Esophageal Emergencies

Tintinalli chapter 75

Anatomy/Physiology

• Muscular tube 20-25 cm long

• Majority in mediastinum, post/lat to trachea

• Outer longitudinal & inner circular muscles

• Upper 1/3 striated muscle, lower half all smooth muscle

• Two sphincters; UES cricopharyngeus muscle, LES lower 1-2 cm of esophagus

Anatomy/Physiology

• Three anatomic constrictions:– Cricopharyneus– Aortic arch/left mainstem bronchus– Gastroesophageal junction

Anatomy/Physiology

• Innervation mirrors cardiac, a convergence of somatic and visceral stimuli; cardiac and esophageal chest pain similar.

• Blood supply; inferior thyroid artery, branches from thoracic aorta, branches from left gastric and inferior phrenic arteries.

Anatomy/Physiology

• Venous; submucosal plexus drains into plexus outside of esophagus

• Outer plexus to :– Inferior thyroid– Azygos– Coronary– Gastric venous system

Dysphagia

• Defined; difficulty swallowing– Majority will have organic process

• Two types:– Transfer dysphagia; early in swallowing

process– Transport dysphagia; impaired movement

down esophagus through LES, perceived later in process, feeling of food “getting struck”

Dysphagia

• Transfer: – 80 % neuromuscular; CVA,scleroderma,

myasthenia gravis, parkinsons, lead poisoning, thyroid disease

– Risk of aspiration– Discoordinated food bolus transfer to

esophagus– Symptoms; gagging, coughing, nasal regurg.

Dysphagia

• Transport:– 85 % obstructive disease; foreign body,

carcinoma, webs, strictures, thyroid enlargement, vessel abnormalities, diverticuli

– Less aspiration risk– Improper transfer from esophagus to stomach– symptoms; food sticking, retrosternal fullness,

odonophagia

Dysphagia

• History– Acute vs. chronic– Solids vs. liquids– Intermitent or progressive– Feeling of “something stuck”

• Physical exam; focus on head and neck and neuro, helpful to watch pt swallow sip of water. Physical exam often normal.

Dysphagia

• ED work-up: AP & lat neck x-rays. CXR. – Diagnosis often made outside ED. Barium

swallow usually first test. Ultimately best worked up with video-esophagography.

Structural/Obstructive causes

• Neoplasm: common cause of both types.– 95 % squamous cell– Male : female , 3:1– Fast progression from solids to liquid

dysphagia– Pts >40 yo with dysphagia assume neoplasm.

Need expedient work up to rule out malignancy

Structural/Obstructive causes

• Esophageal stricture: results from scaring from GERD– Generally distal esophagus, may interfere with

LES– Symptoms develop over years, usually only

solids– Must rule out malignancy

Structural/Obstructive causes

• Schatzki ring: most common cause of intermittent dysphagia with solids– Fibrous stricture near GE junction in 15 % of

population– Pts frequently present with food impacted

after poorly chewed meat– Treatment is dilatation

Structural/Obstructive causes

• Esophageal webs: thin structures of mucosa and submucosa– Often mid or proximal esophagus– Congenital or acquired– Plummer-Vinson syndrome, with iron

deficiency anemia– Tx is dilatation

Structural/Obstructive causes

• Diverticula: can be found throughout esaphagus– Zenker; progressive outpouching of

pharyngeal mucosa above UES. d/t increased pressure when swallowing.

– Usually seen after age 50– Halitosis– Feeling of a neck mass

Motor lesion causes

• Neuromuscular disorders; misdirection of food bolus, – liquid > solids. – Symptoms intermittent.– CVA #1 cause– Polymyositis/Dermatomyositis #2 causes

Motor lesion causes

• Achalasia; dysmotility disorder, – unknown cause. – Impaired LES relaxation, – absence of esophageal peristalsis. – Patients 20-40 yo. – Symptoms; regurgitation, weight loss,

odonophagia

Motor lesion causes

• Diffuse esophageal spasm; – dysphagia intermittent and does not

progress. – Tx =control any reflux present

Chest Pain of Esophageal Origin

• Differentiating esophageal from ischemic pain very difficult. Often not done in ED.

• Pain at night, spontaneous onset, regurgitation, odynophagia, dysphagia, meal induced= can be seen in both

• High admission rate of chest pain found not to be cardiac is appropiate.

• 20-60% of chest pain is esophageal and normal coronary arteries.

GERD

• 25% of adults

• Weak or transient relaxing of LES is primary cause

• Other causes= high fat diet, nicotine, ETOH, caffeine, pregnancy, meds(nitrates, Ca channel blockers, estrogen, progesterone)

• Heartburn is classic symptom

GERD

• Other symptoms= odynophagia,dysphagia, acid regurgitation, hyperslivation. Asthma exac, dental erosions, frequent URI’s, vocal cord ulcers, laryngitis, hoarseness, chronic cough

• Postural changes in pain= increasing intraabdominal pressure can increase pain

• Relief with antacids

GERD

• Complications= strictures, esophageal inflammation, Barrett esophagus (columnar epith replaces strat squamous) premalignant.

