Oesophagus

DISEASES OF THE OESOPHAGUS

المحاضر: الدكتور خلدون ذنون- كلية طب نينوى- المرحله الرابعه
Objectives
1. To know the features of GERD and its management and complications because it is a common disease.
2. To know the features that make you suspect carcinoma of the oesophagus.
3. Motility disorders are important diseases of the esophagus e.g achalasia.
4. The esophagus is liable for infection especially by candida.

GASTRO-OESOPHAGEAL REFLUX DISEASE GERD

Prevalence : 30% of the population .
Pathophysiology
oesophageal mucosa exposed to gastric contents for prolonged period of time resulting in symptoms and in some oesophagitis .
Factors associated with the development of GERD
1.Abnormalities of the lower oesophageal sphincter LES
( LES tone , when intra-abdominal pressure rises reflux occurs .
or basal LES tone is normal but with frequent episodes of inappropr iate sphincter relaxation .
2.Hiatus hernia
Types : A-rolling (para-oesophageal). B-sliding .
Pressure gradient between abdominal & thoracic cavities is lost , oblique angle between cardia and oesophagus disappears .
Relationship between the presence of a hernia&symptoms is poor
H.H is very common in individuals without symptoms
Almost all patients who develop oesophagitis , Barretts oesophagus or peptic stricture have H.H .
3.Delayed oesophageal clearance
Defective oesophageal peristaltic activity,it is a primary abnormality which lead to ( acid exposure time .
4.Defective gastric emptying (delayed)
5.Gastric contents : gastric acid and sometimes bile are irritant .
6.( intra-abdominal pressure : pregnancy & obesity .
7.Dietary & environmental factors
Fat,chocolate,alcohol & coffee : relax sphincter .


Clinical features
Heart burn & regurgitation , provoked by bending , straining ,or lying down .
Water brash reflex is often present .
History of weight gain is common .
Choking at night and recurrent cough (simulate asthma) .
Odynophagia & dysphagia .
Atypical chest pain mimicking angina .

Investigation

Empirical treatment for young patients with typical GERD without dysphagia, weight loss , anaemia .
Middle&old age need investigation,also for atypical symptoms or complications .
Endoscopy : investigation of choice .
Endoscopy might be normal,but still patient need treatment for symptoms .
24hour PH monitoring : when endoscopic diagnosis is unclear or if surgery is considered
Record PH in relation to symptoms (episodes of pain) a PH < 4 for > 6-7% of the study time is diagnostic .

Management

Weight loss , avoid diet which worsen symptoms , elevation of the head of the bed , avoidance of late meals , smoking cessation .
Antacids , alginates(protect mucosa) give symptomatic relief .
H2-receptors antagonist : help symptoms without healing of oesophagitis .
Proton pump inhibitors are the treatment of choice for severe symptoms and complicated GERD ,resolve symptoms and heals oesophagitis .
Recurrence of symptoms are common when therapy is stopped and some require life-long treatment at the lowest dose .
Anti-reflux surgery : failure of medical therapy , unwilling to take long term therapy , severe regurgitation . Types : open operation , laparoscopic , (fundoplication) complications : inability to vomit , abdominal bloating .
When patient improves on PPI he can be shifted to H2 blockers an then to antacids .


Complications
1.Oesophagitis
Mild to severe redness,ulceration & bleeding with stricture formation
Significant GERD may be associated with normal endoscopy & histology .

2.Barretts esophagus

Columnar lined oesophagus CLO : premalignant glandular metaplasia of lower oesophagus .
Squamous lining is replaced by columnar mucosa containing areas of intestinal metaplasia .
Found in 10% of patients undergoing gastroscopy for reflux symptoms .
Often asymptomatic and patients may present with cancer.
CLO : mainly in western caucasian males , rare in other races .
Major risk for oesophageal adenocarcinoma .cancer risk 10% .Cancer incidence 0.5% per year . Absolute risk is low .
Prevalence is increasing,more common in men & those > 50 y. weakly associated with smoking but not alcohol .
Metaplasia( dysplasia( cancer .Genes & cytokines may play roles in neoplastic progression .
Diagnosis : multiple biopsies to detect intestinal metaplasia & or dysplasia .

