Esophageal disease

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

 Dysphagia is the essential feature of the majority of
esophageal disorders.
 Dysphagia means difficulty swallowing. Odynophagia
is the proper term for pain while swallowing. Both
dysphagia and odynophagia can lead to weight loss.
Hence, weight loss cannot be used to answer the
"What is the most likely diagnosis?" question.
 When severe, some forms of esophageal disorders will
also give anemia and heme-positive stool.
 When any of these alarm symptoms are present,
endoscopy should be performed to exclude cancer.

Alarm symptoms indicating endoscopy include:
•Weight loss
• Blood in stool
• Anemia

 is due to the rapid increase in intraesophageal
pressure combined with negative intrathoracic
pressure caused by vomiting.
 Perforation of the esophagus can present with:
• Severe and acute onset of excruciating retrosternal
chest pain
• Odynophagia
• Positive Hamman sign, a crunching heard upon
palpation of the thorax due to subcutaneous
emphysema
• Pain that can radiate to the left shoulder

 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.

 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

A 53-year-old obese man presents with sudden onset of
abdominal pain that radiates to his right shoulder.The
patient also says he has vomited blood earlier in the day.
The patient has a full bottle of esomeprazole in his
pocket and says he uses those for his heartburn. Physical
examination reveals rebound tenderness in the
midepigastrum. Upright chest x-ray shows air under the
diaphragm.
What is the most likely diagnosis?
a. Gastric perforation
b. Hemorrhagic ulcer
c. Cholecystitis
d. Ischemic colitis

Answer: A.This is gastric perforation in the setting
of peptic ulcer disease.The patient's bottle filled
with PPis is due to his history of ulcers.The fact
that it is a full bottle implies the patient is
noncompliant with his medication. Hemorrhagic
ulcers will present with hematemesis, specifically
coffee ground emesis. Cholecystitis would have
right upper quadrant pain that is colicky in nature.
Ischemic colitits would have an abdominal pain
that is out of proportion to physical findings.

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.

esophagram depict contrast extravasation
from the distal esophagus in a patient with
spontaneous perforation of the esophagus

A 20-year-old female presents to the hospital with severe
chest pain. She states that the pain started suddenly and is
retrosternal in nature.The pain began shortly after lunch and
is worse with swallowing. She has no prior medical history
except for a brief inpatient stay for what she describes as an
"eating disorder." On exam her vitals are as follows: HR 120,
RR 22, BP 145/90. She is flushed and taking deep breaths.
Which of the following is the best confirmatory test for the
most likely cause of this presentation?
1. Chest x-ray
2. EKG
3. Gastrografin esophogram
4. Barium esophogram
5. Observation

 DISCUSSION:The patient in this vignette may be suffering from
an esophageal rupture (Boerhaave's syndrome) as a result of
repeated induced vomiting. As time is essential in treating
esophageal ruptures, the most appropriate step is a water-
soluble (gastrografin) esophogram.
 Symptoms of esophageal rupture include sudden-onset, severe,
retrosternal chest pain, and difficult or painful swallowing.While
hematemesis may be present, it is more common in Mallory-
Weiss tears. Physical exam may show pleuritic chest pain,
hyperventilation, and tachycardia. Evaluation includes a chest CT
(may show left-sided hydropneumothorax,
pneumomediastinum, or esophageal thickening) or contrast
studies (may show leakage from esophageal tear). Of note, water
soluble contrasts should be used before barium studies.

 incorrectAnswers:
 Answer 1: Chest x-ray is not the best test for
esophageal ruptures.
 Answer 2: An EKG is not an unreasonable test here but
not the best choice when esophageal rupture must be
ruled-out.
 Answer 4: Barium esophogram is not the first line
choice of contrast agents used in suspected
esophageal ruptures to avoid barium associated
inflammation of the mediastinum.
 Answer 5: Observation would not be appropriate and
may have potentially devastating consequences.

 A 19-year-old female college freshman
presents to the hospital with severe
retrosternal chest pain that is aggravated by
swallowing. She appears flushed and is taking
long ,deep breaths. Her friends report that
she got sick after a fraternity party and has
not been feeling well ever since

 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

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

Chest CT
 left-sided hydropneumothorax
 pneumomediastinum
 esophageal thickening
Contrast studies
 may show leakage from esophageal tear
 use water-soluble contrast agent
(Gastrografin)

Medical management
conservative therapy
 indicated in mild cases with stable patient and includes
 intraveous 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

 The most accurate test is an esophogram
using diatrizoate meglumine and diatrizoate
sodium solution (Gastrografin; Bracco
Diagnostics, Princeton, New Jersey); it will
show leakage of contrast outside of the
esophagus.
 Barium cannot be used because it is caustic
to the tissues.

