Esophagus

Esophagus-


-Esophagitis-

-Many causes of esophagitis

-Eosinophillic Esophagitis is found in up to 15 percent of patients with dysphagia.
-Typically have stacked circular rings, strictures, linear furrows and white papules that can lead to food impaction
-Diagnosis is made by biopsy
-Treated by elimination of dietary elements that cause allergic response.  Start patient on proton pump inhibitor.
-Topical steroids can be helpful in eosinophillic esophagitis
-Esophageal dilation necessary for patients with symptomatic strictures

-Radiation esophagitis may occur in patients being treated for head, neck, or thoracic cancers.
-these patients have dysphagia and odynophagia

-Lymphocytic esophagitis is when there is a dense peripapillary lymphocytic infiltrate involves the lower two thirds of the esophageal epithelium
-etiology is unknown
-Usually seen in older patients
-treat with proton pump inhibitor.  May not be associated with GERD

-Infectious Esophagitis due to many causes.  Most common herpes simplex virus
-Other causes of infectious causes such as cytomegalovirus (CMV), candidia, cryptococcosis, histoplasmosis, blastomycosis, and aspergilliosis
-immunosuppression should be suspected if present

-Medication Induced Esophagitis caused by largely 3 groups of medications:  antibiotics, NSAIDS and others
-Doxcycline is the most common antibiotic causing medication induced esophagitis
-NSAIDS can cause but higher with ASA
-Major players in the others category: KCl, quinidine, and biphosphonates
-mechanism is by caustic injury to the esophagus
-sometimes can be caused by retention of the capsule or scratching of the esophagus
-the most important therapy is to take the offending medication away
-PPI's, antacids, and carafate can be prescribed but their value has not been significantly demonstrated.

-Reflux esophagitis is due to hydrogen ion diffusion into the mucosa leading to cellular acidification and necrosis
-impaired esophageal emptying or decreased salivary function can contributed to increased exposure of the esophagus to the acid and induce this pathology
-Treatment is directed as acid control or increasing esophageal emptying

-if bleeding is present, melena is much more common the hematemesis
-other signs of esophagitis include pyrosis, dysphagia, bleeding, and possible pulmonary aspiration
-history is important in the diagnosis.  Non exertional and lasting for hours usually points to a non cardiac etiology
-other key elements include possibly awakens from sleep, worse after meals, and aggravated by laying down.
-usually improved with standing or sitting up.
-Treatment can involve PPI, H2 blockers, antacids, reglan (helps gastric emptying), and carafate
-non pharmacologic measures include weight loss, elevating head of the bed, and eliminating eating before bedtime or laying down.


-Motility Disorders-

-Motility disorders of the esophagus can occur from the upper esophageal sphincter (UES) or lower esophageal sphincter (LES) and body of the esophagus

-oropharyngeal motility disorders may arise from dysfunction of UES such as Zenker's diverticulum or cricopharyngeal bar.
-Can also be caused by stroke, multiple sclerosis, amytrophic lateral sclerosis, brain tumors, muscular dystrophy, myasthenia gravis, cancer, goiter, or cervical spurs.
-high incidence of aspiration with these disorders
-diagnosis with rapid sequence cine-esophagography.  Endoscopy plays a supportive role
-treatment is directed at reversing potential causes, aspiration precautions, and considering PEG tube if the underlying disorder is at high risk of aspiration

-the body of the esophagus can have motility disorders that arise from the smooth muscle or the intrinsic nervous system
-Scleroderma affects the smooth muscle of the esophagus and achalasia and Chagas disease are affected of by disorders of the intrinsic nervous system
-Other disorders can cause diffuse esophageal spasm
-cine esophagography and esophageal manometry confirms the diagnosis
-Achlasia usually responds to brisk dilation of the LES or surgical myotomy
-Scleroderma patients should have aggressive treatment of GERD
-patients with diffuse esophageal spasm sometimes will get some relief with calcium channel blockers, nitroglycerin or anticholinergic patients

-Rings and webs can affect the proximal or distal (Schatzki's rings)
-can cause some intermittent dysphagia especially when eat solid foods


