4-esophageal disease.pptx
- 2. A. Esophageal perforation B. Boerhaave & mallory weiss syndrome C. Diffuse esophageal spasm D. Barett esophagus E. Achalasia F. Zenker diverticulum G. Plummer vinson syndrome H. Hiatal hernia I. Esophagitis J. Esophageal cancer K. Scleroderma
- 3. is due to the rapid increase in intraesophageal pressure combined with negative intrathoracic pressure caused by vomiting. Perforation of the esophagus can present with: 1. Severe and acute onset of excruciating retrosternal chest pain 2. Odynophagia 3. Positive Hamman sign, a crunching heard upon palpation of the thorax due to subcutaneous emphysema 4. Pain that can radiate to the left shoulder
- 4. ◾ Boerhaave syndrome ◾ is a full thickness tear secondary to extreme retching and vomiting. ◾ It is most commonly tested in the setting of an alcoholic.The most common location is at the left posterolateral aspect of the distal esophagus. ◾ Mallory-Weiss syndrome ◾ is a mucosal tear and is also due to vomiting. ◾ It is not a perforation.The most common location is at the gastroesophageal junction.
- 5. ◾ Surgical exploration with debridement of the mediastinum and closure of the perforation is an absolute emergency. ◾ Mediastinitis is a complication that carries a very high mortality rate
- 8. Submucosal dissection of the esophagus in patient with endoscopy for ERCP and "difficulty passing scope." Gastrografin swallow demonstrates intramural dissection of the esophagus from submucosal passage of endoscope with appearance similar to aortic dissection and "true and false lumen." Arrows point to "false lumen" created by passage of endoscope.
- 9. esophagram depict contrast extravasation from the distal esophagus in a patient with spontaneous perforation of the esophagus
- 10. Spontaneous, full-thickness rupture of the distal thoracic esophagus Associated with vomiting often following consumption of large quantities of alcohol in young people Can occur during endoscopic examinations (75% of adult cases) Serious complication of bulimia
- 11. Symptoms ◾ sudden-onset, severe, retrosternal chest pain ◾ difficulty or painful swallowing ◾ hematemesis though more common in Mallory-Weiss tears Physical exam ◾ pleuritic chest pain ◾ hyperventilation ◾ tachycardia
- 12. ChestCT ◾ left-sided hydropneumothorax ◾ pneumomediastinum ◾ esophageal thickening Contrast studies ◾ may show leakage from esophageal tear use water-soluble contrast agent (Gastrografin)
- 13. Medical management conservative therapy indicated in mild cases with stable patient and includes intravenous resuscitation nasogastric suction NPO prophylactic antibiotics- usually broad-coverage to prevent mediastinal infection- imipenim or cilastin Surgical intervention surgical repair of perforation considered standard of care indicated depending on severity of tear and timing of diagnosis
- 18. ◾ The most accurate test is an esophogram (Gastrografin;); it will show leakage of contrast outside of the esophagus. ◾ Barium cannot be used because it is caustic to the tissues.
- 19. ◾ Mallory-Weiss tear presents with upper gastrointestinal bleeding after prolonged or severe vomiting or retching. ◾ Repeated retching is followed by hematemesis of bright red blood, or by black stool. ◾ MalloryWeiss does not present with dysphagia.There is no specific therapy, and it will resolve spontaneously. ◾ Severe cases with persistent bleeding are managed with an injection of epinephrine to stop bleeding or the use of electrocautery. Boerhaave syndrome is full penetration of the esophagus.
