copy of esophageal diseases imag
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ESOPHAGEAL DISEASESESOPHAGEAL DISEASES
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Upper esophageal sphincterUpper esophageal sphincter
Striated muscleStriated muscle
Consists of the cricopharyngeusConsists of the cricopharyngeusand inferior pharyngeal constrictorand inferior pharyngeal constrictor
muscles, striated musclesmuscles, striated muscles
innervated by excitatory somaticinnervated by excitatory somatic
lower motor neurons.lower motor neurons.
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Lower esophageal sphincterLower esophageal sphincter
(LES) is composed of smooth muscle.(LES) is composed of smooth muscle.
Innervated by parallel sets ofInnervated by parallel sets of
parasympathetic excitatory andparasympathetic excitatory andinhibitory pathways.inhibitory pathways.
Supplemented by the striated muscleSupplemented by the striated muscle
of the diaphragmatic crura, whichof the diaphragmatic crura, whichsurrounds the LES and acts as ansurrounds the LES and acts as anexternal LES.external LES.
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Fatty meals, smoking, andFatty meals, smoking, and
beverages with a high xanthinebeverages with a high xanthine
content (tea, coffee, cola) cause acontent (tea, coffee, cola) cause areduction in sphincter pressure.reduction in sphincter pressure.
Adrenergic agonists, gastrin, andAdrenergic agonists, gastrin, and
prostaglandin Fprostaglandin F22 cause itscause its
contractioncontraction..
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SYMPTOMSSYMPTOMS
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DysphagiaDysphagia
Sensation of sticking orSensation of sticking or
obstruction of the passage of foodobstruction of the passage of foodthrough the mouth, pharynx, orthrough the mouth, pharynx, or
esophagus.esophagus.
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OdynophagiaOdynophagia
painful swallowingpainful swallowing..
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Atypical chest painAtypical chest pain
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HeartburnHeartburn
Is a burning retrosternal discomfort thatIs a burning retrosternal discomfort thatmay move up and down the chest like amay move up and down the chest like awave.wave.
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RegurgitationRegurgitation
IIs the effortless appearance of gastric ors the effortless appearance of gastric oresophageal contents in the mouth.esophageal contents in the mouth.
The regurgitated material consists ofThe regurgitated material consists of
tasteless mucoid fluid or undigested food.tasteless mucoid fluid or undigested food.
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DiagnosticDiagnosticTestsTests
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EsophagoscopyEsophagoscopy
Esophagoscopy is the direct method ofEsophagoscopy is the direct method ofestablishing the cause of mechanicalestablishing the cause of mechanicaldysphagia and of identifying mucosaldysphagia and of identifying mucosallesions that may not be identified by thelesions that may not be identified by theusual barium swallow.usual barium swallow.
Endoscopic ultrasonography permitsEndoscopic ultrasonography permitsevaluation of intramural masses andevaluation of intramural masses andstaging of esophageal cancer.staging of esophageal cancer.
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http://www.gastrointestinalatlas.com/CaEscamous1.mpg -
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Esophageal MotilityEsophageal Motility
The study of esophageal motility entailsThe study of esophageal motility entails
simultaneous recording of pressures fromsimultaneous recording of pressures from
different sites in the esophageal lumendifferent sites in the esophageal lumen
with pressure sensors positioned 5 cmwith pressure sensors positioned 5 cm
apart.apart.
The UES and LES appear as zones ofThe UES and LES appear as zones of
high pressure that relax on swallowing.high pressure that relax on swallowing.
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Motor DisordersMotor Disorders
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Striated MuscleStriated Muscle
Oropharyngeal ParalysisOropharyngeal Paralysis
Paralysis of oral muscle leads to difficultyParalysis of oral muscle leads to difficulty
initiating swallowing and drooling of foodinitiating swallowing and drooling of foodout of the mouth. Pharyngeal paralysis,out of the mouth. Pharyngeal paralysis,
characterized by dysphagia, nasalcharacterized by dysphagia, nasal
regurgitation, and aspiration duringregurgitation, and aspiration duringswallowing, occurs in a variety ofswallowing, occurs in a variety of
neuromuscular disorders.neuromuscular disorders.
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Smooth MuscleSmooth Muscle
AchalasiaAchalasia
Achalasia is a motor disorder of theAchalasia is a motor disorder of the
esophageal smooth muscle in whichesophageal smooth muscle in whichthe LES does not relax normally withthe LES does not relax normally with
swallowing, and the esophageal bodyswallowing, and the esophageal body
undergoes nonperistalticundergoes nonperistaltic
contractions.contractions.