 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.
 Mallory Weiss 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.

 A 47-year-old man presents to the
emergency room saying that he is having a
heart attack. He reports that the pain started
after he ate some of his favorite soup. It is
noted that he also had some difficulty
swallowing when the symptoms began

 Strong, non-peristaltic contractions of the
esophageal body
 Often precipitated by by ingestion of hot
and cold liquids
 Patients have normal sphincter function
 Associated with GERD

• 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

Evaluation
•Upper GI/esophageal contrast study
• shows "corkscrew esophagus"
•Manometry
• may show high-amplitude,
simultaneous contractions (non-
peristaltic)
•Endoscopy - normal
•EKG - normal
•Stress test - normal

 Medical management
 symptomatic relief
 antacids for GERD
 nitrates for chest pain/spasms
 calcium channel blockers
 Surgical intervention
 long esophagomyotomy
 indicated for severe, incapacitating
symptoms

A 28-year-old male is brought to the emergency
department (ED) via ambulance with sudden onset of
extreme chest pain.The patient states that he had just
finished his morning run and was drinking from his water
bottle when the pain began. He states that the pain was
like "nothing he had experienced before" and radiated to
his back, neck, and ears. He called EMS and was given
325mg aspirin, sublingual nitroglycerine, and supplemental
oxygen in the field resulting in near resolution of his
symptoms. In the ED, his exam is completely unremarkable
except for a heart rate of 110 bpm. EKG shows sinus
tachycardia, troponin and CK-MB are within normal limits,
and stress test is normal.The medical team next looks to
non-cardiac causes for the patient's chest pain. Given the
most likely diagnosis, which of the following could be seen
on upper GI contrast study?

 Sudden chest pain following ingestion of cold water and relieved with
nitroglycerin is classic of diffuse esophageal spasm. If performed during
an episode, upper GI contrast study will show the "corkscrew" esophagus
shown in Figure E.
 Diffuse esophageal spasm is the painful uncoordinated, non-peristatlic
contraction of the esophagus with normal lower esophageal sphincter
tone. It is often precipitated by the ingestion of hot or cold liquids as
seen in this vignette and is associated with a history of gastric-
esophageal reflux disease (GERD). Associated symptoms include
dysphagia, odynophagia, and chest pain radiating to the back, neck, and
jaw which is unrelated to exertion, but revealed with nitroglycerin. Upper
GI study will show corkscrew esophagus; manometry will show high-
amplitude, simultaneous contractions; endoscopy will be normal.
Medical treatment includes symptomatic relief with nitrates or calcium-
channel blockers, and long esophagomyotomy may be indicated in
refractory cases.

 Figure A shows a hiatal hernia. Rugae of the
stomach can be seen in the herniated contents.
 Figure B shows a stricture of the esophagus in a
patient with Barrett's esophagus.
 Figure C shows the classic bird beak and
proximal dilatation of a patient with achalasia.
 Figure D shows a filling defect in a patient with
esophageal carcinoma.
 FIgure E shows the classic corkscrew esophagus
in a patient experiencing an acute episode of
diffuse esophageal spasm.

 Answer 1: Hiatal hernias can present with GERD
and/or chest pain, or they can be asymptomatic.
They are not associated with sudden pain
relieved by nitroglycerin.
 Answer 2: Esophageal stricture would have more
chronic symptoms of GERD, dysphasia, and
weight loss.
 Answer 3: Achalasia would more likely present
with chronic dysphagia for liquids greater than
solids and weight loss.
 Answer 4: Esophageal carcinoma usually
presents with dysphagia and lymphadenopathy.

 Metaplasia of the squamous cell architecture
of the esophagus to glandular architecture
 A complication of chronic GERD

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)

 Ulceration leading to formation of stricture
 Increased risk of esophageal adenocarcinoma

 A 45-year-old man
presents to his primary
care physician
complaining of difficulty
swallowing solids and
liquids. He also reports
unintentional weight
loss.

