Diseases of Esophagus & Dysphagia

Dr. Vishal Sharma

Diseases of esophagus

Contents
Esophagitis, Barrets esophagus & GERD Esophageal tear & perforation Esophageal web, ring, stricture, atresia Achalasia cardia Esophageal hiatus hernia Esophageal hypermotility disorder Esophageal vascular impression Esophageal neoplasm

Esophagitis

Etiology
Gastro-esophageal reflux disease (commonest) Infective: candidiasis, cytomegalovirus, HIV, herpes simplex, tuberculosis, Crohns disease, actinomycosis Caustic ingestion Medication: Iron, vitamin C, doxycycline, NSAID Iatrogenic: nasogastric tube, radiation Others: graft vs. host disease, uremia, eosinophilic esophagitis, benign pemphigoid, epidermolysis bullosa

Savary Monnier classification of esophageal erosion

Grade 1: Single erosion over single mucosal fold Grade 2: Erosions over multiple folds Grade 3: Circumferential mucosal erosions Grade 4: Erosion with definitive ulcer or stricture Grade 5: Columnar metaplasia (Barrets esophagus)

Grade 1 esophagitis
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Grade 2 esophagitis
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Grade 3 esophagitis
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Grade 4 esophagitis
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Grade 5 esophagitis
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Los Angeles Classification

Grade A: Mucosal break < 5 mm in length over single mucosal fold Grade B: Mucosal break > 5mm over single mucosal fold Grade C: Continuous mucosal break b/w > 2 mucosal folds but < 75% of esophageal circumference Grade D: Mucosal break >75% of esophageal circumference

Los Angeles Classification

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Gastro- Esophageal Reflux Disease

Predisposing factors
Inefficient lower esophageal sphincter due to: Pregnancy Obesity

Fatty food, large meals Coffee, chocolate Cigarette smoking Alcohol ingestion

Reflux promoting drugs (see under treatment) Scleroderma Hiatus hernia

Clinical features
Retro-sternal burning pain (heartburn / pyrosis) Dysphagia Chest pain Hoarseness, choking (laryngospasm), Bronchospasm / asthma Hematemesis & melaena Chronic cough due to aspiration pneumonia Symptomatic relief with trial of Pantoprazole

GERD
Burning pain

Angina pectoris

Gripping / crushing pain

Pain seldom radiates to arms Pain radiates into neck, Produced by bending, drinking hot liquids Relieved by antacids Dyspnea absent

shoulders & both arms Pain produced by exercise Relieved by rest Dyspnea present

Investigations
1. Flexible upper GI endoscopy 2. Ambulatory 24-hour double-probe (esophageal & pharyngeal) pH metry = gold standard
Distal probe = 5 cm above lower esophageal sphincter Proximal probe = 1 cm above upper esophageal sphincter, in hypopharynx behind laryngeal inlet Laryngo-pharyngeal reflux = acidic pH in both probes Gastro-esophageal reflux = acidic pH in distal probe only

24 hour ambulatory double-probe pH monitoing

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pH metry
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GERD Heartburn Hoarseness & dysphagia Nocturnal (supine) reflux Daytime (upright) reflux ed lower esophageal pH ed pharyngeal pH Pantoprazole treatment ++++ + ++++ + ++++ -

LPRD + ++++ ++++ ++ ++++

40 mg OD 40 mg BD X 6 X 6 wk mth

Treatment of GERD
A. Life style modifications: 1. Raise head end of bed by 6 inches. Sleep in left lateral position. Maintain optimum weight. 2. Avoid the following: Tight fitting clothes & belts Lifting of heavy weight / straining / stooping Smoking

B. Dietary modifications: 1. Take 6 small meals. Eat slowly & chew thoroughly. 2. Take high protein diet. 3. Avoid the following: Eating / drinking within 3 hours of reclining Fried food / excess fat / large meals Taking large amount of fluids with meals Aerated drinks / alcohol (especially in evening) Coffee / tea / chocolate / mint / citrus fruit juice

C. Avoid following medicines: Tranquilizers & sedatives Muscle relaxants Calcium channel blockers Anti-cholinergic drugs Theophylline N.S.A.I.Ds Doxycycline

Dietary + Life style modifications + avoid reflux producing medicines + Liquid antacid (2 tsp 1 hour before meals & at bed time) no relief after 4 weeks Ranitidine 150 mg BD + Cisapride 10 mg TID before meals no relief after 4 weeks Pantoprazole 40 mg OD before breakfast no relief after 4 weeks

