The document outlines various esophageal disorders, including their causes, symptoms, diagnosis, and management. Key conditions discussed include esophageal perforation, achalasia, Barrett's esophagus, and Mallory-Weiss syndrome, detailing specific complications and treatment strategies such as surgical interventions, endoscopy, and medical management. It highlights the importance of diagnosis through endoscopic examination and contrast studies to guide appropriate therapeutic approaches.

1. ESOPHAGEAL
DISORDER
DR JABBAR JASIM
2023

2. A. Esophageal perforation
B. Boerhaave & mallory weiss
syndrome
C. Diffuse esophageal spasm
D. Barett esophagus
E. Achalasia
F. Zenker diverticulum
G. Plummer vinson syndrome
H. Hiatal hernia
I. Esophagitis
J. Esophageal cancer
K. Scleroderma

3.  is due to the rapid increase in
intraesophageal pressure combined
with negative intrathoracic pressure
caused by vomiting.
 Perforation of the esophagus can
present with:
1. Severe and acute onset of
excruciating retrosternal chest pain
2. Odynophagia
3. Positive Hamman sign, a
crunching heard upon palpation
of the thorax due to

4. ◾ Boerhaave syndrome
◾ is a full thickness tear secondary to
extreme retching and vomiting.
◾ It is most commonly tested in the
setting of
an alcoholic. The most common
location is at the left posterolateral
aspect of the distal esophagus.
◾ Mallory-Weiss syndrome
◾ is a mucosal tear and is also due to
vomiting.
◾ It is not a perforation. The most

5. ◾ Surgical exploration with debridement of
the mediastinum and closure of the
perforation is an absolute emergency.
◾ Mediastinitis is a complication that
carries a very high mortality rate

8. Submucosal dissection of the esophagus
in patient with endoscopy for ERCP
and "difficulty passing scope."
Gastrografin swallow demonstrates
intramural dissection of the esophagus
from submucosal passage of endoscope
with appearance similar to aortic
dissection and "true and false lumen."
Arrows point to "false lumen" created
by passage of endoscope.

9. esophagram depict contrast extravasation from
the distal esophagus in a patient with
spontaneous perforation of the esophagus

10. Spontaneous, full-thickness rupture of
the distal thoracic esophagus
 Associated with vomiting often
following consumption of large
quantities of alcohol in young people
Can occur during endoscopic
examinations (75% of adult cases)
 Serious complication of bulimia

11. Symptoms
◾ sudden-onset, severe, retrosternal chest
pain
◾ difficulty or painful swallowing
◾ hematemesis
though more common in Mallory-
Weiss tears
Physical exam
◾ pleuritic chest pain
◾ hyperventilation
◾ tachycardia

12. Chest CT
◾ left-sided hydropneumothorax
◾ pneumomediastinum
◾ esophageal thickening
Contrast studies
◾ may show leakage from esophageal tea
use water-soluble contrast agent
(Gastrografin)

13. Medical management
conservative therapy
indicated in mild cases with stable patient and
includes
 intravenous resuscitation
 nasogastric suction
 NPO
 prophylactic antibiotics- usually broad-
coverage to prevent mediastinal infection-
imipenim or cilastin
Surgical intervention
surgical repair of perforation considered
standard of care
 indicated depending on severity of tear and
timing of diagnosis

18. ◾ The most accurate test is an esophogram
(Gastrografin;); it will show leakage of
contrast outside of the esophagus.
◾
Barium cannot be used because it is
caustic to the tissues.

19. ◾ Mallory-Weiss tear presents with upper
gastrointestinal bleeding after prolonged or
severe vomiting or retching.
◾ Repeated retching is followed by hematemesis
of
bright red blood, or by black stool.
◾ Mallory Weiss does not present with dysphagia.
There is no specific therapy, and it will resolve
spontaneously.
◾ Severe cases with persistent bleeding are
managed
with an injection of epinephrine to stop bleeding
or the use of electrocautery.
Boerhaave syndrome is full penetration of the

20. Strong, non-peristaltic contractions of the
esophageal body
Often precipitated by by ingestion of hot
and cold liquids
 Patients have normal sphincter function
 Associated with GERD

22. • Symptoms
• symptoms may occur following ingestion of
cold liquids and include
• difficulty swallowing
• painful swallowing
• sudden onset chest pain not related to exertion
• spontaneous and radiated to back, ears, and neck
• Physical exam
• symptomatic relief with nitroglycerin

