Disease 1.

Achalasia 40 and above

Description Absent or ineffective peristalsis of distal esophagus, with failure of the esophageal sphincter to relax in response to swallowing Narrowing just above the stomach: increasing dilation in the upper chest

Signs and Symptoms Dysphagia (both liquid & solid) Sensation of food sticking in the lower portion of the esophagus Regurgitation happens as the dse progresses to relieve discomfort Chest pain Heartburn (pyrosis) Aspiration

Diagnosis Manometry confirms diagnosis; measures esophageal pressure. X-ray shows esophageal dilation above the narrowing at gastroesophageal junction.

Medical/Surgical Mgt Calcium channel blockers and nitrates

Description/Rationale Decrease pressure and improve swallowing Inhibits contraction of smooth muscle Stretch narrowed area Separate esophageal muscle fibers

Nursing Mgt Eat slowly Drink fluids with meals!

Botox via endoscopy Pneumatic dilation *Monitor perforation: abd tenderness, fever Esophagomyotomy laparoscopically, with or without antireflux

2. Diffuse Esophageal Spasm Women of middle age

Motor disorder Unknown cause; stress possible

Dysphagia Odynophagia Chest pain similar to coronary artery spasm

Manometry measures motility and pressure reveals simultaneous contractions. X-ray show separate areas of spasm

Conservative therapy: sedatives, long acting nitrates, calcium channel blockers Bougienage, pneumatic dilation or esophagomyotomy Esophageal Heller myotomy

Relieve pain

SFF Soft diet

If pain becomes intolerable

Transhiatal esophagectomy

Cardiac sphincter id cut, allowing food and liquids to pass into stomach Open surgical approach

3. Hiatal Hernia Women

Hiatus; Opening in the diaphragm thru which the esophagus passes becomes enlarged, part of upper stomach tends to move up to lower portion of the thorax I. Sliding: upper stomach and gastroesophageal junction are displaced upward and slide in and out of the thorax II. Paraesophageal: all part of the stomach pushes through the diaphragm beside the esophagus

Heartburn Regurgitation Dysphagia At least 50% asymptomatic Sliding: reflux Paraesophageal: sense of fullness or chest pain after eating, or no sx; no reflux because sphincter is intact

X-ray Barium swallow Endoscopy

Mgt same to gastroesophageal reflux May require emergency surgery

To correct torsion (twisting) of the stomach that leads to the restriction of blood flow

SFF Do not recline 1 hour after eating. Elevate head of bed 4-8 inch to prevent sliding

Any type: Hemorrhage Obstruction Estrangulation

4. Diverticulum Men

Outpouching of the mucosa and submucosa that protrudes through a weak portion of the musculature May occur in one of the three areas: 1. Upper: Zenkers diverticulum aka Pharyngoesophageal pulsion diveticulum or pharyngeal pouch Most common; occurs posteriorly through cricopharyngeal muscle in the midline of the neck; M >60 years

1. Upper/Zenkers/ Pharyngoesophageal: dysphagia, fullness in the neck, belching, regurgitation when lying, coughing due to irritation of trachea, gurgling noises after eating, pouch filled with food or liquid, halitosis or sour taste

Barium swallow to etermine exact nature and location Manometry for epiphrenic to rule out motor do

Contra: 1. Esophagoscopy (danger of

Pharyngoesophageal (progressive): removal of diverticulum through diverticulectomy Myotomy of cricopharyngeal muscle NGT

Care is taken to avoid trauma to common carotid and interjugular veins To relieve spasticity of the musculature

Postop: Monitor leakage from the esophagus and a developing fistula Food and fluids withheld until x-ray shows no leakage at surg. Site

2. Midesophageal uncommon, less acute, does not require surgery 3. Lower: Epiphrenic Larger, just above the diaphragm r/t improper functioning of lower esophageal sphincter or motor do 4. Intramural Occurrence of many divurticula in the upper esophagus

2. Midesophageal: less acute 3. Lower/Epiphrenic: 1/3 Asymptomatic, 2/3 dysphagia and chest pain 4. Intramural: dysphagia

perforation, mediastinitis) 2. Blind insertion of NGT

Diet begins with liquids Mid and epiphrenic: Surgery only if sx are worse, troublesome Intramural: Regress even if stricture is dilated through surgery

5. Perforation