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MISSED COMMON ESOPHAGEAL
DISORDERS
Presenter: Dr Maria Nadeem
Supervisor: Dr Arsalan Shahzad
LEARNING OBJECTIVES
 Eosinophilic Esophagitis
 Diffuse Esophageal spasm
 Nutcracker Esophagus
 Esophageal Scleroderma
 Achalasia
CASE 1
 A 24-year-old male presents to the emergency room with a
chief complaint of “I can’t swallow.” He states that while
eating dinner, chicken suddenly “got stuck, and I could not
swallow.” He can swallow saliva; however, he cannot
swallow liquids. He has associated mid-chest discomfort.
He denies GI bleeding, heartburn, weight loss or any
additional symptoms. Over the last two to three years, he
has experienced intermittent solid food dysphagia,
which has caused him to eat slowly and chew food
repeatedly. There are no prior episodes of food impaction.
He has a history of seasonal allergies for which he takes
an over-the-counter antihistamine. What’s the diagnosis?
EOSINOPHILIC ESOPHAGITIS
EOSINOPHILIC ESOPHAGITIS
 Food or environmental antigens stimulate an inflammatory
response.
 Once considered a rare condition.
 Now one of the most common conditions diagnosed during
the assessment of feeding problems in children and during
the evaluation of dysphagia and food impaction in adults.
CLINICAL FINDINGS
 Dysphagia, one episode of food impaction.
 Children: Abdominal pain, vomiting, failure to thrive.
 Heartburn/ Chest pain.
 Lab: Eosinophilia, Raised IgE.
 Barium Swallow: Small Caliber Esophagus,
strictures, rings.
 Endoscopy: EREFS
 5% grossly normal Endoscopy.
GASTRO TOPICS common in public now .pptx
GASTRO TOPICS common in public now .pptx
GASTRO TOPICS common in public now .pptx
TREATMENT
 PPI’s
 Topical corticosteroids
 Food elimination diets
 Esophageal dilation.
CASE # 2
 An 87-year-old woman with severe retrosternal pain
and intermittent dysphagia was referred to the clinic for
further evaluation. She described paroxysms of crampy
pain almost exclusively during the intake of solid foods.
In the past several months, she noted a weight loss of 5
kg.
 Endoscopy revealed no mucosal lesions.
 Barium swallow revealed normal study.
 pH manometry - no pathologic regurgitation
 What’s the diagnosis?
DIFFUSE ESOPHAGEAL SPASM (DES)
 On HRM, this patient
had esophageal
spasms, associated
with symptoms, which
were provoked by a
multiple rapid
swallowing test, and
thereby was diagnosed
with DES.
DIFFUSE ESOPHAGEAL SPASM (DES)
Signs/ Symptoms:
 Chest pain, Dysphagia,
Regurgitation.
 With swallowing, with
emotional stress.
 Pain can radiate.
 Mimic Cardiac Angina.
Imaging:
Barium Swallow: Normal
Cork-screw in Severe cases
 Manometry:
More than 20% of wet swallows as
simultaneous contractions.
Can be entirely normal.
Treatment:
Reassurance.
PPIs.
Nitrates.
Calcium channel blockers.
CASE # 3
 A 72-year-old obese woman presents to her primary care
physician with intermittent chest pain and difficulty
swallowing liquids and solid foods. Cardiac work up
including electrocardiogram, cardiac enzymes, and
coronary angiography is normal.
 She undergoes Barium Swallow radiography, which was
normal.
 Further testing with esophageal manometry shows 182
mmHg of pressure created by the esophagus during
peristalsis.
 What’s the diagnosis?
NUTCRACKER ESOPHAGUS
 An esophagus with hypertensive peristalsis
or high amplitude peristaltic contractions in
which pressures more than 180mmHg
develop.
 Extremely forceful peristaltic contraction
leads to episodic chest pain and
dysphagia.
 Most painful of all disorders.
GASTRO TOPICS common in public now .pptx
NUTCRACKER ESOPHAGUS
 Symptoms
 Asymptomatic
 Chest pain (non-exertional) that may radiate to arm,
back, neck, or jaw
 dysphagia to solid and liquid foods
 Physical exam
 no specific findings.
