Clinical Aspects of Esophageal Diseases

Question 1

What forms the upper and lower esophageal sphincters?

Answer 1

Upper - primarily the cricopharyngeus muscle, with some contribution from the inferior constrictor muscle

Lower - Specialzed region of circular smooth muscle of distal esophagus

Question 2

Where does the upper 1/3, middle 1/3, and lower 1/3 of the esophagus drain its lymph?

Answer 2

Upper 1/3 - Deep cervical nodes

Middle 1/3 - Mediastinal nodes

Lower 1/3 - Gastric and celiac nodes

Question 3

Where is the venous drainage from from the upper 1/3, middle 1/3, and lower 1/3 of the esophagus? Where does the portal system connect?

Answer 3

Upper 1/3 - Superior vena cava via inferior thyroid veins

Middle 1/3 - azygous system

Lower 1/3 - portal system via left gastric vein (coronary vein), which forms an anastamosis with the azygous system

Question 4

Why is it so easy for cancer to metastasize from the esophagus?

Answer 4

Serosa is absent from the surface

-> no defined layer separating it from the surrounding tissues

Question 5

What are the two plexuses found in the wall of the GI tract? Where are they located and what is their function?

Answer 5

Meissner’s - subMucosal - receive sensory input from esophageal wall layers

Auerbach’s - myenteric - sits between IC and OL layers of muscularis propria -> coordinates perstalsis

Question 6

What is the usual first procedure done in the workup of dysphagia?

Answer 6

Barium esophagogram

X-ray of esophagus after barium swallow
-> excellent and safe evaluation allowing planning before more invasive tests

Question 7

What is an esophagogastroduodenoscopy (EGD)? What is it good for? Is it invasive?

Answer 7

Using an endoscope to directly visualize the esophageal lumen

-> shows mucosal disease but not function of an organ. Also allows biopsy, culturing, and some therapeutic manuevers

Invasive since patient has to be under anesthesia, but is safe.

Question 8

What is endoscopic ultrasound useful for?

Answer 8

Ultrasound which shows all the layers of the esophageal wall and associated structures

Useful for possible biopsy as well as visualization of what layer of the wall a mass is in

Question 9

What is the definition of “transfer” as it relates to swallowing?

Answer 9

Bolus propulsion into posterior pharynx and proximal esophagus, past the UES

Question 10

What are the three types of peristaltic waves and what initiates them?

Answer 10

Primary - propulsive -> initiated by swallow

Secondary - propulsive, initiated by stretch and material in the lumen (from behind the bolus)

Tertiary - nonpropulsive and uncoordinated contractions

Question 11

What is the definition of “transport” as it relates to swallowing?

Answer 11

Peristalsis propels food through esophagus into stomach

Question 12

How does esophageal manometry work?

Answer 12

Evaluates motility and pressure at various points in the esophagus, demonstrating peristalsis and sphincter function.

Lower pressures indicate relaxation, higher pressures indicate peristaltic or tonic contractions

Question 13

What is impedance testing good for with manometry?

Answer 13

Tests actual proper functioning of esophageal transport -> impedance will decrease as food actually travels with peristalsis. Should travel in accordance to the generated high resolution manometry

Question 14

How is pH monitoring done now with manometry?

Answer 14

Can put a telemetric capsule which measures the pH over 24-48 hours

Question 15

What is dysphagia vs odynophagia?

Answer 15

Dysphagia - Swallowing difficulty - food gets stuck due to mechanical or motor lesion in esophagus

Odynophagia - painful swallowing, usually indicates inflammation

Question 16

What is transfer dysphagia?

Answer 16

Also known as oropharyngeal dysphagia, it is difficulty swallowing due to failure of bolus transfer from mouth to esophagus

Question 17

What are neurologic and striated muscle disorders which can cause transfer dysphagia?

Answer 17

Neurologic - strokes, botulism

Striated muscle - Polymyositis, myasthenia gravis -> poor bolus formation and difficulty propelling food

Question 18

What are disorders of the UES which can cause transfer dysphagia?

Answer 18

Cricopharyngeal achalasia - UES won’t open

Zenker’s diverticulum - food entering weakspot in UES, worsened by cricopharyngeal achalasia (high pressures)

Question 19

What type of dysphagia is achalasia and why does it occur?

Answer 19

Transport dysphagia

Occurs because LES fails to fully relax after swallow
-> esophageal contractions are often uncoordinated or absent as well, leading to absent persitalsis

Question 20

What are the clinical features of achalasia? Include the diagnostic finding.

Answer 20

Dysphagia for both solids and liquids

Putrid breath - halitosis

“Bird-beak sign” on barium swallow study

High LES pressure on esophageal manometry

Question 21

What is happening pathologically to cause achalasia?

Answer 21

Loss of Auerbach’s (myenteric) plexus, with preferential loss of inhibitor neurotransmitters like NO and VIP -> tonically increased sphincter contraction

Vagal fibers also degenerate -> decreased overall peristalsis, with esophageal dilatation

Question 22

What can cause achalasia?

Answer 22

Primary - neurological degeneration

Secondary - Chagas disease, viral infection, autoimmune diseases

Question 23

What are two possible complications of achalasia?

Answer 23

1. Epiphrenic diverticulum - just above LES, due to increased pressures
2. Squamous cell esophageal cancer - due to chronic irritation

Question 24

What is pseudoachalasia?

