Symptoms of esophagitis
Dysphagia (difficulty swallowing), odynophagia (painful swallowing), GERD/”heartburn” symptoms almost always indicate a primary esophageal disorder
Causes of esophageal dysphagia via mechanical obstruction
Solids worse than liquids (in beginning)
Schatzki ring
-mechanical
intermittent dysphagia, not progressive; band around esophagus that sometimes spasms in, impinges esophagus, then releases
-know what this looks like on barium swallow
-tiny band of esophagus that pinches esophagus
-may vomit up food because it can’t go down
-next bite of food may go down fine
Peptic stricture
- mechanical causes dysphagia
- from chronic heartburn, progressively worse
Esophageal cancer
- mechanical causes dysphagia
- progressively worse, usually age >50yo, smoker/drinker (extraluminal mass may impinge)
Eosinophilic esophagitis
- mechanical causes dysphagia
- young adults, strictures, papules
Motility disorders
Solid and liquid foods equally affected
Achalasia
- motility cause of dysphagia
- progressive dysphagia
- *Birds beak appearance**
Diffuse esophageal spasm
- motility cause of dysphagia
- intermittent, presents with chest pain (swallow something cold, have substernal chest pain; or when vomiting)
Scleroderma
- motility cause of dysphagia
- chronic heartburn, substernal discomfort (autoimmune disease)
Case: A 68yo woman with a h/o rheumatoid arthritis presents to your office with a c/o painful swallowing which is becoming worse over the past 2 weeks. She also complains of some substernal burning. Raynauds issues in past, worse when laying down, ask if pt is taking meds (naproxen) or steroids (both can effect esophagus)
Think odynophagia
Odynophagia is
a sharp, substernal pain on swallowing
Usual cause of odynophagia
Often due to infectious etiologies such as esophageal candida, herpes, or cytomegalovirus
*This should be in the differential for immunocompromised patients, HIV patients, etc.
______ is the study of choice for evaluating persistent GERD, dysphagia, odynophagia, and structural abnormalities
Upper Endoscopy (EGD)
-Biopsy, cultures, and intervention can be performed if warranted
When is Barium esophagography performed?
- Dysphagia patients often evaluated via barium swallow first before EGD is performed
- If a high suspicion exists for a mechanical lesion, EGD often is done first
Esophageal manometry is used to
Determine the etiology of dysphagia in patients where there is no obvious mechanical obstruction
-Done pre-op as well prior to anti-reflux surgeries (Nissen fundoplication)
Esophageal pH recording provides information regarding
esophageal reflux
Case: A 56yo man who smokes 1PPD and drinks 2 beers/night comes into your office complaining of a chronic cough. His wife reports he sometimes coughs himself awake at night.
Think GERD
This is reflux- tobacco and alcohol make it worse (especially if consumed close to bedtime, meals before med too; pregnancy causes loss of LE tone too)
Aging- lose some lower esophageal tone.
GERD is a condition that develops when
the reflux of stomach contents causes substernal burning, chronic cough, foul taste, etc.
Cause of GERD is
Impaired lower esophageal sphincter
- This is essentially a barrier to reflux when functioning properly; normal pressure is 10-30mmHg
- Patients with severe erosive GERD often have a sphincter tone of
Irritants from GERD cause
Mucosal damage, gastric acid often with a pH
GERD can also be from __________, associated with more severe esophagitis, especially Barrett esophagus
Hiatal hernias
stomach is sliding through diaphragm, this causes chronic s/s
S/S of GERD
- Typical symptom is heartburn
- Usually 30-60min after eating and while reclining
- Relief with antacids, patients will often report taking daily
Occasionally can diagnose GERD with a trial of
PPIs
- Essentially a clinical diagnosis and empiric therapy
- The “purple pill” 14 day challenge
- EGD or Esophageal pH testing can be considered as well
- Biopsy can help delineate the extend of mucosal damage
One complication of GRED is
Barrett Esophagus
Barrett Esophagus is a condition where
the squamous epithelium of the esophagus is replaced by columnar epithelium containing goblet and columnar cells
- This is essentially a metaplastic process and can lead to malignancy (esophageal cancer)
- Present in up to 10% of those with severe, chronic reflux induced injury
Hallmark of Barretts Esophagus is ________
the presence of orange, gastric type epithelium that extends from the stomach into the esophagus in a circumferential manner
KNOW HISTO PIC
(clinical pic too, esophagus appears “orange”)
With Barretts esophagus diagnosis, EGD every _________
3-5 years recommended to look for changes
Barretts esophagus presents with no skip lesions or ulcers, crawls up esophagus homogenously, treated with
2x PPI for life
Peptic stricture
- another complication of GERD
- Usually presents with gradual solid food dysphagia over months to years
- Usually located at the GE junction
- Patients usually require, and benefit from, dilation with gradual catheters inserted over guide wires or balloon procedures
- A luminal diameter of ~15mm is needed to relieve dysphagia
- Long term PPI use is required to try and reduce the chance of relapse
GERD treatment for mild-intermittent S/S
- Lifestyle modifications
- Avoid bothersome foods (citrus, tomatoes, coffee, spicy foods, chocolate, fatty foods, peppermint, alcohol)
- Antacids are the mainstay of therapy for rapid relief
- OTC oral H2-receptor blockers – cimetidine, ranitidine, famotidine
GERD treatment for troublesome S/S
- PPIs become the mainstay of therapy
- Take 30min before breakfast for 4-8 weeks (takes this long to heal ulcers/lacerations; will recur if you don’t change your diet or take H2 receptor blockers)
- Some patients may require BID therapy
- Long-term Therapy, many patients experience relapse and begin continuous PPI therapy
Surgical treatment for GERD
Nissen fundoplication has an 85% success rate in controlling symptoms and ultimately healing esophagitis
- Side effects are dysphagia, bloating, flatulence, dyspepsia and diarrhea happen in over 30% of patients
- Not recommended in patient currently well controlled with PPIs
Nissen fundoplication entails
Grab fundus of stomach, wrap fundus around esophagus and create more pressure around lower esophageal sphincter to make more tone/make the sphincter tighter
Infectious esophagitis
MOST COMMON cause of odynophagia and dysphagia
- Often present with substernal chest pain or discomfort
- Oral thrush is a poor indicator, however should be assessed for possible clues (assume thrush is also in esophagus)
- Also look for oral ulcers or consideration for CMV infection in other sites (retina, colon)
For colitis patients with infectious esophagitis, think
think CVM (CMV Colitis, especially HIV patients)
Case: A 26yo man is being treated for a condition stemming from a tick bite which an erythema migrants rash. He presents half-way through his treatment with a c/o severe retrosternal chest pain and dysphagia after taking his medication.