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LLoss of intramural neurons. Inhibitoryoss of intramural neurons. Inhibitory
neurons are predominantly involved.neurons are predominantly involved.
Pathophysiology of AchalasiaPathophysiology of Achalasia
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Clinical features ofClinical features ofAchalasiaAchalasia
Dysphagia, chest pain, and regurgitationDysphagia, chest pain, and regurgitation
are the main symptoms.are the main symptoms.
Dysphagia appears early, occurs with bothDysphagia appears early, occurs with both
liquids and solids, and is worsened byliquids and solids, and is worsened by
emotional stress and hurried eating.emotional stress and hurried eating.
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Diagnosis ofDiagnosis ofAchalasiaAchalasia
CChest x-rayhest x-ray shows absence of the gastric airshows absence of the gastric airbubble and sometimes a tubular mediastinalbubble and sometimes a tubular mediastinal
mass beside the aorta.mass beside the aorta.
AAir-fluid level in the mediastinum in the uprightir-fluid level in the mediastinum in the upright
position represents retained food in theposition represents retained food in the
esophagus.esophagus.
Barium swallowBarium swallow shows esophageal dilation,shows esophageal dilation,and in advanced cases the esophagus mayand in advanced cases the esophagus may
become sigmoid.become sigmoid.
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ManometryManometryLES pressure to be normalLES pressure to be normalor elevated, and swallow-inducedor elevated, and swallow-induced
relaxation either does not occur or isrelaxation either does not occur or is
reduced in degree, duration, andreduced in degree, duration, and
consistency.consistency.
The esophageal body shows an elevatedThe esophageal body shows an elevated
resting pressure.resting pressure.
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TreatmentTreatment
Nitroglycerin, is used sublinguallyNitroglycerin, is used sublingually
before meals and as needed forbefore meals and as needed for
chest pain.chest pain.
Isosorbide dinitrate, sublingually isIsosorbide dinitrate, sublingually is
used before meals.used before meals.
NNifedipine, orally or sublinguallyifedipine, orally or sublingually
before meals, is also effective.before meals, is also effective.
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Heller's extramucosal myotomy ofHeller's extramucosal myotomy of
the LES, in which the circular musclethe LES, in which the circular muscle
layer is incised.layer is incised.
Laparoscopic myotomy is theLaparoscopic myotomy is the
procedure of choice.procedure of choice.
Diffuse Esophagealuse sop agea
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Diffuse Esophagealuse sop ageaSpasm and Related MotorSpasm and Related Motor
DisordersDisordersDiffuse esophageal spasm isDiffuse esophageal spasm is
characterized by nonperistalticcharacterized by nonperistaltic
contractions, large amplitude andcontractions, large amplitude and
long duration.long duration.
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PathophysiologyPathophysiology
Nonperistaltic contractionsNonperistaltic contractions:: dysfunction ofdysfunction of
inhibitory nerves.inhibitory nerves.
Diffuse esophageal spasm may progress toDiffuse esophageal spasm may progress to
achachaalasia.lasia.
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Clinical featuresClinical features
Present with chest pain, dysphagia,Present with chest pain, dysphagia,
or both.or both.
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TreatmentTreatment
Sublingual nitroglycerinSublingual nitroglycerin
Isosorbide dinitrateIsosorbide dinitrate
Nifedipine.Nifedipine.TrTranquilizers are helpful in allayinganquilizers are helpful in allaying
apprehension.apprehension.
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Scleroderma EsophagusScleroderma Esophagus
The esophageal lesions in systemicThe esophageal lesions in systemic
sclerosis consist of atrophy of smoothsclerosis consist of atrophy of smooth
muscle, manifested by weakness in themuscle, manifested by weakness in the
lower two-thirds of the esophageal bodylower two-thirds of the esophageal bodyand incompetence of the LES.and incompetence of the LES.
The esophageal wall is thin and atrophicThe esophageal wall is thin and atrophic
and may exhibit areas of patchy fibrosis.and may exhibit areas of patchy fibrosis.
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SymptomsSymptoms
These patients usually also complainThese patients usually also complain
of heartburn, regurgitation, andof heartburn, regurgitation, and
other symptoms of gastroesophagealother symptoms of gastroesophageal
reflux disease (GERD).reflux disease (GERD).