 Motor disorder of the distal esophagus caused
by degeneration of Aurbach'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

 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

 Symptoms
 dysphagia for solids and liquids
▪ usually worse for liquids
 weight loss

 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

 most accurate test that may show
 increased LES pressure
 inability of LES to relax
 decreased peristalsis in the esophageal body
 diffuse esophageal spasm

 useful in excluding secondary causes of
achalasia (i.e. malignancy)
 use to rule out malignancy
 shows normal mucosa

 medications to reduce LES tone
▪ nifedipine
▪ nitrates
▪ CCBs
▪ botulinum toxin injections
▪ wears off in approximately 3-6 months
▪ requires reinjection

 endoscopic balloon dilation of LES
▪ cures 80%
▪ leads to perforation in < 3% of patients
 myotomy with fundoplication
▪ more effective and dangerous than
pneumatic dilation

 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 chronic GERD

A 29-year-old female presents to general medical clinic with
dysphagia. Her symptoms began several months ago. She has
trouble swallowing solids and liquids though liquids seem to
make her choke and sputter the most; therefore, she has been
unable to eat and has thus experienced significant weight loss.
She has no significant past medical history apart from a 20-
pack-year smoking history. She denies any recent travel.Vital
signs are stable. Physical examination is within normal limits. A
barium esophagram shows the following (Figure A).
Subsequent esophageal manometry reveals elevated resting
lower esophageal sphincter pressure, incomplete lower
esophageal sphincter relaxation after swallowing, and almost
total absence of peristalsis in the esophageal body.What is the
next best step in management?

 1. Begin a calcium channel
blocker
 2. Begin botulinum toxin
injections
 3. Endoscopic balloon dilation
of the lower esophageal
sphincter
 4. Upper endoscopy
 5. Myotomy with
fundoplication
fIGURES:A

 DISCUSSION: In diagnosing achalasia, one must first rule out
malignancy with an endoscopic evaluation. After a barium swallow and
esophageal manometry suggest achalasia, one must perform endoscopy
prior to beginning medical or surgical management.
 Recall that achalasia is a motor disorder of the distal esophagus resulting
from degeneration of Aurbach's plexus. It is the most common motility
disorder and is often found in patients under 50. The lower esophageal
sphincter fails to relax during swallowing. As a consequence, natural
peristalsis is disrupted and the patient experiences dysphagia to solids
and liquids, with liquids often being most problematic. A barium
esophagram is helpful in making the diagnosis and should reveal the
classic bird's beak tapering at the esophageal sphincter. This is the first
step in management. Subsequently, diagnosis may be confirmed with
esophageal manometry. Once endoscopy is completed, palliative
treatment may begin. Treatment includes medical management consisting
of calcium channel blockers, botulinum toxin injections, and surgical
therapy may include endoscopic balloon dilation of the lower esophageal
sphincter or a more invasive option, myotomy with fundoplication.

 Incorrect Answers:
 Answers 1, 2, 3, and 5: All of these are
potential treatments for achalasia. However,
treatment should not begin until malignancy
is ruled out with an upper endoscopy.

A 37-year-old man presents to general medical clinic with
dysphagia. He notes that his symptoms began several
weeks ago and have worsened over time. He now has
trouble swallowing solids and liquids, though liquids have
always given him the most trouble. He denies any other
symptoms. He has no significant past medical history.Travel
history reveals a recent trip to South America but no other
travel outside the United States.Vital signs are stable.
Physical examination is within normal limits. He has no
palpable masses.What is the next step in management?
1. Upper endoscopy
2. Barium esophagram
3. Esophageal manometry
4. CT of the chest
5. Administer nifurtimox

 DISCUSSION:This patient presents with signs and symptoms concerning
for achalasia, possibly due toChagas disease.A barium esophagram is
the next step in management and should precede endoscopy in patients
with dysphagia and a broad differential diagnosis.
 Recall that achalasia is a motor disorder of the distal esophagus resulting
from degeneration ofAuerbach's plexus where lower esophageal
sphincter fails to relax during swallowing.As a consequence, natural
peristalsis is disrupted and the patient experiences dysphagia to solids
and liquids, with liquids often being most problematic. It is the most
common motility disorder and is often found in patients under 50.The
condition has been associated withChagas disease, where the parasitic
amastigotes destroy ganglion cells.
 A barium esophogram is helpful in making the diagnosis and should
reveal the classic bird's beak tapering at the esophageal sphincter (see
IllustrationA). Diagnosis is eventually confirmed with esophageal
manometry.