Answer 24

Achalasia caused by carcinomas of the proximal stomach
-> may infiltrate Auerbach plexus by mass effect or cause ganglionic destruction by paraneoplastic secretion

-> EGD is needed to make this diagnosis in the presence of achalasia

Question 25

What is diffuse esophageal spasm (DES) and how does it differ from achalasia?

Answer 25

Disorder of esophageal motility where peristalsis is replaced by a series of repetitive, non-propulsive, high amplitude contractions Major difference from achalasia: Peristalsis and LES function are preserved. They are really opposite ends of the spectrum.

Question 26

What is the clinical presentation of DES and what precipitates it?

Answer 26

Dysphagia and chest pain Made worse with emotional stress and by drinking very hot or cold liquids. Symptoms are intermittent, and the underlying cause is unknown

Question 27

How is diagnosis of DES made?

Answer 27

Corkscrew appearance of barium esophagogram, or peaked waves on manometry -> often very difficult to catch though because the spasm is intermittent

Question 28

What is nutcracker esophagus and what will manometry show?

Answer 28

Esophagus with extremely high pressure peristaltic contractions Causes chest pain for patients - manometry shows high amplitude peristalsis

Question 29

What characterizes sclerodermal esophageal dysmotility (the E in CREST)?

Answer 29

Smooth muscle (distal 1/2) infiltration and atrophy from collagen deposition - > Decreased LES pressure (always open) - > minimal or aperistalsis (dysmotility)

Question 30

What are the early and late manifestations of sclerodermal esophageal dysmotility?

Answer 30

Early - passage of solids / liquids is stopped due to aperistalsis. GERD symptoms worse when supine Late - Esophagitis with benign stricture causes late dysphagia for solids

Question 31

How will the symptoms progress in mechanical obstruction of the esophagus?

Answer 31

Symptoms are due to progressive narrowing of the lumen -> solid food will be harder to swallow than liquids

Question 32

What type of esophagitis is often seen in children and young adults which can lead to food impaction and dysphagia (mechanical obstruction)? What type of inflammation is associated?

Answer 32

Eosinophilic esophagitis -> allergic inflammation associated with many eosinophils, likely a reaction to some food

Question 33

What gross pathology is seen in eosinophilic esophagitis?

Answer 33

Mucosal ring and small eosinophilic abscesses, usually biopsied at mid-esophageal level

Question 34

Give several general etiologies of mechanical obstruction of the esophagus.

Answer 34

Strictures Webs/rings Neoplasms Diverticula

Question 35

What modalities are used in the treatment of tumors causing dysphagia and their success rate?

Answer 35

Surgery, chemo and radiation Poor success, but often used in palliation

Question 36

How do the palliative techniques of dilation, laser ablation, photodynamic therapy, and stenting work?

Answer 36

Dilation - mechanical stretching by balloon Laser ablation - tissue obstruction Photodynamic therapy - sensitize tumor to a light wavelength using drug, then expose to light Stenting - use a semirigid tube to prevent obstruction

Question 37

How is eosinophilic esophagitis treated?

Answer 37

Swallowing of inhaled corticosteroids, PPI's, elimination of triggering food

Question 38

How is transfer dysphagia treated?

Answer 38

Depending on the cause. I.e. treatment of neuromyopathies like dermatomyositis or MG (immunosuppressants or anti-Ach-E) Treatment of UES dysfunction via myotomy (incision of sphincter muscle) or Botulinum toxin (botox) for cricopharyngeal achalasia Altering food consistency if post-stroke / postsurgical

Question 39

How can speech therapists play a role in the treatment of dysphagia?

Answer 39

Speech therapists also help with "swallowing training" -> help correct lack of initial peristalsis

Question 40

What are the treatments for achalasia?

Answer 40

Forceful "pneumatic dilation" to split muscles of LES via a balloon for more permanent relief, but risk perforation. May also do a surgical myotomy as a permanent procedure, but risk development of GERD. Always done if there is a perforation which occurs.

Question 41

What is the treatment for odynophagia?

Answer 41

Topical anesthetics, and treatment of underlying cause of inflammation Often, start taking the locally toxic drugs causing the inflammation with LOTS of fluids

Question 42

What are the mechanical / lifestyle treatments of GERD?

Answer 42

Mechanical - elevate head of bed Lifestyle - eat smaller meals, lose weight, stop smoking / alcohol, avoid fatty foods which decrease gastric emptying, reduce excess caffeine which lowers LES pressure

Question 43

You know most of the antacids, H2 blockers, and PPIs used in the treatment of GERD. Give one prokinetic agent which can be used to improve LES tone in GERD?

Answer 43

Metoclopramide - D2 receptor antagonist, promotes gastric emptying

Question 44

What is the surgical treatment for persistent GERD when all other measures fail?

Answer 44

Fundoplication - take the fundus of the stomach and wrap it around the distal esophagus

Question 45

What do you use to treat spastic conditions of the esophagus and what must be ruled out first?

Answer 45

Nitrates, calcium channel blockers, tricyclics r/o cardiac disease first before starting all these cardiac-active drugs

Question 46

What is pyrosis?

Answer 46

Heartburn - burning sensation in lower esophagus spread into the upper chest after heavy meals or when lying down