diseases of esophagus & dysphagia

Diseases of Esophagus &

Dysphagia

Dr. Vishal Sharma

Diseases ofesophagus

Contents• Esophagitis, Barret’s esophagus & GERD

• Esophageal tear & perforation

• Esophageal web, ring, stricture, atresia

• Achalasia cardia

• Esophageal hiatus hernia

• Esophageal hypermotility disorder

• Esophageal vascular impression

• Esophageal neoplasm

Esophagitis

Etiology• Gastro-esophageal reflux disease (commonest)

• Infective: candidiasis, cytomegalovirus, HIV, herpes

simplex, tuberculosis, Crohn’s disease, actinomycosis

• Caustic ingestion

• Medication: Iron, vitamin C, doxycycline, NSAID

• Iatrogenic: nasogastric tube, radiation

• Others: graft vs. host disease, uremia, eosinophilic

esophagitis, benign pemphigoid, epidermolysis bullosa

Savary Monnier classification of esophageal erosion

• Grade 1: Single erosion over single mucosal fold

• Grade 2: Erosions over multiple folds

• Grade 3: Circumferential mucosal erosions

• Grade 4: Erosion with definitive ulcer or stricture

• Grade 5: Columnar metaplasia (Barret’s esophagus)

Grade 1 esophagitis

Grade 2 esophagitis

Grade 3 esophagitis

Grade 4 esophagitis

Grade 5 esophagitis

Los Angeles Classification • Grade A: Mucosal break < 5 mm in length over

single mucosal fold

• Grade B: Mucosal break > 5mm over single

mucosal fold

• Grade C: Continuous mucosal break b/w > 2

mucosal folds but < 75% of esophageal

circumference

• Grade D: Mucosal break >75% of esophageal

circumference

Los Angeles Classification

Gastro- Esophageal Reflux Disease

Predisposing factors

Inefficient lower esophageal sphincter due to:

Pregnancy Obesity

Fatty food, large meals Coffee, chocolate

Cigarette smoking Alcohol ingestion

Reflux promoting drugs (see under treatment)

Scleroderma Hiatus hernia

Clinical features• Retro-sternal burning pain (heartburn / pyrosis)

• Dysphagia

• Chest pain

• Hoarseness, choking (laryngospasm),

• Bronchospasm / asthma

• Hematemesis & melaena

• Chronic cough due to aspiration pneumonia

• Symptomatic relief with trial of Pantoprazole

GERD

• Burning pain

• Pain seldom radiates to

arms

• Produced by bending,

drinking hot liquids

• Relieved by antacids

• Dyspnea absent

Angina pectoris

•Gripping / crushing pain

•Pain radiates into neck,

shoulders & both arms

•Pain produced by

exercise

•Relieved by rest

•Dyspnea present

Investigations1. Flexible upper GI endoscopy

2. Ambulatory 24-hour double-probe (esophageal &

pharyngeal) pH metry = gold standard

• Distal probe = 5 cm above lower esophageal sphincter

• Proximal probe = 1 cm above upper esophageal

sphincter, in hypopharynx behind laryngeal inlet

• Laryngo-pharyngeal reflux = acidic pH in both probes

• Gastro-esophageal reflux = acidic pH in distal probe only

24 hour ambulatory double-probe pH monitoing

pH metry

GERD LPRD

Heartburn ++++ +

Hoarseness & dysphagia + ++++

Nocturnal (supine) reflux ++++ -

Daytime (upright) reflux + ++++

ed lower esophageal pH ++++ ++

ed pharyngeal pH - ++++

Pantoprazole treatment 40 mg OD X 6 wk

40 mg BD X 6 mth

Treatment of GERD

A. Life style modifications:

1. Raise head end of bed by 6 inches. Sleep in left

lateral position. Maintain optimum weight.