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DiagnosticDiagnostic
Barium swallow shows dilation andBarium swallow shows dilation and
loss of peristaltic contractions in theloss of peristaltic contractions in the
middle and distal portions of themiddle and distal portions of the
esophagusesophagus
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GASTROESOPHAGEALGASTROESOPHAGEAL
REFLUX DISEASEREFLUX DISEASE
GERDGERD
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Gastroesophageal RefluxGastroesophageal Reflux
Disease (GERD)Disease (GERD)
Any symptoms or esophageal mucosalAny symptoms or esophageal mucosal
damage that results from reflux of gastricdamage that results from reflux of gastricacid into the esophagus.acid into the esophagus.
Classic GERD symptomsClassic GERD symptoms
Heartburn .Heartburn . Regurgitation.Regurgitation.
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Important Reasons to Diagnose andImportant Reasons to Diagnose and
Treat GERDTreat GERD
Negative impact on health-related quality ofNegative impact on health-related quality of
lifelife..
Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma..
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E h l
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ExtraesophagealExtraesophageal
Manifestations of GERDManifestations of GERDPulmonaryPulmonary
AsthmaAsthma
Aspiration pneumoniaAspiration pneumonia
Chronic bronchitisChronic bronchitis
Pulmonary fibrosisPulmonary fibrosis
OtherOther
Chest painChest pain
Dental erosionDental erosion
ENTENT
HoarsenessHoarseness
LaryngitisLaryngitis
PharyngitisPharyngitis
Chronic coughChronic cough
Globus sensationGlobus sensation
DysphoniaDysphonia
SinusitisSinusitis
Subglottic stenosisSubglottic stenosis
Laryngeal cancerLaryngeal cancer
Potential Oral and LaryngopharyngealPotential Oral and Laryngopharyngeal
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Potential Oral and LaryngopharyngealPotential Oral and Laryngopharyngeal
Signs Associated with GERDSigns Associated with GERD
Edema and hyperemia ofEdema and hyperemia oflarynxlarynx
Vocal cord erythema,Vocal cord erythema,
polyps, granulomas,polyps, granulomas,
ulcersulcers Hyperemia and lymphoidHyperemia and lymphoid
hyperplasia of posteriorhyperplasia of posterior
pharynxpharynx
Interarytenyoid changesInterarytenyoid changes Dental erosionDental erosion
Subglottic stenosisSubglottic stenosis
Laryngeal cancerLaryngeal cancer
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Pathophysiology ofPathophysiology of
Extraesophageal GERDExtraesophageal GERD
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Wh t P f Di tiWh t P f Di ti
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When to Perform DiagnosticWhen to Perform Diagnostic
TestsTests????Uncertain diagnosis.Uncertain diagnosis.
Atypical symptoms.Atypical symptoms.
Symptoms associated with complications.Symptoms associated with complications.Inadequate response to therapy.Inadequate response to therapy.
Recurrent symptoms.Recurrent symptoms.
Prior to anti-reflux surgery.Prior to anti-reflux surgery.
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Diagnostic Tests for GERDDiagnostic Tests for GERD
Barium swallow.Barium swallow.
Endoscopy.Endoscopy.
Ambulatory pHAmbulatory pH
monitoring.monitoring.
Esophageal manometry.Esophageal manometry.
Barium SwallowBarium Swallow
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Barium SwallowBarium Swallow
Useful first diagnostic test forUseful first diagnostic test forpatients with dysphagiapatients with dysphagia Stricture (location, length).Stricture (location, length).
Mass (location, length).Mass (location, length). Hiatal hernia (size, type).Hiatal hernia (size, type).
LimitationsLimitations
Detailed mucosal exam forDetailed mucosal exam forerosive esophagitis, Barrettserosive esophagitis, Barrettsesophagusesophagus
E dE d
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EndoscopyEndoscopy
Indications for endoscopyIndications for endoscopy
Alarm symptomsAlarm symptoms
Empiric therapy failureEmpiric therapy failure Preoperative evaluationPreoperative evaluation
Detection of BarrettsDetection of Barretts
esophagusesophagus
Ambulatory 24 hr pHAmbulatory 24 hr pH
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Ambulatory 24 hr. pHAmbulatory 24 hr. pHMonitoringMonitoring
Physiologic studyPhysiologic study
Quantify reflux inQuantify reflux in
proximal/distalproximal/distal
esophagusesophagus % time pH < 4% time pH < 4
Symptom correlationSymptom correlation
b l h i i
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Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring
NormalNormal
GERDGERD
re ess, a e er- ree sop agea p
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, p g pMonitoring
Improved patientImproved patient
comfort and acceptancecomfort and acceptance
Continued normal work,Continued normal work,activities and diet studyactivities and diet study
Longer reporting periodsLonger reporting periods
possible (48 hours)possible (48 hours)
Maintain constant probeMaintain constant probe
position relative to SCJposition relative to SCJ
Potential AdvantagesPotential Advantages
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Esophageal ManometryEsophageal Manometry
Limited role in GERDLimited role in GERD
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Treatment Goals for GERDTreatment Goals for GERD
Eliminate symptoms.Eliminate symptoms.