Nissens complete fundoplication Click to edit Master text styles

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Nissens complete fundoplication Click to edit Master text styles

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Belsey Mark IV partial fundoplication

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Toupet repair
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Laparoscopic fundoplication
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Transoral fundoplication
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Hills fundoplication + posterior gastropexy

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anterior & posterior phreno-esophageal bundles (esophagogastric junction) sutured to pre-aortic fascia after fundoplication

Complications of GERD
Esophageal ulceration Esophageal stricture Iron-deficiency anemia Barrett's esophagus Laryngitis, laryngeal ulcers Bronchial asthma Aspiration pneumonia

Barrets esophagus
Presence of gastric epithelium more than 3 cm above gastro-esophageal junction caused by columnar metaplasia of squamous epithelium due to chronic acid exposure Pre-malignant condition for adenocarcinoma Rx: Pantoprazole + periodic esophagoscopy every 2 years to rule out dysplasia / malignancy

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Barrets esophagus
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Barrets esophagus with adenocarcinoma

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Esophageal ring, web, stricture & atresia

Web

Ring
Circumferential Consist of mucosa + muscle Involves distal esophagus E.g. Schatzki's ring of lower esophagus

Only part of lumen Consists of mucosa only

Involves proximal esophagus

E.g. web of Plummer Vinson Syndrome

Schatzkis ring
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Plummer Vinson Syndrome

Synonym: 1. Patterson Brown Kelly syndrome 2. Sideropenic dysphagia Seen in middle-aged females due to iron deficiency caused by atrophic gastritis or vitamin B12 deficiency (pernicious anemia) Classical Triad: upper esophageal web iron deficiency anemia (sideropenia) cheilitis / glossitis

Clinical features
Dysphagia: more to solids than liquids. Due to upper esophageal web caused by epithelial fibrosis. Pallor: iron deficiency anemia Koilonychia (spoon nails): iron deficiency anemia Cheilitis + glossitis: vitamin B12 deficiency sub-

Investigations
Barium swallow Esophagoscopy anterior wall web in upper esophagus

Blood smear: microcytic, hypochromic anemia Serum iron: decreased Total iron binding capacity: increased Gastric juice analysis: achlorhydria

Normal Iron levels

Male Total Iron 45-160 g / dL Female 30-160 g / dL 220-420 g / dL

Total iron binding 220-420 g / dL capacity Serum ferritin 20-323 ng /mL

10-291 ng /mL

Upper esophageal web

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Treatment
Supplementation: iron + vitamin B12 + vitamin B6 + folic acid Endoscopic dilatation of web with elastic bougie or Hurst mercury pneumatic dilator Electrosurgical incision or surgical resection of web for refractory cases Regular check endoscopy to rule out post-cricoid malignancy (seen in 10% cases)

Esophageal strictures
Definition: narrowing of esophageal lumen (normal diameter = 20 mm Dysphagia is main symptom (Solids > liquids) Etiology for multiple esophageal strictures: benign pemphigoid, epidermolysis bullosa, caustic ingestion, candidiasis, graft vs. host disease

Causes of single stricture

GERD, esophagitis, Barrets esophagus Caustic ingestion: corrosives, hot fluid Trauma: foreign body, external injury Medication capsules & tablets Radiotherapy, sclerotherapy Surgical anastomosis of esophagus Malignancy Congenital: involves lower 1/3rd

Benign stricture
Multiple Regular mucosa Proximal esophageal dilation present At sites of normal constrictions

Malignant stricture
Single Irregular mucosa Proximal dilation absent due to cancer invasion Involves any site in esophagus

Caustic stricture
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Benign pemphigoid
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Multiple strictures

Benign epidermolysis bullosa

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Multiple strictures

Hand contractures

Asymmetric malignant stricture

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Esophageal compression
Extrinsic compression
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Intra-mural compression
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Esophagoscopy
Confirms diagnosis Evaluates position of stricture Evaluates length of stricture Rules out malignancy
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Treatment of corrosive Acid = superficial coagulative necrosis (better) ingestion

Alkali = penetrating liquefaction necrosis (worse) 1. Hospitalize + treatment of shock & acid-base balance 2. Stricture prevention by: Steroid given within 48 hours for 6 weeks Careful nasogastric tube insertion for 3 weeks N-acetyl cysteine / Penicillamine: es collagen bonding 3. IV antibiotics + antacids + analgesics

