Diseases of the esophagus

Diseases of the esophagus
Krisztina Gecse, MD, PhD
First Department of Medicine
Semmelweis University
Budapest, Hungary
Overview
• Diverticula
• Zenker’s diverticulum
• Hiatus hernia
• Motility disorders
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GERD
Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
Secondary: DM, amyloidosis, motoneuron, etc.
Esophagitis
Infectious (mycotic, viral: HSV-1, CMV)
Eosinophil
Corrosive
Tumors
Benign (leiomyoma, lipoma, adenoma)
Malignant (squamous cell cc. or adenocc.)
Pathomechanism
Symptoms/Diagnosis
Management
Zenker’s diverticulum
• Pathomechanism
- posterior "false" diverticulum
- sac-like outpouching of the mucosa and
submucosa through Killian's triangle, an
area of muscular weakness (between the
transverse fibers of the cricopharyngeus
and the oblique fibers of the lower
inferior constrictor)
• Signs and symptoms
- Oropharyngeal dysphagia in the elderly
- Aspiration pneumonia
• Diagnosis
- barium swallow
• Management
- surgery: myotomy and diverticulectomy
- endoscopy: cricopharyngeal myotomy
Hiatus hernia
• Pathomechanism
- age-related degeneration of the
phrenooesophageal memebrabene
- repetitive stress of swallowing,
abdominal strain, episodes of
vomiting, tonic contraction of the
esophageal longitudinal muscle
induced by gastroesophageal reflux
• Signs and symptoms
- asymptomatic
- GERD
- dysphagia (gastric volvulus)
- ulcerations: Cameron lesions
Hiatus hernia
• Diagnosis
- Barium-swallow
- Upper endoscopy:
Sliding: 2-cm separation between the
squamocolumnar junction and the
diaphragmatic impression
Paraoesophageal: etroflexed view on upper
endoscopy shows a portion of the stomach
herniating upward through the diaphragm
adjacent to the endoscope
- High resolution manometry
• Management
- asymptomatic: no need to treat
- GERD sliding: medical and surgical
- paraesophageal: surgery
GERD
Definition
Montreal classification: a condition that develops when the
reflux of stomach contents causes troublesome symptoms and/or
complications
NERD: non-erosive reflux esophagitis (60%)
ERD: erosive reflux esophagitis (35%)
complicated ERD: ulcer, sricture, BE, adenocc. (5%)
Vakil N et al. Am J Gastroenterol 2006
GERD
Pathomechanism
1. LES dysfunction
• anatomic dysruption: hiatus hernia
• transient LES relaxation: provoking factors
2. Aggressive reflux secretum:
• HCl  H. pylori (NH3 production, buffer capacity)
• pepsin,
• bile acid
3. Decreased clearence
4. Tissue resistance
• preepithelial: mucus layer
• epithelial: epithelial cells + TJ
• postepithelial: vascularisation
5. Gastric emptying
GERD
Symptoms
Typical
symptoms
heartburn
Atypical
Alarm
symptoms
symptoms
linked-angina
dysphagia
asthma bronchiale,
laryngitis, coughing
regurgitation
globus
weight loss
foetor ex ore, teeth
erosions
epigastric pain
sleep disturbances
anaemia
GERD
Diagnosis
PPI-test
2w for typical and 8-12w for atypical symptoms
Upper endoscopy
Los Angeles classification:
Grade A – one or more mucosal breaks ≤5mm in
lenght
Grade B – at least one mucosal break >5 mm
long, but not continuous between the tops of
adjacent mucosal folds
Grade C – at least one mucosal break that is
continuous between the tops of adjacent
mucosal folds, < 75% of circumference
Grade D – mucosal break involving >75%
GERD
Diagnosis
24-hour pH-monitoring
transnasally placed catheter or
wireless, capsule-shaped device: Bravo
system
Multichannel intraluminal impedance
also measure non-acid and gas reflux
Tutuian R et al. GI motility online 2006
GERD
Management
1. Lifestyle recommendations
• Weight loss
• Smoking cessation
• Avoid provoking and late food, drinks
• Sleeping with head of the bed elevated
2. Medical management
PPI (pantoprazol, esomeprazol, rabeprazol, etc.):
Initial treatment:
- typical symptoms: 1-2x daily 4-6w in NERD, 8w in ERD
- atypical symptoms: 2x daily 8-12w
Maintanence treatment: gradual dose reduction as long as possible
Prokinetics (donperidon, metoclopramide): mixed acid + bile reflux
GERD
Management
3. Surgical treatment
Nissen fundoplication
lack of response to a PPI has traditionally been a negative predictor for
response to laparoscopic fundoplication.
GERD Complications
Barrett-esophagus
Significance: Precancerous condition: adenocc. developes in 0.5%
Definition: presence of intestinal metaplasia above the OG junction
Types:
According to type of metaplasia:
gastric (fundic, cardia)
intestinal
pancreatic
According to length:
SSBE: < 3cm
LSBE: > 3cm
According to severity of dysplasia (Vienna):
no dysplasia
non-definitive regarding dysplasia
dysplasia present: low or high grade
Diagnosis: endoscopy + quadrantbiopsy + histo
GERD Complications
Barrett-esophagus
Management
1. Treat GERD! (Lifestyle + Medical management)
2. How to handle dysplasia? Surveillance!
 no evidence for dysplasia on histology: endoscopy q3years
 low grade dysplasia: endoscopy q1year
 high grade dysplasia: rebiopsy!
