Evaluation of dysphagia and diseases of the esophagus

1. Evaluation of Dysphagia
Diseases of the Esophagus
Dr. Krishna Koirala
2016/06/08

2. Evaluation of Dysphagia
• History
• Physical Examination
• Investigations

3. History
• Onset / Duration
• Initiation of Swallowing or after it?
• Painful or not?
• Solids /Liquids or both?
• Progressive/ intermittent ?

4. HISTORY-HOPCAssociated symptoms
• Heartburn
• Voice change
• Cough / Sore Throat
• Hematemesis / Hemoptysis
• Weight Loss
• Autoimmune Disorders
• Neurological Disorders

5. • Past History
–Trauma, Caustic Ingestion
• Personal History
–Smoking
–Alcohol

7. Examination
• General Physical Examination
• Body Weight
• Pallor, Koilonychia : Plummer-Vinson Syndrome

8. Local Examination
• Oral Cavity
• Oropharynx
• Laryngopharynx
–PFS, Posterior pharyngeal wall, Post cricoid area
• Laryngeal Crepitus
• Neck Nodes
• Cranial Nerves

9. Investigations
• Barium Swallow
• Video - Fluoroscopic Swallow Study / Modified
Barium Swallow
• Rigid and flexible Esophagoscopy
• Esophageal Manometry
• Ambulatory pH Monitoring
• CT/MRI

10. Ba swallow Modified Ba Swallow
Conventional Fluoroscopic
Static Films Video Films
Assessed by
Radiologist
Assessed by Speech
Pathologist
Assesses Structural
lesions primarily
Assesses Swallow Reflex with
different consistency of foods
Differences between Barium swallow
and Modified Barium swallow

12. Esophagoscopy
• Procedure of choice for suspected mucosal pathology
• Enables Biopsy
• FEES / FEES -ST
• Types:
– Flexible / Rigid / Transnasal

13. •Rigid esophagoscopy
•Transoral
•GA
•Instrumentation +
•Flexible esophagoscopy
•Transoral
• Topical /IV sedation
•Biopsy only

14. Esophageal manometry
• Measures Intraluminal
pressure at UES, Body, LES
• Uses
–Achalasia
–Diffuse Esophageal
Spasm

15. pH Monitoring
• Gold Standard inv. for
GERD
• Detects reflux as pH <4
• Involves Endoscopic
placement of an electrode
5 cm above GE Junction
• Bravo capsule ( wireless pH
Monitor)

16. Common Diseases of
the Esophagus

17. Disorders of the Esophagus
• Structural abnormalities
– Esophageal atresia, tracheo -esophageal fistula,
lower esophageal ring, hiatus hernia
• Motility disorders
– Achalasia cardia
• Inflammatory disorders
– Reflux, infection, corrosive burns, radiation
• Mass lesions : Benign / malignant

18. Esophagitis
• Infective
– Candida/CMV/Herpes Simplex
• Drug Induced
–Fe, KCl, Vitamin C, Doxycycline, NSAIDs
• Miscellaneous
–Acid Reflux, Radiation, Uremia, Aphthous Ulcers

19. • Clinical Features
– Odynophagia
• Investigations
– Esophagoscopy
– Esophagogram
• Shaggy /Foamy Esophagus
• Treatment
– Fluconazole for Candidiasis
– Ganciclovir for CMV

20. HSV CMV

21. Reflux Esophagitis
• GERD occurs in 10-15% of the population
• LES Dysfunction resulting in exposure to acid and
pepsin from the stomach to esophagus
• Reflux Esophagitis
–Inflammatory changes in the esophageal mucosa
–C/F: Heartburn

22. • Investigation
– 24 hour ambulatory pH monitoring : Gold Standard
• Treatment
– Started empirically in the absence of alarm signs
– Lifestyle change
– PPI 6-8 weeks
– Prokinetic agents

23. Esophageal tear
• Instrumentation - Most common cause
– Upper end > Lower end
• Severe vomiting : affects lower end only
• C/F :
–Odynophagia , Drooling, Chest and Back Pain
–Fever, Prostration
–Subcutaneous emphysema neck
–Pneumo - Mediastinum: HAMMAN SIGN

24. • Investigations
– CxR: Mediastinal Air
– Gastrograffin Swallow : site of tear
• Treatment
– NPO
– IV Fluids
– IV Antibiotics
– Thoracotomy & Repair
• Life Threatening Condition !!

