Esophageal Diseases

It includes :

Esophageal motility disorder
Esophageal diverticulum
Benign esophageal tumors
Malignant esophageal tumors
GERD and Hiatus Hernia
Esophageal perforation
Caustic Injury
Barrett’s Esophagus

1. Achalasia

Achalasia is an uncommon disease of esophageal motility disorder

It is characterized by degeneration of the myenteric neurons that innervate LES and esophageal body

lower esophageal sphincter

the pathogenesis :

all these factors autoimmune ? Viral ? Familial ?

Clinical features

most commonly presents in patients between the ages of 25 and 60 years. an equal male-to-female gender distribution.

both at the same time (not progressive)

Dysphagia to solids and liquids is the most common presenting symptom, experienced by greater than 90% of patients.

(unlike cancer esophagous)

more in male
older age group (>50) • but both have dysphagia in cancer, starts as:
solid
semisolid
liquid
saliva (pagressive dysphagia)

Clinical features

Regurgitation is the second most common symptom, occurring in approximately 60% of patients.
Nocturnal regurgitation of esophageal contents can lead to night time cough and aspiration.

Glead to aspiration Pneumonia

its nocturnal because LES is closed, and esophagous

is dilated, so it acts as reservoir (opposite to its function)

food will accumulate, and when laying down → aspiration of

Weight loss occurs in end-stage disease.

function of esophagous: Transient transmission of food from pharynx to stomach

Clinical features

Chest pain is reported in 20% to 60% of patients
Heartburn is reported in a large number of patients with Achalasia (30% of Achalasia patients). may be related to direct irritation of the Esophageal lining by retained food, pills, or acidic by products of bacterial metabolism of retained food.

• heart burn → from achalasia → from GERD: its from acidity from stomach because sphincter is open

• H / E

Diagnosis

CXR may show air-fluid level
Barium study quite dilated, and an air-fluid level may be secondary to retained secretions. The classic finding is a gradual tapering at the end of the Esophagus, similar to a bird’s beak.
Upper endoscopy is the next diagnostic test in a patient with dysphagia or suspected Achalasia.

or cat’s tail or pencil shape

Diagnosis

Findings can include :

dilated esophagus with retained food or secretions
normal in as many as 44% of patients with achalasia

Difficulty traversing the GEJ should raise suspicion for pseudo-achalasia due to neoplastic infiltration of the distal esophagus.

Prepare patient carefully before doing endoscopy (because esophagus is full of food) Keep NPO for few days irrigate Put NGT

Chest x-ray

okey dilated esophagous

barium swallow

bird’s beak / rat tail / pencil share

dilated esophagous

if disease develop in patient and left untreated, its effect will be irreversible.

→ esophagous looks like haustration of colon

→ end stage achalasia

Diagnosis

golden standard in diagnosis of esophagous

• Esophageal manometry has the highest sensitivity for the diagnosis of achalasia :

3 findings:

- aperistalsis of the distal esophageal body
- incomplete or absent LES relaxation
- hypertensive LES

Manometric variants of achalasia exist

The best known is vigorous achalasia
defined by the presence of normal to high amplitude esophageal body contractions in the presence of a non-relaxing LES

Diagnosis

Manometric variants of achalasia exist

→ (anything raising amplitude of LES)

vigorous achalasia may represent an early stage of achalasia

Chagas’ disease is a parasitic infection

caused by Trypanosoma cruzi which can cause secondary achalasia.

The most concerning secondary etiology

is cancer, which can present as achalasia through mechanical obstruction of the GEJ

Treatment

The primary therapeutic goal in achalasia is to reduce the LES basal pressure
Treatment options include medical therapy: botulinum toxin injection, pneumatic dilation, and surgical myotomy
Symptom relief, particularly relief of dysphagia, is accepted as the primary desired outcome

Medical Therapy

Is inconvenient, only modestly effective, and frequently associated with side effects

It is reserved for patients who are awaiting or unable to tolerate more invasive treatment modalities

Pharmacologic therapies attempt to decrease the LES pressure by causing smooth muscle relaxation

Medical Therapy

① Nitrates were first recognized as an effective treatment of achalasia their systemic vasodilatory effects and headaches limit their tolerability by patients

② Calcium channel antagonists have a better side-effect profile when compared with nitrates

30% of patients report adverse side effects including peripheral edema, hypotension, and headache → from VD effect of drugs

Botulinum Toxin

3. Botulinum Toxin

→ not successful in high percentage

Response rates at 1 month following administration average 78% , By 6 months, the clinical response rate drops to 58% and by 12 months to 49% Given the limitations of the efficacy and durability of response, Botulinum toxin is generally reserved for use in patients who are not candidates for more invasive treatments.

