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  1. Approach To Medicine
  2. Gastroenterology
  3. Esophagus / Pharynx

Esophagus / Pharynx

Modified 15:19, 20 Oct 2017 by apavel | Page History
    Table of Contents
    1. 1. Introduction
    2. 2. Dysphagia
      1. 2.1. Oropharyngeal
      2. 2.2. Esophageal
    3. 3. Odynophagia
    4. 4. GERD
      1. 4.1. Side Effects of PPI
      2. 4.2. Surgery
      3. 4.3. Endoscopic
      4. 4.4. Extraesophageal Symptoms
    5. 5. Hypertonic Motility Disorders
      1. 5.1. Achalasia / Pseudoachalasia
      2. 5.2. Diffuse Esophageal Spasm
    6. 6. Hypomotility Disorders
      1. 6.1. Scleroderma
    7. 7. Esophagitis
      1. 7.1. Infectious
      2. 7.2. Pill Induced
      3. 7.3. Eosinophilic Esophagitis
    8. 8. Esophageal Malignancy
      1. 8.1. Barrett's Esophagus
      2. 8.2. Esophageal Carcinoma

     

    Introduction

    • Think of it as a muscular tube stretching from the upper esophageal sphincter to lower esophageal sphincter.
    • Innervation is different:
      • Upper Esophagus = Striated muscle
      • Lower Esophagus = Smooth muscle

    Dysphagia

    • Difficulty swallowing.
    • Symptoms:
      • Sensation of obstruction or difficulty passing food and/or liquids.
      • Can sense obstruction at the mouth, pharynx, or chest (esophagus).
    • Types:

    DysphagiaApproach2.png

     

    Oropharyngeal

    • Difficulty passing bolus from mouth to esophagus.
    • Can be: neuromuscular or anatomic.
    • Symptoms: (Clues to diagnosis)
      • Coughing (Aspiration, recurrent pneumonia)
      • Nasal Regurgitation (soft palate dysfunction)
      • Dysphonia, diplopia, musclar weakness  (neurologic)
    • Diagnosis:
      • Videofluoroscopy ("aka modified barium swallow").
      • (Foods of various consistencies are assessed)
    • Management:
      • Treat cause
      • Dietary (consistency etc..) and postural changes to improve swallowing
      • Consider consulting speech pathology

     

    Esophageal

    • Sense of food sticking in esophagus, which typically occurs right after swallowing.
      • (Where the patient is pointing is not very accurate)
    • Must distinguish solid from liquid:
      • Solid dysphagia (liquid OK) ==> Structural cause (intraluminal obstruction: Schatzki's ring, cancer, stricture)
      • Solid + Liquid Dysphagia ==> Underlying motility disorder (achalasia or scleroderma)
    • History
      • Heartburn/reflux (peptic stricture?)
      • Recurrent chest pain (negative cardiac workup): Diffuse esophageal spasm, achalasia
      • Weight loss: malignancy.
    • Diagnosis:
      • Must rule out a structure abnormality (esp if solid food)
      • Endoscopy is the best test for esophageal dysphagia

     

    Odynophagia

    • Painful swallowing
    • Sign of esophageal ulceration
    • Causes:
      • Infections: (Candida, Herpes, CMV)
      • Pill-Induced Esophagitis
      • etc..

    GERD

    • Reflux of stomach contents causing symptoms/comlications --> heartburn, regurgitation.
      • Retrosternal chest discomfort that improves with therapy. (20% have this daily).
      • Symptom severity DOES NOT correlate with degree 
    • Rule out cardiac cause!!!
    • Complications:
      • Esophagitis
      • Bleeding (ulcerative complications)
      • Lower Esophageal Strictures
      • Barrett's Esophagus + Adenocarcinoma
      • Strictures
    • Causes:
      • Mild GERD: Transient lower esophageal sphincter (LES) relaxations.
      • Severe GERD: Disruption of normal GE junction anatomy.
      • Conditions:
        • Xerostomia (less saliva)
        • Gastroparesis
      • Drugs: (reduce LES tone)
        • Nicotine
        • Obesity
    • Diagnosis:

      • Diagnosis of GERD

        (ONE of:)

             1.  Clinical: based on symptoms (and no ALARM sx) -->  often trial of therapy.

        • Heartburn,  regurgitation or both (+/- response to PPI) ==> enough to diagnose GERD.

