Professional Documents
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Esophageal Disorders
Motility
Anatomic &
Structural
Reflux
Infectious
Neoplastic
Miscellaneous
Esophageal Anatomy
Upper Esophageal
Sphincter (UES)
Esophageal Body 18 to 24 cm
(cervical & thoracic)
Lower Esophageal
Sphincter (LES)
Normal Phases of Swallowing
Voluntary
oropharyngeal phase – bolus is voluntarily
moved into the pharynx
Involuntary
UES relaxation
peristalsis (aboral movement)
LES relaxation
Esophageal Motility
Disorders
Motility Disorders
Upper esophageal Primary disorders
UES disorders achalasia
neuromuscular disorders diffuse esophageal spasm
Esophageal body nutcracker esophagus
achalasia nonspecific esophageal
diffuse esophageal spasm dysmotility
nutcracker esophagus Secondary disorders
nonspecific esophageal severe esophagitis
dysmotility scleroderma
LES diabetes
achalasia Parkinson’s
hypertensive LES stroke
Diagnostic
Bariumesophagram
Esophageal manometry
Endoscopy
Normal Manometry
Motility Disorders
Based on Manometry
Achalasia
– Inadequate LES relaxation
Diffuse Esophageal Spasm
– Uncoordinated contraction
Nutcracker Esophagus
– Hypercontraction
Ineffective Esophageal Motility
– Hypocontraction
Achalasia
Achalasia
first clinically recognized esophageal
motility disorder
described in 1672, treated with
whale bone bougie
term coined in 1929
epidemiology
1-2 per 200,000 population
usually presents between ages
25 to 60
male=female
Caucasians > others
average symptom duration at
diagnosis: 2-5 years
Pathophysiology
Degeneration of NO producing inhibitory neurons
loss of ganglionic cells in the myenteric plexus (distal
to proximal)
vagal fiber degeneration
underlying cause: unknown
autoimmune? (antibodies to myenteric neurons in
50% of patients)
that affect relaxation of LES
Basal LES pressure rises
Clinical Presentation
clinical presentation
solid dysphagia 90-100% (75% also with
dysphagia to liquids)
post-prandial regurgitation 60-90%
chest pain 33-50%
pyrosis 25-45%
weight loss
nocturnal cough and recurrent aspiration
Diagnostic
plain film (air-fluid level, wide mediastinum,
absent gastric bubble, pulmonary infiltrates)
barium esophagram (dilated esophagus with
taper at LES) Bird peak
good screening test (95% accurate)
endoscopy (rule out GE junction tumors, esp.
age>60)
esophageal manometry (absent peristalsis,
LES relaxation, & resting LES >45 mmHg)
Treatment of Achalasia
Goals
reduce LES pressure and
increase emptying
Nitrates and Calcium Channel
Blockers
Isosorbide dinitrate
Reduces LES Pressure 66% for 90 min
Nifedipine
Reduces LES pressure 30-40% for > 60 minutes
frequent non-peristaltic
contractions
simultaneous onset
(or too rapid
propagation) of
contractions in two
or more recording
leads
occur with >30% of
wet swallows (up to
10% may be seen in
“normals”)
Nutcracker Esophagus
high pressure peristaltic
contractions
avg pressure in 10
wet swallows is >180
mm Hg
33% have long duration
contractions (>6 sec)
may inter-convert with
DES
Nonspecific
Hypertensive Esophageal
LES Dysmotility
abnormal motility
high LES pattern
pressure fits in no other
>45 mm Hg category
normal non-peristalsis in
20-30% of wet
peristalsis
swallows
often overlaps low pressure
with other waves (<30 mm
motility disorders Hg)
prolonged
contractions
Diagnosis of Spastic Motility
Disorders of the Esophagus
Manometry
Barium Esophagram
Endoscopy
PH monitoring
Spastic Motility Disorders
of the Esophagus
treatment
reassurance
nitrates, anticholinergics, hydralazine - all
unproven
calcium channel blockers - too few data with
negative controlled studies in chest pain
psychotropic drugs – trazodone, imipramine and
setraline effective in controlled studies
dilation - anecdotal reports, probable placebo
effect
Hypomotilty Disorders
primary (idiopathic)
aging produces gradual decrease in contraction
strength
reflux patients have varying degrees of hypomotility
more common in patients with atypical reflux
symptoms
usually persists after reflux therapy
defined as
low contraction wave pressures (<30 mm Hg)
incomplete peristalsis in 30% or > of wet
swallows
Hypomotilty Disorders
secondary
scleroderma
in >75% of patients
progressive, resulting in aperistalsis in smooth-muscle region
incompetent LES with reflux
other “connective tissue diseases”
CREST
polymyositis & dermatomyositis
diabetes
60% with neuropathy have abnormal motility on testing (most
asx)
other
hypothyroidism, alcoholism, amyloidosis
GERD
36-77% of all Americans experience
GERD
– 7% have daily GERD symptoms
– 14-20% weekly symptoms
– 15-50% monthly
Symptoms include: heartburn, acid
regurgitation, water brash, dysphagia,
atypical symptoms (asthma, globus,
laryngitis, cough, throat clearing)
Pathophysiology
Lower esophageal sphincter dysfunction
Delayed gastric emptying
Esophageal dysmotility
+/- hiatal hernia
Repetitive mucosal injury / esophagitis
Barrett’s Esophagus
Medical Treatment
Lifestyle modifications
– avoid coffee, fatty foods, smoking;
lose weight, raise head of bed,
eliminate late night meals
Acid suppressin via PPI’s
Indications for Surgery
Failed medical management
Need for lifelong medical therapy
Hiatal hernia
Atypical symptoms with (+) pH probe
Complications
– Barrett’s esophagus (5-15% develop
BE)
– Erosive esophagitis
Surgical Treatment
Pre-operative evaluation
– Esophagram
– EGD
– Manometry (resting LES >5, length
>2cm)
– 24-hr esophageal pH monitoring
Surgical Treatment
Laparoscopic Nissen Fundoplication
Goals of antireflux surgery:
– Recreate Angle of His
– Reconstitute LES with wrap
GASTROESOPHAGEAL
REFLUX DISEASE.
