14. GERD-Diagnosis
• Symptoms !!
Diagnostic evaluation is NOT needed in most cases of
GERD and treatment is started empirically.
• Endosocpy: low sensitivity, highest yield in complicated
GERD
• Barium studies
• 24-hour pH monitoring
16. GERD-Management
LIFESTYLE
• Type of foods
• Bed elevation
• Small frequent meals
• Weight loss
MEDICATIONS
• Antacids
• H2 Blockers
• PPI (Proton pump
inhibitors
17. Barrett’s Metaplasia
• Definition:
- Prolonged lower esophageal acid exposure
leads to replacement of the lower esophageal
squamous epithelium by columnar epithelium
- Premalignant Condition
23. Esophageal AdenoCarcinoma
Risk Factors
• Barrett’s mucosa: most significant (40 fold)
• GERD
• AC is largely a disease of Caucasians and males
• Obesity has been associated with AC but not SCC
• Smoking probably increases the risk of AC
– Development of HGD in Barrett’s
• Alcohol is probably not an important risk factor
25. • Dysphagia:
– Most common
– Initially intermittent
– Solids then liquids
• History of GERD (AdenoCa):
– Esophagitis / Barrett’s in 50% on presentation
• Food intolerance, anorexia and wt. Loss
• Odynophagia and back pain:
– Mediastinal involvement
• Hoarseness
• Esophago-pulmonary fistula
• Liver / diaphragm / airway mets
Esophageal Cancer
Clinical Presentation
26. • Endoscopy:
– Location: Distal vs. proximal
– Associated Barrett’s
– Appearance: Flat vs. polypoid
• Endoscopic biopsy:
– Most valuable
– Sensitivity of 6-8 bxies: 98%
– Sensitivity of cytology and bx: 100%
• Radiology:
– Esophagogram: Filling defect
– CAT scan: Thickening
Esophageal Cancer
Diagnosis
29. • T: Primary tumor
– Tis: Carcinoma in situ / high grade dysplasia
– T1: Mucosa and submucosa
– T2: Muscularis propria
– T3: Transmural / periesophageal
• N: Regional lymph nodes
– N0: No adenopathy
– N1: Regional nodal metastasis
• M: Distant metastasis
– M0 vs. M1
Esophageal Cancer
Staging Classification-TNM
30. • Endoscopic Ultrasound (EUS)
– Best modality for locoregional staging
– Limited role in distant metastasis
• CAT scan:
– T staging: no role
– Nodal staging: very low sensitivity
– Detection of metastasis
• PET scan:
– Whole body survey
– Helpful in diagnosing metastatic disease
– Limited role in T / local staging
Esophageal Cancer
Staging Tools
32. Treatment: Early Disease
• Stages: Tis, I and IIA
• Surgery:
– Mainstay of treatment
– Surgery alone
– Best outcome:
• Tis & HGD: cure rate of 100%
• Stages I & IIA: cure rate ~ 80%
33. Treatment: Locally advanced
Disease
• Stages IIB and III
• Difficult and controvercial
• Surgery alone: 10% cure!
• Neoadjuvant chemo or XRT: No difference
• Neoadjuvant chemo and radiation:
– Greatest chance for prolonged survival
– Cisplatin and 5-Fluorouracil
• Patient and Dr.’s decision!!!
34. Treatment: Metastatic Disease
• Palliative
• Chemotherapy +/- XRT:
– Potential prolongation of life?
– Fit and willing patient