             2.  Endoscopy  

                   (ONLY if empiric therapy fails, or ALARM symptoms)

             3.  Ambulatory pH monitoring
                   (ONLY if no responce to therapy, negative endoscopy, considering fundoplication)

        • Traditional: tube catheter through nose into distal esophagus (24 hrs)
        • New technology "tubeless": sensor in lower esophagus, wirelessly transmits pH (48hrs)

         
      • ALARM symptoms of mucosal injury (indications for scope)
        • Dysphagia
        • Anemia
        • Vomiting
        • Weight loss
    • Treatment:
      • Conservative:
        • Stop smoking!
        • Weight loss.
        • Avoid eating large meals (esp late at night) before lying down.
          • Small meals, wait 3-4 hrs before lying in bed.
        • Elevate head of the bed (put phone books under head of bed)
        • Avoid foods:
          • onions, peppermints, spicy foods, carbonated beverages.
        • Avoid medications that worsen it.
      • Medical:
        • 1st Line: Proton Pump Inhibitors (PPI)
          • Achieve LOWEST dose of PPI to achieve resolution of symptoms. (r/a dose in 8-12w)
          • Start once daily, can titrate to BID if needed, take 30-45m before meal.
          • If symptoms not controlled or endoscopy --> endoscopy.
          • ALL PPI's have the same efficacy (use cost, coverage)
            • If on clopidogrel, non-omeprazole recommended. (pantoprazole)
              • Interferes less with enzyme to activate clopidogrel.
        • 2nd Line H2 Blockers (i.e. ranitidine) - only if intolerant to PPI.
          • Not as effective as PPI
          • Tachyphylaxis develops (lose efficacy)
        • No Role: metoclopramide.

     

    Side Effects of PPI

    • Headache, Diarrhea, Abdo pain, constipation.
      • Reduce dose or switch to different one.
    • Long-Term use:
      • C. difficile
      • Pneumonia
      • Hip Fractures (conflicting data - acid inhibition decr. Ca++ reabsorption)
        • Still recommend Ca++ and VitD for all patients on PPI
      • Possible interaction with clopidogrel (increased cardiac events reported), use non-omeprazole.

     

    Surgery

    • Saved for refractory reflux (confirmed dx of esophagitis or pH)
      • Also intolerance to PPI therapy or don't want long-term meds.
    • Efficacy rates are similar to chronic PPI therapy.
    • Gastric fundus wraps around sub-diaphragmatic esophagus forming a collar (makes "speed bump"  - slows it down).
      • Gives functional closure of the sphincter, and still relaxes appropriately.
      • May have dysphagia, bloating (cannot belch), diarrhea. 
    • Down sides:
      • Up to 1/3 may need acid suppression after sugery.
      • Can re-open, and need re-operation (lower success rates).
      • Surgery does NOT reduce the risk of endocarcinoma of esophagus.

     

    Endoscopic

    • Done much less nowadays (2014), examples:
      • Radiofrequency ablation of sphincter (more stiff)
      • Endoscopic sewing
      • Injection of polymers into lower esophageal sphincter. (collagen)
    • Work for 6-12mo, but lose effectiveness.
    • AGA guidelines: No indication for endoscopic therapy for GERD

     

    Extraesophageal Symptoms

    • Chest pain, esophagitis, strictures, cancer.
    • Laryngitis, cough, asthma.
    • Recurrent otitis media, pulmonary fibrosis, sinusitis.