2. Avoid the following:

• Tight fitting clothes & belts

• Lifting of heavy weight / straining / stooping

• Smoking

B. Dietary modifications:

1. Take 6 small meals. Eat slowly & chew thoroughly.

2. Take high protein diet.

3. Avoid the following:

• Eating / drinking within 3 hours of reclining

• Fried food / excess fat / large meals

• Taking large amount of fluids with meals

• Aerated drinks / alcohol (especially in evening)

• Coffee / tea / chocolate / mint / citrus fruit juice

C. Avoid following medicines:

• Tranquilizers & sedatives

• Muscle relaxants

• Calcium channel blockers

• Anti-cholinergic drugs

• Theophylline

• N.S.A.I.Ds

• Doxycycline

Dietary + Life style modifications + avoid reflux

producing medicines + Liquid antacid (2 tsp 1 hour

before meals & at bed time)

no relief after 4 weeks

Ranitidine 150 mg BD

+ Cisapride 10 mg TID before meals

no relief after 4 weeks

Pantoprazole 40 mg OD before breakfast

no relief after 4 weeks

Nissen’s fundoplication + Hill’s posterior gastropexy

Nissen’s complete fundoplication

Nissen’s complete fundoplication

Belsey Mark IV partial fundoplication

Toupet repair

Laparoscopic fundoplication

Transoral fundoplication

Hill’s fundoplication + posterior gastropexy

anterior & posterior phreno-esophageal bundles (esophagogastric

junction) sutured to pre-aortic fascia after fundoplication

Complications of GERD

• Esophageal ulceration

• Esophageal stricture

• Iron-deficiency anemia

• Barrett's esophagus

• Laryngitis, laryngeal ulcers

• Bronchial asthma

• Aspiration pneumonia

Barret’s esophagus

• Presence of gastric epithelium more than 3 cm

above gastro-esophageal junction caused by

columnar metaplasia of squamous epithelium due

to chronic acid exposure

• Pre-malignant condition for adenocarcinoma

• Rx: Pantoprazole + periodic esophagoscopy every

2 years to rule out dysplasia / malignancy

Barret’s esophagus

Barret’s esophagus with adenocarcinoma

Esophageal ring, web, stricture & atresia

Web• Only part of lumen

• Consists of mucosa

only

• Involves proximal

esophagus

• E.g. web of Plummer

Vinson Syndrome

Ring• Circumferential

• Consist of mucosa +

muscle

• Involves distal

esophagus

• E.g. Schatzki's ring of

lower esophagus

Schatzki’s ring

Plummer Vinson Syndrome• Synonym: 1. Patterson Brown Kelly syndrome

2. Sideropenic dysphagia

• Seen in middle-aged females due to iron

deficiency caused by atrophic gastritis or vitamin

B12 deficiency (pernicious anemia)

• Classical Triad: upper esophageal web

iron deficiency anemia (sideropenia)

cheilitis / glossitis

Clinical features

• Dysphagia: more to solids than liquids. Due to

upper esophageal web caused by

sub-epithelial fibrosis.

• Pallor: iron deficiency anemia

• Koilonychia (spoon nails): iron deficiency anemia

• Cheilitis + glossitis: vitamin B12 deficiency

Investigations

• Barium swallow anterior wall web in

• Esophagoscopy upper esophagus

• Blood smear: microcytic, hypochromic anemia

• Serum iron: decreased

• Total iron binding capacity: increased

• Gastric juice analysis: achlorhydria

Normal Iron levels

Male Female

Total Iron 45-160 g / dL 30-160 g / dL

Total iron binding capacity

220-420 g / dL 220-420 g / dL

Serum ferritin 20-323 ng /mL 10-291 ng /mL

Upper esophageal web

Treatment• Supplementation: iron + vitamin B12 + vitamin B6

+ folic acid

• Endoscopic dilatation of web with elastic bougie

or Hurst mercury pneumatic dilator

• Electrosurgical incision or surgical resection of

web for refractory cases

• Regular check endoscopy to rule out post-cricoid

malignancy (seen in 10% cases)

Esophageal strictures

• Definition: narrowing of esophageal lumen

(normal diameter = 20 mm

• Dysphagia is main symptom (Solids > liquids)