Reports he feels like he is “swallowing over a lump”
Developing sharp, severe retrosternal pain; Lyme disease tx is doxycycline, VERY acidic, causes ulcers
Feel like food is getting stuck when swallowing, or feel pain
THINK PILL ULCER
Pill induced esophagitis
- Caused by numerous medications, classically NSAIDs, potassium, iron, Vitamin C, and antibiotics (especially tetracycline and doxycline
- More likely to occur if pills are swallowed without water or with minimal water
- May occur suddenly and persist for days
- Think elderly pts (take multiple pills, laying down, small amt of water)
Pill induced- Other caustic injuries can be caused by
toxic ingestions
- Suicide attempts or accidental consumption by children (child consuming dish washer pod)
- Burning, pain, gagging, dysphagia, drooling
Mallory Weiss Syndrome
A non-penetrating mucosal tear at the G-E junction that generally results from increased transabdominal pressure
-people who vomit a lot (alcoholics, bulimics)
Mallory Weiss Syndrome may also present with
hematemesis or melena too
Treatment for Mallory Weiss Syndrome
injection of epinephrine or cautery if there is active bleeding that does not spontaneously resolve
Esophageal varicies rupture vs mallory weiss
Esophageal varicies rupture- huge amount of frank red blood
Mallory Weiss- bloody tinged vomit, small amount of oozing blood (may be in stools as well)
Zenker Diverticulum
a protrusion of pharyngeal mucosa at the pharyngoesophageal junction
- Small sac, when you swallow food particles get stuck in sac
- Symptoms include dysphagia, halitosis, and regurgitation of undigested food (regurgitate food you ate 2-3 days ago)
Zenker Diverticulum often occurs in
the elderly and complications can include aspiration pneumonia and lung abscesses as well
-Curative treatment is a surgical diverticulectomy
A 46yo man with a known h/o chronic alcohol dependence presents to the emergency room with substernal pain, hematemesis, and waning mental status. He is found to be hypotensive and immediate resuscitation efforts begin with IVF and blood transfusions. His roommate brought him into the ER stating he projectile vomited blood 15 minutes prior.
Think esophageal varices
Esophageal varices are
-Dilated submucosal veins that develop in patients with serious portal hypertension
What might occur with esophageal varices?
Severe upper GI bleeding
- Bleeding varices can present with severe hematemesis and shock
- 50% of all cirrhotics have esophageal varices, and 30% of them will experience bleeding at some point
Treatment for esophageal varices
Treatment can be multifactorial depending on the severity of the varices and the severity of the underlying disease
Vasoactive drugs used to treat esophageal varices
Somatostatin and octreotide – reduce splanchnic and hepatic blood flow
-Vit K
-many need emergent endoscopy, banding or balloon tamponade
________ for encephalopathy, which can complicate an acute variceal bleeding episode
Lactulose
Antibiotic prophylaxis can be given for tx of varices but
high risk of spontaneous bacterial peritonitis or pneumonia
Portal decompressive procedures
TIPS and portosystemic shunt
TIPS – Transvenous Intrahepatic Portosystemic Shunt
- Over a wire that is passed through the jugular vein, a mesh stent is passed through the liver parenchyma crating a shunt from the portal vein to the hepatic vein
- Can control acute hemorrhage 90% of the time
- Also a strategy for the prevention of re-bleeding in those with severe bleeds
(Needle creates bypass to reroute blood around scarred liver; Alleviates pressure)
Portosystemic shunt
When TIPS procedure is unavailable, shunt surgery can be performed to create similar shunting from the portal vein to the hepatic vein
-40-60% mortality when done in emergency situations
Esophageal Achalasia
- Gradual, progressive dysphagia for solids and liquids
- Loss of peristalsis in the distal 2/3rds (smooth muscle) of the esophagus
S/S of Esophageal Achalasia
- 50% experience substernal chest pain
- Regurgitation of undigested food
- Patients may lift their chins or throw their shoulders back to get food to move through
- Barium esophagram with “bird’s beak” appearance to the distal esophagus
- Diagnosis confirmed with esophageal manometry
Treatment for Esophageal Achalasia
- Botulinum toxin injection
(Results in marked reduction in LES pressure with initial improvement in symptoms in the majority of patients; relapse reoccurs almost universally by 2 years) - Pneumatic dilation
(Less effective in younger patients, but the majority get a long lasting response
Relapse common around the 10 year mark) - Surgical myotomy
(Excellent improvement in 90% of patients; GERD is a common side effect of the procedure; Fundoplication often performed at the same time)
