Internal Medicine EXIMIUS

DISEASES OF THE ESOPHAGUS 2021

Michael Razote, MD SEPT 6, 2019

Structure and function Rumination - Behavior in which recently swallowed food is

regurgitated and repeatedly swallowed.
Chest pain - Pressure type sensation in the midchest,
radiating to the midback, arms, and jaws.
Dysphagia - Feeling of food “sticking” or even lodging in the
chest.
Odynophagia - Pain caused or exacerbated by swallowing
Globus sensation - Perception of lump or fullness in the throat
Water brash - Excessive salivation resulting from vagal reflex
triggered by acidifation of the esophageal
mucosa

Diagnostic studies
 Endoscopy
 Radiography
 Endoscopic utz
 Esophageal manometry
 Reflux testing

STRUCTURAL DISORDERS
(hiatal hernia)

Symptoms
 Heartburn
 Regurgitation
 Chest pain
 Dysphagia
 Odynophagia
 Globus sensation
 Others:
◦ Weight gain/loss, gi bleeding, dietary habits
(meak skipping, smoking, and alcohol)
Heartburn - Discomfort/burning sensation substernally that
originates from the epigastrium and radiates to the
neck
Regurgitation - Effortless return of food or fluid into the pharynx
without nausea/retching
Vomiting - Preceded by nausea and accompanied by retching

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 Internal Medicine EXIMIUS
DISEASES OF THE ESOPHAGUS 2021
Michael Razote, MD SEPT 6, 2019

 Esophageal motility disorders

1. Achalasia
- loss of ganglion cells within the esophageal
myenteric plexus with autoiimune pathology
- beak-like appearance on barium swallow
- impaired les relaxation and absent peristalsis
◦ Esophageal manometry is most sensitive test
◦ Tx:
 Calcium channel blockers
 Nitrates
 Botox
 Sildenafil
 Endoscopic: pneumatic dilation
 Surgical : heller myotomy and partial
fundoplication
◦ Risk for squamous cell ca (17 fold)

 Diffuse esophageal spasm

◦ Dysphagia nd chest pain attributable to
abnormal esophageal contractions with normal
deglutitive les relaxation
◦ Radiographic :corkscrew esophagus
◦ Manometric findings:
 Spastic activity of distal esophagus
 Spontaneous and repetitive
contractions
 High-amplitude and prolonged
contractions
◦ Dysphagia and esophageal pain
◦ Diagnosis of exclusion

 Dxtics:
 Rings and webs ◦ Endoscopy
◦ B ring ◦ Radiography
◦ Schatzki ring  Corkscrew, rosary bead,
◦ Cervical esophageal webs pseudodiverticula, curling
 Diverticula  Txtics:
◦ Epiphrenic ◦ Same as achalasia
◦ Hypopharyngeal ◦ Rct supports anxiolytics
◦ Midesophageal ◦ Surgical therapy by long myotomy and
esophagectomy if with weight loss and
 Tumors unbearable pain
◦ Squamous cell ca
◦ Adenocarcinoma GASTROESOPHAGEAL REFLUX DISEASE (GERD)
◦ Benign:  Family of conditions caused by gastroesophageal reflux
 Leiomyoma resulting in either troublesome symptoms or an array of
 Fibrovascular polyps potential esophageal and extraesophageal symptoms.
 Squamous papilloma ◦ Esophageal injury includes:
 Lipomas  Esophagitis
 Granular cell tumors  Barretts esophagus
 Neurofibromas  Adenocarcinoma
Pathophysiology
 Congenital anomalies  Mechanisms of esophagogastric junction incompetence:
◦ Esophageal atresia ◦ Transient les relaxation
◦ Tef ◦ Les hypotension
◦ Heterotopic gastric mucosa ◦ Anatomic distortion of eg junction inclusive of
hiatus hernia
 Abdominal obesity
 Pregnancy

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 Internal Medicine EXIMIUS
DISEASES OF THE ESOPHAGUS 2021
Michael Razote, MD SEPT 6, 2019

 Gastric hypersecretory states ◦ Mallory-weiss tear

 Disruption of esophageal peristalsis  Transmural tear at eg juntion after
 Gluttony retching, vomiting, or vigorous
 Esophageal injury caused not only by gastric acid but by coughing
bile, pepsin, and pancreatic enzymed in gastric refluxate.  Presents as hematemesis
 Symptoms  Therapeutic endoscop
◦ Heartburn ◦ Radiation esophagitis
◦ Regurgitation  Caomplication of treatment from
◦ Dysphagia thoracic cancers
◦ Chest pain  Radiation dose of more than 5000 cgy
◦ Extraesophageal assoc. Symptoms:  Dysphagia and odynophagia
 Chronic cough  Results in esophageal stricture
 Laryngitis ◦ Corrosive esophagitis
 Asthma  Accidental, suicidal, and homicidal
 Dental erosions  Acid or alkali
 Differential Diagnosis: ◦ Pill esophagitis
◦ Infectious, pill, eosinophillic esophagitis  Lodges in midesophageal area due to
◦ Pud poor pill taking habits
◦ Dyspepsia
◦ Biliary colic  Foreign bodies and food impaction
◦ Cad ◦ Food impaction is an endoscopic emergency
◦ Esophageal motility disorders ◦ chest pain and foaming in the mouth
 Complications: ◦ May result in ischemia and perforation
◦ Chronic esophagitis (bleeding and stricture)  Esophageal cancer
◦ Esophageal adenocarcinoma ◦ Incidence and etiology
 Treatment:  Increasingly common and lethal
◦ Lifestyle modifications  Squamous and adenocarcinoma
 Avoidance of food that reduces les  Different causative mechanisms
pressure A. Squamous carcinoma
 Avoidance of acidic foods ◦ Alcohol, smoking, carcinogens, physical agents,
 Adoption of behaviors to minimize others (table 109.1)
reflux and/or heartburn B. Adernocarcinoma
◦ Pharmacologic: ◦ Barrets metaplasia, obesity, chronic gerd, male,
 Ppi and h2r smoking
◦ Surgical:  Clinical features
 Laparoscopic fundoplication ◦ Upper 5%, middle 20%, distal 75%
◦ Progressive dysphagia
ESOPHAGITIS ◦ Weight loss
 Infectious ◦ Odynophagia
◦ Candida ◦ Hest/back pain
 C. Albicans ◦ Regurgitation/vomiting
 Esophageal stasis sec. To motility ◦ Aspiration pneumonia
disorders and diverticula ◦ Mets to supraclavic ln, liver, lung, pleura and
 Dysphagia and odynophagia bones
 Endoscopy with biopsy ◦ Tef
 Compli: bleeding, perforation, ◦ Hypercalcemia
stricture, and fungemia  Diagnosis:
 Oral azoles and iv echinocandin ◦ Endoscopy
 Aids infection ◦ Bronchoscopy
◦ Herpetic and cmv esophagitis ◦ Ct
◦ Pet
MECHANICAL TRAUMA AND IATROGENIC INJURY  Treatment:
 Esophageal perforation
◦ Total resection of gross tumor (45%) of cases
◦ Instrumentation
◦ Postop mortality rate of 5%
 Endoscopy, ngt placement
◦ Endoscopic resention
 Spontaneous (boerhaave’s syndrome)
◦ Endoscopic ablation
 Endoscopic food disimpaction
◦ Combination of chemo + radiotherapy + surgery
 Esophageal dilation
◦ Palliative care for unresectable lesions.

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