ppt about esophagel disorders

1. PRESENTER – DR.ASWIN MUKESH.R
MODERATOR – DR.PRABHU

2.  Muscular tube ; Approximately
25cms long
 Occupies posterior mediastinum
 Extends :
From Lower border of C6
(Cricopharyngeus)
TO
Junction with Cardia of stomach
 NO SEROSA

3.  Upper Esophagus - Striated muscles
Transitional Zone ( Both striated and Smooth)
 Lower half – Only smooth muscle
 Squamous epithelium (Throughout)
 Nerve supply – Parasympathetic (Vagus)
MYENTRIC PLEXUS
 MEISSNER’S PLEXUS (Sparse)

4.  NARROWINGS / CONSTRICTIONS :

5.  Main function : Swallowing
 3 stages of swallowing :
I. STAGE – 1 : Oral
II. STAGE – 2 : Pharyngeal
III. STAGE – 3 : Esophageal
 Mediated by : Vagus nerve
 Food – Broken down into small particles and lubricated with
saliva

6. OROPHARYNGEAL PHASE :
 Food, broken down and lubricated by mastication
Rolled into a bolus
Pushed into the posterior oropharynx
 Sequential contraction of oropharyngeal musculature ; Closure of nasal and
respiratory passages ; Cessation of breathing ; Opening of Upper esophageal
sphincter
 Soft palate elevation ; Elevation of hyoid bone
 Adduction of vocal cords (Most effective barrier to aspiration)

7. oBackward movement of tongue and contraction of Posterior
pharyngeal constrictors
oIncrease in the pressure of Hypopharynx
oHigh closing pressure of Upper esophageal sphincter
oInitiation of peristaltic wave
oFood Body of esophagus
 PHARYNGEAL PHASE – 1.5 seconds

8. Upper Esophageal Sphincter
 Formed by Cricopharyngeus
 Has Powerful striated muscle
 Vagally mediated
 High resting tone
 Normally, shut off from the pharynx / closed at rest
 On swallowing – opens for 0.2 to 0.3 secs and closes within
0.5 secs of initiation of swallow
HIGH RESTING TONE – Prevents aerophagia and reflux
into pharynx

9. ESOPHAGEAL PHASE :
 Lasts for 8 – 10 seconds (solids) ; 2-3 seconds (liquids)
Co-ordinated muscular contractions
Propel the bolus along with some air
Relaxation of the Lower esophageal sphincter
Stomach
 In Standing position and in case of Liquids GRAVITY – Propulsion
of food

10.  Intrinsic and extrinsic neural factors + Myogenic properties
Organized waves of contraction
 Glossopharyngeal nerve and Superior laryngeal branch of Vagus
nerve (Afferent sensory nerves of pharynx)
 Vagal function : Co-ordinating relaxation of Lower esophageal
sphincter along with Esophageal contraction
 Progress of peristaltic wave in Esophagus – Sequential
activation of Muscles – Initiated by efferent vagal nerve fibres
from swallowing centres

11. Peristalsis
Primary peristalsis Secondary peristalsis
• Esophageal Peristaltic wave,
triggered by swallowing
• Normally, each swallow – 1
peristaltic wave
• If rapid swallow, only the final
swallow  Peristaltic wave
• Movement : 2-4 cm/s
• Without any movement of
Mouth/ Pharynx
• Independent local reflex
Clear the esophagus of
ingested material left behind,
after the passage of 1st wave
• Triggered by Esophageal
distension of residual
bolus

12. Lower Esophageal sphincter
 Zone of relatively high pressure , Normal LES Pressure – 10 to 25mmHg
(manometry)
 Vagus Nerve mediated
Swallowing / Distension of esophagus with food
Reflex relaxation of the LE sphincter within 1.5-2.5secs
Mediated via Myentric plexus and co-ordinated muscular contractions
 After contractions/Passing of peristaltic wave – Reflux of gastric juice back
into Esophagus, from the stomach

13. Lower Esophageal sphincter (cont..)
If pharyngeal swallow does not initiate peristaltic contraction
Co-incident relaxation of LES can occur
Reflex of gastric juice
 ANTIREFLUX MECHANISM :
I. Mechanically effective LES
II. Effective esophageal clearance
III. Adequately functioning Gastric reservoir
(If any defect  Increased esophageal exposure)