Management of Barretts esophagus

Neither potent acid suppression nor anti-reflux surgery will stop progression or induce regression of CLO & treatment only for symptoms .
Regular endoscopic surveillance to detect dysplasia & early malignancy,but most CLO is undetected until cancer develops, so surveillance is unlikely to influence mortality & is expensive . Surveillance is recommended every 1-2 years for those without dysplasia & 6-12 month for those with low grade dysplasia .
Oesophagectomy for those with HGD , resected specimen contain cancer in 40% of cases .
Endoscopic mucosal resection and ablation therapy is an ulternative to surgery.


3.Anaemia
Iron deficiency anaemia from longstanding oesophagitis , most of the patient have a large hiatus hernia .

4.Benign esophageal stricture

Due to longstanding oesophagitis,mostly in the elderly .
Dysphagia worse for solids than for liquids,absolute dysphagia due to obstruction by meat bolus .
History of heart burn is common & many elderly have no preceding heart burn .
Diagnosis : endoscopy & biopsy .
Treatment : endoscopic balloon dilatation or bouginage , followed by long-term therapy with PPI .
Advice : chew food thoroughly & ensure adequate dentition .

5. Gastric volvulus

Occurs with big hiatus hernia.
Severe chest pain, vomiting, dysphagia.
Chest X-ray: air bubble in the chest, barium swallow.
Resolves spontaneously but surgeryis usually needed.

Other causes of oesophagitis

Infection : candidiasis due to broad spectrum antibiotics,cytotoxic and HIV infection .
corrosives : suicide attempt e.g house bleach , battery acid ( ulceration and perforation with mediastinitis,later stricture . Treatment : conservative , analgesia , nutrition . Vomiting should be avoided , endoscopy avoided , later BA.swallow to demonstrate extent of stricture and may need endoscopic dilatation which is difficult .
Drugs : potassium &NSAIDS lead to oesophageal ulcer especially when trapped above stricture , instead liquid form of such drugs should be used . Bisphosphonates (alendronate)(oesophageal ulcer.
Esinophilic esophagitis
Common in children, associated with atopy.
Mucosa infiltrated with esinophils.
Dysphagia, chest pain, vomiting
Endoscopy: normal, mucosal rings, stricture or narrow lumen.
Children may respond to elimination diet.
Adults: PPI, topical corticosteroids as inhalers but swallowed, for 8-12 weeks.
Refractory cases: monteleukast.


MOTILITY DISORDERS
PHARYNGEAL POUCH
Herniation through the cricopharyngeus muscle due to incoordinat- ed swallowing within the pharynx .
Usually elderly and symptomless .
Regurgitation , halitosis , dysphagia , gurgling in the the throat after swallowing .
Diagnosed by BA swallow which may reveal pulmonary aspiration as well . Endoscopy: hazard of perforation .
When symptomatic : surgical myotomy&resection.

ACHALASIA OF THE OESOPHAGUS

Pathophysiology
Hypertonic lower oesophageal sphincter LES + failure of relaxation in response to swallowing .
Failure of propagated oesophageal contraction leading to dilatation of the oesophagus .
Failure of non-adrenergic , non-cholinergic NANA innervation , degeneration of ganglion cells within the sphincter and the body .
Chagas disease (trypanosoma cruzi): endemic in south America( myocarditis , GIT motility disorder, myenteric plexus is destroyed .

Clinical features

usually middle life .
Dysphagia develops slowly , worse for solids and eased by drinking fluids and movement .
Heart burn does not occur .
severe chest pain may occur due to vigrous oesophageal spasm .
Nocturnal pulmonary aspiration later on .
Predisposes to squamous carcinoma .


Investigation
Endoscopy : to exclude CA. as CA of the cardia mimic presentation , radiological & manometric features of achalasia (pseudo-achalasia)
Chest X-ray : wide mediastinum , aspiration pneumonia .
BA swallow : tapered narrowing of the lower oesophagus , later on dilated oesophagus , filled with food , aperistaltic .
Manometry : high pressure-non-relaxing LES with poor contractility of oesophageal body .