• Etiology for multiple esophageal strictures: benign

pemphigoid, epidermolysis bullosa, caustic

ingestion, candidiasis, graft vs. host disease

Causes of single stricture• GERD, esophagitis, Barret’s esophagus

• Caustic ingestion: corrosives, hot fluid

• Trauma: foreign body, external injury

• Medication capsules & tablets

• Radiotherapy, sclerotherapy

• Surgical anastomosis of esophagus

• Malignancy

• Congenital: involves lower 1/3rd

Benign stricture

• Multiple

• Regular mucosa

• Proximal esophageal

dilation present

• At sites of normal

constrictions

Malignant stricture

• Single

• Irregular mucosa

• Proximal dilation absent

due to cancer invasion

• Involves any site in

esophagus

Caustic stricture

Benign pemphigoid

Multiple strictures

Benign epidermolysis bullosa

Multiple strictures Hand contractures

Asymmetric malignant stricture

Esophageal compressionExtrinsic compression Intra-mural compression

Esophagoscopy

• Confirms diagnosis

• Evaluates position of

stricture

• Evaluates length of

stricture

• Rules out malignancy

Treatment of corrosive ingestionAcid = superficial coagulative necrosis (better)

Alkali = penetrating liquefaction necrosis (worse)

1. Hospitalize + treatment of shock & acid-base balance

2. Stricture prevention by:

• Steroid given within 48 hours for 6 weeks

• Careful nasogastric tube insertion for 3 weeks

• N-acetyl cysteine / Penicillamine: es collagen bonding

3. IV antibiotics + antacids + analgesics

4. Neutralize corrosive with weak acid / alkali within 6 hr

5. Discharge after 6 wk; life long follow up to r/o cancer

Surgical treatment of stricture

1. Progressive stricture dilatation over months

a. Prograde: oral route with elastic bougie

b. Retrograde: gastrostomy route

2. Stent insertion

3. Stricture excision + reconstruction with colon

4. Esophageal bypass with jejunum / colon segment

Esophageal atresia

1. Usually occurs with tracheo-esophageal fistula

2. Diagnosed at birth due to:

a. failure to pass nasogastric tube

b. absence of intestinal gas in X-ray abdomen

3. VACTERL: anomalies of Vertebra, Ano-genital,

Cardiac, Trachea, Esophagus, Renal, Limb

4. Rx: immediate repair of esophagus

X-ray abdomen

• NG tube

unable to

pass into

stomach

• Absence of

intestinal gas

Esophageal tear & perforation

Etiology1. Instrumentation: involves upper esophagus

a. Esophagoscopy

b. Dilatation of esophageal stricture

2. Severe vomiting (alcoholic): lower esophagus

a. Superficial mucosal tear = Mallory Weiss tear

b. esophageal perforation = Boerhaave syndrome

3. ed esophageal lumen pressure: childbirth,

forced cough, defecation, seizure, weight lifting

Clinical FeaturesEsophageal tear: painless hematemesis

Esophageal perforation: life threatening condition

• Severe pain in neck, chest, intra-scapular area

• Odynophagia, fever, prostration

• Tachypnea, tachycardia & hypotension

• Subcutaneous emphysema of neck

• Pneumo-mediastinum: Hamman’s mediastinal

crunch on auscultation

Mallory Weiss syndrome

Investigation of perforation

Chest X-ray: pneumothorax,

pneumomediastinum

Gastrograffin esophagogram:

shows perforation. Barium

increases mediastinitis.

Flexible esophagoscopy for

difficult cases

CT scan chest for mediastinitis

Boerhaave syndrome

Mallory Weiss tear

Onset Vomiting Vomiting

Alcoholism Yes Yes

Tear Trans-Mural Mucosal

Hematemesis Absent Present

Pain Present Absent

Investigation Gastrograffin esophagogram

Endoscopy

Treatment Emergency repair Self limiting,Cauterization

Treatment• Conservative: for upper esophageal rupture detected

within 12 hours & peptic stricture ruptures

• Thoracotomy & urgent repair of perforation: for

lower esophageal rupture detected within 12 hours

• Esophageal bypass / resection & anastomosis /

indwelling Celestin feeding tube: for perforation

detected after 12 hours & stricture perforations of

malignancy, caustic ingestion & post-radiotherapy

Conservative treatment

1. Nil by mouth

2. Parenteral nutrition

3. IV high dose broad-spectrum antibiotics

4. Endoscopic insertion of nasogastric tube

5. Continuous nasogastric tube suction for 1 week

• Most perforations heal within 2 weeks

Achalasia Cardia (Cardiospasm)