14. Lower Esophageal sphincter (cont..)
INCREASE LES PRESSURE DECREASE LES PRESSURE
α Adrenergic receptors ; β
blockers
α Blockers ; β Stimulants
Gastrin , Motilin CCK, Secretin, Estrogen,
Glucagon, Progesterone,
Somatostatin
Substance – P, I – Enkephalin,
Bombesin
C-GRP, GIP, Neuropeptide- Y,
VIP
Antacids, Cholinergics,
Domperidone, Metoclopramide,
PGF2
Anticholinergics, Barbiturates,
Calcium channel blockers,
Caffeine, Diazepam, Dopamine,
Meperidine, PGE1, PGE2

16. PHYSIOLOGICAL REFLUX
 Healthy individuals  Occasional episodes of GE reflux
 M/c when awake and upright position > Sleep and in supine position
 Upright position : 12mmHg pressure gradient (+) between resting +ve
intra abdominal pressure measured in stomach and –ve Intrathoracic
pressure in esophagus @ midthoracic level
 LES Pressure increases in Supine > Upright position
 Apposition of Hydrostatic pressure of abdomen to abdomen portion
of sphincter when supine

17. SYMPTOMS – ESOPHAGEAL DISORDERS
 Dysphagia :
If in voluntary phase  A person initiates swallow  Food fails to
enter esophagus  but no features of food sticking
Chronic neurological / Muscular disorders
In Involuntary phase  Esophageal dysphagia  Sensation of food
sticking
 Odynophagia :
Infective/Reflux esophagitis
Chemical injury

18. SYMPTOMS – ESOPHAGEAL DISORDERS
 Regurgitation and Reflex :
- Mechanical / Functional obstruction
- Gastroesophageal reflex disease
- Weight loss, Anemia, Cachexia, Voice change, Cough, Dyspnoea
 Chest Pain :
- GERD and motility disorders
- Afferent visceral sensory fibres from Esophagus and heart 
Thoracic segments
BOTH HAVE SAME SYMPTOMATOLOGY

20.  Radiography
Plain Xrays
Barium swallow
CT Scan
 Endoscopy
 Manometry
 24-hour pH monitoring
 Impedance pH monitoring
 Esophageal transit scintigraphy

21.  Contrast radiography  Overshadowed by ENDOSCOPY
 Changes in Esophageal diameter ; Anatomical distortion /
Abnormal motility
 BARIUM RADIOLOGY – Not accurate in GERD diagnosis
 Plain radiographs  Foreign bodies
 CT  Neoplasms ; Confirmation of the diagnosis

22.  Large hiatal hernias – Contrast radiography > Endoscopy
Presence of Co-ordinated esophageal peristalsis, (Several
individual swallows of Barium)
 HIATAL HERNIAS – Best demonstrated in prone

24. BARIUM SWALLOW
 To study the Upper GI tract including the Esophagus and the stomach
 Contrast used – Barium sulphate
 2 studies
Single contrast study
Double contrast study

25. BARIUM SWALLOW
INDICATIONS :
Dysphagia ; Regurgitation ; Odynophagia
Heartburn/ Retrosternal pain
Hiatus hernia
Reflux esophagitis
Stricture Esophagus
Esophageal carcinoma / Mass – Upper GI
Motility disorders – Achalasia cardia ; DES
Pressure from extrinsic lesions
Abnormalities – Zenker’s, Webs , Cricopharyngeal
achalasia

26. BARIUM SWALLOW
 CONTRA-INDICATIONS :
 Suspected mediastinal / Pleural / Peritoneal leak
 Suspected perforation
 Tracheo esophageal fistula
 Complete large bowel obstruction

27. BARIUM SWALLOW
 TYPES OF STUDY :
 Air esophagogram
 Full column
 Mucosal relief
 VIEWS :
 Soft tissue neck – AP/LATERAL (SCOUT)
Neck –AP/LATERAL
Thorax (RAO VIEW)

28. Full Column
Air Esophagogram Mucosal relief

30. BARIUM SWALLOW
 PREPARATION :
 NPO after midnight
 Antacids, Smoking, Gums to be avoided
 Check for contrast related allergy
 Pregnancy
 Pre-procedure counselling

31. BARIUM SWALLOW -
TECHNIQUE
 Buscopan (20mg) or Glucagon (0.1-0.2mg) --> I/V
RELAX the stomach and suspend peristalsis
 Packet of effervescent Granules swallowed – Water
Releases Co2  GASTRIC DISTENSION
 High contrast Barium is swallowed – Double contrast views -Standing
RAO

