-5- Esophageal Diseases

September-07-08 7:07 PM

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UPPER ENDOSCOPY Picture Slides 1-5. 1) Upper endoscope, used to look at the stomach. High intensity light source, showing the operating area of the scope on upper right. You can maneuver the snake top n any direction, you can retroflex it even and look back at yourself. You can also pass operating instruments through a port. You can inflate and push air in there. You can also irrigate with fluid, and do biopsies with these scopes. And you can cauterize things with this, like bleeding ulcers. 2) This is the lght source there, you can irrigate with this and inflate with air. Operator will see all this on videoscreen.3) This is a variation on the first one with a sideviewing scope. 4) colonoscope: can get into right colon and sometimes cecum with this. 5) fligmoidoscope, can only get to the splenic flexture. Majorty of cancers are on the west side in the western hemisphere.Better to use a real colonscope because if you find something on the left side, likely you can find something on right side too Diseases of the Esophagus Hugh K. Duckworth M.D. The Normal Esophagus * A hollow tube bordered at each end by high pressure valves called sphincters * It conveys liquids and solids from the mouth to the stomach. * The upper esophageal sphincter (UES) prevents aspiration and the swallowing of excess air. * The lower esophageal sphincter (LES) prevents the reflux of gastric contents. * The swallowing process is a complex well coordinated motor activity that involves many muscle groups and Cranial Nerves V, VII, IX and XII. * Swallowing is divided into three involuntary stages, the oral, pharyngeal and the esophageal stages. The Oral Stage * The oral stage involves chewing the food and then the tongue propels the food into the posterior pharynx. The Pharyngeal Stage * The pharyngeal stage passes food by the UES into the proximal esophagus. The Esophageal Stage * In the esophageal stage the food is passed from the UES to the Stomach through the relaxed LES. * This movement of food is accomplished by the primary peristaltic wave. * After the food bolus passes into the stomach the LES re-establishes a tonic contraction that prevents reflux. Clinical Symptoms of Esophageal Disease * Dysphagia refers to difficulty in eating as a result of disruption in the swallowing process. Dysphagia can be a serious threat to one's health because of the risk of aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. * Dysphagia is divided into two types; * oropharyngeal dysphagia (skeletal muscle disease) * esophageal dysphagia (smooth muscle disease or obstruction). * Oral-phase disorders usually result from impaired control of the tongue. Patients may have difficulty chewing solid food and initiating swallows. When drinking a liquid, patients find it difficult to contain the liquid in the oral cavity before swallowing leading to aspiration. * Usually due to neurological disorders such as a stroke. * * * * Oropharyngeal dysphagia is described as the inability to initiate the act of swallowing. The ability to move food from the mouth to the esophagus is impaired. Difficulty initiating swallows, coughing, choking, and nasal regurgitation. Aspiration Stroke patients have impaired control of tongue, they have difficulty swallowing, difficulty initiating the swallow. And when they drink liquid, it drools out of the mouth. Dysphagia can be a serious threat bec of aspiration pneumonia, especially in elderly.

We all swallow air as we breathe and talk and if we swallow too much, it can be detrimental, especially in babies. If you do a KUB on infants who have been crying a lot, you would see stomach inflated with air.

* Esophageal dysphagia is a problem with transporting food down the esophagus and can be caused by motility problems (smooth muscle disease) or mechanical obstruction. * Can result in retention of food and liquid in the esophagus after swallowing. Picture Slides 6-9 6) stricture impars lumen, difficulty swalloing. 7) location of stricture. 8) zenker's: they can contain food in there and impair the lumen. 9) barium swallow showing the zenkers. Clinical Symptoms of Esophageal Disease * With esophageal dysphagia the patient usually reports that the food is getting hung up behind the sternum. * Three questions are crucial: * What food type causes the problem? * Is there heartburn? * Is the dysphagia intermittent or progressive? * Solid Food Dysphagia (mechanical obstruction) Lower esophageal ring (Schatzki's Ring), stricture, Zenkers diverticulum or carcinoma * Both Solid and Liquid Dysphagia (usually neuromuscular disorder) diffuse spasm, scleroderma, achalasia, advanced carcinoma. * * * * Heartburn (pyrosis) is the most common of all esophageal symptoms. Results from the reflux of acidic gastric contents into the lower esophagus. Burning pain that radiates up behind the sternum. Aggravated by fatty foods, caffeine alcohol, spicy foods, chocolate, tobacco, bending over and the supine position. Water brash is the feeling when your mouth is wet with saliva. The patient will tell you that the food gets hung up in their chest, right behind the sternum, will complain when they eat steak or large meals or if they dont chew the food well. In an older patient you need to ro MI

Schatzkis Ring is a stricture formation. If they report both solid and liquid dysphagia, its usually a neuromuscular disorder with spasm, or scleroderma is big, or if the cancer advanced then they would move from just solid difficulties to fluid as well. Achalasia also causes difficulty with fluids.

