Anatomy of Esophagus Hollow tube formed of striated muscle
(upper part) and smooth muscle (lower part). Length about 20-30 cm
in adults. Fibers of the cricopharyngeus muscle represent the upper
esophageal sphincter (UES). In thoracic cavity it lies in posterior
mediastinum, posterior to the trachea. Leaves thorax through
diaphragmatic hiatus Lower esophageal sphincter (LES) about 3-5 cm
long, ?physiological sphincter.
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Esophageal Anatomy Upper Esophageal Sphincter (UES) Lower
Esophageal Sphincter (LES) Esophageal Body (cervical &
thoracic) 18 to 24 cm
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Microscopic Anatomy of esophagus Mucosa: Lined with stratified
squamous epithelium, rich in glycogen. Lamina propria muscularis
mucosa : thin layer of smooth muscle Submucosa The outer muscular
layers: striated in the upper part and smooth in lower 2/3 No
serosal covering.
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Physiology UES: tonically closed, opens 0.2-0.3 sec after a
swallow. Peristaltic contractions, duration less than 7 sec and
amplitude less than 150 mmHg, velocity less than 8 cm/sec LES:
tonically closed at rest, pressure 20 mmHg, cholinergic mediated,
relaxes with swallowing. Transient LES relaxation, independent of
swallowing is the major cause of reflux.
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Normal Phases of Swallowing Voluntary oropharyngeal phase bolus
is voluntarily moved into the pharynx Involuntary UES relaxation
peristalsis (aboral movement) LES relaxation Between swallows UES
prevents air entering the esophagus during inspiration and prevents
esophagopharyngeal reflux LES prevents gastroesophageal reflux
peristaltic and non-peristaltic contractions in response to stimuli
capacity for retrograde movement (belch, vomiting) and
decompression
Upper Esophageal Motility Disorders cause oropharyngeal
dysphagia (transfer dysphagia) patients complain of difficulty
swallowing tracheal aspiration may cause symptoms
pharyngoesophageal neuromuscular disorders stroke Parkinsons
Poliomyelitis multiple sclerosis diabetes myasthenia gravis
dermatomyositis and polymyositis upper esophageal sphincter
(cricopharyngeal) dysfunction
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UES Disorders cricopharyngeal hypertension elevated UES resting
tone poorly understood (reflex due to acid reflux or distension)
cricopharyngeal achalasia incomplete UES relaxation during swallow
may be related to Zenkers diverticula in some patients clinical
manifestations localizes as upper (cervical) dysphagia within
seconds of swallowing coughing, choking, immediate regurgitation,
or nasal regurgitation diagnosis: swallow evaluation & modified
barium swallow
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Motility Disorders of the Body & LES symptoms: usually
dysphagia (intermittent and occurring with liquids & solids)
diagnostic tests barium esophagram endoscopy esophageal manometry
disorders achalasia diffuse esophageal spasm (DES) nutcracker
esophagus hypertensive LES nonspecific esophageal dysmotility
hypomotility hypermotlity
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Achalasia Failure of relaxation of the LES with swallowing and
aperistalsis in lower esophagus. Due to decreased or absent
intramural esophageal ganglion cells.
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Symptoms of Achalasia Dysphagia to fluids and solids,
intermittent, long - standing. Regurgitation of undigested food
Chest pain Aspiration Weight loss
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Diagnosis of achalasia Esophageal manometry: Absent peristalsis
High LES pressure Failure of relaxation of LES. Radiographic
studies Endoscopy to exclude organic disease.
