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ESOPHAGEAL TOPICS. Norman M. Simon, M.D., F.A.C.G. BARRETT ’ S ESOPHAGUS. A change in the lining of the esophagus from the normal squamous lining to an intestinal type lining called intestinal metaplasia.
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ESOPHAGEAL TOPICS Norman M. Simon, M.D., F.A.C.G.
BARRETT’S ESOPHAGUS • A change in the lining of the esophagus from the normal squamous lining to an intestinal type lining called intestinal metaplasia. • Diagnosis suspected on endoscopy but requires confirmation by pathology examination of biopsies. • Vast majority of cases caused by acid reflux and secondary injury to the normal lining. • Incidence appears to have increased substantially.
Increased incidence of Barrett’s seems responsible for increase in cases of esophageal adenocarcinoma. • Controversy re. who to screen for Barrett’s. • When Barrett’s suspected, biopsies taken to confirm diagnosis and to check for dysplasia. • Monitoring generally being done at three to five year intervals unless dysplasia is found. Then depends on whether low or high grade changes.
Candidates For Screening • Caucasian Males • Over 50 years of age • Chronic symptoms of GERD • Nocturnal reflux symptomatology • Increased BMI with intra-abdominal fat distribution • Tobacco use
Some evidence that anti-reflux treatment helps prevent the development of pre-cancerous dysplasia and cancer in patients with Barrett’s. Role of anti-reflux surgery controversial. • Patients with low-grade dysplasia are monitored more frequently than those with no dysplasia. ? Eradicate the Barrett’s. If not, recheck every 6-12 months vs. every 3-5 yrs.
Options for patients with high-grade dysplasia include doing nothing, surgical resection, intensive monitoring, photodynamic treatment, endoscopic mucosal resection, argon plasma coagulation, radio frequency ablation (HALO), and endoscopic spray cryotherapy
26 y/o male with history of recurrent dysphagia for solids which seem to catch at midsubsternal level. Drinks fluids to clear the “obstruction.” Has been going on for about 6 months. Denies heartburn or other reflux symptoms. • Past hx. negative aside from many year hx. of asthma. WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?
EOSINOPHILIC ESOPHAGITIS • Also known as “allergic esophagitis”. • Predominant symptom is dysphagia. • Increasing incidence over past two decades. • Occurs in both children and adults with majority being males. In adults, majority are in their 20’s and 30’s. • High percentage have allergic issues including asthma, food allergies, hives, hay fever.
EOSINOPHILIC ESPHAGITIS (CONT) • Findings can include multiple rings, narrowed esophagus, whitish nodules, furrows, & strictures in upper esophagus. • Some cases have involved several family members. • Etiology may relate to food allergies, additives, pollen, reflux?
TREATMENT • Trial of anti-reflux medication-PPI. • Allergy testing and diet changes. Elemental diet • Avoidance of six most frequent allergenic foods (eggs, soy, wheat, cow-milk protein, peanuts, and seafood). SFED • Steroid inhaler- swallowing rather than inhaling the medication. Fluticasone propionate. • Oral Prednisone- higher incidence of side effects. • Dilitation- risks of perforation.
SCHATZKI’S RING • Occur at the distal end of esophagus at junction of esophagus and stomach. Often are assymptomatic. • Probably are a consequence of reflux. • Treatment is dilitation with bougie or balloon- may be best to go directly to large size ( 50 french or larger). • Data shows decreased rate of recurrence with placing patients on anti-reflux medications.
ESOPHAGEAL STRICTURES • Many causes including reflux, malignancy, radiation, toxic ingestions (e.g. lye), surgical anastomoses, sclerotherapy. • Dilitation generally done gradually stepwise, often no more than three sizes on one day. • Balloons (TTS) and standard dilators seem to produce similar results. • Longterm anti-reflux therapy can reduce recurrence rate in many cases.
69 y/o male with 1 ½ year of dysphagia primarily for solids which sometimes lodge in area of lower neck or upper chest region. Also has experience of coughing up small bits of food he ingested at a previous meal. WHAT DIAGNOSES WOULD YOU CONSIDER?
ZENKER’S DIVERTICULUM • Diverticulum occuring at junction of pharynx and upper esophagus. • The “pocket” faces posteriorly. • Dysphagia often occurs immediately with swallowing. • Presents with dysphagia and/or spitting up of food eaten earlier. Also may complain of halitosis. • Thought to be due to malfunctioning of the upper esophageal sphincter.
Zenker’s Diverticulum (cont.) • Treatment options include surgery through side of the neck with cutting the sphincteralong with possible removal of the diverticulum or an endoscopic technique known as endoscopic staple-assisted esophagodiverticulostomy.
ACHALASIA • Achalasia is well recognized as a cause of swallowing difficulty. • Distal esophageal sphincter does not relax with a swallow and the muscle of the lower esophagus does not propel the food or liquid downwards i.e. abnormal peristalsis. • Result is dysphagia, occasionally chest pain and regurgitation, and weight loss • X-rays can reveal a dilated esophagus.
ACHALASIA (CONT.) • On endoscopy often see retained food and secretions in esophagus even though patient has been NPO. • Characteristic “yield” of LES to the scope being advanced. • “Pseudo-achalasia”
ACHALASIA TREATMENT • Three common treatment options • Pneumatic forceful balloon dilitation with Rigiflex balloon. May not work; uncomfortable for patient; 3-5% risk of perforation. • Botox injection. Not always successful. Tends to lose effect in 6-12 months requiring reinjection. Good option for poor surgical candidates. • Surgery-laparoscopic myotomy. Cut the sphincter and add partial fundoplication. • Rarely, Calcium Channel blockers or Nitrates.
OTHER MOTILITY PROBLEMS • Nutcracker esophagus, diffuse esophageal spasm, and hypertensive lower esophageal sphincter are three patterns often seen. • Controversy as to whether these conditions can cause non-cardiac chest pain and/or dysphagia. • In spite of these uncertainties treatment is often tried to see if clinical response. • In some patients, may be related to reflux and therefore often give trial of anti-reflux medication first.
Treatment • In many patients improvement can be a consequence of learning they don’t have a serious cardiac issue. • First line therapy often consists of a calcium channel blocker (diltiazem) or an antidepressant (imipramine). Can use nitrates or sildenafil on an as needed basis. • Other options include trial of hot liquids with meals, botox injection, bougie.
Esophageal Varices • All patients with cirrhosis should have EGD screening for varices. • No varices- rescope in couple years. • Small varices- consider NSBB in these patients • Large varices- low risk group probably use NSBB. High risk group (red wale signs, advanced liver disease) can choose between NSBB and EVL. Add PPI after EVL (ulceration) • Sclerotherapy not warranted for primary prevention of bleeding.