* Heartburn is usually relieved at least temporarily by antacids, baking soda, or milk. * May be associated with regurgitation and Water Brash, the sudden filling of the mouth with salivary secretions as a result of a vagal mediated reflex from the lower esophagus. * Odynophagia is pain upon swallowing. It is usually associated with caustic ingestion, pill-induced esophagitis, infectious esophagitis (fungal and viral) and rarely severe gastroesophageal reflux disease (GERD).

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Substernal chest pain due to esophageal problems may be indistinguishable from angina pectoris or MI. ** Must R/O the heart as a source! Gastroesophageal Reflux Disease AKA: GERD * The clinical manifestations resulting from the reflux of gastric and duodenal contents into the esophagus. * Symptoms related to reflux are quite common, even amongst healthy people. But it becomes (..only is called GERD when...) GERD when the symptoms are severe or mucosal damage is seen. * Studies have shown that in the US 45% of adults experience "heartburn" at least once a month, 20% once a week and 10% daily. * The LES is the major barrier against reflux along with the crural diaphragmatic component. Acid refluxing into the esophagus is normally cleared by peristaltic contractions and neutralized by swallowed saliva. Etiology: * Patients with GERD may have one or more of the following; decreased or absent LES tone, inappropriate relaxation of the LES ( independent of swallowing), impaired gastric acid clearance due to a gastric motility disorder (scleroderma or diabetic gastroparesis), or impaired gastric emptying. Contributing Factors: * Fatty Foods * Spicy Foods * Caffeine * Tobacco * Alcohol * Obesity * Pregnancy * Other factors that have been implicated in the development of GERD include excessive acid production, delayed gastric emptying, and the reflux of bile and pancreatic enzymes. * Many patients with GERD have a hiatal hernia which serves as a fluid trap. Two types of Hiatal hernia: Sliding and paraesophageal. * In a sliding hiatal hernia the phrenoesophageal ligament fails to keep the esophagogastric junction below the diaphragm and within the abdomen. The LES is usually inadequate and reflux esophagitis exists. Picture 10.Sliding hiatal Hernia. * With the paraesophageal hiatal hernia the esophagogastric junction is in it's normal location below the diaphragm. The fundus/body of the stomach is rotated into the chest with the greater curve as the leading point. * May or may not have reflux. Picture 11.Paraesophageal Hiatal Hernia. On rare occasions, the paraesoph hernia can rotate and block blood supply and cause herniation. Easy to fix, just close it and pull it back down. Use esophageal wrap. GERD: Clinical Manifestations * Heartburn is the most common symptom. It can range from relatively mild to severe. * Other associated complaints include dysphagia, odynaphagia, regurgitation, water brash, and belching. * Patients presenting with GERD may not have obvious GI symptoms, instead they may have chest pain, chronic cough, chronic aspiration, asthma, hoarseness, laryngitis, pharyngitis, throat clearing or the sensation of a fullness in the neck. Diagnosis * A history of heartburn with a positive response to antacids is sufficient to make the diagnosis. * Specific testing is reserved for those patients who have dysphagia, weight loss, GI bleeding, and for those with atypical chest pain (R/O cardiac source of pain first!!!) * 24 hour Esophageal pH monitoring is the gold standard for diagnosing reflux. * The preferred method for establishing the diagnosis of GERD is a trial of acid suppression therapy with a PPI for 3-4 weeks. Confirmation is made when the PPI is withdrawn and the symptoms return. GERD: Complications * Peptic stricture and Barrett's esophagus are the two major complications. * Peptic stricture is a lesion that narrows the lumen in erosive esophagitis. It is the result of edema, inflammation and fibrosis of the distal esophagus. Dysphagia of solid foods occurs without weight loss or anorexia. * The diagnosis is made with upper endoscopy or barium swallow. Pictures 12, 13. Peptic stricture, if food is chewed up, usually will pass. But professor has seen steak, lobster, and also chicken stuck there. Probably no veggies though. Liquids go down fine. If you grab it with forceps and try to pull it out, you risk aspiration in patient, so you try to push lodged food through * Barrett's esophagus is the replacement of reflux damaged squamous epithelium in the distal esophagus with specialized metaplastic columnar epithelium. * It is found in 10%-15% of patients with GERD, and mostly in whites. * It produces no symptoms * Barrett's esophagus is a premalignant lesion. The incidence of malignancy is 0.5% per year with a lifetime prevalence of 10%. Differential Diagnosis * Achalasia * Cholecystitis * Coronary Artery Disease * Esophageal Cancer * Esophageal Spasm * * * * * Esophagitis Gastritis Peptic Ulcer Disease Irritable Bowel Syndrome Crohn's Disease True GERD bypasses all of this

