Esophageal Disorders By George Vagujhelyi MD
Cardinal symptoms • Heartburn • Bland or sour regurgitation • Chest Pain • Dysphagia • Odynophagia
Atypical Symptoms • Dyspepsia(epigastric burning and fullness) • Nausea and Vomiting • Hematemesis • Globus • Coughing • Throat clearing • Throat pain • Hoarseness • Wheezing/stridor • Dyspnea • Apnea • Halitosis
Esophageal disorders • Gastroesophageal Reflux Disease • Barrett’s Esophagus • Eosinophilic Esophagitis • Intrinsic Structural disorders • Systemic Disorders • Iatrogenic
Gastroesophageal Reflux • Most common esophageal disorder • This is where gastric contents refluxes into the esophagus • TLESR( transient lower esophageal sphincter relaxation) • <1 min inhibition of the tone LES • Decrease contraction of circular muscle of esophagus • Cessation of diaphragmatic • Contraction of the longitudinal esophageal muscle. • Requires an intact vagal nerve • Triggered by abd distension, awake and in postprandial state • All this is a normal physiological response to venting
GERD • People with GERD develop more acid reflux during TRLES and extended further proximally • Compounding factors: • Obesity • Conditions that increase pressure difference between the abd and thoracic cavity • Delayed emptying • Delay in clearance of acid contents ( salivary production, peristalsis)
GERD • Most commonly diagnosed GI disorder • 9 million o/p visits annually • Occurs in all ages • 40 % of adults have an event monthly • 18% report weekly • Actual organ damage in fewer then 50% of patients who present with symptoms • Of those who have EGD 10 % have esophagitis,3-4% Barrett’s, Adeno CA
GERD risk factors • Obesity • Hiatal hernia • Smoking • NSAIDS • Aging • IBS • Anxiety/depression • FHx • HP and Chronic atrophic gastritis (inverse association)
GERD complications • Esophagitis and ulceration • Strictures • Peptic • Distal location near GEJ • Erosions, ulcerations and Barrett’s • Higher • Pill • Neoplasia • EoE
GERD complications • Barrett’s Esophagus • demonstrates salmon-colored mucosa and the biopsy shows intestinal metaplasia with goblet cells. • Prevalence is about 1-2 % • Half don’t report typical GERD symptoms • Risk factors • Erosive esophagitis • Male • White • Heavy ETOH • Hiatal hernia • Low LES • Dysfunctional peristalsis
Extra esophageal manifestation of GERD • These structures are not normal exposed to acid reflux • Thus no neutralizing mechanism • No clearance mechanism • Asthma • Aspiration pneumontitis/pul fibrosis • Laryngitis/vocal cord lesions • Chronic cough • Dental erosions • Sinusitis • Otitis media
Therapy • Lifestyle changes • Medical therapy • PPI once a day prior to the first meal • Twice a day dosage for those with erosive disease for a period of time only to be titrated down to control symptoms • Non erosive reflux disease • Consider short course therapy to control symptoms • Surgery • Initial results are good but then symptoms of dysphagia and gas-bloat may off set • About half of the patients will require repeat surgery or medical therapy.
Eosinophilic Esophagitis • Is an esophageal dysfunction accompanied by pathological evidence of predominantly eosinophilic inflammation in the esophagus • The eosinophilic infiltration is about 15/high powered field • Prevalence <1 per 1000 • It seems to be increasing • Diagnosis is less in the winter months • More prevalent in Male non-Hispanic whites 20
EoE • Clinical presentation • Solid food dysphagia • Most common diagnosis in young people with food impaction • May have other atopic conditions ( eczema, allergic rhinitis,food allergy) • Endoscopic findings • Corrugated mucosa • Longitudinal mucosal furrows • Whites spots/plaques • Focal rings and strictures • Diffusely small-caliber esophageal lumen • Fragile mucosa • Try to involve an allergist
EoE • Therapy • Removal food impactions • Dilation which may need to be repeated, may results in rents and odynophagia • However unless there is not a dominant stricture driving the dysphagia • Defer dilation try avoidance of the food • Medical therapy • PPI therapy 20-40 mg QD-BID • Systemic steroids 2mg/kg/d 60 mg max for 4 wks course severe symptoms • Fluticasone 880-1760 mcg/d risk of candida esophagitis • Elemental diet great for kids, expensive poorly tolerated do to feeding tube • Six food elimination( wheat,milk,eggs,soy,peanuts,fish,shell) • Targeted elimination based on allergy test ( low response rate)
EoE • Associated conditions • GERD • Eosinophilic gastritis • Celiac disease • IBD • Drug reactions • Hypereosinophilic syndromes • Infections • Autoimmune disorders
Systemic Disorders • Diabetes • Predispose to GERD • Type 2 DM • Obese • Hyperglycemia increase TLESR response to gastric distension • Delayed gastric emptying • Less sensitive to abnormal amounts of reflux • Reflux esophagitis common finding in DKA • Candida esophagitis
Systemic disorders • Connective tissue disorders • Systemic sclerosis • Mixed connective tissue • Reduced LES • Atrophic smooth muscle • Delayed gastric emptying • Sjogrens syndrome • Reduced saliva • Risk for iatrogenic causes secondary to immunosuppression, pill injury and bisphosphonates
Dermatological disorders • There is squamous epithelial tissue in the esophagus thus several systemic disease that affect the skin can manifest in the esophagus as well • Epidermolysis bullosa • Bullous phemphigoid • Pemphigus vulgaris • Steven-Johnson • Lichen planus
iatrogenic • Pill induced • ASA,NSAIDS • Bisphosphonates • KCL • Doxycycline/tetracycline • Ascorbic acid • Ferrous sulfate • They cause symptoms of worsening heartburn, chest pain , dysphagia and/or odynophagia • Medications • Inhibit smooth muscle tone and contractility • Calcium channel blocker • Theophylline • Beta-agonist • Anticholinergic properties • radiation
Diagnosis • For patients with classical symptoms • Heartburn( substernal postprandial burning with upward radiation) • High likelihood they have GERD • Trail of PPI therapy good response no further testing • Odynophagia, dysphagia • Need EGD • Alarming symptoms • Wt loss • FFt • Vomiting • Hematemesis
Therapy failures No n compliance • • Improper timing • Inadequate dosage • Rapid metabolizer • Nocturnal acid breakthrough • False positive GERD • Another esophageal disorder( achalasia,EoE) • Functional disorder • Z-E syndrome • EoE • Celiac disease • Medication induced • Infection • Delayed gastric emptying
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