Esophageal Disorders and GERD Overview

Esophageal Disorders

• Gastroesophageal Reflux Disease (GERD)

  • Gastric juice moves from stomach to esophagus
  • "Reflux" back into esophagus
  • Lower esophageal sphincter (LES) dysfunction
  • Decrease in LES tone
  • Precise mechanism not fully understood

• Reflux Esophagitis

  • Inflammation of the epithelial layer
  • Mucosa: erythema and edema
  • Erosions (damage/loss of epithelial layer)
  • Histology:
    • Basal zone (epithelium) hyperplasia
    • Lamina propria papillae elongate
    • Eosinophils and neutrophils

Pediatric GERD

• Immature lower esophageal sphincter (LES)
• Vomiting
• Crying

GERD Risk Factors

• Alcohol
• Smoking
• Obesity
• Fatty foods
• Caffeine
• Hiatal hernia

GERD Symptoms

• Heartburn (retrosternal burning sensation)
• After meals or lying flat
• Dysphagia (difficulty swallowing)
• Painful esophagitis
• Respiratory symptoms (reflux into respiratory tract)
• Asthma (adult-onset)
• Cough
• Dyspnea
• Damage to tooth enamel

GERD Treatment

• Weight loss
• Dietary modification (avoid triggers)
  • Fatty foods
  • Caffeine
  • Chocolate
  • Spicy foods
  • Carbonated beverages
  • Peppermint
• Refractory GERD: Nissen fundoplication
• Histamine (H2) blockers
  • Famotidine, Ranitidine, Nizatidine, Cimetidine
  • Block histamine receptors in parietal cells
• Proton Pump Inhibitors (PPIs)
  • Omeprazole, Pantoprazole, Lansoprazole, Esomeprazole
  • Inhibit H+/K+ pump in parietal cells

Potential GERD Complications

• Ulcers, Fibrosis, Strictures

  • Acid destroys mucosa (causes ulcers)
  • Mucosa replaced with fibrous tissue
  • Strictures can lead to dysphagia

• Lye Ingestion

  • Alkali substances (sodium or potassium hydroxide)
  • Accidentally ingested by children
  • Found in household cleaners, drain openers
  • Causes liquefactive necrosis
  • Rapid damage through mucosa into esophagus wall
  • Neutralized in stomach by acid
  • Child usually recovers
  • Can result in strictures

Barrett's Esophagus

• Result of long-standing GERD
• Metaplasia of esophagus
• Squamous epithelium changes to intestinal epithelium

Barrett's Esophagus - Diagnostics

• Endoscopy often performed in GERD patients
• If Barrett's seen → regular surveillance endoscopy
• Biopsies to look for carcinoma

Esophageal Cancer

• Squamous cell or adenocarcinoma

• Both types: increased risk in smokers

• Often presents late with advanced disease/mets

• Presents with "progressive" dysphagia

  • Starts with solids
  • Progresses to liquids

• Other symptoms:

  • Weight loss
  • Hematemesis

• Adenocarcinoma - most common in the US

  • Normally no glandular tissue lining the esophageal lumen
  • Need GERD → Barrett's → Glandular epithelium
  • Develops in lower 1/3 of esophagus (near stomach acid)
  • Obesity is a risk factor (also GERD)

• Squamous cell – most common worldwide

  • Usually in middle or upper esophagus
  • Results from processes that damage upper esophagus – Food (alcohol, hot tea) – Achalasia (backup of food) – Esophageal webs (backup of food) – Zenker's – Lye ingestion – Can cause special symptoms due to upper location – Hoarse voice (recurrent laryngeal nerve) – Cough (tracheal involvement)

Lymph Nodes (Esophageal Cancer)

• Upper esophagus (neck): cervical nodes
• Middle (chest): mediastinal, tracheobronchial nodes
• Lower (abdomen): celiac, gastric nodes

Infectious Esophagitis

• Candida (white membranes, pseudohyphae on biopsy)
• HSV-1 (oral herpes, can involve esophagus, "punched out" ulcers)
• CMV ("punched out" ulcers)
• AIDS (CD4 < 50), linear ulcers

Eosinophilic Esophagitis

• Allergic reaction (unknown antigen)
• Immune-mediated
• Esophageal dysfunction (dysphagia)
• Biopsy: eosinophil-predominant inflammation
• Diagnosis of exclusion: rule out other causes of esophagitis (i.e., GERD)
• Classic scenario:
  • Dysphagia
  • Poor response to GERD treatment
  • Eosinophils on biopsy

Achalasia

• Inability to relax lower esophageal sphincter (LES)
• Due to loss of ganglion cells in Auerbach's plexus
• Found in muscular layer (below submucosa)
• Causes:
  • Often idiopathic
  • Chronic Chagas Disease (Protozoa: Trypanosoma cruzi)
• Symptoms:
  • Dysphagia to solids and liquids
  • Closed LES
  • Contrast with obstruction (solids only)
  • Bad breath
  • Accumulation of food in esophagus
• Diagnostic Testing:
  • Dilation of esophagus
  • "Bird's beak" on barium swallow
  • Esophageal manometry
    • Helpful in dysphagia
    • Measures pressure change with contraction
    • Shows ↑ LES tone in achalasia
    • Contrast with scleroderma (LES tone)

Esophageal Varices

• Dilated submucosal veins (usually in lower 1/3 of esophagus)
• Usually due to portal hypertension (cirrhosis)
• Can lead to upper GI bleeding (variceal rupture)
• Painless bleeding
• Common cause of death in liver disease
• Cirrhotic patients often screened with endoscopy
• Treatment for variceal bleed:
  • Emergent endoscopy for banding/ligation

Mallory-Weiss Syndrome

• Damage to esophageal mucosa at GE junction
• Causes painful hematemesis
• Epigastric pain or pain in the back
• Caused by severe, chronic vomiting
  • Alcoholism
  • Bulimia

Boerhaave Syndrome

• Transmural rupture of esophagus
• Result of severe, chronic vomiting or retching
• Air exits esophagus
• Air in mediastinum on chest X-ray (pneumomediastinum)
• Air under skin in neck ("subcutaneous emphysema")

Esophageal Webs and Rings

• Extension/protrusion of mucosa into lumen of esophagus
• Obstructs food movement → dysphagia
• Webs: Common in upper esophagus
• Rings: Common in lower esophagus
• Risk of squamous cell carcinoma

Schatzki Ring

• Ring at squamocolumnar junction
• Common cause of dysphagia to solids
• Squamous mucosa proximally, columnar distally

Plummer-Vinson Syndrome

• Rare condition; poorly understood cause
• Triad:
  • Iron deficiency anemia
  • Beefy red tongue
• Damage to tongue mucosal layer (bright red from blood vessel exposure)
• Esophageal web
• Common in middle-age, white women

Zenker's Diverticulum

• Occurs at junction of esophagus and pharynx
• Mucosa/submucosa through muscular wall
• Usually the result of a chronic swallowing problem
• Cricopharyngeal muscle must relax for food to pass
• Failure to relax = difficulty swallowing
• Chronic high pressure in pharynx to force food down = diverticulum
• Classic location: Killian's Triangle
  • In the hypopharynx
  • Just proximal to upper esophageal sphincter
  • Cleavage plane between thyropharyngeus and cricopharyngeus muscles
• Symptoms:
  • Dysphagia
  • Halitosis (bad breath due to food trapped in diverticulum)

Video Swallowing Study

• Used to diagnose swallowing issues
• Usually part of an upper endoscopy