NUTCRACKER ESOPHAGUS
 Imaging
 Upper gastrointestinal Barium Swallow
 can be normal
 can have a spiral appearance
 Esophageal Manometry
 diagnostic
 peristaltic contractions with ≥ 180 mmHg amplitude
 Endoscopy
 normal
 used to rule out anatomical causes of dysphagia
GASTRO TOPICS common in public now .pptx
TREATMENT
 Risk factor modification
 weight loss
 First-line
 Calcium channel blockers and nitrates
 Trazodone antidepressant
 Interventional
 Endoscopic injection of Botulinum Toxin
 Endoscopic dilatation
 Heller myotomy
 indicated for cases refractory to other treatment
 relaxes the lower esophageal sphincter and myenteric
plexus
CASE #4
 A 48 years old male,
 C/C Dysphagia since adulthood.
 Complaint worsened in the last three months followed by
odynophagia, nausea, and vomiting undigested, retained
food and heartburn.
 Was previously diagnosed with a variant of angina
pectoris but his symptoms didn't improve with medication.
 The patient had a history of weight loss but no anorexia,
no prior history of corrosive ingestion.
 Physical examination revealed no abnormality.
Gastroscopy revealed dilatation on the lower third of the
esophagus. Computed Tomography revealed dilatation of
distal esophagus.
ACHALASIA
ACHALASIA
 A rare swallowing disorder, but a lifelong condition
 Loss of peristalsis in the distal two-thirds (smooth
muscle) of the esophagus
 Impaired relaxation of the LES.
 Denervation of the esophagus resulting primarily from
 loss of nitric oxide–producing inhibitory neurons in the myenteric
plexus
 Greek- ‘failure to relax’
 Achalasia typically affects adults between 30 and 60 years
of age, with a peak in the 40s.
 About twice as common in men than women.
SYMPTOMS & SIGNS
 Occur during or after eating.
 The feeling that food or liquid are hard to
swallow and are getting caught in the
esophagus or “sticking” on the way down to the
stomach
 Regurgitation
 Substernal discomfort or fullness, which can be
severe and awaken the person from sleep
 Heartburn
 Coughing, especially at night
 Choking or aspiration.
 Weight loss common. Normal examination.
IMAGING
IMAGING
IMAGING
SPECIAL EXAMINATIONS
 Endoscopy
 High Resolution Esophageal manometry
 Endoscopic Ultrasonography
 Chest CT
TREATMENT
 Botulinum Toxin
Injection
 Pneumatic Dilation.
 Surgical Heller
Cardiomyotomy
 Per Oral Endoscopic
Myotomy (POEM)
CASE # 5
 A 20-year-old female patient who had difficulty in
swallowing solid foods for 2 years and liquid foods for
the last four months was admitted to our clinic.
 History- Raynaud’s phenomenon.
 Already being treated for GERD.
 On physical examination, cachexia, ‘fish mouth’
appearance, ulceration in the distal phalanges and MCP
joint ulceration were identified. Esophageal endoscopy
demonstrated hyperemia and extreme narrowness at 29
cm obstructing the passage of the endoscope. The
endoscopic biopsy result indicated esophagitis.
 HRM - decreased lower esophageal sphincter (LES)
pressure and absent or ineffective peristalsis of the
distal esophagus
SCLERODERMA ESOPHAGUS
 Occurs as part of connective tissue disorder.
CREST Syndrome.
 Atrophy of esophageal smooth muscle with loss of
LES tone and force of peristalsis.
 Raynaud’s phenomenon.
 Intramural neuronal dysfunction.
 Reflux esophagitis, Strictures.
 Pulmonary Interstitial Fibrosis.
 S/S: GERD, chest pain, dysphagia.
 Anti-Scl-70, Antiendonuclear Ab, Anti-centromere
Ab.
SCLERODERMA ESOPHAGUS
SCLERODERMA ESOPHAGUS
COMPARATIVE CHANGES IN MANOMETRY
CONCLUSION
 Not all chest pain is GERD—esophageal dysmotility
disorders can masquerade as GERD, leading to
misdiagnosis and ineffective treatment.