Diabetic gastroparesis can impair gastric clearance or emptying. So can gastric carcinoma.

Sliding hernia: fails to keep junction below diaphragm, moves up into chest, tone is not adequate in LES and patient gets reflux esophagitis. All sliding hernia patients have GRED. Paraesophageals may or may not have reflux.

Mild is only present with certain foods. Severe is present constantly.

May not have obvious GI symptoms. May complain of chest pain or cough especially at night when they lay down and have microaspiration. They may have asthma: gastric contenst aspirated into lungs may bring on asthma. They may have hoarseness, laryngitis, pharyngitis, throat clearing or sensation of fullness in the neck. Consider GERD when patients complain of these symptoms What relieves it? "Antacids work really well, but they stopped working well thats why im here." Professor would give them Omeprazole (prilosec), but you can also give them H2 blocker. Specific testing for people who have dysphagia, weight loss, GI bleeding, and for those with atypical chest pain. Dysphagia and weight loss concern you about cancer. Esoph pH monitoring is gold standard, but patient does not tolerate it well so not routinely done. Probe must be passe down for 24 hours. Other preferred method is proton pump inhibitor for 3 weeks then take it off to see if symptoms return. But in reality thats not done. Professor is ok with keeping them on their PPI and seeing how they do. With repeated attacks of peptic stricture, you get fibrosis and scar formation. Peptic stricture is intermittent dysphagia. Diagnosis is made with upper endoscopy, but out in boondocks, use barium swallow. We worry about Barrett's esophagus because it predisposes to adenocarcinoma.

Needs to make sure you are biopsying the distal esophagus and not proximal stomach!!

Treatment * Phase I: * Lifestyle modification: * Elevate the head of the bed - only needs to be 10 degrees or so

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* Elevate the head of the bed - only needs to be 10 degrees or so * Avoid eating or drinking 2-3 hrs before sleeping * Avoid fatty or spicy foods * Avoid cigarettes & alcohol * Avoid chocolate, coffee. Nooooooooooooooooo * Lose weight * Antacids * H2 receptor blockers Treatment Phase II - H2 receptor blockers - Proton pump inhibitors (PPI) Phase III - PPI or high dose H2 blocker - H2 blockers or PPI plus promitility drugs Phase IV - Surgical intervention: * Patients that do not respond to therapy after 6 months. * Risk of pulomanry or neoplastic complications * Must do 24 hr pH monitoring to confirm the diagnosis prior to surgery. - Options: Nissan fundoplication Pictures 17, 18.. 17) Hiatal Laproscopy. Sliding hernia patient. Wrap the most proximal portion of the stomach around the esophagus and suture it together. It creates a faux sphincter, not a true one. Diaphragm is tightened up.18) Nissan fundoscopy. procedure used to be rarely done, in prelaproscopic area. In past you had to open abdomen chest. But now you can do it laproscopically with far fewer complications and better turnout. Now you can see forceps have both sides of stomach, and now its wrapped and sutured. Complications: PATIENTS CANNOT BELCH!!! Treatment of Complications * Peptic strictures are treated with dilation and PPI therapy. * Barrett's esophagus is treated like other patients with GERD but with endoscopy and biopsy every 2-3 years. If atypia or carcinoma is found then an esophagectomy should be performed. Case Study * 51 year old male presents complaining of periodic severe "heartburn" which radiates from the epigastrium into his chest for the last month. No other symptoms. History? Labs? Tests? Differential? Treatment? What makes better/wosre? Baking soda makes it better. Bending over and Tobasco makes it worse. Certain foods that aggravate it it, does pain move anywhere? Yes into chest. Has happened before? Yes, couple of years ago, for about a month, but after baking soda made it worse. Any weight loss?

