Diseases of the Esophagus PDF

Universidad de Monterrey Access Provided by: Harrison's Principles of Internal Medicine, 21e Chapter 323: Diseases of the Esophagus Peter J. Kahrilas; Ikuo Hirano ESOP...

Universidad de Monterrey Access Provided by: Harrison's Principles of Internal Medicine, 21e Chapter 323: Diseases of the Esophagus Peter J. Kahrilas; Ikuo Hirano ESOPHAGEAL STRUCTURE AND FUNCTION The esophagus is a hollow, muscular tube coursing through the posterior mediastinum joining the hypopharynx to the stomach with a sphincter at each end. It functions to transport food and fluid between these ends, otherwise remaining empty. The physiology of swallowing, esophageal motility, and oral and pharyngeal dysphagia are described in Chap. 44. Esophageal diseases can be manifested by impaired function or pain. Key functional impairments are swallowing disorders and excessive gastroesophageal reflux. Pain, sometimes indistinguishable from cardiac chest pain, can result from inflammation, infection, dysmotility, or neoplasm. SYMPTOMS OF ESOPHAGEAL DISEASE The clinical history remains central to the evaluation of esophageal symptoms. A thoughtfully obtained history will often expedite management. Important details include weight gain or loss, gastrointestinal bleeding, dietary habits including the timing of meals, smoking, and alcohol consumption. The major esophageal symptoms are heartburn, regurgitation, chest pain, dysphagia, odynophagia, and globus sensation. Heartburn (pyrosis), the most common esophageal symptom, is characterized by a discomfort or burning sensation behind the sternum that arises from the epigastrium and may radiate toward the neck. Heartburn is an intermittent symptom, most commonly experienced after eating, during exercise, and while lying recumbent. The discomfort is relieved with drinking water or taking an antacid but can occur frequently, interfering with normal activities including sleep. The association between heartburn and gastroesophageal reflux disease (GERD) is so strong that empirical therapy for GERD has become accepted management. However, the term heartburn is often misused and/or referred to using other terms such as indigestion or repeating, making it important to clarify the intended meaning. Regurgitation is the effortless return of food or fluid into the pharynx without nausea or retching. Patients report a sour or burning fluid in the throat or mouth that may also contain undigested food particles. Bending, belching, or maneuvers that increase intraabdominal pressure can provoke regurgitation. A clinician needs to discriminate among regurgitation, vomiting, and rumination. Vomiting is preceded by nausea and accompanied by retching. Rumination is a behavior in which recently swallowed food is regurgitated and then reswallowed repetitively for up to an hour. Although there is some linkage between rumination and cognitive deficiency, the behavior is also exhibited by unimpaired individuals. Chest pain is a common esophageal symptom with characteristics similar to cardiac pain, sometimes making this distinction difficult. Esophageal pain is usually experienced as a pressure­type sensation in the mid chest, radiating to the mid back, arms, or jaws. The similarity to cardiac pain is likely because the two organs share a nerve plexus and the nerve endings in the esophageal wall have poor discriminative ability among stimuli. Esophageal distention or even chemostimulation (e.g., with acid) will often be perceived as chest pain. Gastroesophageal reflux is the most common cause of esophageal chest pain. Esophageal dysphagia (Chap. 44) is often described as a feeling of food “sticking” or even lodging in the chest. Important distinctions are between uniquely solid food dysphagia as opposed to liquid and solid, episodic versus constant dysphagia, and progressive versus static dysphagia. If the dysphagia is for liquids as well as solid food, it suggests a motility disorder such as achalasia. Conversely, uniquely solid food dysphagia is suggestive of a stricture, ring, or tumor. Of note, a patient’s localization of food hang­up in the esophagus is notoriously imprecise. Approximately 30% of distal esophageal obstructions are perceived as cervical dysphagia. In such instances, the absence of concomitant symptoms generally associated with oropharyngeal dysphagia such as aspiration, nasopharyngeal regurgitation, cough, drooling, or obvious neuromuscular compromise should suggest an esophageal etiology. Odynophagia is pain either caused