Surgical treatment of stricture

1. Progressive stricture dilatation over months a. Prograde: oral route with elastic bougie b. Retrograde: gastrostomy route 2. Stent insertion 3. Stricture excision + reconstruction with colon 4. Esophageal bypass with jejunum / colon segment

Esophageal atresia
1. Usually occurs with tracheo-esophageal fistula 2. Diagnosed at birth due to: a. failure to pass nasogastric tube b. absence of intestinal gas in X-ray abdomen 3. VACTERL: anomalies of Vertebra, Ano-genital, Cardiac, Trachea, Esophagus, Renal, Limb 4. Rx: immediate repair of esophagus

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X-ray abdomen
NG tube unable to pass into stomach Absence of intestinal gas

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Esophageal tear & perforation

Etiology
1. Instrumentation: involves upper esophagus a. Esophagoscopy b. Dilatation of esophageal stricture 2. Severe vomiting (alcoholic): lower esophagus a. Superficial mucosal tear = Mallory Weiss tear b. esophageal perforation = Boerhaave syndrome 3. ed esophageal lumen pressure: childbirth, forced cough, defecation, seizure, weight lifting

Clinical Features
Esophageal tear: painless hematemesis Esophageal perforation: life threatening condition Severe pain in neck, chest, intra-scapular area Odynophagia, fever, prostration Tachypnea, tachycardia & hypotension Subcutaneous emphysema of neck Pneumo-mediastinum: Hammans mediastinal crunch on auscultation

Mallory Weiss syndrome

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Investigation of perforation
Chest X-ray: pneumothorax, pneumomediastinum Gastrograffin esophagogram: shows perforation. Barium increases mediastinitis. Flexible esophagoscopy for difficult cases CT scan chest for mediastinitis Click to edit Master text styles Second level Third level Fourth level Fifth level

Boerhaave Mallory Weiss syndrome tear

Onset Alcoholism Tear Hematemesis Pain Investigation Treatment Vomiting Yes Trans-Mural Absent Present Gastrograffin esophagogram Emergency repair Vomiting Yes Mucosal Present Absent Endoscopy Self limiting, Cauterization

Treatment
Conservative: for upper esophageal rupture detected within 12 hours & peptic stricture ruptures Thoracotomy & urgent repair of perforation: for lower esophageal rupture detected within 12 hours Esophageal bypass / resection & anastomosis / indwelling Celestin feeding tube: for perforation detected after 12 hours & stricture perforations of malignancy, caustic ingestion & post-radiotherapy

Conservative treatment
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Nil by mouth Parenteral nutrition IV high dose broad-spectrum antibiotics Endoscopic insertion of nasogastric tube Continuous nasogastric tube suction for 1 week

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Most perforations heal within 2 weeks

Achalasia Cardia (Cardiospasm)

Etiology: 1. degeneration of ganglion cells of inhibitory neurons in Auerbachs myenteric plexus 2. Chagas disease (American trypanosomiasis) Pathogenesis: failure of lower esophageal sphincter relaxation + uncoordinated peristalsis food retention dilated + tortuous lower esophagus Clinical features: Dysphagia more to liquids than solids Regurgitation of undigested food

Chest X-ray: mediastinal widening + air-fluid level

Barium swallow: Smooth fusiform lower esophageal dilation (mega-esophagus) with abrupt tapering of lower end (bird's beak appearance). Absence of fundic gas shadow. Absence of peristalsis.

Esophagoscopy: sudden dilatation of lower esophageal lumen (like entering a dirty cave). Rule out malignancy (0.15% ) causing pseudo-achalasia.

Esophageal manometry: pressure in esophageal body; pressure at lower esophageal sphincter

Barium swallow
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Fluoroscopic barium swallow

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Esophagoscopy
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Esophageal manometry
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Treatment
Smooth muscle relaxants (nitrates or calcium channel blockers): afford short-lived relief Endoscopic Botulinum toxin injection into lower esophageal sphincter: gives relief for many weeks Endoscopic dilatation of lower esophageal sphincter: with elastic bougie / pneumatic dilator Hellers laparoscopic cardio-myotomy: surgical division of lower esophageal sphincter + Nissens complete fundoplication to prevent post-op reflux

Hellers cardiomyotomy
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Laparoscopic cardiomyotomy
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Fundoplication
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Scleroderma (CREST syndrome)

Atrophy & fibrosis of esophageal smooth muscle + incompetent LES C/F: GERD + Calcinosis + Raynauds phenomenon + Esophageal dysmotility + Sclerodactyly + Telengiectasia Rx: Pantoprazole + Cisapride

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Esophageal hiatus hernia

Definition: herniation of part of stomach above esophageal hiatus in diaphragm

Sliding hiatus hernia: gastro-esophageal junction slides > 2 cm above esophageal hiatus in diaphragm. Esophagoscopy is diagnostic. Para-esophageal or rolling hernia: part of gastric fundus rolls up via esophageal hiatus in diaphragm, alongside esophagus. Gastro-esophageal sphincter remains below diaphragm & is competent . Esophagogram is diagnostic.