Professor would not s tart with antacids, H2 blockers work much better.

Treatment: Peptic strictures can result in inflammation.Carofate is a drug that is taken that is actually covers over areas of inflammation, helps with healing. And bring patient back in a month and do a dilation. You dont want to do dilation in the face of acute inflammation. You can tear it! Inflamed tissue becomes very thin walled, becomes really easy to tear esophagus with lots of inflammation. So you want to resolve inflammation before you do that. People with barretts, treat them like anyone else with GERD, but follow them closely. Bring them every 2 years and do a scope of random biopsies. If you see atypia or carcinoma, then an esophagectomy should be performed. This is an opportunity to cure the patient and patient has very good prognosis. Any difficulty swallowng? Yes. Has it gotten worse? Yes. Scale, 1-10: Its about a 3. Describe it: Burning pain. What time does it occur? Anytime after food, but wakes him up at night. EVER HAD HISTORY OF HEART DISEASE Any cough, diaphoresis, change in bowel habits, color of stool, nausea/vomiting, any other medication, smoking/alcohol, family history, past medical history.

Next order physical exam: its normal (H/L). Then order EKG, its normal. Unless he has significant family history or has high blood pressure, then its good he has no angina. Give him PPI and tell him to come back in 2 weeks. Its not H pylori, its an ulcer. Diet modification, elevate head of bed. Ask him to lose weight if he needs to. And ask him to give you lots of money for that advice Now, after 2 weeks, if he is still not better, you are going to scope hm. He has barretts on biopsy. You increase the dose of PPI from 20mgs to 40mgs of Omeprazole. He comes back in 2 weeks and he is better. Tell him then to come back every year for follow-up, and if he's ok, then to start coming back every 2 years. Case Study * 78 year old man presents with substernal chest pain which began after eating steak. He is salivating and unable to swallow his saliva. He is continuously spitting in a cup. He denies other symptoms. Case Study * History? * Labs? * Tests? * Differential? * Treatment?

Study shows people with Barrets taking PPI for years start to revert their epithelium back to normal! If scope does not show barretts, then leave them alone until it gets worse.

Esophageal Infections
Candidal Esophagitis * Risk factors: * Fungal overgrowth due to esophageal stasis: * Abnormal esophageal motility (achalasia or scleroderma) * Mechanical causes (strictures) * Impaired cell-mediated immunity: * Immunosuppressive therapy (steroids, chemotherapy) * Critical illness with broad spectrum antibiotic use * Malignancies * AIDS * Congenital immunodeficiencies * Diabetes mellitus * Clinical Features: * Dysphagia and/or odynophagia * Investigations: * X-ray * Endoscopy + cytology * Treatment: * Nystatin * Ketoconazole * Fluconazole * Amphotericin B (Severe cases) Picture 18. Candidal Esophagitis. Right: Classic white plaques. Left: Good radiologist can tell the difference between candida and other causes. Nistatin swish and swallow can be taken prophylactically if your patient is at risk!! A couple of times aday maybe. Look it up. That prevents oral candidiasis, can get it in oral pharynx as well. HSV Esophagitis * Risk Factors: * Immunosuppression * Clinical Features: * Dysphagia/Odynophagia * Investigations: Candida: common in ICU setting with immunocompromised Coronary artery bypass graft with complications. Has been on ventilator for number of days, antibiotics to treat pneumonia. Get off ventilator, get extubated. When they start to eat, they have odynophagia (severe pain on swallowing). That is due to candida. They get a fungal overgrowth from esophageal stasis. Strictures can cause stasis. More commonly caused by achalasia or scleroderma

It has a classic appearances: odynophagia, dysphagia. Make diagnosis with xray and endoscopy. Treatment with nistatin, ketoconazole, fluconazole, and amphotericin B.