Etiology: 1. degeneration of ganglion cells of inhibitory

neurons in Auerbach’s myenteric plexus

2. Chagas disease (American trypanosomiasis)

Pathogenesis: failure of lower esophageal sphincter

relaxation + uncoordinated peristalsis food

retention dilated + tortuous lower esophagus

Clinical features:

– Dysphagia more to liquids than solids

– Regurgitation of undigested food

– Weight loss, aspiration pneumonia

• Chest X-ray: mediastinal widening + air-fluid level

• Barium swallow: Smooth fusiform lower esophageal

dilation (mega-esophagus) with abrupt tapering of

lower end (bird's beak appearance). Absence of

fundic gas shadow. Absence of peristalsis.

• Esophagoscopy: sudden dilatation of lower

esophageal lumen (like entering a dirty cave). Rule

out malignancy (0.15% ) causing pseudo-achalasia.

• Esophageal manometry: pressure in esophageal

body; pressure at lower esophageal sphincter

Barium swallow

Fluoroscopic barium swallow

Esophagoscopy

Esophageal manometry

Treatment• Smooth muscle relaxants (nitrates or calcium

channel blockers): afford short-lived relief

• Endoscopic Botulinum toxin injection into lower

esophageal sphincter: gives relief for many weeks

• Endoscopic dilatation of lower esophageal

sphincter: with elastic bougie / pneumatic dilator

• Heller’s laparoscopic cardio-myotomy: surgical

division of lower esophageal sphincter + Nissen’s

complete fundoplication to prevent post-op reflux

Heller’s cardiomyotomy

Laparoscopic cardiomyotomy

Fundoplication

Scleroderma (CREST syndrome)

• Atrophy & fibrosis of

esophageal smooth muscle

+ incompetent LES

• C/F: GERD + Calcinosis +

Raynaud’s phenomenon +

Esophageal dysmotility +

Sclerodactyly + Telengiectasia

• Rx: Pantoprazole + Cisapride

Esophageal hiatus hernia

• Definition: herniation of part of stomach above

esophageal hiatus in diaphragm

• Sliding hiatus hernia: gastro-esophageal junction slides >

2 cm above esophageal hiatus in diaphragm.

Esophagoscopy is diagnostic.

• Para-esophageal or rolling hernia: part of gastric fundus

rolls up via esophageal hiatus in diaphragm, alongside

esophagus. Gastro-esophageal sphincter remains below

diaphragm & is competent . Esophagogram is diagnostic.

• Rx: Reduction of hernia + Nissen’s fundoplication

Sliding hernia

Para-esophageal hernia

Para-esophageal hernia

Mixed hiatus hernia

Esophageal Hypermotility

disorders

Cricopharyngeal spasm

• Cricopharyngeous muscle

remains contracted

between swallows

• Smooth posterior

impression in hypopharynx

seen at C6 level

• Cricopharyngeal myotomy

Diffuse esophageal spasm• Dysphagia & chest pain mimicking myocardial

infarction especially on drinking cold liquids

• Barium swallow: simultaneous, uncoordinated,

non-peristaltic contractions in esophagus body

(cork-screw esophagus). Normal LES relaxation.