32. BARIUM SWALLOW -
TECHNIQUE
 Patient faces Xray table , lowered to horizontal
Turned to the Left side --> Supine ( Rolled over)
 To see Esophagus : Single contrast – Multiple mouthfuls (80% barium
suspension
Prone Swallow – Assess esophageal Contraction
(Useful in Esophageal compression / Disordered motility)

33. BARIUM SWALLOW
 Density of Barium meal used – Affects the accuracy of examination
 Full column technique : Circumferential Carcinoma, Peptic strictures,
Large esophageal ulcers, Hiatal hernias, Extrinsic lesions
 Small neoplasms, Hiatal hernias, Mild esophagitis, Varices
Full column technique + Double contrast/ Mucosal relief films
 If dysphagia (+) , Obstructive lesions (-) --> Barium impregnanted
marshmallow / Piece of bread / Hamburger

36. ENDOSCOPY
 For most Esophageal conditions
 View – inside of esophagus and Esophagogastric junction
 Two types :
i. Rigid
ii. Flexible

38. ENDOSCOPY
 INDICATIONS :
Gastroesophageal reflux disease
Barret’s esophagus
Evaluation of Dysphagia and odynophagia
Esophageal carcinoma
Foreign body / Food bolus
Varices – Rx and evaluation
Esophageal stenting ; Stricture dilatation
Feeding - PEG
D
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THERAPEUTIC

40. ENDOSCOPY
 CONTRA-INDICATIONS :
Haemodynamic instability
Possibility of a perforation
 Anticoagilation ( Stricture dilatation)
 Head and neck surgeries
 Pharyngeal diverticulum
ABSOLUTE
RELATIVE

41. ENDOSCOPY
 PREPARATION :
Nil per Oral
Oral cavity examination
Pre procedure counselling
Anaesthetic spray – Mouth
Position : Left lateral decubitus
Moderate sedation – Narcotic +
Benzodiazepine

42. ENDOSCOPY
 COMPLICATIONS :
Bleeding
Infection
Perforation
Aspiration
Over sedation
Hypoventilation
Cervical sepsis
Dental injury

43. ENDOSCOPY
 TYPES :
I. Chromoendoscopy
II. Magnification endoscopy
III. Narrow band imaging
IV. Optical coherence tomograph
spectroscopy
ROUTES – Transoral / Transnasal

44. CHROMOENDOSCOPY
OPTICAL COHERENCE
TOMOGRAPH
SPECTROSCOPY

45. ENDOSCOPY
 GERD  Detect if esophagitis / Barret’s esophagus is (+)
LOS ANGELES GRADING SYSTEM (COMMONEST)
Grade- A
Grade- B
Grade- C
Grade- D
One or more erosions–
Mucosal fold
: Erosions – Mucosal folds ;
¾ of circumference
: Confluent Erosions < ¾
of circumference
MORE SEVERE ESOPHAGITIS
STRICTURE FORMATION

46. ENDOSCOPY
(

47. ENDOSCOPY
 BARRET’S ESOPHAGUS – Difficulty visualising Squamocolumnar
junction at its normal location
 Ulceration , Bleeding, Stricture, Malignant degeneration
 Patchy distribution is seen
Multiple biopsies ( atleast 4), spaced 2cm apart
 Most – within 2cm of Squamo columnar junction
 Confirmation --> BIOPSY

48. REDDENED, SALMON
COLOURED MUCOSA IN
LOWER ESOPHAGUS
WITH CLEAR LINE OF
DEMARCATION AT THE
TOP OF THE SEGMENT

49. ENDOSCOPY
 GE FLAP VALVE --> Retroflexion of Endoscope
DUE TO INCREASED ACID EXPOSURE

50. ENDOSCOPY
 Hiatal hernia --> Pouch lined with Gastric rugal folds – 2cm or more
above the margins of Diaphragmatic crura
 Best Demonstrated – Fully inflated stomach
 GE Junction – Retroflexed endoscope
‘ INTRAGASTRIC RETROFLEX / J MANUEUVER ’
 Paraesophageal hernia – Exclude Cameron’s ulcer / Gastritis in the
pouch

52. ENDOSCOPY
 LATEST TECHNIQUES :
1) Capsule endoscopy
2) ERCP
3) Endoscopic Ultrasound
4) Endoscopic mucosal resection
5) Narrow band imaging

53. ENDOSCOPIC ULTRASOUND
 Ultrasound + Endoscopy
 Relies on high frequency transducer (5-30MHz) - @ Tip of scope
 Layers of esophageal wall and mediastinal structures closer
 RADIAL ECHOENDOSCOPES : Rotating transducer – Circular image
with endoscope at the centre.
 LINEAR ECHOENDOSCOPES : Sectoral image in the line of
endoscope (Biopsy submucosa esophageal lesions/ Mediastinal
masses like Lymph nodes, Suspicious lesions outside the field)
 Radial scanners without optical components - Available