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* Investigations: * X-ray: Small ulcers * Endoscopy: Small, isolated ulcers * Biopsy: Multinucleated giant cells with nuclear inclusions * Treatment: * Vidarabine * Acyclovir Picture 19. HSV Esophagitis CMV Esophagitis * Risk Factors: * Immunosuppression * Clinical Features: * Dysphagia * Odynophagia * Investigations: * X-ray: Large ulcers * Endoscopy: Scattered ulcers merging together * Biopsy: Intranuclear inclusions * Treatment: * Ganciclovir or foscarnet Picture 20. CMV Esophagitis HIV Esophagitis * Clinical Features: * Dysphagia * Odynophagia * Investigations: * X-ray: Ulcerations * Endoscopy: Diffuse inflammatory esophagitis or ulcerations * Treatment: * Steroids Picture 21. HIV Esophagitis. Ulcer is visible. Pill-induced Esophagitis * Esophageal mucosal injury may be caused by potassium chloride tablets, nonsteroidal antiinflammatory drugs (NSAIDs), and antibiotics (eg, doxycycline, tetracycline, clindamycin, trimethoprim-sulfamethoxazole). Picture 22. Pill Induced Esophagitis. Case Study * You are consulted to evaluate a 78 year female in the ICU. Past medical history includes DM II, and heart disease. She has recently been treated for 14 days with broad spectrum antibiotics for pneumonia and sepsis. A diabetic diet was ordered for her yesterday but she is unable to swallow due to odynophagia. * * * * * History? Labs? Tests? Differential? Treatment?

In old days, people used to make their own soap wth lye. Toddlers used to think it was milk and drink it. They would develop severe strictures throughout their esophagus because of caustic injury. They eventually needed esophagectomy. Professor saw it in elderly. You have to pull the stomach up in chest and connect it (anastomse it), with whats left of esophagus.

You suspect candidiasis most commonly. SO scope her right there in the bed. Barium swallow is another option. If you see candidiasis, you treat with Nystatin or Ketoconazole.

Esophageal Motility Disorders

Esophageal Achalasia * Pathophysiology: * There is a marked reduction in distal esophageal cholinergic innervation (ganglion cells in Auerbachs plexus) * This will result in: * Loss of normal peristalsis * LES uncoordinated contraction * LES tonic contractions * Incomplete relaxation of LES during swallowing * Clinical Features: * Dysphagia of solids and liquids * Regurgitation of food or saliva * Weight loss * Chest pain Dysphagia is not intermittent, its progressive! They will regurgitate food and saliva. They will have * Nocturnal cough weight loss, chest pain, nocturnal cough (due to nocturnal aspirations from the poorly dilated distal * Recurrent bronchitis or pneumonia esophagus), and a recurrent bronchitis or pneumonia. * Esophageal Achalasia Investigations Upper GI X-ray: * Esophageal dilatation * Bird Beak narrowing of distal segment * Spasm of lower esophageal sphincter Picture. Dilated proximal esophagus with contracted distal birds beak. Again, birds beak appearance. Only small amount of barium getting through to stomach after big huge esophagus * Cine-esophagography and esophageal manometry: * Confirms the diagnosis * Absence of normal peristalsis * Elevated LES * Incomplete relaxation of LES Can measur epressure with the manometer Have to pass NG down or something. * Esophageal Achalasia Treatment Medical: Nitrates Calcium channel blockers (Nifidipine) Lots of different families of drugs. Whats it tell you? None of them work really well. Bougie system to Beta agonists swallow, to dilate the lower esophagus. But the pneumatic dilatation is th way to go. Anticholinergic Pneumatic dilatation of esophagus Surgical myotomy: * Heller procedure Myotomy is safer now wth laporotic techniques involved.

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Esophageal Spasm * Pathophysiology: * Usually affects the elderly * Waves of peristalsis occur simultaneously * Peristalsis preserved to some extent * Muscular hypertrophy of the lower esophagus with these spasms * Clinical Features: * Chest pain that may mimic angina * Investigations: * Barium swallow: * Corkscrew esophagus * Uncoordinated contractions * Treatment: * Avoid precipitating factors, e.g. hot or cold liquids or foods. * Medications may be ineffective: * Nitrates * Calcium channel blockers * Pneumatic dilatation Esophageal Spasm. Cork screw appearance on barium swallow. Esophageal Cancer * Overview: Always evaluate larynx and * Squamous cell carcinoma 50%: pharynx as well * Upper two thirds * Higher incidence in African-Americans * Predisposing factors: * Smoking, alcohol, caustic injury, and achalasia * Adenocarcinoma 50%: * Lower one third * Increased acid exposure * Associated with Barretts esophagus * Middle aged white men * Esophageal carcinoma accounts for 10,000 to 11,000 deaths per year * The incidence of esophageal carcinoma is approximately 3-6 cases per 100,000 persons * Clinical Findings: * Progressive dysphagia (most common finding) * Dysphagia first with solid foods, then with liquid foods * Weight loss -everyone of them! * Chest pain * Aspiration pneumonia - especially when they lie in supine postions at sleep

Very pain ful, looks like angina or MI.