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Sliding hernia
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Para-esophageal hernia
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Para-esophageal hernia
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Mixed hiatus hernia

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Esophageal Hypermotility disorders

Cricopharyngeal spasm

Cricopharyngeous muscle remains contracted between swallows

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Smooth posterior impression in hypopharynx seen at C6 level

Cricopharyngeal myotomy

Diffuse esophageal spasm

Dysphagia & chest pain mimicking myocardial infarction especially on drinking cold liquids Barium swallow: simultaneous, uncoordinated, nonperistaltic contractions in esophagus body (cork-screw esophagus). Normal LES relaxation. Esophageal manometry: simultaneous repetitive contractions in esophageal body Treatment: Nitrates, Nifedipine, Amytriptilline

Barium esophagogram
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Esophageal manometry
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Coordinated, normal amplitude contractions in normal esophagus

Esophageal manometry
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simultaneous, uncoordinated, non-peristaltic contractions in esophagus body in diffuse esophageal spasm

Esophageal manometry
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High amplitude contractions in nutcracker esophagus

Esophageal vascular impressions

Vascular impressions
A. Intrinsic esophageal varices Uphill: in portal hypertension Downhill: in superior vena cava obstruction B. Extrinsic (dysphagia lusoria) Aberrant right subclavian artery Right aortic arch Double aortic arch Aberrant left pulmonary artery

Esophageal varices

Etiology: portal hypertension & SVC obstruction Clinical presentation: hematemesis Endoscopy: bluish esophageal varices Barium swallow: string of black pearls appearance Treatment: a. Cure of etiology b. Endoscopic variceal sclerotherapy c. Endoscopic variceal ligation (banding) d. Porto-systemic vascular shunt e. Devascularization of lower 5 cm of esophagus

Esophagoscopy
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String of black pearls

These filling defects change shape during respiration due to venous emptying
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Uphill varices
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Downhill varices
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Aberrant Rt subclavian artery

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Aberrant Rt subclavian artery

Fluoroscopic barium swallow shows esophageal compression at level of third & fourth thoracic vertebrae
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Double aortic arch

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Aberrant left pulmonary artery

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Forrestiers disease

Dysphagia caused by cervical esophageal compression by vertebral column osteophyte

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Inv: a. X-ray neck lateral b. Esophagogram

Rx: Osteophytectomy

Esophagogram
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Esophageal neoplasm

Benign esophageal tumors

Rare condition Types: Leiomyoma (commonest) Fibro-vascular polyp Squamous papilloma > 50% are asymptomatic Endoscopic / thoracotomy excision for dysphagia

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Esophageal malignancy
Squamous cell carcinoma (upper 2/3rd) Adenocarcinoma (lower 1/3rd) Spindle cell carcinoma Leiomyosarcoma Lymphoma Metastasis

Clinical features
progressive, painless dysphagia for solid foods acute food bolus obstruction weight loss in late stages chest pain or hoarseness: mediastinal invasion coughing after swallowing, pneumonia & pleural effusion: tracheo-esophageal fistula cervical lymphadenopathy: node metastasis

Risk factors
Smoking Alcohol consumption Tobacco chewing Vitamin C deficiency Betel nut chewing Vitamin A deficiency

Barrets esophagus Achalasia cardia Corrosive stricture Human Papilloma Virus

Plummer Vinson syndrome Tylosis (familial hyperkeratosis of palms & soles)

Investigations
1. Barium swallow: a. shouldering: malignant ulcer with everted margin b. rat tail appearance: narrow lower 1/3rd with no proximal dilatation c. apple core appearance: narrow middle 1/3rd only 2. Esophagoscopy & biopsy from growth 3. CT scan chest: for staging of malignancy

Shouldering
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Rat tail appearance