    Hypertonic Motility Disorders

    Achalasia / Pseudoachalasia

    • Loss of esophageal parastalsis
    • Failure of LES to relax appropriately when patient's swallow.
    • Thought to be caused by degeneration of myenteric plexus.  Loss of inhibitor neurons in lower esophageal sphincter (tonically contracted).
    • Symptoms:
      • Chest pains (rarely)
      • Dysphagia
      • Regurgitating fermtented food
    • Diagnostic Tests:
      • Chest XRay: Dilated esophagus with air-fluid level.
      • Barium Swallow: (First Line!  [screening test])
        • Dilated, smoothly tapering esophagus ("Bird beek" of LES).
      • Manometry (Confirm Diagnosis):
        • Aparistalsis, incomplete or absent relaxation of LES when swallows.
      • Upper Endoscopy (MUST DO, even if classic manometric findings)
        • Must rule out pseudoachalasia (tumor at the lower esophagus) causing achalasia-type dx.
        • Consider in older individual, profound weight loss, short duration of sx.
    • Treatment Options:
      • 1st line:
        • Laparoscopic myotomy. (shorter hospital stay, faster recovery, similar results to open procedures).
      • Nissen fundoplication:
        • performed post-OR to decrease post-op reflux.
      • Endoscopic Dilatation (IF not surgical candidate):
        • 5% risk of perforation, shorter duration of response.
        • Less successful in younger patients.
      • Endoscopic injection of Botulinum toxin into the LES: symptom relief, temporary 6-9mo.
        • Only for patients who cannot undergo surgery, and cannot tolerate endoscopic dilation (due to risk of perforation).
      • Medications:
        • Nitrates, CCB, inconsistent benefit (can provide some relief).

     

    Diffuse Esophageal Spasm

    • More commonly seen in older patients, intermittent high-amplitude contractions, no peristalsis.
    • Exclude cardiac disease
    • Diagnosis:
      • Clinical Presentation (Dysphagia or chest pain)
      • Barium Swallow (see DES)
    • "Corkscrew esophagus"
      • On esophogram: multiple simultaneous contractions (looks like corkscrew) - diffuse spasm.
    • "Nutcracker esophagus"
      • Extreme spasm
    • Mannometric finding: average distal esophagus pressure >220mmHg (during peristalsis)
    • Treatment:
      • Symptomatic
      • 1st Line:  Calcium Channel blockers
      • Others:
        • Trazodone
        • Imipramine (modulate visceral sensory)
        • Botox

    Hypomotility Disorders

    Scleroderma

    • Dysphagia, slower transit times.
    • Mannometry:
      • Lower amplitude contractions, often non-peristalsis.
    • Causes:
      • Opioid drug users!
      • Scleroderma (aparistalsis on mannometry, decreased pressure in LES on mannomery)
        • vs. Achalasia (Increased pressure of LES)
    • Symptoms:
      • Often get severe esophagitis --> can cause strictures
    • Treatment:
      • High-dose PPI
      • (Cannot do fundoplication b/c poor peristalsis, would cause severe dysphagia)

     

    Esophagitis

    • Ddx:
      • Infectious, pill induced, eosinophilic

    Infectious

    • Organisms:
      • Candidate albicans (most common, sometimes even in immunocompetent)
        • Dysphagia with curdy white plaques on endoscopy
      • HSV - Large superficial ulcerations, biopsy edge of ulcer.
      • CMV - Causes large isolated ulcerations, biopsy base of ulcer.
      • Others (HPV, trypanosoma cruzi, TB, treponema pallidum, etc.. )
    • Almost always in immunocompromized (steroids, azathioprine, TNF-a inhibitors, congenital/acquired, inhaled corticosteroids)
    • Symptoms:
      • Often see candida (oral thrush) - if have dysphagia, treat as esophagitis.
      • Treat cause:
        • Candida (antifungal)
        • HSV (acyclovir)
        • CMV (gancyclovir

    Pill Induced

    • Often pain with swallowing, chest pain.
    • Caused by pills stucking areas of the esophagus, producing inflammation.
    • Symptoms:
      • Odynophagia
      • Dysphagia
      • Retrosternal chest pain
    • Several places can happen:
      • Aortic arch (indentation in esophagus)
      • GE junction
      • Enlarged L atrium
    • Most common pills:
      • Tetracycline (+ derivatives)
      • Iron tablets 
      • Bisphosphonates
      • Potassium 
      • NSAIDs
      • Quinidine
    • Management:
      • HOLD drug
      • If need to take:
        • Take with large glass of water to ensure it washes out.
        • Avoid laying recombant for 30-60min after.