 Recognizing the nuances of these disorders is vital
for ensuring patients receive the right care and
relief.
GASTRO TOPICS common in public now .pptx

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GASTRO TOPICS common in public now .pptx

  • 1. MISSED COMMON ESOPHAGEAL DISORDERS Presenter: Dr Maria Nadeem Supervisor: Dr Arsalan Shahzad
  • 2. LEARNING OBJECTIVES  Eosinophilic Esophagitis  Diffuse Esophageal spasm  Nutcracker Esophagus  Esophageal Scleroderma  Achalasia
  • 3. CASE 1  A 24-year-old male presents to the emergency room with a chief complaint of “I can’t swallow.” He states that while eating dinner, chicken suddenly “got stuck, and I could not swallow.” He can swallow saliva; however, he cannot swallow liquids. He has associated mid-chest discomfort. He denies GI bleeding, heartburn, weight loss or any additional symptoms. Over the last two to three years, he has experienced intermittent solid food dysphagia, which has caused him to eat slowly and chew food repeatedly. There are no prior episodes of food impaction. He has a history of seasonal allergies for which he takes an over-the-counter antihistamine. What’s the diagnosis?
  • 5. EOSINOPHILIC ESOPHAGITIS  Food or environmental antigens stimulate an inflammatory response.  Once considered a rare condition.  Now one of the most common conditions diagnosed during the assessment of feeding problems in children and during the evaluation of dysphagia and food impaction in adults.
  • 6. CLINICAL FINDINGS  Dysphagia, one episode of food impaction.  Children: Abdominal pain, vomiting, failure to thrive.  Heartburn/ Chest pain.  Lab: Eosinophilia, Raised IgE.  Barium Swallow: Small Caliber Esophagus, strictures, rings.  Endoscopy: EREFS  5% grossly normal Endoscopy.
  • 10. TREATMENT  PPI’s  Topical corticosteroids  Food elimination diets  Esophageal dilation.
  • 11. CASE # 2  An 87-year-old woman with severe retrosternal pain and intermittent dysphagia was referred to the clinic for further evaluation. She described paroxysms of crampy pain almost exclusively during the intake of solid foods. In the past several months, she noted a weight loss of 5 kg.  Endoscopy revealed no mucosal lesions.  Barium swallow revealed normal study.  pH manometry - no pathologic regurgitation  What’s the diagnosis?
  • 12. DIFFUSE ESOPHAGEAL SPASM (DES)  On HRM, this patient had esophageal spasms, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES.
  • 13. DIFFUSE ESOPHAGEAL SPASM (DES) Signs/ Symptoms:  Chest pain, Dysphagia, Regurgitation.  With swallowing, with emotional stress.  Pain can radiate.  Mimic Cardiac Angina. Imaging: Barium Swallow: Normal Cork-screw in Severe cases  Manometry: More than 20% of wet swallows as simultaneous contractions. Can be entirely normal. Treatment: Reassurance. PPIs. Nitrates. Calcium channel blockers.
  • 14. CASE # 3  A 72-year-old obese woman presents to her primary care physician with intermittent chest pain and difficulty swallowing liquids and solid foods. Cardiac work up including electrocardiogram, cardiac enzymes, and coronary angiography is normal.  She undergoes Barium Swallow radiography, which was normal.  Further testing with esophageal manometry shows 182 mmHg of pressure created by the esophagus during peristalsis.  What’s the diagnosis?
  • 15. NUTCRACKER ESOPHAGUS  An esophagus with hypertensive peristalsis or high amplitude peristaltic contractions in which pressures more than 180mmHg develop.  Extremely forceful peristaltic contraction leads to episodic chest pain and dysphagia.  Most painful of all disorders.
  • 17. NUTCRACKER ESOPHAGUS  Symptoms  Asymptomatic  Chest pain (non-exertional) that may radiate to arm, back, neck, or jaw  dysphagia to solid and liquid foods  Physical exam  no specific findings.