4. Pneumatic Dilation

pneumatic dilation remains one of the most effective first-line therapies for achalasia

Long-term follow-up studies reported significant symptom relapse of 50% at 10 years

Complications of pneumatic dilation exist

Gastroesophageal reflux 25-35% → if dilate more than needed
Esophageal perforation 3%

treatment

Drug therapy:

Smooth muscle relaxant (nitrate, calcium channel blocker, anticholinergic))
10% of pts. Benefit from this treatment (elderly)

Pneumatic dilation: → by endoscopy, put balloon in LES and inflate it, keep it for

a couple of minutes

A balloon is insufflated at the level of the G.O junction to rupture the muscle fibre
Success rate 70-80%
50% will require more than 1 dilation.

then repeat it

a few times.

and repeat

every 6 months

give some symptom relief but only temporarily, for 6 months to 1 year. so needs to be repeated

Balloon Dilation

Bougie Dilation

Surgical Therapy

more preferred than medical therapy

has success rates in excess of 90% with hospital stays averaging only a few days acid exposure is a known complication of surgical intervention for achalasia

Even with a successful myotomy, it is expected that patients will have some degree of dysphagia as a consequence of esophageal peristaltic dysfunction

Surgical Therapy

Delayed recurrence of postoperative dysphagia is most commonly caused by development of a recurrent high pressure zone at the LES or a peptic stricture complicating acid reflux

Laparoscopic Heller’s myotomy

demonstrated excellent results, with 98% of patients reporting symptomatic improvement at 5.3 years

98% Success rate done through scope, then open hiatus and isolate esophagous and cut the longitudinal and circular muscles, and expose the mucosa. then 60 a positive to prevent reflux in the future

Complications

The primary complications of achalasia are related to the functional obstruction rendered by the non-relaxing LES and include progressive malnutrition and aspiration.

Uncommon but important secondary complications of achalasia include the formation of epiphrenic diverticula and esophageal cancer → Squamous Cell Carcinoma

(*achalasia patient has risk to develop SCC more than normal population)

Complications

(There is an established link between achalasia and esophageal cancer, most commonly squamous cell carcinoma)
(The overall prevalence of esophageal cancer in achalasia is approximately 3% with an incidence of approximately 197 cases per 100,000 persons per year)

2. Esophageal Diverticula

blind end sac

most diverticula are a result of a primary motor disturbance or an abnormality of the UES or LES
can occur in several places along the esophagus

The three most common sites of occurrence are pharyngoesophageal (Zenker’s), parabronchial (midesophageal), and epiphrenic

epiphrenic diverticula develop when there is motility disorder

Esophageal Diverticula

can be classified into:

True diverticula involve all layers of the esophageal wall, including mucosa, sub-mucosa, and muscularis
A false diverticulum consists of mucosa and submucosa only
Pulsion diverticula are (false diverticula) that occur because of elevated intra luminal pressures generated from abnormal motility disorders

can be classified into:

Esophageal Diverticula

Zenker’s diverticulum and an epiphrenic diverticulum fall under the category of false, pulsion diverticula.

Traction, or true, diverticula result from external inflammatory mediastinal lymph nodes adhering to the esophagus

usually in middle 1/3 (where LNs are present)

here, The management is not designed to treat the diverticulum itself because the diverticulum is not the main pathology its only a result. So removing diverticulum it will still reoccur. So treat the LNs, TB, and inflammatory process. and the diverticulum will heal by itself.

