Esophageal DisordersBy

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• Non 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