by or exacerbated by swallowing. Although typically considered distinct from dysphagia, odynophagia may manifest concurrently with dysphagia. Odynophagia is more common with pill or infectious esophagitis than with reflux esophagitis and should prompt a Downloaded 2025­1­28 5:48 P Your IP is search for323: Chapter these entities.of Diseases When odynophagiaPeter the Esophagus, does J. occur in GERD, Kahrilas; Ikuoit Hirano is likely related to an esophageal ulcer or extensive erosions. Page 1 / 20 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Globus sensation, also known as globus pharyngeus, is the perception of a lump or fullness in the throat that is felt irrespective of swallowing. Although such patients are frequently referred for an evaluation of dysphagia, globus sensation is often relieved by the act of swallowing. As implied by esophageal obstructions are perceived as cervical dysphagia. In such instances, the absence of concomitant symptoms generally associated with Universidad de Monterrey oropharyngeal dysphagia such as aspiration, nasopharyngeal regurgitation, cough, drooling, or obvious neuromuscular compromise should suggest Access Provided by: an esophageal etiology. Odynophagia is pain either caused by or exacerbated by swallowing. Although typically considered distinct from dysphagia, odynophagia may manifest concurrently with dysphagia. Odynophagia is more common with pill or infectious esophagitis than with reflux esophagitis and should prompt a search for these entities. When odynophagia does occur in GERD, it is likely related to an esophageal ulcer or extensive erosions. Globus sensation, also known as globus pharyngeus, is the perception of a lump or fullness in the throat that is felt irrespective of swallowing. Although such patients are frequently referred for an evaluation of dysphagia, globus sensation is often relieved by the act of swallowing. As implied by its alternative name, “globus hystericus,” globus sensation often occurs in the setting of anxiety or obsessive­compulsive disorders. Clinical experience teaches that it is often attributable to GERD. Water brash is excessive salivation resulting from a vagal reflex triggered by acidification of the esophageal mucosa. This is not a common symptom. Afflicted individuals will describe the unpleasant sensation of the mouth rapidly filling with salty thin fluid, often in the setting of concomitant heartburn. DIAGNOSTIC STUDIES ENDOSCOPY Endoscopy, also known as esophagogastroduodenoscopy (EGD), is the most useful test for the evaluation of the proximal gastrointestinal tract. Modern instruments produce high­quality, color images of the esophageal, gastric, and duodenal lumen. Endoscopes also have an instrumentation channel through which biopsy forceps, injection catheters for local delivery of therapeutic agents, balloon dilators, or devices for hemostasis or removal of mucosal lesions can be used. The key advantages of endoscopy over barium radiography are as follows: (1) increased sensitivity for the detection of mucosal lesions; (2) vastly increased sensitivity for the detection of abnormalities mainly identifiable by color, such as Barrett’s metaplasia or vascular lesions; (3) the ability to obtain biopsy specimens for histologic examination of suspected abnormalities; and (4) the ability to dilate strictures during the examination. Submucosal endoscopy has emerged as a diagnostic modality for assessment of subepithelial lesions and therapy of esophageal motility disorders. The main disadvantages of endoscopy are low sensitivity for detection of diffuse, nonfocal esophageal strictures, cost, and the need for sedatives or anesthetics. RADIOGRAPHY Contrast radiography of the esophagus, stomach, and duodenum can demonstrate reflux of the contrast media, hiatal hernia, mucosal granularity, erosions, ulcerations, and strictures. The sensitivity of radiography compared with endoscopy for detecting reflux esophagitis reportedly ranges from 22 to 95%, with higher grades of esophagitis (i.e., ulceration or stricture) exhibiting greater detection rates. Conversely, the sensitivity of barium radiography for detecting esophageal strictures is greater than that of endoscopy, especially when the study is done in conjunction with a 13­mm barium tablet. Barium studies also provide an assessment of esophageal function and morphology that may be undetected on endoscopy. Tracheoesophageal fistula, altered postsurgical anatomy, and extrinsic esophageal compression are conditions where