• Esophageal manometry: simultaneous repetitive

contractions in esophageal body

• Treatment: Nitrates, Nifedipine, Amytriptilline

Barium esophagogram

Esophageal manometry

Coordinated, normal amplitude contractions in

normal esophagus

Esophageal manometry

simultaneous, uncoordinated, non-peristaltic

contractions in esophagus body in diffuse

esophageal spasm

Esophageal manometry

High amplitude contractions in nutcracker esophagus

Esophageal vascular impressions

Vascular impressionsA. Intrinsic esophageal varices

• Uphill: in portal hypertension

• Downhill: in superior vena cava obstruction

B. Extrinsic (dysphagia lusoria)

• Aberrant right subclavian artery

• Right aortic arch

• Double aortic arch

• Aberrant left pulmonary artery

Esophageal varices

• Etiology: portal hypertension & SVC obstruction

• Clinical presentation: hematemesis

• Endoscopy: bluish esophageal varices

• Barium swallow: string of black pearls appearance

• Treatment: a. Cure of etiology

b. Endoscopic variceal sclerotherapy

c. Endoscopic variceal ligation (banding)

d. Porto-systemic vascular shunt

e. Devascularization of lower 5 cm of esophagus

Esophagoscopy

String of black pearls

These filling

defects change

shape during

respiration due to

venous emptying

Uphill varices

Downhill varices

Aberrant Rt subclavian artery

Aberrant Rt subclavian artery

Fluoroscopic barium

swallow shows

esophageal

compression at level

of third & fourth

thoracic vertebrae

Double aortic arch

Aberrant left pulmonary artery

Forrestier’s disease

• Dysphagia caused by

cervical esophageal

compression by vertebral

column osteophyte

• Inv: a. X-ray neck lateral

b. Esophagogram

• Rx: Osteophytectomy

Esophagogram

Esophageal neoplasm

Benign esophageal tumors

• Rare condition

• Types:

• Leiomyoma (commonest)

• Fibro-vascular polyp

• Squamous papilloma

• > 50% are asymptomatic

• Endoscopic / thoracotomy

excision for dysphagia

Esophageal malignancy

• Squamous cell carcinoma (upper 2/3rd)

• Adenocarcinoma (lower 1/3rd)

• Spindle cell carcinoma

• Leiomyosarcoma

• Lymphoma

• Metastasis

Clinical features

• progressive, painless dysphagia for solid foods

• acute food bolus obstruction

• weight loss in late stages

• chest pain or hoarseness: mediastinal invasion

• coughing after swallowing, pneumonia & pleural

effusion: tracheo-esophageal fistula

• cervical lymphadenopathy: node metastasis

Risk factors Smoking Alcohol consumption

Betel nut chewing Tobacco chewing

Vitamin A deficiency Vitamin C deficiency

Barret’s esophagus Achalasia cardia

Corrosive stricture Human Papilloma Virus

Plummer Vinson syndrome

Tylosis (familial hyperkeratosis of palms & soles)

Investigations

1. Barium swallow:

a. shouldering: malignant ulcer with everted margin

b. rat tail appearance: narrow lower 1/3rd with no

proximal dilatation

c. apple core appearance: narrow middle 1/3rd only

2. Esophagoscopy & biopsy from growth

3. CT scan chest: for staging of malignancy

Shouldering

Rat tail appearance

Also seen in

advanced

cases of

achalasia

cardia

Palliative treatment 70% patients have advanced disease at

presentation & require palliative treatment

1. Endoscopic tumour ablation using laser

2. Low dose intra-cavitary radiotherapy

3. Indwelling feeding tube (Mousseau-Barbin, Celestin)

4. Feeding jejunostomy

5. Chemotherapy (5 Fluorouracil)

6. Nutritional support & analgesia with morphine

Definitive TreatmentUpper 1/3rd: early: radical radiotherapy (5500 cGy)

advanced: chemo-radiation

Middle 1/3rd: early: radical RT or radical surgery

advanced: radical surgery + CT

Lower 1/3rd: early: radical surgery

advanced: radical surgery + CT

Radical surgery: esophagectomy + gastrectomy +

reconstruction with gastric / jejunal flap

Chemotherapy (CT): Cisplatin + 5-fluorouracil

Evaluation of dysphagia

Extra-esophageal causes

• Neoplasm: jaw / oral cavity / oropharynx /

hypopharynx / supraglottis

• Inflammation: TM joint arthritis / aphthous ulcer /

Ludwig’s angina / tonsillitis / quinsy / epiglottitis /

retropharyngeal abscess / parapharyngeal abscess

• Paralysis: tongue / soft palate

Esophageal intra-luminal causes

• Impacted foreign body / food bolus

• Esophageal atresia

• Esophageal web (Plummer Vinson Syndrome)

