Problems in Ingestion EASY

• The esophagus is a mucus-lined, muscular tube that transports food from the mouth to the stomach.
• It begins at the base of the pharynx and ends about 4 cm below the diaphragm.
• The upper esophageal sphincter (hypopharyngeal sphincter) is at the junction of the pharynx and esophagus.
• The lower esophageal sphincter (gastroesophageal or cardiac sphincter) is at the junction of the esophagus and stomach.
• An incompetent lower esophageal sphincter leads to reflux (backward flow) of gastric contents
• The esophagus does not have a serosal layer, making surgery more difficult.
• Esophageal disorders include motility disorders, hiatal hernias, diverticula, perforation, foreign bodies, chemical burns, GERD, Barrett esophagus, benign tumors, and carcinoma.
• Dysphagia is the most common symptom of esophageal disease, ranging from a feeling of food being stuck to pain on swallowing (odynophagia).

Achalasia

• Achalasia is when there is absent or ineffective peristalsis of the distal esophagus with failure of the esophageal sphincter to relax during swallowing
• Results in narrowing above the stomach and gradual dilation of the esophagus.
• Rare condition, progresses slowly, and occurs mostly in people aged 20-40 and 60-70 years.
• The main symptom is dysphagia, with difficulty swallowing solid food.
• Patients feel food is stuck in the lower esophagus, regurgitate food to relieve discomfort, and may experience noncardiac chest or epigastric pain or pyrosis.
• Mirror GERD symptoms, so patients are often misdiagnosed at first.
• X-ray studies show esophageal dilation above the lower gastroesophageal sphincter (bird's beak deformity).
• Diagnosis includes barium swallow, CT scan, endoscopy, and high-resolution manometry (peristalsis, contraction amplitudes and esophageal pressure).
• Management includes eating slowly with fluids.
• Botulinum toxin injections can be used but the benefits fade over time
• Pneumatic dilation stretches the narrowed area but usually requires two dilations.
• Esophagomyotomy (Heller myotomy) involves cutting the esophageal muscle fibers, and is usually performed laparoscopically with or without fundoplication.
• Endoscopic myotomy (POEM) is a newer alternative procedure.

Esophageal Spasm

• Types: jackhammer esophagus, diffuse esophageal spasm (DES), and type III (spastic) achalasia.
  • Jackhammer esophagus: Spasms occur on >20% of swallows with high amplitude, duration, and length.
  • DES: Spasms are normal in amplitude but are uncoordinated, move quickly, and occur at various places in the esophagus at once.
  • Type III achalasia: Lower esophageal sphincter obstruction with esophageal spasms
• All forms are characterized by dysphagia, pyrosis, regurgitation, and chest pain similar to coronary artery spasm.
• Esophageal manometry is the standard test for irregular spasms.
• Management: Smooth muscle relaxants (calcium channel blockers and nitrates) to reduce pressure and amplitude of contractions.
• Botulinum toxin, PPIs (if GERD is present), small frequent feedings, and a soft diet may be recommended
• Heller myotomy or POEM may be considered if conservative therapies do not provide relief.

Hiatal Hernia

• When the opening in the diaphragm enlarges and part of the upper stomach moves into the thorax.
• More common in women than men.
• Sliding (Type I) Hiatal Hernia: The upper stomach and gastroesophageal junction move upward and slide in and out of the thorax
  • 90-95% of cases
• Paraesophageal Hernia: Part of the stomach pushes through the diaphragm beside the esophagus.
  • Classified as Types II, III, or IV depending on herniation extent; Type IV is the greatest herniation, with other abdominal viscera present.
• Sliding hiatal hernia symptoms include pyrosis, regurgitation, and dysphagia, but many are asymptomatic.
• Large hiatal hernias can cause food intolerance, nausea, and vomiting
• Complications include hemorrhage, obstruction, volvulus, and strangulation, more common with paraesophageal hernia
• Diagnosis is confirmed by x-ray studies, barium swallow, EGD, esophageal manometry, or chest CT scan.
• Management includes frequent small feedings, elevation of the head of the bed, and avoiding reclining for 1 hour after eating.
• Surgical hernia repair is indicated for symptomatic patients, primarily to relieve GERD symptoms: laparoscopic approach (Toupet or Nissen fundoplication).
• Open approach is reserved for complications such as bleeding or injury to the spleen.
• Postoperative care includes advancing the diet slowly, managing nausea and vomiting, tracking nutritional intake, and monitoring weight.
• Monitor for belching, vomiting, gagging, abdominal distention, and epigastric chest pain, reporting them immediately.
• Surgical repair is reserved for extreme cases involving gastric outlet obstruction or suspected gastric strangulation.

Diverticulum

• An esophageal diverticulum is an out-pouching of mucosa and submucosa through a weak portion of the esophageal musculature.
• Can occur in the upper (pharyngoesophageal), middle (midesophageal), or lower (epiphrenic) esophagus.
• Zenker Diverticulum (ZD): Most common, located in the pharyngoesophageal area. Caused by the dysfunctional sphincter that fails to open, leading to pressure that forces the mucosa to herniate. Most common in people over 60.
• Midesophageal diverticula are uncommon, symptoms are less acute, and surgery usually not required.
• Epiphrenic Diverticula: Usually larger, located in the lower esophagus; may be related to improper functioning of the lower esophageal sphincter.
• Intramural Diverticulosis: Numerous small diverticula associated with a stricture in the upper esophagus.
• Pharyngoesophageal pulsion diverticulum symptoms include dysphagia, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating.
• Lying down leads to regurgitation of undigested food, potentially leading to coughing or aspiration. Halitosis and a sour taste are common due to food decomposition in the diverticulum.
• Dysphagia is the primary symptom in other diverticula types.
• Diagnosis includes barium swallow to determine the nature and location.
• Management: ZD can be treated by endoscopy/POEM or open surgery; endoscopic septotomy is effective with a recurrence rate of 11-30%.
• Surgery involves diverticulectomy and myotomy of the cricopharyngeal muscle.
• Observe for leakage from the esophagus postoperatively; food and fluids are withheld initially until x-ray studies show no leakage.
• A liquid diet is progressed as tolerated
• Surgery is indicated for epiphrenic and midesophageal diverticula only if symptoms worsen. Treatment consists of diverticulectomy and long myotomy. Intramural diverticula usually regress after esophageal stricture dilation.

Gastroesophageal Reflux Disease

• GERD involves backflow of gastric or duodenal contents into the esophagus which causes troublesome symptoms and/or mucosal injury.
• Excessive reflux occurs due to incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder.
• Associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori.
• Hallmark symptom of GERD is pyrosis; others include dyspepsia, dysphagia or odynophagia, hypersalivation, and esophagitis.
• Can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications
• Ambulatory pH monitoring is the gold standard for diagnosis or a PPI trial.
• Endoscopy or barium swallow is used to evaluate damage to the esophageal mucosa, as well as strictures and hernias.
• Management: Educate the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. Lifestyle changes include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, and altering the diet.
• Surgical management involves Nissen fundoplication, which involves wrapping of a gastric fundus portion around the sphincter area of the esophagus

Overview of the esophagus, a muscular tube connecting the mouth to the stomach. Discusses sphincters, lack of serosal layer, and common disorders like achalasia, hiatal hernias, and GERD. Dysphagia is highlighted as a key symptom of esophageal issues.