23. Evaluation
•Upper GI/esophageal contrast study
• shows "corkscrew esophagus"
•Manometry
• may show high-amplitude,
simultaneous contractions (non-
peristaltic)
•Endoscopy - normal
•ECG - normal
•Stress test - normal

24. Medical management
 symptomatic relief
 antacids for GERD
 nitrates for chest pain/spasms
 calcium channel blockers
Surgical intervention
 long esophagomyotomy
indicated for severe, incapacitating
symptoms

25. ◾ Metaplasia of the squamous cell
architecture of the esophagus to
glandular architecture
◾ A complication of chronic GERD

26. Biopsy
 glandular metaplasia of distal esophagus
presence of stomach acid resutls in
conversion of normal squamous cells into
columnar and goblet cells (normally found
in stomach and small intestine)

28. ◾ Ulceration leading to formation of
stricture
◾ Increased risk of esophageal
adenocarcinoma

29. ◾ Motor disorder of the distal esophagus
caused by degeneration of Aurbach's
plexus
 the most common motility disorder
◾ Pathophysiology
 autoimmune process causes loss of NO-
producing neurons which normally relax the
sphincter muscles
▪association with HLA-DQw1
 leads to failure of the LES to relax during
ACHALASIA

30.  Associated with
 Chagas' disease
amastigotes destroy
ganglion cells
 Scleroderma
presents in 70% of these
patients
◾ Epidemiology
 more common in
people under 50 years
of age
ACHALASIA

31. ◾ Symptoms
 dysphagia for solids and liquids
▪usually worse for liquids
 weight loss

32. ◾ Barium swallow may
show
 narrowing of the
distal esophagus
 loss of peristalsis in the
distal two thirds
 dilated proximal
esophagus
 classic "bird's beak"
tapering at the
esophageal sphincter

33. most accurate test that may show
◾ increased LES pressure
◾ inability of LES to relax
◾ decreased peristalsis in the
esophageal body
◾ diffuse esophageal spasm

35. ◾
useful in excluding secondary causes of
achalasia (i.e. malignancy)
◾ use to rule out malignancy
◾ shows normal mucosa

36.  medications to reduce LES tone
1. nifedipine
2. nitrates
3. CCBs
4. botulinum toxin injections
▪wears off in approximately 3-6 months
▪requires reinjection

37.  endoscopic balloon dilation of LES
▪cures 80%
▪leads to perforation in < 3% of patients
 myotomy with fundoplication
▪more effective and dangerous than
pneumatic dilation

38. ◾ Prognosis
 medical and surgical outcomes are similar
 often require multiple treatments
◾ Prevention
 no preventive measures are available at this
time
◾ Complications
 esophageal malignancy secondary to
Barrett's esophagus secondary to chronic
GERD

39. ◾ Pharyngeal pouch that develops in the
proximal esophageal wall
◾ Pulsion diverticula involving only the
mucosa
 located between thyropharyngeal and
cricopharyngeus muscle
◾ Etiology remains unknown, however, some
have
suggested the causes to be related to
structural or physiological abnormalities of
the cricopharyngeus
◾ Epidemiology

41. ◾ Symptoms
◾ dysphagia
◾ regurgitation
◾ choking
◾ chronic cough
◾ bad breath (halitosis)
◾ Physical exam
◾
palpable, fluctuant neck mass may be
appreciable

42. Diagnosis is based highly on clinical
observations and patient history
Avoid upper endoscopy if known or
highly suspicious due to risk of
rupture
Barium swallow
 confirms diagnosis by visualizing
pharyngeal outpouch

43.  myotomy of cricopharyngeus
muscle
 -with diverticula resection
 - endoscopic has better success
rates compared to external
approach

44. ◾ Complications surgery can lead to
significant complications including
death given location of lesion and
age/health of average patient
population with this pathology
-may develop carcinoma within the pouch
if not resected

45. ◾ Small, thin web-like tissue growth
partially obstruct the upper esophagus
◾ Characterized by atrophic glossitis,
esophageal webs, and anemia
◾ Etiology unknown
◾ Epidemiology
 most commonly observed in elderly woman
 associated with chronic iron-deficiency anemia
◾ Patients at increased risk of developing
squamous cell carcinoma of the
esophagus

46. Symptoms
◾ difficulty
swallowing
◾ chronic cough
◾ weakness/malaise
◾ nail changes
Physical exam
◾ atrophic glossitis
◾ esophageal webs
◾ anemia
◾ spoon nail

47.  Diagnosis can be aided by clinical
observations, including skin and nail
changes
 Upper endoscopy
 may identify esophageal webs
 CBC
 may indicated chronic anemia
 Fe studies
 show Fe deficiency