Heal esophagitis.Heal esophagitis.
Manage or preventManage or prevent
complications.complications.
Maintain remission.Maintain remission.
Lifestyle Modifications areLifestyle Modifications are
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Lifestyle Modifications areesty e od cat o s a e
Cornerstone of GERD TherapyCornerstone of GERD Therapy
Elevate head of bed 4-6 inches.Elevate head of bed 4-6 inches.
Avoid eating within 2-3 hours of bedtime.Avoid eating within 2-3 hours of bedtime.
Lose weight if overweight.Lose weight if overweight.
Stop smoking.Stop smoking.
Modify diet:Modify diet:
Eat more frequent but smaller meals.Eat more frequent but smaller meals.
Avoid fatty/fried food, peppermint, chocolate,Avoid fatty/fried food, peppermint, chocolate,alcohol, carbonated beverages, coffee andalcohol, carbonated beverages, coffee and
tea.tea.
Acid Suppression Therapy forAcid Suppression Therapy for
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Acid Suppression Therapy forAcid Suppression Therapy for
GERDGERD
HH22-Receptor-Receptor
AntagonistsAntagonists
Cimetidine.Cimetidine.
Ranitidine.Ranitidine.
Famotidine.Famotidine.Nizatidine.Nizatidine.
Proton Pump InhibitorsProton Pump Inhibitors
(PPIs)(PPIs)
Omeprazole.Omeprazole.
Lansoprazole.Lansoprazole.
Rabeprazole.Rabeprazole.
Pantoprazole.Pantoprazole.Esomeprazole.Esomeprazole.
Eff ti f M di l Th i fEff ti f M di l Th i f
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Effectiveness of Medical Therapies forEffectiveness of Medical Therapies for
GERDGERD
TreatmentTreatment ResponseResponse
Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %
HH22-receptor antagonists-receptor antagonists 50 %50 %
Single-dose PPISingle-dose PPI 80 %80 %
Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %
Treatment Modifications forTreatment Modifications for
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Treatment Modifications forTreatment Modifications for
Persistent SymptomsPersistent Symptoms
Improve compliance.Improve compliance.
Optimize pharmacokineticsOptimize pharmacokinetics
Adjust timing of medication to 15 30Adjust timing of medication to 15 30
minutes before meals.minutes before meals.
Allows for high blood level.Allows for high blood level.
Consider switching to a different PPI.Consider switching to a different PPI.
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Erosi e EsophagitisErosive Esophagitis
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Erosive EsophagitisErosive Esophagitis
When to Discuss Anti RefluxWhen to Discuss Anti Reflux
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When to Discuss Anti-RefluxWhen to Discuss Anti-Reflux
Surgery with PatientsSurgery with Patients
Intractable GERD (rare):Intractable GERD (rare): Difficult to manage strictures.Difficult to manage strictures.
Severe bleeding from esophagitis.Severe bleeding from esophagitis.
Non-healing ulcers.Non-healing ulcers.
GERD requiring long-term PPI in aGERD requiring long-term PPI in ahealthy young patient.healthy young patient.
Persistent regurgitation/aspirationPersistent regurgitation/aspirationsymptoms.symptoms.
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Endoscopic GERD TherapyEndoscopic GERD Therapy
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Endoscopic GERD TherapyEndoscopic GERD Therapy
Radiofrequency energy delivered to theRadiofrequency energy delivered to the
LESLES ( (Stretta procedure)Stretta procedure)
Suture ligation of the cardiaSuture ligation of the cardia
((Endoscopic plication)Endoscopic plication)
Submucosal implantation of inertSubmucosal implantation of inert
material in the region of the lowermaterial in the region of the lower
esophageal sphincter.esophageal sphincter.
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Thank youThank you