• Esophageal ring (Schatzki’s ring)

• Esophageal stricture: benign / malignant

• Esophageal neoplasm: benign / malignant

Esophageal intra-mural causes

• Inflammation: esophagitis (GERD commonest)

• Hypomotility disorders: Achalasia / scleroderma

• Hypermotility disorders: cricopharyngeal spasm /

diffuse esophageal spasm / nutcracker esophagus

• Other neuro-muscular disorders: Myasthenia

gravis / Multiple sclerosis / Motor neuron disease

Esophageal extra-mural causes

• Pharyngeal pouch

• Hiatus hernia

• Thyroid enlargement: benign / malignant

• Mediastinal: Ca left bronchus / lymphadenopathy /

cardiomegaly / aortic aneurysm /

neoplasm

• Vascular ring: dysphagia lusoria

• Cervical spine osteophyte: Forrestier’s disease

History taking• Level of dyphagia: oral cavity / pharynx / esophagus

• Acute onset: foreign body / trauma / inflammation

• Intermittent: hypermotility disorder

• Progressive: malignancy / stricture

• More for liquids: neuromuscular disorder

• Difficulty in initiation of swallow or after swallow

• Fever + odynophagia: inflammation

• Esophageal trauma / caustic ingestion

History taking• Hoarseness / stridor: laryngo-tracheal invasion

• Hemoptysis: Ca bronchus

• Heartburn: GERD

• Hematemesis: esophageal varices

• Regurgitation: pharyngo-esophageal obstruction

• Neck mass: metastatic lymph node / goitre

• Neurological disorder

• Smoking & alcohol consumption

Examination

• General: pallor + koilonychia = Plummer Vinson synd

• Oral cavity, oropharynx

• Indirect laryngoscopy: larynx, pyriform sinus,

posterior pharyngeal wall, post cricoid

area

• Laryngeal crepitus: absent in post-cricoid

malignancy, retropharyngeal abscess

• Neck node & cranial nerve examination

Investigations

• Barium swallow with or without air contrast

• Video-fluoroscopic (modified) Barium swallow

• Esophagoscopy: flexible & rigid

• Esophageal manometry: achalasia, esophageal spasm

• 24 hour double probe ambulatory pH monitoring

• Fibreoptic Endoscopic Evaluation of Swallowing

with Sensory Testing (FEESST)

Investigations

Bolus scintigraphy

Chest X-ray: mediastinal mass / cardiomegaly

CT scan chest: mediastinal or pulmonary tumor

Bronchoscopy: Ca bronchus

Thyroid scan: thyroid malignancy

Angiography: vascular rings (dysphagia lusoria)

Peripheral blood smear: Plummer Vinson syndrome

Barium SwallowPlain Air-contrast

Video-fluoroscopic swallow study

Video-fluoroscopic swallow study

Rigid Esophagoscopy

Flexible (oral) esophagoscopy

Esophageal manometry

24 hour ambulatory double-probe pH monitoing

Bravo capsule

Capsule has

no catheter.

Transmits

radio signals.

Fibreoptic Endoscopic Evaluation of Swallowing with Sensory Testing

• Air-pulse stimuli delivered to ary-epiglottic fold

mucosa innervated by superior laryngeal nerve to

elicit laryngeal adductor reflex for airway

protection

• Swallowing evaluation performed with variety of

food consistencies containing green food dye

• Look for aspiration into larynx

Sensory Testing with air pulse

Fibreoptic Endoscopic Evaluation of Swallowing

Complete aspiration Minimal aspiration

Normal swallowing

Bolus scintigraphy

Uses food bolus with radio-isotope to quantify

amount of reflux

Thank You