 High grade dysplasia confirmed: 1y adenocc. risk 50%
surgery – esophageal resection
minimally invasive endoscopy: RFA or EMR
Achalasia
Pathomechanism
Park W et al. Am J Gastroenterol 2005
Achalasia
Symptoms & Diagnosis
• Symtoms: dysphagia (both solid and liquid), regurgitation, retrosternal chest pain
• OGD: normal mucosa (exclude „pseudoachalasia”)
• Barium swallow
• Esophageal manometry
absent peristalsis and a non-relaxing LES
Vaezi MF et al. Am J Gastroenterol 2013
Achalasia
Management
Vaezi MF et al. Am J Gastroenterol 1999
Esophageal cancer
Etiology
Squamous cell carcinoma (85%)
• Genetics
• Alcohol consumption
• Dietary factors: N-nitroso compounds,
high temperature beverages
• Corrosive damage
• Achalasia
• HPV?
Adenocarcinoma (15%)
• 90% arise from a region of
Barrett's metaplasia, which is
due to gastroesophageal reflux
disease (GERD)
• Obesity
Esophageal cancer
Symptoms & Diagnosis
Symptoms: LATE!
• dysphagia
• odynophagia
• loss of apetite
• anorexia
• chest pain
• hick-ups
Upper endoscopy + biopsy: histology
Barium swallow:
stricture length, function, fistula
EUS
CT
PET
staging
Esophageal cancer
Staging
Esophageal cancer
Management
• Tis: EMR
• St. I-II: surgery – subtotal esophageal resection
• St. III-IV: primary R0 resection not possible
neoadjuvant chemo- or chemo- + radiotherapy down-staging
(5-FU, cisplatin)
restaging after 4-6 weeks
radical surgery
•
Palliative treatment: endoscopic expandable metal stent implantation
bougie dilation
PEG placement
best supportive care
Gastrointestinal bleeding
Krisztina Gecse, MD, PhD
First Department of Medicine
Semmelweis University
Budapest, Hungary
GI tract
• The gastrointestinal tract extends
from the mouth to the anus and is
divided into two parts:
• Upper GI tract
• Lower GI tract
• Separated by the ligament of
Treitz at the duodenojejunal
junction
GI bleeding: upper vs. lower
Localization of the
bleeding
Incidence
(100000/year)
Upper GI
(above the ligament of Treitz)
Esophagus
Stomach
Duodenum
55-150
Lower GI
(below the ligament of Treitz)
Jejunum, ileum
Colon, rectum
20
(without hemorrhoids)
Upper GI bleeding
Upper GI non-variceal
Upper GI variceal
Etiology
Prevalence (%)
Gastric/duodenal ulcer
Gastroduodenal erosions
Mallory-Weiss tears
Gastric tumor
Rare other causes
(eg.: angiodysplasia,
haemobilia)
Non-identified
50
15
15
5
3
Esophageal
Gastric fundus
2
10
Lower GI bleeding
Etiology
Small bowel
Small bowel tumors, M. Crohn, Meckel-diverticulum, Angiodysplasia,
Mesenterial ischaemia
Colon
Young adult
UC, CD, Polyps
Adult<60 years
Diverticulosis
UC, CD
Polyps, carcinoma
Infectious colitis, Angiodysplasia
Adults>60 years
Angiodysplasia, Diverticulosis
Polyps, carcinoma
Ischaemic colitis
Rectum
Haemorrhoids (80%), Carcinoma, Proctitis, Iatrogenic
GI bleeding
Signs & Symptoms
• Anaemia
• Hypovolaemic shock
• Upper GI bleeding:
hematemesis, melaena, hematochesia, occult GI bleeding
• Lower GI bleeding:
hematochesia, melaena, occult GI bleeding
Upper GI variceal bleeding
Classification (AASLD)
Small: < 5mm
Large: > 5mm
Predisposing factors to variceal bleeding:
• Size of of the varix (small vs. large)
• Child-Pugh stage of liver cirrhosis
• “cherry red spots”
Upper GI variceal bleeding
Management
Primary prophylaxis
• Regular endoscopic evaluation
• In case of large varices chemoprofilaxis with propranolol or
endoscopic treatment if intolerant
Upper GI variceal bleeding
Management
Acute bleeding
• Stabilize patient
(volumen resuscitation + balloontamponade)
• Prophylactic AB
• Vasoactive drugs (terlipressin, octreotide)
• Perform endoscopy
sclerotherapy or EVL
• Consider TIPS
2nd endoscopy fails and ongoing bleeding
Upper GI variceal bleeding
Management
Secondary prophylaxis
• chemoprophylaxis
• spironolactone
• endoscopic treatment (EVL or sclerotherapy)
• TIPS
Upper GI non-variceal bleeding
Forrest Classification
Upper GI non-variceal bleeding
Management
Endoscopy + Medical management
Medical management