48. ◾ Fe supplementation
 indicated to treat chronic anemia state
◾ esophageal dilation

can be performed concurrently
with upper GI endoscopy or
manometry

most commonly done with radial
expansion balloon method

49. ◾ Prognosis
 most patients respond to treatment
◾ Prevention
 Fe supplementation in patients with known
anemia may prevent web development
◾ Complications
 bleeding may occur secondary to esophageal
tear during dilation
 esophageal carcinoma

50. ◾Herniation of the stomach through the
diaphragm into the chest cavity
Type I
 sliding hiatal hernia
◾ most common type (>95%)
◾ occurs at the GE junction
◾ stomach slides into the mediastinum
Type II
 paraesophageal hiatal hernia (<5%)
◾ herniation of stomach fundus through
diaphragm
◾ GE junction remains below diaphragm
◾ parallel to the esophagus
◾ Associated with GERD in 80% of sliding hiatal

52. ◾ Symptoms

may be asymptomatic,
usually identified incidentally
on radiography
 chest pain
 heart burn
 GERD
◾ Physical exam
◾ usually no significant findings

53. ◾ Barium swallow
- may observe stomach in chest
cavity
◾ Usually an incidental finding

55. Medical
management
◾
◾ symptom management and
lifestyle modifications
indicated in type I (sliding hiatal
hernias) to relieve GERD symptoms
anta
cids
weight
loss


 dietin
g
Surgical intervention -surgical
repair
 indicated in type II (paraesophageal
cases) due
to risk of
strangulation

56. Prognosis
◾ treatment relieves most symptoms
Prevention
◾ lifestyle modifications can prevent
symptoms
Complications
◾ aspirate pneumonia
◾ gastric strangulation
◾ iron-deficiency/malnutrition

57. Schatzki ring
 "Steakhouse syndrome" = dysphagia from
solid food associated with Schatzki ring
 Schatzki ring is often from acid reflux and is
associated with hiatal hernia. This is a type of
scarring or tightening (also called peptic stricture)
of the distal esophagus.
 Schatzki ring is associated with
intermittent dysphagia and is treated
with pneumatic dilation in an endoscopic
procedure

59. Corrosive Esophagitis
Caused by ingestion of strongly acidic or
basic chemical
◾ Lye, HCl
Results in
◾ esophageal perforation
◾
esophageal stricture formation
Often seen in suicide attempts or in
the
pediatric population

60. Infectious Esophagitis
•Commonly seen in AIDS patients
and the Immunocompromised
•May be viral or fungal
• HSV (punched out lesions on
EGD)
• CMV (large solitary ulcers
or erosions on EGD)
• Candida (white mucosal
plaque- like lesions on EGD)

61. These pills cause esophagitis if in prolonged
contact:
• Doxycycline
• Alendronate
• KCI
Pills esophagitis

62. "What Is the Most Likely Diagnosis?"
Look for:
 Age 50 or older
 Dysphagia first for solids, followed
later (progressing) to dysphagia for
liquids
 Association with prolonged alcohol
and tobacco use
 More than 5-10 years of GERD
symptoms

64. 1.Endoscopy is indispensible, since only a
biopsy can diagnose cancer.
2.Barium might be the "best initial test," but no
radiologic test can diagnose cancer.
3.CT and MRI scans are not enough to diagnose
esophageal cancer; they are used to determine the
extent of spread into the surrounding tissues.
4.PET scan is used to determine the contents of
anatomic lesions if you are not certain whether
they contain cancer. PET scan is often used to
determine whether a cancer is resectable. Local
disease is resectable, and widely metastatic
disease is not.

65. 1.No resection (removal) = no cure.
Surgical resection is always the thing to
try.
2.Chemotherapy and radiation are used
in addition to surgical removal.
3.Stent placement is used for lesions
that cannot be resected surgically just
to
keep the esophagus open for palliation

66. ◾ These patients present with symptoms of
reflux and have a clear history of
scleroderma, or progressive systemic
sclerosis.
◾ Manometry shows decreased lower
esophageal sphincter pressure from an
inability to close the LES.
◾ The management is with PPis as it would
be for any person with reflux symptoms.
◾ The disorder is simply one of

67. ◾ Esophageal smooth muscle
atrophydecrease LES pressure and
dysmotilityacid reflux and dysphagia
stricture,Barrett esophagus, and
aspiration.
◾ Part of CREST syndrome.

68. Manometry is the answer for:
1. Achalasia
2. Spasm
3. Scleroderma