  • 18. NUTCRACKER ESOPHAGUS  Imaging  Upper gastrointestinal Barium Swallow  can be normal  can have a spiral appearance  Esophageal Manometry  diagnostic  peristaltic contractions with ≥ 180 mmHg amplitude  Endoscopy  normal  used to rule out anatomical causes of dysphagia
  • 20. TREATMENT  Risk factor modification  weight loss  First-line  Calcium channel blockers and nitrates  Trazodone antidepressant  Interventional  Endoscopic injection of Botulinum Toxin  Endoscopic dilatation  Heller myotomy  indicated for cases refractory to other treatment  relaxes the lower esophageal sphincter and myenteric plexus
  • 21. CASE #4  A 48 years old male,  C/C Dysphagia since adulthood.  Complaint worsened in the last three months followed by odynophagia, nausea, and vomiting undigested, retained food and heartburn.  Was previously diagnosed with a variant of angina pectoris but his symptoms didn't improve with medication.  The patient had a history of weight loss but no anorexia, no prior history of corrosive ingestion.  Physical examination revealed no abnormality. Gastroscopy revealed dilatation on the lower third of the esophagus. Computed Tomography revealed dilatation of distal esophagus.
  • 23. ACHALASIA  A rare swallowing disorder, but a lifelong condition  Loss of peristalsis in the distal two-thirds (smooth muscle) of the esophagus  Impaired relaxation of the LES.  Denervation of the esophagus resulting primarily from  loss of nitric oxide–producing inhibitory neurons in the myenteric plexus  Greek- ‘failure to relax’
  • 24.  Achalasia typically affects adults between 30 and 60 years of age, with a peak in the 40s.  About twice as common in men than women.
  • 25. SYMPTOMS & SIGNS  Occur during or after eating.  The feeling that food or liquid are hard to swallow and are getting caught in the esophagus or “sticking” on the way down to the stomach  Regurgitation  Substernal discomfort or fullness, which can be severe and awaken the person from sleep  Heartburn  Coughing, especially at night  Choking or aspiration.  Weight loss common. Normal examination.
  • 29. SPECIAL EXAMINATIONS  Endoscopy  High Resolution Esophageal manometry  Endoscopic Ultrasonography  Chest CT
  • 30. TREATMENT  Botulinum Toxin Injection  Pneumatic Dilation.  Surgical Heller Cardiomyotomy  Per Oral Endoscopic Myotomy (POEM)
  • 31. CASE # 5  A 20-year-old female patient who had difficulty in swallowing solid foods for 2 years and liquid foods for the last four months was admitted to our clinic.  History- Raynaud’s phenomenon.  Already being treated for GERD.  On physical examination, cachexia, ‘fish mouth’ appearance, ulceration in the distal phalanges and MCP joint ulceration were identified. Esophageal endoscopy demonstrated hyperemia and extreme narrowness at 29 cm obstructing the passage of the endoscope. The endoscopic biopsy result indicated esophagitis.  HRM - decreased lower esophageal sphincter (LES) pressure and absent or ineffective peristalsis of the distal esophagus
  • 32. SCLERODERMA ESOPHAGUS  Occurs as part of connective tissue disorder. CREST Syndrome.  Atrophy of esophageal smooth muscle with loss of LES tone and force of peristalsis.  Raynaud’s phenomenon.  Intramural neuronal dysfunction.  Reflux esophagitis, Strictures.  Pulmonary Interstitial Fibrosis.  S/S: GERD, chest pain, dysphagia.  Anti-Scl-70, Antiendonuclear Ab, Anti-centromere Ab.
  • 36. CONCLUSION  Not all chest pain is GERD—esophageal dysmotility disorders can masquerade as GERD, leading to misdiagnosis and ineffective treatment.  Recognizing the nuances of these disorders is vital for ensuring patients receive the right care and relief.

Editor's Notes

  • #18: Because this patient had normal relaxation of the esophagogastric junction, no premature contractions, and a mean distal contractile integral (a calculation of the amplitude, duration, and span of the esophageal contraction) greater than 5000, this motility disorder can be described as nutcracker esophagus
  • #24: About eight to 12 people per 100,000
  • #26: Nocturnal regurg can provoke coughing/aspiration.
  • #30: integrated post-swallow relaxation pressure greater than 15 mm Hg has a diagnostic sensitivity of 97%.
  • #31: Esophageal achalasia is irreversible but the symptoms can be significantly improved with treatment.