55. RADIAL ECHOENDOSCOPE LINEAR ECHOENDOSCOPE

56. MANOMETRY
 Widely used for : Esophageal motility disorders
 To detect : LES Pressures , Esophageal peristalsis
 Flexible catheter with pressure sensors placed @5cm intervals
 There are two forms of catheter used :
Electronic, Pressure sensitive transducers within
the catheter
Water perfused with lateral side holes attached
to transducers outside the body

58. MANOMETRY
 INDICATIONS :
Primary motility disorders/Motor abnormalities
GERD, for planning the surgery
Non cardiac chest pain/Esophageal symptoms
(ENDOSCOPY)
Non specific esophageal motility disorders and
abnormalities secondary to Systemic diseases
(Scleroderma,Dermatomyositis)
 CONTRAINDICATIONS :
Altered mental status
Pharyngeal/ Upper esophageal obstruction
(Tumour)
Severe clotting disorders
Other esophageal disorders(Deep
ulcers,Varices,Strictures,Zenker’s)

59. MANOMETRY - TECHNIQUE
 When brought across GEJ -- Pressure above gastric baseline
Beginning of Lower esophageal sphincter
 Upper border of LES – Drop in pressure to esophageal baseline

60. MANOMETRY - TECHNIQUE
 Respiratory inversion point --> Change in Positive excursions in the
abdomen w.r.t. Negative deflections in the thorax (With breathing)
 RIP @ which amplitude of LES Pressure and length of sphincter
exposed to abdominal pressure are measured
 Abdominal length can also be measured

61. MANOMETRY
MECHANICALLY DEFECTIVE SPHINCTER :
Average LES Pressure < 6mmHg
Average length exposed to +ve
pressure in abdomen – 1cm or less
Average overall sphincter length : 2cm
or less

62. MANOMETRY - ASSESSMENT
 LES ASSESSMENT :
 STATION PULL THROUGH – Mean resting pressure :
12-30 mmHg
 RAPID PULL THROUGH – Higher pressures due to
artefact
 ESOPHAGEAL BODY ASSESSMENT :
 Assess effectivity of Peristaltic activity
Percentage of initiated swallows transmitted
successfully
 Measures amplitude – Avg. of pressures @ distal
end of esophagus, while transmitting peristaltic
waves ( Normal - >30mmHg)

63. HIGH RESOLUTION MANOMETRY
 Increased number of recording sites + 3 dimensional assessment
 36 miniatured pressure sensors (Every centimeter along length of
catheter)
 Visual display – Amplitude, duration, Morphology of each contractions
 ADVANTAGES :
 Effective continuous recording of motor
activity
 No pseudo relaxation
 Focal motor abnormalities can be
assesed too

64. HIGH RESOLUTION MANOMETRY

65. 24-HOUR PH MONITORING
 Gold standard – Diagnosing and quantifying Gastroesophageal reflux
 Small probe – Distal esophagus – 5cm above upper margin of LES
 Miniature digital recorder which is belt worn
 Patient marks symptomatic events – Such as Heartburn
 Radiotelemetry pH probes : Placed endoscopically to esophageal wall
 Limitations : Detects reflux – pH < 4

66. 24-HOUR PH MONITORING
 INDICATIONS :
Regurgitation
Chest pain
Cough
Heart burn / GERD
 Can find out - Total number of episodes of Reflux ; Longest
episodes ; Extent of reflex in upright and supine

67. IMPEDENCE PH MONITORING
 Newer technique – Esophageal function and reflux
 Intraluminal electrical impedence catheter
 Probe measures impedence distance between Adjacent electrodes
 AIR – High impedence
 Saliva & Food – Low impedence
 Luminal dilatation – Decrease impendece

68. IMPEDENCE PH MONITORING
 ADVANTAGES :
Differentiate Alkaline and acidic reflux
Estimation of Proximal extent of reflux
Distinction between True reflex and ingestion
of an Acidic liquid
 DISADVANTAGES :
Availability
Over estimate the number of episodes

69. ESOPHAGEAL TRANSIT
SCINTIGRAPHY
 Esophageal motor disorders (Achalasia, Scleroderma, DES, Nutcracker
esophagus)
 Delayed bolus transit
 10ml water bolus – Technitium 99m sulfur colloid  Gamma camera

70. THANK YOU