Case Study * A 78 year old man presents complaining of severe substernal chest pain which began about an hour ago when he was drinking a cup of coffee. * Ask him of: Family history of heart disease: NO Describe the pain: Elephant sitting on chest. Radiates to: Left jaw Sweating, Diaphoresis, Nausea: Scared to death. No Nausea. Anything alleviates/aggravates: Hot cup of coffee really precipitated it. Ever had before? Yes, but not this severe, 2 months ago. What precipitated it then? Hot cup of coffee. Any medication? Antihypertensives, aspirin daily. Movement does not change it. Ask about weight loss? No weight loss. If achalasia would have weight loss. Get the cardiac enzymes. If in a hospital, send him to ER. Do barium swallow. EGD is not as useful in this case. Go back to Mr Hudson patient, you have gastroenterologist available that can do enoscopy. He said he had it hung up right there in his chest. And he has cup he is spitting saliva in. The worst thing you can do as ER doctor is order a barium swallow!! Do NOT order a barium swallow. Your gastroenterologist will yell at you. What will they see when they put the scope down? Nothing but barium, and you have to do the scope to get the bolus out. So whenever theres an obstruction like that, then you HAVE to do a scope. So call the Gastroenterologist to do it. Glucagon can relax sphincter of Oddi, not really this thing. If theres lymph node involvement, patient is not good candidate for surgery.

* Investigations: * Barium swallow * Endoscopy and biopsy (choice for diagnosis) * Endoscopic ultrasound (choice for staging) -good check for lymph node involvement * Metastatic work-up: * CT scan * Bronchoscopy * Ultrasound for liver metastasis * Treatment: * Stage I-II: Surgery * Stage III-IV: Chemoradiotherapy * Photodynamic therapy or stent placement for palliation Picture 32. Apple core lesion. Classic apple core is in colon, but this is seen similarly here Picture 33. Colon cancer Picture 34. Another example of tumor. Someone put barium before endoscopy, so you can see it covering * Prognosis: Survival depends on the stage of the disease. Lymph node metastases or solid organ metastases are associated with low survival rates. The overall 5-year survival rate for esophageal cancer remains approximately 20-25% for all stages. Patients without lymph node involvement have a significantly better prognosis and 5year survival rate compared to patients with involved lymph nodes. Stage IV lesions are associated with a 5-year survival rate of less than 5%.

Earlier stages are candidates for surgery. Smaller tumor size with no lymph node involvement Later stages for chemoradiatheraphy. Create the lumen to improve their quality of life, and give them stent placement so they can eat: probably will have to eat pureed food, but better than nothing at all.

Case Study * A 56 year old man presents with dysphagia, weight loss and anterior chest pain. Pretty young for esophageal cancer, but he is middle aged. * Ask Him: Hematemesis: Yes, small amounts. Solids or liquids: Problem with solids, progressively getting worse Change in bowel habits, blood in stool. Onset: Difficulty swallowing started one month ago Wakes up coughing at times. How much Weight loss: Weighing himself, lost 20 lbs over past month. Fatigued, Low energy: Yes, cant climb Mount Everest anymore If patient not well-educated, then ask: Is close fitting well Smokes cigarettes, pack a day since 12, Drinks Jack Daniels Describe: Dull ache No alelrgies. Radiation: No Family history of heart disease: No Intensity: 3 Of cancer: Yes, father had lung cnacer History of heart disease: No Any history of heart burn: Yes, over counter zantac worked. Were they still able to eat? Yes, early on were able to. * Differentials: Cancer - number one because ofweight loss. Stricture - altho usually not progressive, is internmittent. Achalasia - little young for it, but not unheard of. Hiatal hernia Angina - has to always be there Crohns on every dfferential * Physical Exam: Normal. * Barium Swallow: Big mass visible. * Get CT of anterior chest and abdomen. * Have to get a scope, and gastroenterologist complains of barium all over scope. * CT scan: No evidence of lung cancer or pharyngial cancer. * If no metastasis, then surgical consult. Need to do bronchoscopy, need to a stage so then do an endoscopic ultrasound to find the small metastatic nodes. Get 2 cm nodule in lower esophagus, so you take it out. If you have no infiltrative margns then it is good. Preoperative chemo is good for breast and certain rectal cancers, but not colon cancer or this.

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