by Ashiq” Disorders of the oesophagus

✅ Manometry
- The confirmatory test of choice (SBA) *****
- The gold standard test for achalasia (SBA)) *****
- It confirms the high pressure, non-relaxing lower oesophageal sphincter with poor
contractility of the oesophageal body.

Management:-

Endoscopic:-

Forceful pneumatic dilatation disrupts the oesophageal sphincter and improves

symptoms in 80% of patients. Some patients require more than one dilatation, but those
needing frequent dilatation are best treated surgically.
Endoscopically directed injection of botulinum toxin into the lower oesophageal
sphincter induces clinical remission, but relapse is common, with worsening response
on repeated treatments. It tends to be reserved for frail individuals in old age where
other treatments are too risky.
Peroral endoscopic myotomy (POEM) is a newer advanced endoscopic technique for
the management of achalasia, but is currently only performed in specialist centres.

Surgical:-

Heller's cardiomyotomy (Laparoscopic myotomy)

- The best initial treatment for most patients with achalasia***(SBA)
- is effective but is more invasive than endoscopic dilatation.
- PPI therapy is often necessary after surgery.

Complications:-
● Both pneumatic dilatation and myotomy may be complicated by gastro-oesophageal
reflux, and this can lead to severe oesophagitis because oesophageal clearance is so
poor. For this reason, Heller’s myotomy is accompanied by a partial fundoplication
anti-reflux procedure.

♦️ Other oesophageal motility disorders:-

1. Distal oesophageal spasm.

2. ‘Nutcracker’oesophagus (is a condition in which extremely forceful peristaltic activity
leads to episodic chest pain and dysphagia)
“Note's & Note's by Ashiq” Disorders of the oesophagus

♦️ Secondary causes of oesophageal dysmotility:-

1 ) systemic sclerosis or CREST syndrome .

2 ) Dermatomyositis,
3 ) rheumatoid arthritis and
4 ) myasthenia gravis.

🔰 Reference:

🖤
❤️
Davidson 24th edition.

💙
Step up to MRCP , Dr Khaled El Magraby.
NOTE'S & NOTE'S, 3rd edition Dr. Yousif Hamad.

©️ Dr Mohammad Asiqur Rahman

MBBS ( SMC), BCS ( 42nd) Health,
FCPS Part-1 ( Medicine),
Medical officer, Kaliganj Upazila Health Complex, Satkhira .