 Incorrect Answer:
 Answer 1: Upper endoscopy would be more costly than barium
esophagram and is not the preferred next step in management in
dysphagia.
 Answer 3: Esophageal manometry may be used to confirm a
diagnosis of achalasia but should not be the next step in
management.
 Answer 4: CT of the chest is not needed in the diagnosis of
achalasia but could be warranted if malignancy were the cause of
this patient's dysphagia.
 Answer 5: Nifurtimox is successful in treating Chagas disease
which is caused byTrypanosoma cruzi and transmitted by the
Reduviid bug. However, diagnosis should be made by blood smear
before treating this patient.

A 66-year-old woman presents to your outpatient clinic for her
regular checkup. During the visit, she tells you that she feels "in
great health," with the exception of some recent trouble
swallowing. Further questioning reveals that she has difficulty
swallowing solids and liquids.These symptoms have been
worsening slowly for the past 5 months.Vital signs are within
normal limits, but her weight has decreased by 12 pounds since
her last visit 6 months ago. Barium swallow reveals smooth
tapering of the distal esophagus (Figure A). Which of these
choices is the most appropriate next step in management?
FIGURES: A
1. Nifedipine
2. High-calorie nutritional supplementation
3. Botulinum toxin injection
4. Surgical myotomy
5. Upper GI endoscopy

 5
 DISCUSSION:This patient presents with the classic signs and
symptoms of achalasia. Upper GI endoscopy to rule out
malignancy is indicated prior to treatment in cases of suspected
achalasia.
 Achalasia is a disorder of esophageal motility in which esophageal
peristalsis is absent and lower esophageal sphincter relaxation
after swallowing is impaired. Patients report difficulty swallowing
both solids and liquids, and barium swallow shows the classic
"bird's beak" appearance. Besides dysphagia, patients frequently
report heartburn, chest pain, weight loss, and regurgitation.
Esophageal manometry and pH monitoring are also used in the
diagnosis of this condition.

 Incorrect Answers:
 Answer 1: Calcium channel blocker administration may help
decrease lower esophageal sphincter pressure and ease the
symptoms of achalasia; however, malignancy must be ruled out
first through endoscopy.
 Answer 2: High-calorie nutritional supplementation is
inappropriate in this case, as her weight loss is most likely caused
by a GI condition such as achalasia or malignancy.
 Answer 3: Botulinum toxin administration may help decrease
lower esophageal sphincter pressure and ease the symptoms of
achalasia; however, malignancy must be ruled out first through
endoscopy.
 Answer 4: Surgical myotomy is indicated for treatment of
achalasia in many patients; however, malignancy must first be
ruled out through endoscopy

 A 73-year-old female is being seen at the
emergency department after having
recurrent coughing spells and regurgitation
following meals. Her breath is nearly
unbearable upon arrival to the ED. She is also
noted to have a palpable, fluctuant neck mass
on physical examination.

 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)

 Symptoms
 dysphagia
 regurgitation
 choking
 chronic cough
 bad breath (halitosis)
 Physical exam
 palpable, fluctuant neck mass may be
appreciable

 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

 myotomy of cricopharyngeus muscle
-with diverticula resection
- endoscopic has better success rates compared
to external approach

 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

A 78-year-old male presents to clinic with a chief
complain of regurgitation after eating meals.The
patients vitals are stable and he is currently in no
distress. On exam you note that his breath is
particularly foul.Which of the following is the most
accurate diagnostic test for this patient's condition?
1. Clinical observations and history are sufficient for
diagnosis
2. Upper endoscopy
3. Chest radiograph
4. Barium swallow
5. Manometry

 4
 DISCUSSION:This patient is experiencing aZenker's diverticulum
(ZD). Clinical observations, history, and a barium swallow study are
the keys needed to make this diagnosis.
 Zenker's diverticulum is a condition characterized by a false
diverticula of the esophagus.The pathophysiology of this
condition includes a pulsion diverticula involving only the mucosa
of the esophagus. It is often located at the junction of the pharynx
and esophagus where there is an area of weakness involving the
cricopharyngeus muscle. Symptoms include dysphagia,
regurgitation, and choking. Physical examination can sometimes
show a neck mass, but will often include halitosis secondary to
trapped food particles.