.
Definitions of Reflux
Clinical manifestations of reflux of stomach & duodenal
contents into the esophagus.
Characterized by any combination of symptoms,
radiologic, endoscopic, or pathologic changes.
In its milder forms, is common.
Its most severe forms is uncommon but life-threatening.
GERD is preferable to "reflux esophagitis“
GERD may be associated with a sliding HH, but
"symptomatic HH" is an anatomic entity & not the
underlying pathophysiology in GERD.
PATHOGENESIS.
Stomach
The LA Classification system
– Grade B reflux esophagitis
Grade B: One (or more) mucosal break, more than 5 mm long,
that does not extend between the tops of two mucosal
folds.
Stomach
The LA Classification system
– Grade C reflux esophagitis
Grade C: One (or more) mucosal break that is continuous between
the tops of two or more mucosal folds, but which involves
less than 75% of the circumference.
Stomach
The LA Classification system
– Grade D reflux esophagitis
Grade D: One (or more) mucosal break that involves at least
75% of the esophageal circumference.
Stomach
APPROACH TO THE PATIENT
Step 1
Step 2
Step 3
Endoscopic therapies – gastroplication
A B
C D
Hiatal Hernia
Pathophysiology & Classification
Type I - sliding
Type II -
paraesophageal
Type III - para and
sliding component
Type IV - other
viscera involved
Clinical Presentation
postprandial fullness (63%),
Reflux (31%),
Dysphagia (34%),
Bleeding (24%)
Regurgitation/vomiting (36%)
Dyspnea (11%)
Work Up
Surgical Treatment
Effective repair includes:
– Excision of hernia sac
– Reduction of hernia contents
– Repair of crural defect
– Fundoplication, gastropexy, PEG,
esophageal lengthening (Collis
gastroplasty)
Gastroenteritis
Inflammation of stomach or intestines
Inhibits nutrient absorption and excessive H2O and
electrolyte loss
Bacterial
Viral
Parasites
Poisoning by microbial toxins
food borne intoxication
Signs and Symptoms:
General features: diarrhea, loss of appetite, abdominal
cramps, nausea, vomiting and possibly fever
Dysentery
Typically self Limiting
Enteric fevers
Systemic with severe headache, high fever, abscesses,
intestinal rupture, shock and death
Epidemiology
Occurs worldwide
Oral to fecal route of transmission
Water common reservoir
Overcrowding & poor sanitation are risk factors
Animals may be source of infection
Prevention
Hand washing
Proper food handling and complete cooking
Pasteurization of milk and juices
Adequate sanitation
Safe water supplies
Treatment
Rapid replacement of fluids and electrolytes
Anti-nausea medication
Antimicrobials may be used in severe cases
Bacterial Gastroenteritis
Enterotoxigenic E. coli
Enterotoxins
Type III secretion system
Typically self limiting
Enterohemorrhagic E. coli
O157:H7
Produce potent Shiga-like toxins and type III secretion
systems
Star-like Noroviruses
Wound botulism
deep crushing wounds
Infant botulism
Inhalationor ingestion of spores
Commonly associated with honey
or juices
Prevention
Proper sterilization and sealing of canned food
No honey or unpasteurized juices for infants!!
Treatment
Antitoxin
Gastric washing and surgical removal of tissues
Artificial respiration may be required
Anti-microbials given to kill bacteria in infant and wound
botulism
INFLAMMATORY
BOWEL DISEASE
CROHN’S DISEASE-
DEFINITION
Chronic Inflammatory Bowel Disease
(IBD)
Unknown Aetiology
Characterised by
1. Focal
2. Asymmetrical
3. Transmural
4. Occasionally granulomatous
inflammation
CROHN’S DISEASE-
EPIDEMIOLOGY
Incidence: 9.56 per 100,0001
Prevalence: 115,000 in the UK
Age of onset: 2 peaks 1) 15-30 Y (more
common)
2) 60-80 Y
Female: Male 1.8:1 Children this is
reversed!
Risk Factors2
Mycobacterium paratuberculosis, Pseudomonas spp. &
Listeria spp.
↑TNF-alpha
High-fat diets
Genetic mutations
1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-5
2) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011
CROHN’S DISEASE-
SYMPTOMS
• Abdominal pain, cramping or swelling
• Anaemia
• Fever
• Gastrointestinal bleeding
• Joint pain
• Malabsorption
• Persistent or recurrent diarrhoea
• Stomach ulcers
• Vomiting
• Weight loss
CROHN’S DISEASE- ON
EXAMINATION
General ill health- weight loss & dehydrated
Methotrixate
Imaging
Abdo x-ray- acute setting
Barium enema- can show mucosal structure
Bleeding
Toxic Megacolon
Impending perforation
Carcinoma
SUMMARY
SUMMARY: CROHN’S VS. UC
Symptoms of Crohn's Symptoms of Ulcerative
Disease Colitis