• Pain; squeezing, pressusre-like, onset with exertion, diaphoresis, pallor, nausea, vomiting, radiation to arms and neck, shoulder and back. All similar to cardiac pain

GERD

• TX; – Avoid exacerbating agents– Elevate head of bed 30 degrees– Don’t eat 3 hours before going to bed– H2 blockers or PPI’s

Esophagitis

• Inflammatory: can progress to ulceration, scarring, stricture– Reflux induced- aggressive tx. with acid

suppression– Med induced-NSAIDs, KCL, doxy, clinamycin,

tetracycline

• Infectious: immunosuppression; AIDS– Candida #1, HSV, CMV, aphthous ulceration– Fungal, vericella, EBV.

Esophageal Motility Disorders

• Chest pain, dull/achy, at rest, 5th decades, intermittent dysphagia

• Esophageal dysmotility: excessive, uncoordinated contraction

• Achalasia & diffuse es. spasm as above• Ineffective esophageal motility• Hypertensive LES• Nutcracker esophagus; high amplitude, long

duration contractions LES, >180 mmHg• Tx with NTG, Ca channel blockers

Esophageal Perforation

• Iatrogenic 75%– endoscopy #1 cause

• Boerhaave syndrome 10-15%– ETOH– emesis

Esophageal Perforation

• Trauma 10%– Blunt rare– Penetrating wounds more common, often

masked by more critical wounds in the area

• FB ingestion; perforation usually at anatomic narrowings. d/t pressure necrosis(coin), penetrating from sharp object(pin), chemical irritant(battery)

Esophageal Perforation

• Esophageal contents to ; • Mediastinum-fulminant necrotizing

mediastinitis and polymicrobial infection to shock

• Pleural/peritoneal space- rapidly progressive infection/shock

• Most spontaneous perfs through left post-lat wall in distal esophagus. Proximal perfs with instrumentation

Esophageal Perforation

• Pain- acute, severe, unrelenting, diffuse, chest neck and abdomen.

• May radiate to back and shoulders

• Exacerbated by swallowing

• Dysphagia, dyspnea, hematemesis, cyanosis may all be present

• Confused w/(MI, PE, ulcer, aortic catastrophe, acute abd.)= delays in dx.

Esophageal Perforation

• Physical; abd rigidity, hypotension, fever, tachycardia, tachypnea all common.

• Cervical sub-q emphysema if cervical perf

• Mediastinal emphysema takes longer

• “Hammon crunch” air in mediastinum being moved by beating heart

• Pleural effusion in 50% w/ intrathoracic perfs.

Esophageal Perforation

• CXR=suggestive

• CT=confirms

• Endoscopy= confirms

• Pleural fluid aspirate= high amylase

Esophageal Perforation

• High mortality rate regardless of cause– Location, etiology, time until dx all affect

outcome

• Rapid aggressive mgt is key– Tx shock– Surgical consult

Esophageal Bleeding

• General approach:

• UGIB= airway mgt., NG tube, gastric lavage, blood if needed, GI consult

• 60% vericeal bleeds resolve w/ supportive care. 80% if bleed is not vericeal.

• If continue to bleed= early endoscopy

• Pharmacologic= somatostatin analogs

• Balloon tamponade= last resort

Esophageal Bleeding

• Varices:

• Seen in chronic liver ds & portal HTN

• 60% of pts with chronic liver ds. – 25-30% experience hemorrhage

• Varices from ETOH abuse have higher risk of bleeding– 2/3 that bleed have recurrent hemorrhage

Esophageal Bleeding

• Varices:

• Endoscopy first line to control bleeding

• Sclerotherapy and ligation are alternatives

• Despite tx, mortality remains high

Esophageal Bleeding

• Mallory-Weiss syndrome:

• Arterial bleeding from longitudinal mucosal lacs. of distal esoph/prox stomach

• 5-15% of UGIB

• 4th – 6th decades

• Acute onset of UGIB

• Overall low relative incidence of surgical intervention or adverse outcomes is seen

Esophageal Bleeding

• Mallory-Weiss syndrome:

• Initial tx = supportive, most stop spontaneously

• Ongoing bleeding= electrocoagulation, sclerotherapy, laser photocoagulation, angiographic embolization, surgery.