 Answer 1: Although necessary, clinical observations and
history alone are not the appropriate way to diagnose a
Zenker's diverticulum. Barium swallow studies are also
necessary for confirmation of clinical suspicion.
 Answer 2: Upper endoscopy is not used in the diagnosis of
Zenker's diverticula.
 Answer 3: Although a chest radiograph would be used in
the overall workup, in order to diagnosis Zenker's
diverticula, a barium swallow study must be performed.
 Answer 5: Manometry would be the appropriate choice for
a younger patient experiencing dysphagia that also
perhaps some regurgitation but less fetid breath in the
case of achalasia.The demographics of this case better fit
ZD

llustration A is a lateral view of a barium
study showing a Zenker's diverticulum.
Illustration B is an artists rendition of a
diverticulectomy.

Illustration C is an artists rendition of a
diverticulopexy.

 A 63-year-old woman with chronic anemia
presents to her primary care physician
complaining of difficulty swallowing.An
upper endoscopy is ordered.

 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

Symptoms
 difficulty swallowing
 chronic cough
 weakness/malaise
 nail changes
Physical exam
 atrophic glossitis
 esophageal webs
 anemia
 spoon nail deformitie

 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

 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

 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

A 45-year-old man presents to the emergency
room with chest pain, difficulty swallowing, and
heartburn after meals, especially when
reclining.

 Herniation of the stomach through the diaphragm into the chest cavity
Type I
 sliding hiatal hernia
 most common type (>95%)
 occurs at the GE 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 with GERD in 80% of sliding hiatal hernia cases

 Symptoms
 may be asymptomatic, usually identified
incidentally on radiography
 chest pain
 heart burn
 GERD
 Physical exam
 usually no significant findings

 Barium swallow
- may observe stomach in chest cavity
 Usually an incidental finding

Medical management
 symptom management and lifestyle
modifications
 indicated in type I (sliding hiatal hernias) to
relieve GERD symptoms
 antacids
 weight loss
 dieting
Surgical intervention -surgical repair
 indicated in type II (paraesophageal cases) due
to risk of strangulation

Prognosis
 treatment relieves most symptoms
Prevention
 lifestyle modifications can prevent symptoms
Complications
 aspirate pneumonia
 gastric strangulation
 iron-deficiency/malnutrition

Schatzki ring is
associated with
intermittent dysphagia
and is treated with
pneumatic dilation in an
endoscopic procedure
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.
"Steakhouse syndrome" =
dysphagia from solid food
associated with Schatzki
ring

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

Infectious Esophagitis
•Commonly seen in AIDS 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

A 43-year-old man recently diagnosed with AIDS comes
to the emergency department
with pain on swallowing that has become progressively
worse over the last
several weeks.There is no pain when not swallowing. His
CD4 count is 43 mm3•
The patient is not currently taking any medications.
What is the most appropriate next step in management?
a. Esophagram
b. Upper endoscopy
c. Oral nystatin swish and swallow
d. Intravenous amphotericin
e. Oral fluconazole

Answer: E.The most commonly asked infectious
esophagitis question is esophageal candidiasis in a person
with AIDS. Oral candidiasis (thrush) need not be present in
order to have esophageal candidiasis. One does not
automatically follow from the other.
Although other infections such as CMV and herpes can also
cause esophageal infection,over 90% of esophageal
infections in patients with AIDS are caused by Candida.
Empiric therapy with fluconazole is the best course of
action. If fluconazole does not improve symptoms, then
endoscopy is performed. Intravenous amphotericin is used
for confirmed candidiasis not responding to fluconazole.
Oral nystatin swish and swallow is not sufficient to control
esophageal candidiasis. Nystatin treats oral candidiasis.

These pills cause esophagitis if in prolonged
contact:
• Doxycycline
• Alendronate
• KCI

"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 of GERD symptoms

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.

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

 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 .

 Esophageal smooth muscle
atrophydecreaseŽ•LES pressure and
dysmotility Žacid reflux and dysphagia
stricture,Barrett esophagus, and aspiration.
Part of CREST syndrome.

TIP
Manometry is the answer for:
o Achalasia
o Spasm
o Scleroderma

Esophageal disease

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