radiographic imaging complements endoscopic assessment. Hypopharyngeal pathology and disorders of the cricopharyngeus muscle are better appreciated on radiographic examination than with endoscopy, particularly with rapid sequence or video fluoroscopic recording. The major shortcoming of barium radiography is that it rarely obviates the need for endoscopy. Either a positive or a negative study is usually followed by an endoscopic evaluation to obtain biopsies, provide therapy, or clarify findings in the case of a positive examination or to add a level of certainty in the case of a negative examination. ENDOSCOPIC ULTRASOUND Endoscopic ultrasound (EUS) instruments combine an endoscope with an ultrasound transducer to create a transmural image of the tissue surrounding the endoscope tip. The key advantage of EUS over alternative radiologic imaging techniques is much greater resolution attributable to the proximity of the ultrasound transducer to the area being examined. Available devices can provide either radial imaging (360­degree, cross­sectional) or a curved linear image that can guide fine­needle aspiration of imaged structures such as lymph nodes or tumors. Major esophageal applications of EUS are to stage esophageal cancer, to evaluate dysplasia in Barrett’s esophagus, and to assess submucosal lesions. ESOPHAGEAL MANOMETRY Esophageal manometry, or motility testing, entails positioning a pressure­sensing catheter within the esophagus and then observing the contractility following test swallows. The upper esophageal sphincter and lower esophageal sphincter (LES) appear as zones of high pressure that relax on Downloaded 2025­1­28 swallowing, whereas the 5:48 P Your IP is intersphincteric esophagus exhibits peristaltic contractions. Manometry is used to diagnose motility disorders (achalasia, Chapter 323: Diseases of the diffuse esophageal spasm [DES]) Esophagus, Peter and to assess J. Kahrilas; peristaltic Ikuoprior integrity Hirano Page 2 / 20 to the surgery for reflux disease. Technologic advances have enhanced ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility esophageal manometry as high­resolution esophageal pressure topography (Fig. 323­1). Manometry can also be combined with intraluminal impedance monitoring. Impedance recordings use a series of paired electrodes added to the manometry catheter. Esophageal luminal contents in are to stage esophageal cancer, to evaluate dysplasia in Barrett’s esophagus, and to assess submucosal lesions. Universidad de Monterrey Access Provided by: ESOPHAGEAL MANOMETRY Esophageal manometry, or motility testing, entails positioning a pressure­sensing catheter within the esophagus and then observing the contractility following test swallows. The upper esophageal sphincter and lower esophageal sphincter (LES) appear as zones of high pressure that relax on swallowing, whereas the intersphincteric esophagus exhibits peristaltic contractions. Manometry is used to diagnose motility disorders (achalasia, diffuse esophageal spasm [DES]) and to assess peristaltic integrity prior to the surgery for reflux disease. Technologic advances have enhanced esophageal manometry as high­resolution esophageal pressure topography (Fig. 323­1). Manometry can also be combined with intraluminal impedance monitoring. Impedance recordings use a series of paired electrodes added to the manometry catheter. Esophageal luminal contents in contact with the electrodes decrease (liquid) or increase (air) the impedance signal, allowing detection of anterograde or retrograde esophageal bolus transit. FIGURE 323­1 High­resolution esophageal pressure topography (right) and conventional manometry (left) of a normal swallow. E, esophageal body; LES, lower esophageal sphincter; UES, upper esophageal sphincter. REFLUX TESTING GERD is often diagnosed in the absence of endoscopic signs of esophagitis, which would otherwise define the disease. This occurs in the settings of partially treated disease, an abnormally sensitive esophageal mucosa, or, most commonly, in nonerosive reflux disease. In such instances, reflux testing can demonstrate excessive esophageal exposure to refluxed gastric fluid, the physiologic abnormality of GERD. This can be done by ambulatory 24­ to 96­h esophageal pH recording using either a wireless pH­sensitive transmitter that is affixed to the esophageal mucosa or a transnasally positioned wire electrode with the tip stationed in the distal esophagus. Either way, the outcome is expressed as the percentage of the day that the pH was