Also seen in advanced cases of achalasia cardia
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Palliative treatment
70% patients have advanced disease at presentation & require palliative treatment
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Endoscopic tumour ablation using laser Low dose intra-cavitary radiotherapy Indwelling feeding tube (Mousseau-Barbin, Celestin) Feeding jejunostomy Chemotherapy (5 Fluorouracil) Nutritional support & analgesia with morphine

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Definitive Treatment
Upper 1/3rd: early: radical radiotherapy (5500 cGy) advanced: chemo-radiation Middle 1/3rd: early: radical RT or radical surgery advanced: radical surgery + CT Lower 1/3rd: early: radical surgery advanced: radical surgery + CT Radical surgery: esophagectomy + gastrectomy + reconstruction with gastric / jejunal flap Chemotherapy (CT): Cisplatin + 5-fluorouracil

Evaluation of dysphagia

Extra-esophageal causes
Neoplasm: jaw / oral cavity / oropharynx / hypopharynx / supraglottis Inflammation: TM joint arthritis / aphthous ulcer /

Ludwigs angina / tonsillitis / quinsy / epiglottitis / retropharyngeal abscess / parapharyngeal abscess

Paralysis: tongue / soft palate

Esophageal intra-luminal causes Impacted foreign body / food bolus

Esophageal atresia Esophageal web (Plummer Vinson Syndrome) Esophageal ring (Schatzkis ring) Esophageal stricture: benign / malignant Esophageal neoplasm: benign / malignant

Esophageal intra-mural causes Inflammation: esophagitis (GERD commonest)

Hypomotility disorders: Achalasia / scleroderma Hypermotility disorders: cricopharyngeal spasm / diffuse esophageal spasm / nutcracker esophagus Other neuro-muscular disorders: Myasthenia gravis / Multiple sclerosis / Motor neuron disease

Esophageal extra-mural causes Pharyngeal pouch

Hiatus hernia Thyroid enlargement: benign / malignant Mediastinal: Ca left bronchus / lymphadenopathy / cardiomegaly / aortic aneurysm / neoplasm Vascular ring: dysphagia lusoria Cervical spine osteophyte: Forrestiers disease

History taking
Level of dyphagia: oral cavity / pharynx / esophagus Acute onset: foreign body / trauma / inflammation Intermittent: hypermotility disorder Progressive: malignancy / stricture More for liquids: neuromuscular disorder Difficulty in initiation of swallow or after swallow Fever + odynophagia: inflammation

Esophageal trauma / caustic ingestion

History taking
Hoarseness / stridor: laryngo-tracheal invasion Hemoptysis: Ca bronchus Heartburn: GERD Hematemesis: esophageal varices Regurgitation: pharyngo-esophageal obstruction Neck mass: metastatic lymph node / goitre Neurological disorder Smoking & alcohol consumption

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Examination
General: pallor + koilonychia = Plummer Vinson synd Oral cavity, oropharynx Indirect laryngoscopy: larynx, pyriform sinus, posterior pharyngeal wall, post cricoid area Laryngeal crepitus: absent in post-cricoid malignancy, retropharyngeal abscess Neck node & cranial nerve examination

Investigations
Barium swallow with or without air contrast Video-fluoroscopic (modified) Barium swallow Esophagoscopy: flexible & rigid Esophageal manometry: achalasia, esophageal spasm 24 hour double probe ambulatory pH monitoring Fibreoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)

Investigations
Bolus scintigraphy Chest X-ray: mediastinal mass / cardiomegaly CT scan chest: mediastinal or pulmonary tumor Bronchoscopy: Ca bronchus Thyroid scan: thyroid malignancy Angiography: vascular rings (dysphagia lusoria)

Barium Swallow
Plain
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Air-contrast
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Video-fluoroscopic swallow study

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Rigid Esophagoscopy
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Flexible (oral) esophagoscopy

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Esophageal manometry
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24 hour ambulatory double-probe pH monitoing

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Bravo capsule
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Transmits radio signals.

Fibreoptic Endoscopic Evaluation of Swallowing with Sensory Testing

Air-pulse stimuli delivered to ary-epiglottic fold mucosa innervated by superior laryngeal nerve to elicit laryngeal adductor reflex for airway protection Swallowing evaluation performed with variety of food consistencies containing green food dye Look for aspiration into larynx

Sensory Testing with air pulse

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Fibreoptic Endoscopic Evaluation of Swallowing

Complete aspiration
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Minimal aspiration
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Normal swallowing
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Bolus scintigraphy
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Uses food bolus with radio-isotope to quantify amount of reflux

Thank You
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