ESOPHAGEAL TOPICS

Norman M. Simon, M.D., F.A.C.G.

BARRETTS ESOPHAGUS
A

change in the lining of the esophagus

from the normal squamous lining to an
intestinal type lining called intestinal
metaplasia.
Diagnosis suspected on endoscopy but
requires confirmation by pathology
examination of biopsies.
Vast majority of cases caused by acid reflux
and secondary injury to the normal lining.
Incidence appears to have increased
substantially.

 Increased

incidence of Barretts seems

responsible for increase in cases of
esophageal adenocarcinoma.
Controversy re. who to screen for
Barretts.
When Barretts suspected, biopsies
taken to confirm diagnosis and to
check for dysplasia.
Monitoring generally being done at
three to five year intervals unless
dysplasia is found. Then depends on
whether low or high grade changes.

Candidates For Screening

Caucasian

Males
Over 50 years of age
Chronic symptoms of GERD
Nocturnal reflux symptomatology
Increased BMI with intra-abdominal
fat distribution
Tobacco use

BARRETTS WITHOUT
DYSPLASIA

BARRETTS LOW-GRADE
DYSPLASIA

BARRETTS HIGH-GRADE
DYSPLASIA

BARRETTS HIGH GRADE

DYSPLASIA

 Some

evidence that anti-reflux treatment

helps prevent the development of precancerous dysplasia and cancer in
patients with Barretts. Role of anti-reflux
surgery controversial.
Patients with low-grade dysplasia are
monitored more frequently than those
with no dysplasia. ? Eradicate the
Barretts. If not, recheck every 6-12
months vs. every 3-5 yrs.

 Options

for patients with high-grade

dysplasia include doing nothing,
surgical resection, intensive
monitoring, photodynamic treatment,
endoscopic mucosal resection, argon
plasma coagulation, radio frequency
ablation (HALO), and endoscopic
spray cryotherapy

Barrx 360 RFA Balloon

Catheter

 26

y/o male with history of recurrent

dysphagia for solids which seem to
catch at midsubsternal level. Drinks
fluids to clear the obstruction. Has
been going on for about 6 months.
Denies heartburn or other reflux
symptoms.
Past hx. negative aside from many
year hx. of asthma.
WHAT IS YOUR DIFFERENTIAL
DIAGNOSIS?

EOSINOPHILIC ESOPHAGITIS
Also

known as allergic esophagitis.

Predominant symptom is dysphagia.
Increasing incidence over past two
decades.
Occurs in both children and adults with
majority being males. In adults, majority
are in their 20s and 30s.
High percentage have allergic issues
including asthma, food allergies, hives,
hay fever.

EOSINOPHILIC ESPHAGITIS (CONT)

Findings

can include multiple rings,

narrowed esophagus, whitish
nodules, furrows, & strictures in
upper esophagus.
Some cases have involved several
family members.
Etiology may relate to food allergies,
additives, pollen, reflux?

FURROWS

TREATMENT
Trial

of anti-reflux medication-PPI.
Allergy testing and diet changes. Elemental
diet
Avoidance of six most frequent allergenic
foods (eggs, soy, wheat, cow-milk protein,
peanuts, and seafood). SFED
Steroid inhaler- swallowing rather than
inhaling the medication. Fluticasone
propionate.
Oral Prednisone- higher incidence of side
effects.
Dilitation- risks of perforation.

SCHATZKIS RING
Occur

at the distal end of esophagus at

junction of esophagus and stomach.
Often are assymptomatic.
Probably are a consequence of reflux.
Treatment is dilitation with bougie or
balloon- may be best to go directly to
large size ( 50 french or larger).
Data shows decreased rate of recurrence
with placing patients on anti-reflux
medications.

SCHATZKIS RING

ESOPHAGEAL STRICTURE

ESOPHAGEAL STRICTURES
Many

causes including reflux,

malignancy, radiation, toxic ingestions
(e.g. lye), surgical anastomoses,
sclerotherapy.
Dilitation generally done gradually
stepwise, often no more than three sizes
on one day.
Balloons (TTS) and standard dilators
seem to produce similar results.
Longterm anti-reflux therapy can reduce
recurrence rate in many cases.