(LNs involved in inflammatory process, as in TB) (lead to adhesions)

Pull all layers of esophagus Traction True

Pharyngoesophageal (Zenker’s) Diverticulum

(False, pulsion)

Is the most common esophageal diverticulum found today

It usually presents in older patients in the 7th decade of life

found herniating into Killian’s triangle, between the oblique fibers of the thyro- pharyngeus muscle and the horizontal fibers of the crico-pharyngeus muscle

Symptoms and Diagnosis

Commonly, patients complain of a

sticking in the throat.
nagging cough, excessive salivation, and intermittent dysphagia often are signs of progressive disease

because its beside the airway (trochea)

when patient short eating, part of food pass through real lumen, part go in the diverticulum, once diverticulum is full of food, start to press on esophagus leading to dysphagia.

As the sac increases in size, regurgitation of foul-smelling, undigested material is common

because food stuck in diverticulum

Symptoms and Diagnosis

→ bad smell of breath
Halitosis, voice changes, retro-sternal pain, and respiratory infections are especially common in the elderly population
The most serious complication from an untreated Zenker’s diverticulum is aspiration pneumonia or lung abscess → due to aspiration of food from diverticulum

Symptoms and Diagnosis

Diagnosis is made by barium esophagram → Show diverticulum or different site

Neither esophageal manometry nor endoscopy is needed to make a diagnosis of Zenker’s diverticulum.

Neck of diverticulum

barium swallow

Zenker dineticulum

Treatment

excision → boys

Surgical or endoscopic repair of a

Zenker’s diverticulum is the gold standard of treatment

if unfit for surgly
put rigid phayrengoscope, esophagoscope and put fiber optic, and see real lumen, and blind end of diverticulum.
retract fiber optic scope, adjust rigid scope until see the wall between real lumen and the diverticulum.
put a Stapler at the end and divide the wall.

3. Barrett’s Esophagus

Barrett’s esophagus is a condition whereby an intestinal, columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus

Chronic gastro-esophageal reflux is the factor that both injures the squamous epithelium and promotes repair through columnar metaplasia

→ although, these metaplastic cells are more resistant to injury from GERD, but more prone to malignancy → That’s why they develop adenocarcinoma

→ histo Pathological diagnosis

→ So need multiple biopsy by endoscopy

Barrett’s Esophagus

Although these metaplastic cells may be more resistant to injury from reflux, they also are more prone to malignancy
10 % of patients with GERD develop Barrett’s esophagus
the 40-fold increase in risk for developing esophageal carcinoma in patients with Barrett’s esophagus

Barrett’s Esophagus

With continued exposure to the reflux disease, metaplastic cells undergo cellular transformation to low- and high-grade dysplasia → mild, moderate, severe dysplasia → one step away from becoming CIS then become adenocarcinoma these dysplastic cells may evolve to cancer

Barrett’s Esophagus

70% of patients are men aged 55 to 63 years
Men have a 15-fold increased incidence over women of adenocarcinoma of the esophagus, but women with Barrett’s esophagus are increasing in number as the differences in the Western lifestyle between men and women diminish
Smoking
Stress

Symptoms and Diagnosis

Many patients harboring intestinal metaplasia in their distal esophagus are asymptomatic
Most patients present with symptoms of GERD. Heartburn, regurgitation, acid or bitter taste in the mouth, excessive belching, and indigestion are some of the common symptoms associated with GERD

Symptoms and Diagnosis

Recurrent respiratory infections, adult asthma, and infections in the head and neck also are common complaints.
The diagnosis of BE is made by endoscopy and pathology
The presence of any endoscopically visible segment of columnar mucosa within the esophagus that on pathology identifies intestinal metaplasia defines BE

Symptoms and Diagnosis

lower esophagus

need, white, inflamed

Treatment

Yearly surveillance endoscopy is recommended in all patients with a diagnosis of Barrett’s esophagus For patients with low-grade dysplasia, surveillance endoscopy is performed at 6-month intervals for the first year and then yearly thereafter if there has been no change

Treatment

Patients undergoing surveillance are placed on acid suppression medication and monitored for changes in their reflux symptoms. for life

Controversy surrounds the benefits of anti-reflux surgery in patients with Barrett’s esophagus Play role in treatment of early barrett esophagus