25. ESOPHAGEAL TEAR
Boerhaave
syndrome
Mallory Weiss tear
Onset Vomiting Vomiting
Alcoholism + +
Tear Trans-Mural Mucosal
Bleeding None +++
Pain +++ None
Investigation X-Ray, CT
Gastrograffin
Endoscopy
Treatment Emergency Repair Self Limiting,
Cauterization

27. Plummer Vinson Syndrome
(Patterson Brown Kelly Syndrome)
• F > M
• Triad:
– Upper Esophageal Web
– Iron Deficiency Anemia
– Atrophic Stomatitis / Glossitis
• Increased risk of Post-Cricoid Malignancy

28. • Esophagogram
– Most sensitive test
• Treatment
– Endoscopic dilation
– Refractory rings may require
pneumatic dilatation,
electrosurgical incision and
surgical resection

29. Esophageal strictures
• Narrowing of lumen
– Normal 20 mm in diameter
• Dysphagia
– Main symptom
– Solids > Liquids
• Acid / Peptic stricture (60%–
70%)

30. • Intrinsic Strictures
– Acid peptic, Pill -induced
– Chemical
– Post- nasogastric tube
– Infectious esophagitis
– Radiation-induced
– Esophageal/gastric
malignancies
– Surgical anastomotic
– Congenital
• Extrinsic strictures
– Pulmonary / mediastinal
malignancies
– Anomalous vessels and
aneurysms
– Metastatic submucosal
infiltration (breast cancer,
adenocarcinoma of gastric
cardia)

31. • Esophagogram
– Initial Diagnostic Study
– Delineate the Stricture
• Endoscopy
– Evaluate the Mucosa
– Rule Out Malignancy
Distal stricture

32. Treatment
• Esophageal Dilation (Depends on the length and
diameter)
– Simple strictures
• Maloney dilators
– Complex strictures (<10mm diameter,>2cm
length)
• Wire-guided bougies under fluoroscopic and
endoscopic control

33. • Dilation performed progressively over weeks to
months with a gradual increase in diameter of
the dilators
• Radiation-induced or malignant strictures are
at higher risk of perforation

34. Achalasia Cardia
• Primary Esophageal motility disorder
– Insufficient LES relaxation
• Pathology
– Loss of Ganglion cells in the myenteric plexus
– Infiltrate of T lymphocytes, Eosinophils, and mast
cells
• Symptoms
– Dysphagia to Liquids > Solids

35. • Barium esophagogram
– Best initial diagnostic tool
– Loss of peristalsis
– Upper esophageal dilatation
– Closed LES
• Mega Esophagus
• Bird's beak appearance
• Rat Tail appearance
Investigations

36. • Esophageal Manometry
– Most specific test to establish the diagnosis
• Absent or incomplete LES relaxation
• Loss of peristalsis
• Endoscopy
– Performed to rule out carcinoma at the
gastroesophgeal junction (pseudoachalasia)

37. • Pneumatic Dilatation
– 2 to 5% risk of perforation (Gastrograffin study
performed after dilatation to exclude
perforation)
– Efficacy : 50 - 93%
Treatment

38. • Botulinum Toxin
– 50% Relapse in 6 months
– 100 % Relapse in 2 years
• Laproscopic Myotomy
– Modified Heller's Operation
– Myotomy across the LES
– Complication - GERD in 10% to 20%

39. Barret’s esophagus
• A complication of long-standing GERD
• Stratified squamous epithelium of the distal
esophagus is replaced by gastric columnar epithelium
(Metaplasia )
• Pre - malignant condition : risk of esophageal
adenocarcinoma

41. Benign tumors
•Rare condition
•Leiomyoma most common
–Single, midesophageal
– Asymptomatic
– Thoracotomy and excision if symptomatic

42. Carcinoma esophagus
• Epidemiology
– Age > 45 years
– No sex and racial Predisposition
– Most Common: Squamous cell ca : upper 2/3
– Adenocarcinoma : lower 1/3
• Risk Factors
– Alcohol, Smoking (SCC)
– GERD, Barrett’s Disease (Adenocarcinoma)

43. • C/F
– Progressive dysphagia , solids >> liquids
– Weight loss
– Hematemesis, hoarseness, pain
• Investigations
– Esophagography
– Endoscopy + Biopsy
– CT: Staging
• Treatment
– Surgery, Chemotherapy + RT

44. Hiatus Hernia
• Stomach herniates in chest
through the esophageal
opening
• Types
– Sliding
– Paraesophageal
• Esophagogram is diagnostic
• Treatment
– Nissen Fundoplication