Esophageal Bleeding

• Esophageal Cancer:

• Heme-positive stools

• Uncommon cause of significant UGIB or LGIB

Swallowed Foreign Bodies

Tintinalli

Chapter 76

Swallowed FB

• Peds 80% of all cases

• Prisoners, psych, edentulous adults

• Adults=meat and bones

• Peds = coins, toys, crayons, pen caps

• Psych and prisoners = unlikely objects, spoons, razors

Pathophysiology

• Most pass spontaneously

• 10-20% require some intervention

• 1% surgical

• Most are at “anatomic narrowings”– Peds: cricopharyngeal(C6) most common,

thoracic inlet(T1), aortic arch(T4), tracheal bifurcation(T6), hiatal narrowing(T10-11)

Pathophysiology

• Once object passes pylorus, usually passes out with stool.

• Irregular or sharp edges may lodge anywhere though.

Clinical Presentation

• Objects in esophagus:

• Anxiety, discomfort, retrosternal pain, retching, vomiting, dysphagia, choking, coughing.

• In peds= refusal to eat, vomiting, gagging, choking, stridor, neck or throat pain, increased salivation, inability to swallow.

Clinical Presentation

• Physical exam:• Nasopharynx, oropharynx, sub-q tissue for

air.• Laryngoscopy (direct or indirect)• Objects warrenting endoscopy consult:

– Sharp/elongated, multiple FB, button batteries, evidence of perf, child w/ coin at cricopharyngeous, airway compromise, FB for >24 hours

ED Management

• General Care:• Expectant once FB past pylorus• If FB obstructs esoph, insert tube above FB to

remove unswallowed material• Locate FB:

– Standard x-ray– Endoscopy= locates and removes FB, procedure of

choice– Esophagogram- consult endoscopist prior to contrast

ED Management

• Type of contrast:

• Perf expected= water soluble contrast, Gastrografin

• Aspiration is possible use Barium, Gastrografin is pulmonary irritant

• Perf and aspiration possible: use nonionic contrast

ED Management

• Monitor FB progress w/ x-rays 2-4 hrs apart

• Frequent abd exams for peritonitis should perf occcur

ED Management

• Food impaction:• Meat= time and sedation allow meat to pass. Do

not allow in esoph >12 hrs• Endoscopy #1• Glucagon 1 mg IV, repeat 2 mg IV in 20 min,

relaxes esoph smooth muscle• Nifedipine 10 mg sub lingual, reduces LES

pressure • DO NOT use meat tenderizer d/t complications

including perforation

ED Management

• Coin injestion: (usually children)

• 35% are asymptomatic

• Coins lie in frontal plane in esoph, = flat side visible on AP films

• Coins in trachea in sagittal plane

• Foley catheter removal if <24 hrs– Secondary to endoscopy– Protect airway first = ET tube

ED Management

• Button Battery:

• True emergency, rapid action of alkaline on mucusa, burns in 4 hrs, perfs in 6hrs.

• Lithium cells= bad outcomes

• Mercury containing= get blood and urine mercury levels

ED Management

• Locate battery on x-ray

• In esophagus get endoscopy

• Past esophagus: asymptomatic don’t remove. Remove if not past pylorus > 48hrs

• Most pass through body in 48-72 hrs

• Pts with s/s of GI tract injury need surgical consult

ED Management

• Sharp Objects:

• Longer than 5cm, wider than 2 cm rarely able to pass stomach.

• Large objects(above) and extremely pointed (safety pins) must be removed prior to passing stomach. 15-35% will perf intestines.

ED Management

• Initial radiograph on all.

• Symptomatic or sewing needle FB= surgical consult

• Sharp object and asymptomatic= expectant w/ serial radiographs– Not passing stomach=water soluble contrast– First sign of perf or object not passing=

surgical consult

ED Management

• Cocaine Ingestion:

• Packet = condom, holds 5 grams

• Rupture of one packet can be fatal

• Surgery not endoscopy recommended.

• If packet passing intact through intestinal system, may be able to wait and watch.

Questions

• 1. GERD symptoms include:– A)pressure pain– B)diaphoresis– C)nausea– D)pain radiation to arm/neck– E)all of the above

• 2. common causes of Trasport dysphagia include all of the following except:– A)carcinoma– B)thyromegally– C)CVA– D)strictures

Questions

• 3. Esophageal perforation is most commonly due to:– A)Iatrogenic– B)ETOH use– C)Boerhaave syndrome– D)blunt trauma

• 4. Of the anatomic narrowings in children the most common spot for FB’s to lodge is:– A)cricopharyngus– B)aortic arch– C)tracheal bifurcation– D)hiatal narrowing

Questions

• 5. Treatment for meat impaction includes all of the following except:– A) endoscopy– B)glucagon– C)Nifedipine– D)meat tenderizer

Answers

• 1. E

• 2. C (CVA is a cause of transfer dysphagia)

• 3. A

• 4. A

• 5. D