- 20. Strong, non-peristaltic contractions of the esophageal body Often precipitated by by ingestion of hot and cold liquids Patients have normal sphincter function Associated withGERD
- 22. • Symptoms • symptoms may occur following ingestion of cold liquids and include • difficulty swallowing • painful swallowing • sudden onset chest pain not related to exertion • spontaneous and radiated to back, ears, and neck • Physical exam • symptomatic relief with nitroglycerin
- 23. Evaluation •UpperGI/esophageal contrast study • shows "corkscrew esophagus" •Manometry • may show high-amplitude, simultaneous contractions (non- peristaltic) •Endoscopy - normal •ECG - normal •Stress test - normal
- 24. Medical management symptomatic relief antacids forGERD nitrates for chest pain/spasms calcium channel blockers Surgical intervention long esophagomyotomy indicated for severe, incapacitating symptoms
- 25. ◾ Metaplasia of the squamous cell architecture of the esophagus to glandular architecture ◾ A complication of chronicGERD
- 26. Biopsy glandular metaplasia of distal esophagus presence of stomach acid resutls in conversion of normal squamous cells into columnar and goblet cells (normally found in stomach and small intestine)
- 28. ◾ Ulceration leading to formation of stricture ◾ Increased risk of esophageal adenocarcinoma
- 29. ◾ Motor disorder of the distal esophagus caused by degeneration ofAurbach's plexus the most common motility disorder ◾ Pathophysiology autoimmune process causes loss of NO-producing neurons which normally relax the sphincter muscles ▪ association with HLA-DQw1 leads to failure of the LES to relax during swallowing results in loss of peristalsis ACHALASIA
- 30. Associated with Chagas' disease amastigotes destroy ganglion cells Scleroderma presents in 70% of these patients ◾ Epidemiology more common in people under 50 years of age ACHALASIA
- 31. ◾ Symptoms dysphagia for solids and liquids ▪ usually worse for liquids weight loss
- 32. ◾ Barium swallow may show narrowing of the distal esophagus loss of peristalsis in the distal two thirds dilated proximal esophagus classic "bird's beak" tapering at the esophageal sphincter
- 33. most accurate test that may show ◾ increased LES pressure ◾ inability of LES to relax ◾ decreased peristalsis in the esophageal body ◾ diffuse esophageal spasm
- 35. ◾ useful in excluding secondary causes of achalasia (i.e. malignancy) ◾ use to rule out malignancy ◾ shows normal mucosa
- 36. medications to reduce LES tone 1. nifedipine 2. nitrates 3. CCBs 4. botulinum toxin injections ▪ wears off in approximately 3-6 months ▪ requires reinjection
- 37. endoscopic balloon dilation of LES ▪ cures 80% ▪ leads to perforation in < 3% of patients myotomy with fundoplication ▪ more effective and dangerous than pneumatic dilation
- 38. ◾ Prognosis medical and surgical outcomes are similar often require multiple treatments ◾ Prevention no preventive measures are available at this time ◾ Complications esophageal malignancy secondary to Barrett's esophagus secondary to chronicGERD
- 39. ◾ Pharyngeal pouch that develops in the proximal esophageal wall ◾ Pulsion diverticula involving only the mucosa located between thyropharyngeal and cricopharyngeus muscle ◾ Etiology remains unknown, however, some have suggested the causes to be related to structural or physiological abnormalities of the cricopharyngeus ◾ Epidemiology incidence unknown most often occurs in age group (>70 years old)
- 41. ◾ Symptoms ◾ dysphagia ◾ regurgitation ◾ choking ◾ chronic cough ◾ bad breath (halitosis) ◾ Physical exam ◾ palpable, fluctuant neck mass may be appreciable
- 42. Diagnosis is based highly on clinical observations and patient history Avoid upper endoscopy if known or highly suspicious due to risk of rupture Barium swallow confirms diagnosis by visualizing pharyngeal outpouch
- 43. myotomy of cricopharyngeus muscle -with diverticula resection - endoscopic has better success rates compared to external approach
- 44. ◾ Complications surgery can lead to significant complications including death given location of lesion and age/health of average patient population with this pathology -may develop carcinoma within the pouch if not resected
- 45. ◾ Small, thin web-like tissue growth partially obstruct the upper esophagus ◾ Characterized by atrophic glossitis, esophageal webs, and anemia ◾ Etiology unknown ◾ Epidemiology most commonly observed in elderly woman associated with chronic iron-deficiency anemia ◾ Patients at increased risk of developing squamous cell carcinoma of the esophagus