Diffuse Esophageal Spasm frequent non-peristaltic contractions
simultaneous onset (or too rapid propagation) of contractions in
two or more recording leads occur with >30% of wet swallows (up
to 10% may be seen in normals)
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Nutcracker Esophagus high pressure peristaltic contractions avg
pressure in 10 wet swallows is >180 mm Hg 33% have long duration
contractions (>6 sec) may inter-convert with DES
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Hypertensive LES Nonspecific Esophageal Dysmotility high LES
pressure >45 mm Hg normal peristalsis often overlaps with other
motility disorders abnormal motility pattern fits in no other
category non-peristalsis in 20- 30% of wet swallows low pressure
waves (
Spastic Motility Disorders of the Esophagus epidemiology any
age (mean age 40) female > male symptoms dysphagia to solids and
liquids intermittent and non-progressive present in 30-60%, more
prevalent in DES (in most studies) chest pain constant % across the
different disorders (80-90%) swallowing is not necessarily impaired
can mimic cardiac chest pain pyrosis (20%) and IBS symptoms
(>50%) symptoms and manometry correlate poorly
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Spastic Motility Disorders of the Esophagus diagnosis manometry
barium esophagram endoscopy pH monitoring treatment reassurance
nitrates, anticholinergics, hydralazine - all unproven calcium
channel blockers - too few data with negative controlled studies in
chest pain psychotropic drugs trazodone, imipramine and setraline
effective in controlled studies dilation - anecdotal reports,
probable placebo effect
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Hypomotilty Disorders primary (idiopathic) aging produces
gradual decrease in contraction strength reflux patients have
varying degrees of hypomotility more common in patients with
atypical reflux symptoms usually persists after reflux therapy
defined as low contraction wave pressures ( of wet swallows
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secondary scleroderma in >75% of patients progressive,
resulting in aperistalsis in smooth-muscle region incompetent LES
with reflux other connective tissue diseases CREST polymyositis
& dermatomyositis diabetes 60% with neuropathy have abnormal
motility on testing (most asx) other hypothyroidism, alcoholism,
amyloidosis
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Gastroesophageal Reflux
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DEFINITIONS Gasrtoesophageal reflux: Reflux of gastric contents
to the esophagus Gastroesophageal reflux disease (GERD): Any
significant symptomatic clinical condition or histopathological
changes resulting from reflux. Reflux esophagitis: GERD patients
with histopathologically demonstrable changes in the esophageal
mucosa.
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Epidemiology of GERD Heartburn is a very common condition: 3%
of population experience heartburn daily 7% frequently 15% weekly
25% monthly Most common in pregnant women: 80% Common in obese and
smokers
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Mechanisms of GERD Transient LES relaxation Hypotensive LES
Decreased esophageal acid clearance Hiatus hernia Impaired
salivation.
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CLINICAL PICTURE OF GERD ESOPHAGEAL SYMPTOMS EXTRAESOPHAGEAL
SYMPTOMS
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ESOPHAGEAL SYMPTOMS OF GERD HEARTBURN REGURGITATION Dysphagia
Chest pain Water brash Nausea and vomiting Belching Hicough
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EXTRAESOPHAGEAL SYMPTOMS OF GERD Chronic cough Asthma recurrent
pneumonitis nocturnal choking hoarseness of voice posterior
laryngitis with ulceration and granuloma formation. sore throat
dental disease Earache Globus sensation
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Diagnosis of GERD Clinical picture. UGI endoscopy. 24 hour pH
monitoring Radioisotope scanning Bernstein test : esophageal acid
perfusion Barium swallow.
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Endoscopy: Normal Junction
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Reflux esophagitis
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Complications of GERD Stricture formation Chronic blood loss
Barretts epithelium Adenocarcinoma
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Esophageal stricture
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Barrettes epithelium
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Natural history of GERD May be acute condition in a small
percentage Mostly chronic condition with recurrent symptoms
Majority can be controlled on drugs Majority may require a sort of
acid suppressive therapy at 5 years No clear relation exists
between symptoms of reflux, amount of reflux or degree of
esophagitis.
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Management of GERD Life- style modification: avoid cigarette
smoking dietary manipulation: decrease fatty, spicy and acidic
foods decrease weight elevation of the head of the bed avoid tight
abdominal binders avoid constipation avoid large meals avoid drugs
which decrease LES pressure avoid sleeping after meals for at least
3 hours.
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Pharmacologic therapy of GERD Antacids: Mg trisilicate
Aluminium hydroxide Ca carbonate sodium bicarbonate. H2-blockers:
Cimetidine ranitidine famotidine nizatidine
Antireflux surgery Indications: complicated reflux non
compliance for medication refractory GERD patients preference
severe disease in young person Most popular operation now is
laparoscopic fundoplication
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Treatment of Barretts epithelium BE usually occurs in
longstanding severe reflux disease BE does not regress after
fundoplication or PPI therapy Screening for dysplasia? If high
grade dysplasia found: esophagectomy Ablation of BE: Photodynamic
therapy Argon plasma coagulation Endoscopic mucosal resection