    Eosinophilic Esophagitis

    • Somewhat like an "allergic reaction of esophagus.
    • Eosiophilic infiltration into esophageal mucosa.
    • Solid food dysphagia --> solid foods
    • Symptoms:
      • Recurrent food impactions, or hx of solid food dysphagia.
      • May have non-specific sx: vomiting, abdo pain, failure to thrive (cannot swallow).
    • Typical presentation:
      • Often pt with esophagitis --> put on PPI x6w --> does not get better --> endoscopy biopsy --> eosinophilic.
    • Associated with asthma and allergies.
    • COMMON, male predominance, 54 in 100,000 in US.
    • Diagnosis:
      • >15 eosinophils / HPF on esophageal endoscopic biopsy (taken MID esophagus).
        • Exclude GERD (causes eosinophilia in DISTAL esophagus).
      • Endoscopy: "corrigated" esophagus, strictures, "cracks", but can be normal.
    • Management
      • 1st LINE:
        • INTENTIONALLY swallowing aerosolized corticosteroids (asthma inhaler).
        • RINSE mouth afterwards (avoid thrush)
          • Only given after given PPI trial to ensure ruled out reflux disease.
      • Children: Food elimination diets (not as effective in adults)
      • Adults: May need to dilate
      • Last Line:
        • Systemic steroids rarely needed.

     

    Esophageal Malignancy

    • Upper Esophagus --> Squamous Cell Carcinoma
    • Lower Esophagus --> Adenocarcinoma
    • Upper Endoscopy is the gold standard test for solid food dysphagia concerning for malignancy (Not CT)

     

     

    Barrett's Esophagus

    • Pre-malignant complication of GERD
    • Normal squamous epithelium of distal esophagus is replaced by specialized columnar epithelium.
    • More common in white pts with longstanding GERD.
    • Risk of esphageal carcinoma of 0.5% (30-50 fold increase risk of CA)
    • Screening/Surveillance Guidelines:
      • Do not screen for Barrett's esophagus in patients with GERD
      • Screening for BE can be considered in MEN:
        • MEN with chronic chronic (>5 years) and/or frequent (weekly or more) sx GERD
          AND
        • ≥2 RFs for BE or EAC:
          • Age >50 years
          • Caucasian
          • Central obesity (waist circumference >102 cm or waist–hip ratio (WHR) >0.9)
          • Smoking (current or past)
          • Family history of BE or EAC (1st degree relative)
      • Women do not get Berretts (very rare), only screen if many RFs
    • Diagnosis:

      • Diagnosis of Barrett's Esophagus:

          1.  Endoscopic Findings (replacement of normal mucosal surface with dark pink columnar epithelium)

             AND

          2.  Histopathology (intestinal metaplasia with acid-mucin containing goblet cells)
    • Classification:
      • Long-Segment:  > 3cm of metaplasia above the EG Junction
      • Short-Segment: < 3cm of metaplasia
    • Management:
      • Screening for Cancer:  (Based on Pathology)
      • (Screen for invasive adenocarcinoma)
      • Pathology Grade Recommended Screening
        No Dysplasia

        Repeat endoscopy 1yr post-diagnosis (to ensure not missed dysplasia),

        if second endoscopy is negative, then endoscopy q3yrs.
        Low Grade Dysplasia

        Consider Endoscopic Ablation  

        (Can also do surveillance q1yr)
        High Grade Dysplasia

        Endoscopic Ablation
      • PPI's may prevent progression (only retrospective cohort studies, no RCTs).
      • Fundoplication does not reduce risk of progression
      • If high grade dysplasia:
        • Photodynamic,  RF ablation, and Cryotherapy effective in treating high grade.
          • (risk of strictures)
        • Ablation allows Barrett's Epithelium replacement with normal

    Esophageal Carcinoma

    • Adenocarcinoma or Squamous Cell
    • last 3 decades --> 300% increase in adenocarcinoma (and less squamous cell).
      • Adenocarcinoma correlates more with GERD (dietary, size, etc..)
    • Dyspagia, weight loss = poor prognosis 
    • 5 year survival <20%, (often diagnosed in advanced stage)
    • Risk Factors:
      • Squamous Cell
        • Alcohol, Tobacco, Nitrosamine (foods), corrosive injury, Zinc/Selenium deficiency, 
        • Achalasia, HPV
      • Adenocarcinoma (more common)
        • Tobacco use, Obesity (central obesity), symptomatic GERD, Barrett's esophagus
    • Symptoms:
      • Progressive dysphagia of solid foods
      • Weight loss (less food)
      • Anemia (loss in esophagus)
      • Reflux symptoms can decrease! (tumor now constricts)
    • Diagnosis:
      • Upper Endoscopy + biopsy
    • Staging
      • CT scan (distant metastasis)
      • Local/regional staging
      • If indeterminate lesions --> PET
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