- 46. Symptoms ◾ difficulty swallowing ◾ chronic cough ◾ weakness/malaise ◾ nail changes Physical exam ◾ atrophic glossitis ◾ esophageal webs ◾ anemia ◾ spoon nail deformitie
- 47. Diagnosis can be aided by clinical observations, including skin and nail changes Upper endoscopy may identify esophageal webs CBC may indicated chronic anemia Fe studies show Fe deficiency
- 48. ◾ Fe supplementation indicated to treat chronic anemia state ◾ esophageal dilation can be performed concurrently with upper GI endoscopy or manometry most commonly done with radial expansion balloon method
- 49. ◾ Prognosis most patients respond to treatment ◾ Prevention Fe supplementation in patients with known anemia may prevent web development ◾ Complications bleeding may occur secondary to esophageal tear during dilation esophageal carcinoma
- 50. ◾Herniation of the stomach through the diaphragm into the chest cavity Type I sliding hiatal hernia ◾ most common type (>95%) ◾ occurs at theGE junction ◾ stomach slides into the mediastinum Type II paraesophageal hiatal hernia (<5%) ◾ herniation of stomach fundus through diaphragm ◾ GE junction remains below diaphragm ◾ parallel to the esophagus ◾ Associated withGERD in 80% of sliding hiatal hernia
- 52. ◾ Symptoms may be asymptomatic, usually identified incidentally on radiography chest pain heart burn GERD ◾ Physical exam ◾ usually no significant findings
- 53. ◾ Barium swallow - may observe stomach in chest cavity ◾ Usually an incidental finding
- 55. Medical management ◾ ◾ symptom management and lifestyle modifications indicated in type I (sliding hiatal hernias) to relieveGERD symptoms antacids weight loss dieting Surgical intervention -surgical repair indicated in type II (paraesophageal cases) due to risk of strangulation
- 56. Prognosis ◾ treatment relieves most symptoms Prevention ◾ lifestyle modifications can prevent symptoms Complications ◾ aspirate pneumonia ◾ gastric strangulation ◾ iron-deficiency/malnutrition
- 57. Schatzki ring "Steakhouse syndrome" = dysphagia from solid food associated with Schatzki ring Schatzki ring is often from acid reflux and is associated with hiatal hernia. This is a type of scarring or tightening (also called peptic stricture) of the distal esophagus. Schatzki ring is associated with intermittent dysphagia and is treated with pneumatic dilation in an endoscopic procedure
- 59. Corrosive Esophagitis Caused by ingestion of strongly acidic or basic chemical ◾ Lye, HCl Results in ◾ esophageal perforation ◾ esophageal stricture formation Often seen in suicide attempts or in the pediatric population
- 60. Infectious Esophagitis •Commonly seen inAIDS patients and the Immunocompromised •May be viral or fungal • HSV (punched out lesions on EGD) • CMV (large solitary ulcers or erosions on EGD) • Candida (white mucosal plaque- like lesions on EGD) •Odynophagia is main symptom
- 61. These pills cause esophagitis if in prolonged contact: • Doxycycline • Alendronate • KCI Pills esophagitis
- 62. "What Is the Most Likely Diagnosis?" Look for: Age 50 or older Dysphagia first for solids, followed later (progressing) to dysphagia for liquids Association with prolonged alcohol and tobacco use More than 5-10 years ofGERD symptoms
- 64. 1.Endoscopy is indispensible, since only a biopsy can diagnose cancer. 2.Barium might be the "best initial test," but no radiologic test can diagnose cancer. 3.CT and MRI scans are not enough to diagnose esophageal cancer; they are used to determine the extent of spread into the surrounding tissues. 4.PET scan is used to determine the contents of anatomic lesions if you are not certain whether they contain cancer. PET scan is often used to determine whether a cancer is resectable. Local disease is resectable, and widely metastatic disease is not.
- 65. 1.No resection (removal) = no cure.Surgical resection is always the thing to try. 2.Chemotherapy and radiation are used in addition to surgical removal. 3.Stent placement is used for lesions that cannot be resected surgically just to keep the esophagus open for palliation and to improve dysphagia
- 66. ◾ These patients present with symptoms of reflux and have a clear history of scleroderma, or progressive systemic sclerosis. ◾ Manometry shows decreased lower esophageal sphincter pressure from an inability to close the LES. ◾ The management is with PPis as it would be for any person with reflux symptoms. ◾ The disorder is simply one of mechanical immobility of the esophagus .
- 67. ◾ Esophageal smooth muscle atrophydecrease LES pressure and dysmotilityacid reflux and dysphagia stricture,Barrett esophagus, and aspiration. ◾ Part ofCREST syndrome.
- 68. Manometry is the answer for: 1. Achalasia 2. Spasm 3. Scleroderma