Treatment

Those in favour of surgery argue that medical therapy and endoscopic surveillance may treat the symptoms but fail to address the problem → acid reflux

The problem is the functional impairment of the LES that leads to chronic reflux and metaplastic transformation of the lower esophageal mucosa

Treatment

Surgery renders the LES competent and restores the barrier to reflux

Studies have demonstrated regression of metaplasia to normal mucosa up to 57% of the time in patients who have undergone antireflux surgery

Treatment

Photodynamic therapy (PDT) is the most common ablative method used to treat BE

Endoscopic mucosal resection (EMR) is gaining favor for the treatment of Barrett’s esophagus with low-grade dysplasia.

of severe dysplasia treated as CIS → subtotal resection

Treatment

(mucosal resection or esophagectomy)

→ aggressive therapy if moderate or severe dysplasia

Esophageal resection for Barrett’s esophagus is recommended only for patients in whom high-grade dysplasia is found

Pathologic data on surgical specimens demonstrate a 40% risk for adenocarcinoma within a focus of high-grade dysplasia

Benign esophageal tumor

Benign Esophageal Tumors and Cysts

Benign tumors are rare (< 1 %)

Classified in two groups

Mucosal
Extramucosal (intramural)

More useful classification:

60% of benign neoplasms are leiomyomas
20% are cysts
5% are polyps
Others (< 2 percent)

4. Esophageal Cysts

Arise as diverticula of the embryonic foregut

¾ of this cyst present in childhood

Over 60% are located along the right side of the esophagus

Are often associated with vertebral anomalies (ex: spina bifida)

60% present in the first year of life with either respiratory or esophageal symptoms

Cyst found in the upper third of the esophagus present in infancy while lower third lesions present later in childhood

Pedunculated Intraluminal Tumors

(Polyps)

Benign polyps are rare

Usually occur in older men and may cause intermittent dysphagia

Are sometimes easily missed with barium swallow and esophagoscopy

6- Leiomyoma

Leiomyomas constitute 60% of all benign esophageal tumors

They are found in men slightly more often than women and tend to present in the 4th and 5th decades

They are found in the distal two thirds of the esophagus more than 80% of the time

Leiomyoma

They are usually solitary and remain intramural, causing symptoms as they enlarge.

*Tumor of the muscularis, under neath mucosa, so by endoscopy will find large, taking biopsy from mucosa will be normal.

Recently, they have been classified as a gastrointestinal stromal tumor (GIST)

GIST tumors are the most common mesenchymal tumors of the gastrointestinal tract and can be benign or malignant

need to take biopsy from tumor itself (arising from muscularis or submucosal)

Leiomyoma

Nearly all GIST tumors occur from mutations of the c-KIT oncogene, which codes for the expression of c-KIT (CD117).

All leiomyomas are benign with malignant transformation being rare

*esophagus is a distensible organ, any cause dysphagia with 2/3 of lumen is blocked. → That’s why presentation of patients with cancer esophagus is late

Symptoms and Diagnosis

Many leiomyomas are asymptomatic → if <2cm

during swallowing

Dysphagia and pain are the most

occur as lumen enlarge

common symptoms and can result from even the smallest tumors

A chest radiograph is not usually helpful to diagnose a leiomyoma, but on barium esophagram, a leiomyoma has a characteristic appearance.

filling defect
pressure from outside
normal mucosa
smooth

barilum Swallow

[Non-Text]

Leiomyoma

During endoscopy, extrinsic compression is seen, and the overlying mucosa is noted to be intact

Diagnosis also can be made by an endoscopic ultrasound (EUS), which will demonstrate a hypoechoic mass in the submucosa or muscularis propria

biopsy → normal mucosa

FNA → if in doubt about tumor if its submucosa, leiomyoma, cancer, LN needle through endoscope, EUS guided

Treatment

Leiomyomas are slow-growing tumors with rare malignant potential that will continue to grow and become progressively symptomatic with time

Although observation is acceptable in patients with small (<2 cm)

asymptomatic tumors or other

significant co morbid conditions, in most patients, surgical resection is advocated

do CT, barium swallow, MRI, endoscopy, all to see exact location to know how to approach

Treatment

if in lower esophagus → approach from abdomen laproscoccally

Surgical enucleation of the tumor remains

the standard of care and is performed through a thoracotomy or with video or robotic assistance

The mortality rate is less than 2%, and success in relieving dysphagia approaches 100%

expose esophagus from outside, exercise tumor, leave mucosa intact, close remaining muscles don’t injure mucosa because its submucosal tumor.