 69

y/o male with 1 year of

dysphagia primarily for solids which
sometimes lodge in area of lower neck
or upper chest region. Also has
experience of coughing up small bits
of food he ingested at a previous meal.
WHAT DIAGNOSES WOULD YOU
CONSIDER?

ZENKERS DIVERTICULUM
Diverticulum

occuring at junction of
pharynx and upper esophagus.
The pocket faces posteriorly.
Dysphagia often occurs immediately with
swallowing.
Presents with dysphagia and/or spitting
up of food eaten earlier. Also may
complain of halitosis.
Thought to be due to malfunctioning of
the upper esophageal sphincter.

ZENKERS DIVERTICULUM

Zenkers Diverticulum
(cont.)
Treatment

options include surgery

through side of the neck with cutting
the sphincter along with possible
removal of the diverticulum or an
endoscopic technique known as
endoscopic staple-assisted
esophagodiverticulostomy.

NORMAL ESOPHAGEAL
MANOMETRY

ACHALASIA
Achalasia

is well recognized as a cause of

swallowing difficulty.
Distal esophageal sphincter does not
relax with a swallow and the muscle of
the lower esophagus does not propel the
food or liquid downwards i.e. abnormal
peristalsis.
Result is dysphagia, occasionally chest
pain and regurgitation, and weight loss
X-rays can reveal a dilated esophagus.

ACHALASIA (CONT.)
On

endoscopy often see retained

food and secretions in esophagus
even though patient has been NPO.
Characteristic yield of LES to the
scope being advanced.
Pseudo-achalasia

X-RAYS OF ACHALASIA

ACHALASIA TREATMENT
Three

common treatment options

Pneumatic forceful balloon dilitation with
Rigiflex balloon. May not work;
uncomfortable for patient; 3-5% risk of
perforation.
Botox injection. Not always successful. Tends
to lose effect in 6-12 months requiring
reinjection. Good option for poor surgical
candidates.
Surgery-laparoscopic myotomy. Cut the
sphincter and add partial fundoplication.
Rarely, Calcium Channel blockers or Nitrates.

OTHER MOTILITY PROBLEMS

Nutcracker esophagus, diffuse esophageal
spasm, and hypertensive lower esophageal
sphincter are three patterns often seen.
Controversy as to whether these
conditions can cause non-cardiac chest
pain and/or dysphagia.
In spite of these uncertainties treatment is
often tried to see if clinical response.
In some patients, may be related to reflux
and therefore often give trial of anti-reflux
medication first.

DIFFUSE ESOPHAGEAL SPASM

HYPERTENSIVE LES

NUTCRACKER ESOPHAGUS

Treatment
In

many patients improvement can be a

consequence of learning they dont have
a serious cardiac issue.
First line therapy often consists of a
calcium channel blocker (diltiazem) or an
antidepressant (imipramine). Can use
nitrates or sildenafil on an as needed
basis.
Other options include trial of hot liquids
with meals, botox injection, bougie.

Esophageal Varices
All patients with cirrhosis should have EGD
screening for varices.
No varices- rescope in couple years.
Small varices- consider NSBB in these
patients
Large varices- low risk group probably use
NSBB. High risk group (red wale signs,
advanced liver disease) can choose between
NSBB and EVL. Add PPI after EVL (ulceration)
Sclerotherapy not warranted for primary
prevention of bleeding.

Esophageal Varices

Esophageal Varices

Case Presentation
18 y/o female in excellent general health
awakens in the morning with rather severe
substernal chest pain when she swallows
anything even saliva. Has never had
similar problems in the past.
Her only medication is doxycycline which
she has taken for acne for 2 years.
WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

Medication Ulcers
First

reported with KCl. Now known to be

associated with multiple meds including
quinidine, tetracyclines (doxycycline),
iron products, alendronate, and antiinflamatory medications most often ASA
Onset is usual rapid and most often
noticable on awakening in AM. Chest
pain, odynophagia.
Injury caused by direct contact of the
caustic contents of the medication

Treatment of Pill Ulcers

No

evidence that any medication

speeds healing. Typically resolves in a
few days.
Pain meds.
May need parenteral support in rare
cases.
Can try suspension of sucralfate
(Carafate) or topical anesthetic
(xylocaine).