Management

Endoscopic pneumatic dilatation by balloon , improves symptoms in 80% of patients .
Endoscopic injection of botulinum toxin into LES, relapse is common .
Surgical myotomy (Hellers operation) : effective (open or laparoscopic) .
Both pneumatic dilatation & myotomy may be complicated by GERD , for this reason myotomy is accompanied by a partial fundoplication anti-reflux operation .
PPI is often necessary following surgical or endoscopic intervention to prevent oesophagitis .

Other oesophageal motility disorders

Diffuse oesophageal spasm : chest pain mimic angina & in some dysphagia , some occur with GERD & need PPI , attacks are relieved by nitrate on nifedipine .
Nutcracker oesophagus: vigorous peristalsis(chest pain&dysphagia treated by nitrates & nifedipine .
Non-specific motility disorders : elderly , chest pain , dysphagia .
secondary : systemic sclerosis( muscle replaced by fibrosis , heart burn , dysphagia , often severe oesophagitis , stricture may occur , long term treatment with PPI . Other causes : dermatomyositis , rheumatoid arithritis , myasthenia gravis , all can cause dysphagia.

OESOPHAGEAL STRICTURE

Causes : GERD , webs & rings , CA oesophagus or cardia , extrinsic compression from CA bronchus, esinophilic esophagitis, corrosive ingestion , postoperative , post-radiation , long-term nasogastric intubation .
Most often in elderly .
Schatzki ring : occur at oesophago-gastric junction , cause dysphagia in middle age .
Plumer-vinson syndrome : post-cricoid web complicate IDA , may change into squamous CA.
Benign stricture : endoscopic dilatation .
Malignant : surgery or stent .


CARCINOMA OF THE OESOPHAGUS
A-SQUAMOUS CANCER
West : rare 4:100,000 common in Iran , South Africa , China 200 : 100,000 , arise in any part of the oesophagus .
Causes : smoking , alcohol , chewing betel nuts or tobacco , celiac disease , achalasia , post-cricoid web , post-caustic stricture , tylosis (familial hyperkeratosis of palms and soles)
B-ADENOCARCINOMA
Arise in the lower 1/3 from Barretts oesophagus or gastric cardia .
Incidence is increasing 5:100,000 in UK due to ( GERD .

Clinical features

Progressive painless dysphagia for solid foods.
Acute presentation : food bolus obstruction .
Weight loss .
Chest pain & hoarseness suggest mediastinal invasion .
Fistula between oesophagus & trachea or bronchus( cough and pneumonia , pleural effusion .
Catchexia , cervical LAP .
Investigation
Endoscopy : of choice with cytology and biopsy .
BA swallow : add little information .
Staging of tumor to define operability .
CAT scan of chest & abdomen to identify metastasis, which preclude surgery.
Endoscopic U/S EUS : the most sensitive modality to detect depth of involvement of esophageal wall, local invasion to lymph nodes & aorta.
Management
Surgery : at early stage may be curative & survival Can still be improved by pre-operative neoadjuvant chemotheray e.g cisplatin & 5FU .
Squamous CA is radiosensitive .
Palliative treatment if metastasis occurs , relief of dysphagia and pain , nutritional support .
Endoscopic laser tumor ablation , insertion of stents to improve swallowing .
Palliative radiotherapy may induce tumor shrinkage of squamous and adenocarcinoma .
Prognosis
Over all 5 year survival is 6-9% and depend on the stage .
Best survival with tumor confined to oesophageal wall without spread to lymph nodes , 5 y survival 30% .
Radiotherapy : 5 y survival 5% .


PERFORATION OF THE OESOPHAGUS
Iatrogenic :.
most common following dilatation or intubation
Malignant , corrosives & post radiation strictures are liable for perforation after dilatation more than peptic strictures .
Treatment : broad-spectrum antibiotics & parenteral nutrition . Malignant,caustics and radiation stricture perforation : require surgical resection or intubation .

Spontaneous oesophageal perforation (Boerhaaves syndrome)

Result from forceful vomiting & retching
May result in severe chest pain & shock due to mediastinitis . Subcutaneous emphysema , pleural effusion , pneumothorax .
Diagnosis : water-soluble contrast swallow .
Treatment : surgical .









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