Malignant esophageal tumor

CARCINOMA OF THE ESOPHAGUS

Esophageal cancer is the fastest growing cancer in the western countries Squamous cell carcinoma still accounts for most esophageal cancers diagnosed However, in the US, esophageal adenocarcinoma is noted in up to 70% of patients presenting with esophageal cancer

CARCINOMA OF THE ESOPHAGUS

Squamous cell carcinomas arise from the squamous mucosa that is native to the esophagus and is found in the upper and middle third of the esophagus 70% of the time

Smoking and alcohol both increase the risk for foregut cancers by 5-fold. Combined

• lower third → adenocarcinoma

CARCINOMA OF THE ESOPHAGUS

Food additives, including nitrosamines found in pickled and smoked foods, long-term ingestion of hot liquids caustic ingestion, achalasia, bulimia, tylosis (an inherited autosomal dominant trait), Plummer-Vinson syndrome, external-beam radiation, and esophageal diverticula all have known associations with squamous cell cancer.

CARCINOMA OF THE ESOPHAGUS

The 5-year survival rate varies but can be as good as 70% with polypoid lesions and as poor as 15% with advanced tumors.

esophageal adenocarcinoma now accounts for nearly 70% of all esophageal carcinomas diagnosed in Western countries

CARCINOMA OF THE ESOPHAGUS

There are a number of factors that are responsible for this shift in cell type:

Increasing incidence of GERD

Western diet

Increased use of acid-suppression medications

Not suppressed look so there is still harmful effect from the acid but patient not feel any symptoms.

Intake of caffeine, fats, and acidic and spicy foods all lead to decreased tone in the LES and an increase in reflux

& and Peppermint

CARCINOMA OF THE ESOPHAGUS

As an adaptive measure, the squamous-lined distal esophagus changes to become lined with metaplastic columnar epithelium (Barrett’s esophagus)
Progressive changes from metaplastic (Barrett’s esophagus) to dysplastic cells may lead to the development of esophageal adenocarcinoma

Symptoms

Early-stage cancers may be asymptomatic or mimic symptoms of GERD

Most patients with esophageal cancer present with dysphagia and weight loss

Because of the distensibility of the esophagus, a mass can obstruct two thirds of the lumen before symptoms of dysphagia are noted

Symptoms

Choking, coughing, and aspiration from a tracheo-esophageal fistula, as well as hoarseness and vocal cord paralysis from direct invasion into the recurrent laryngeal nerve, are ominous signs of advanced disease

Systemic metastases to liver, bone, and lung can present with jaundice, excessive pain, and respiratory symptoms.

Diagnosis

There are a plethora of modalities available to diagnose and stage esophageal cancer

Radiologic tests, endoscopic procedures, and minimally invasive surgical techniques all add value to a solid staging workup in a patient with esophageal cancer.

Esophagram

A barium esophagram is recommended for any patient presenting with dysphagia is able to differentiate intra-luminal from intramural lesions and to discriminate between intrinsic (from a mass protruding into the lumen) and extrinsic (from compression of a structures outside the esophagus) compression

Esophagram

The classic finding of an apple-core lesion in patients with esophageal cancer is recognized easily

Although the esophagram will not be specific for cancer, it is a good first test to perform in patients presenting with dysphagia and a suspicion of esophageal cancer

barium swallow

apme core appearance →irregular

also seen in cancer colon

C64 W112

Esophageal carcinoma

Apple core lesion

Endoscopy

The diagnosis of esophageal cancer is made best from an endoscopic biopsy any patient undergoing surgery for esophageal cancer must have an endoscopy performed by the operating surgeon before entering the operating room for a definitive resection