-Mallory Weiss Tear-

-Mallory Weiss tear is defined as longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach which are caused by retching.
-hiatal hernia is found in a high percentage of patients with Mallory Weiss tears
-alcoholism is a predisposing factor.  Bleeding can be more severe with portal hypertension or esophageal varices
-presenting symptoms are acute GI bleeding, epigastric abdominal pain or back pain
-bleeding occurs because of a tear that involves the esophageal venous or arterial plexus
-patients usually have non bloody vomitus before the bleeding starts
-high percentage of patient need a blood transfusion but bleeding is self limited
-endoscopic therapy is first line treatment in actively bleeding lacerations
-injections with epinephrine, ethanol, or other sclerosing agents are helpful
-can use thermal devices also


-Esophageal Neoplasms-

-most esophageal cancers are squamous cell or adrenocarcinomas
-Barrett's esophagus can give rise to adenocarcinoma
-small cell carcinoma and sarcoma can arise out of the distal esophagus
-family aggregation has been described with a high incidence of squamous cell carcinoma in China.
-family history is a good indicator for Barrett's esophagus
-the presence of underlying esophageal disease such as achalasia and caustic strictures increases the risk of esophageal cancer
-prior gastrectomy increases the risk for squamous cell carcinoma
-atrophic gastritis, human papilloma virus, tylosis, biphosphonates, and poor oral hygiene have been shown to increase the risk of esophageal cancer
-Most all of adenocarcinomas arise from a region of Barrett's esophagus which is due to GERD
-Smoking increases the risk form adenocarcinoma of the esophagus
-alcohol consumption does not increase the risk for esophageal adenocarcinoma
-Obesity has been liked to esophageal adenocarcinoma and adenocarcinoma of the gastric cardia
-Zollinger Ellison Syndrome may be at increased risk for adenocarcinoma
-use of drugs that decreased lower esophageal sphincter pressure may increases the risk of adenocarcinoma
-cholecystectomy and nitrosative stress have been associated with carcinogenesis
-NSAIDS may have a protective effects


-patients with locally advanced cancer can cause some solid food dysphagia
-weight loss may happen from dysphagia
-aspiration pneumonia can happen but infrequent
-chronic GI blood loss is common with esophageal cancer with melena
-tracheobronchial fistulas are a late complication of esophageal cancer because of the direct invasion through the esophageal wall to the main stem bronchus

-esphagectomy is the treatment of choice for superficial esophageal cancers
-the cancer has to be staged as well as the depth determined
-evaluation for distant metastasis can be done with CT or PET scanning
-criteria for unresectable disease includes: distant metastasis to peritoneal, lung, bone, adrenal, brain, or liver mets, thoracic or abdominal esophagus near great vessels, heart or trachea, cervical esophageal tumors
-palliative surgical resection is usually not indicated
-external beam radiation therapy (EBRT) is indicated for unresectable cancer
-chemotherapy and radiation therapy is the standard nonoperative management for unresectable therapy



-Esophageal Stricture-

-most benign esophageal strictures result from a complication of long standing GERD
-treated with acid reducers as well as esophageal dilation therapy
-other causes of strictures can be secondary to external beam radiation, esophageal sclerotherapy, caustic ingestions, surgical anastamosis, and rare dermatologic diseases
-the cardinal symptom of of strictures is dysphagia
-contraindications to esophageal dilation include:  incomplete healed perforation, potentially malignant stricture, pharyngeal or cervical deformity, caution with eosinophilic esophagitis, large thoracic aneurysm, and impacted food bolus
-can be dilated with balloon dilators or mechanical dilators
-simple strictures are related to reflux esophagitis
-complex strictures are long, narrow, tortuous, or strictures associated with hiatal hernias and esophageal diverticulae.



-Esophageal Varices-

-varices are expanded blood vessels in the esophagus and sometimes the stomach
-cirrhosis blocks the blood flow through the liver and this increases the pressure in the portal vein causing portal hypertension
-without treatment 25-40 percent of patients with esophageal varices will have one major episode of bleeding
-15 percent of the people who bleed from varices will die
-varices do not cause symptoms until the bleed or ruptures

-Treatment involves beta blockers for those that have refractory ascites
-patients need to avoid alcohol and lose weight
-variceal band ligation can be placed around the varices to prevent them from bleeding
-PPI's help speed the healing of erosions and ulcers that develop when the band falls off the varices.
-if they rupture will need massive blood transfusion, volume replacement, and emergent endoscopy