Squamous Cell Carcinoma of the Esophagus

→ in middle 1/3

in lower 1/3

Adenocarcinoma of the Esophagus

Computed Tomography

9 for staging → To know treatment and prognosis

CT scan of the chest and abdomen is important to assess the length of the tumor, thickness of the esophagus and stomach, regional lymph node status and distant disease to the liver and lungs

CT-CAP

Positron Emission Tomography

To assess for distant metastasis PET scan evaluates the primary mass, regional lymph nodes, and distant disease

Its sensitivity and specificity slightly exceed those of CT; however, they remain low for definitive staging

Endoscopic Ultrasound

EUS is the most critical component of esophageal cancer staging.

The information obtained from EUS will help guide both medical and surgical therapy

biopsy samples can be obtained of the mass and lymph nodes in the paratracheal, subcarinal, paraesophageal, celiac region

There is high mortality due to late presentation

Treatment

→ multi disciplining management.

Chemotherapy → neo adjuvant → 3-4 sessions Then restage by CT, MRI, PET

Radiation therapy

has effect in upper 1/3 SCC affect SCC more than adenocarcinoma

Chemo-Radiotherapy

Then put Patient in tumor board and refer to Thoracic Surgeon

Surgical resection → best one esp. in early stage

esophagectomy → and after 2-3 weeks, give adjuvant chemotherapy ± radiotherapy

GASTROESOPHAGEAL REFLUX DISEASE

LES has the primary role of preventing reflux of the gastric contents into the esophagus

GERD may occur when the pressure of the high-pressure zone in the distal esophagus is too low to prevent gastric contents from entering the esophagus

There are barriers (anatomical) preventing acidity to come.

angle of Hiss
Crura
Presence of abd. part of esophagus in abdomen

→ if these barriers are gone ⇒ GERD

different from hiatus hernia

GASTROESOPHAGEAL REFLUX DISEASE

GERD is often associated with a hiatal hernia

the most common is the type I hernia, also called a sliding hiatal hernia → medical or surgical treatment

→ surgical treatment → mixed: Sliding and Para esophageal

Type II and III hiatal hernias are often referred to as para-esophageal hernias and they may be associated with GERD

asymptoms: dysphagia, early satiety, palpitation, chest pain, abd. pain

Type IV when there is other organ herniated into the chest (Spleen, Colon)

Treatment should be surgical because risk of stomach to be strangulated and get necrotized → ischemia

GE junction

GASTROESOPHAGEAL REFLUX

DISEASE

Definition :

Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus

Often chronic and relapsing

May see complications of GERD in patients who lack typical symptoms

GASTROESOPHAGEAL REFLUX DISEASE

Epidemiology :

About 44% of the US adult population have heartburn at least once a month

14% of Americans have symptoms weekly

7% have symptoms daily

Clinical Presentations of GERD

1 Classic GERD 2 Extra esophageal/Atypical GERD 3 Complicated GERD

Clinical Presentations of GERD

Classic GERD :

Substernal burning and or regurgitation

Postprandial pain

Aggravated by change of position

Prompt relief by antacid → diagnostic factor

nexium
Pentobarbital

2 Extra-esophageal Manifestations of

GERD

These patients are wrongly treated for causes other than GERD

Pulmonary

Asthma

Aspiration pneumonia

Chronic bronchitis

Pulmonary fibrosis

from chronic aspiration

Other

Chest pain

Dental erosion

ENT

Hoarseness

Laryngitis

Pharyngitis

Chronic cough

Globus sensation

Dysphonia

Sinusitis

Subglottic stenosis

Laryngeal cancer

Clinical Presentations of GERD

3 Symptoms of Complicated GERD :

Dysphagia

Difficulty swallowing: food sticks or hangs up

Odynophagia

Retrosternal pain with swallowing

Bleeding

Stricture formation

Diagnostic Tests for GERD

Barium swallow

Endoscopy

Ambulatory pH monitoring

→golden standard

↓ask patient to stop antineflux for 2-3 weeks,

Put probe scan above GEJ and leave for 24 hours

→ and will monitor the pH. and give patient

Esophageal manometry

booklet to write every time 1st symptoms

and what he was doing.

if in doubt, patient has GERD and at

the same time, has dysphagia symptoms.

do this (with ambulatory pH monitoring)

to rule out any motility disorders. → because they have different surgeries

Treatment

→ for GERD with or without sliding hernia

Lifestyle Modifications

Acid Suppression Therapy

Anti-Reflux Surgery

Endoscopic GERD Therapy

Treatment

Lifestyle Modifications

Elevate head of bed 4-6 inches

Avoid eating within 2-3 hours of bedtime

Lose weight if overweight

Stop smoking

Modify diet

Eat more frequent but smaller meals
Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea

OTC medications prn

Acid Suppression Therapy for GERD

H₂-Receptor Antagonists

(H₂RAs)

Proton Pump Inhibitors

(PPIs)

Cimetidine

(Tagamet®)

Ranitidine (Zantac®)

Famotidine (Pepcid®)

Nizatidine (Axid®)

Omeprazole

(Prilosec®)

Lansoprazole

(Prevacid®)

Rabeprazole

(Aciphex®)

Pantoprazole

(Protonix®)

Esomeprazole

(Nexium ®)

Anti-Reflux Surgery

Indication for Surgery :

have failed medical management opt for surgery despite successful medical management (due to life style considerations including age, time or expense of medications, etc) have complications of GERD (e.g. Barrett’s esophagus; grade III or IV esophagitis) have medical complications attributable to a large hiatal hernia. (e.g. bleeding, dysphagia) have “atypical” symptoms (asthma, hoarseness, cough, chest pain, aspiration) and reflux documented on 24 hour pH monitoring

Endoscopic GERD Therapy

Endoscopic anti-reflux therapies → high recurrence rate

Radiofrequency energy delivered to the LES Stretta procedure radiofrequency heating of GE junction
Suture ligation of the cardia Endoscopic plication
Sub mucosal implantation of inert material in the region of the lower esophageal sphincter Enteryx

Nissen Fundoplication

→ Steps (?)

→ by laparoscopic

(a) Before

(b) Sutures

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Esophageal Diseases.backup

Esophageal Diseases

Esophageal Diseases

It includes :

1. Achalasia

Clinical features

Clinical features

Clinical features

Diagnosis

Diagnosis

Findings can include :

Diagnosis

Manometric variants of achalasia exist

Diagnosis

Manometric variants of achalasia exist

Chagas’ disease is a parasitic infection

The most concerning secondary etiology

Treatment

Medical Therapy

Medical Therapy

Botulinum Toxin

3. Botulinum Toxin

4. Pneumatic Dilation

treatment

Surgical Therapy

Surgical Therapy

Complications

Complications

2.

Esophageal Diverticula

Esophageal Diverticula

Esophageal Diverticula

Pharyngoesophageal (Zenker’s) Diverticulum

Symptoms and Diagnosis

Symptoms and Diagnosis

Symptoms and Diagnosis

Treatment

Surgical or endoscopic repair of a

Zenker’s diverticulum is the gold standard of treatment

3. Barrett’s Esophagus

Barrett’s Esophagus

Barrett’s Esophagus

Barrett’s Esophagus

Symptoms and Diagnosis

Symptoms and Diagnosis

Symptoms and Diagnosis

Treatment

Treatment

Treatment

Treatment

Treatment

Treatment

Benign esophageal tumor

Benign Esophageal Tumors and Cysts

4. Esophageal Cysts

Pedunculated Intraluminal Tumors

(Polyps)

6- Leiomyoma

Leiomyoma

Leiomyoma

Symptoms and Diagnosis

Leiomyoma

Treatment

Treatment

Surgical enucleation of the tumor remains

Malignant esophageal tumor

CARCINOMA OF THE ESOPHAGUS

CARCINOMA OF THE ESOPHAGUS

CARCINOMA OF THE ESOPHAGUS

CARCINOMA OF THE ESOPHAGUS

CARCINOMA OF THE ESOPHAGUS

CARCINOMA OF THE ESOPHAGUS

Symptoms

Symptoms

Diagnosis

Esophagram

Esophagram

Endoscopy