IM - T - 6.1 - Disorders of the Esophagus.pdf

INTERNAL MEDICINE: Topic 1 | Module 6 (Part 1) DISORDERS OF THE ESOPHAGUS E.G. Santi, M.D. TOPIC OUTLINE → Submucosa...

INTERNAL MEDICINE: Topic 1 | Module 6 (Part 1) DISORDERS OF THE ESOPHAGUS E.G. Santi, M.D. TOPIC OUTLINE → Submucosa → Muscularis propria I. Anatomy and Function of Esophagus The esophagus is unique because unlike all the other segments of II. Diagnostic Tests GI Tract, the esophagus has no serosa or 5th wall layer A. Esophagography 3 areas of anatomic narrowing: B. Upper GI Endoscopy → one in the proximal esophagus called Upper Esophageal C. Esophageal Manometry Sphincter (UES) D. Reflux Testing → one in the mid esophagus created by the indentation of the E. Esophageal Ultrasound aortic arch F. CT-Scan → one in the distal esophagus called Lower Esophageal III. Esophageal Disorders Sphincter (LES) IV. Inflammatory Disorders A. GERD B. Eosinophilic Esophagitis II. DIAGNOSTIC TESTS C. Infectious Esophagitis These tests can be done to assist you in arriving a diagnosis for 1. Candida esophagitis esophageal disorders: 2. HSV esophagitis → Esophagography 3. CMV esophagitis → Upper GI Endoscopy V. Esophageal Motility Disorders → Esophageal Manometry A. Achalasia → Reflux Testing 1. Natural history of achalasia → Endoscopic Ultrasound (EUS) 2. Diagnostic tests → CT Scan 3. Standard treatments 4. Other treatments A. ESOPHAGOGRAPHY (BARIUM SWALLOW) VI. Structural Disorders Radiologic test wherein you have a patient drink water soluble A. Zenker’s Diverticulum contrast and take x-rays to show passage of barium through the B. Esophageal Rings/Webs esophagus 1. B-Ring of Schatzki ring 2. Esophageal Web VII. Trauma/Iatrogenic A. Corrosive Esophagitis 1. Management B. Pill-induced Esophagitis C. Mallory-Weiss Tear D. Foreign body ingestion 1. Diagnostics 2. Treatment VIII. References IX. Review Questions Figure 1. Barium Swallow that shows dilated esophagus with LEGEND typical finding of a Bird’s Beak appearance seen in patients 🚩- Lecturer💡emphasized its importance - Nice to know with Primary Achalasia B. UPPER GI ENDOSCOPY Important terms Can also do endoscopic tests to look for abnormalities in the Transmaker’s notes esophageal mucosa which otherwise cannot be seen in barium swallow I. ANATOMY AND FUNCTION OF ESOPHAGUS Endoscopy enables us to obtain biopsies and do therapeutic Long and hollow tube that serves as a conduit for transport of food procedures, for example, the dilation of esophageal strictures from the mouth to the stomach Lined by stratified squamous epithelium Esophageal wall has 4 layers → Mucosa → Lamina propria Page 1 of 17 DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. E. ENDOSCOPIC ULTRASOUND This modality allows us to see the esophageal wall and its relation with adjacent mediastinal structures like the heart, azygos vein, aorta and mediastinal lymph nodes It can help determine the local extent or the TN stage of the tumor It can guide in treatment based on tumor stage for example giving adjuvant chemotherapy Figure 2. Upper GI Endoscopy C. ESOPHAGEAL MANOMETRY To measure the pressure along the length of the esophagus as the patient swallows. This test is helpful in the diagnosis of motility disorders and assesses esophageal peristaltic activity. Figure 5. Endoscopic Ultrasound of Esophageal wall (Orange arrow) F. CT SCAN This allows for assessment of tumor spread into the more distant structures in the chest cavity including the mediastinum, lungs, chest wall and bony structures. Figure 3. (A) Normal LES pressure and esophageal peristalsis. (B) Hypotonic LES and normal peristalsis. (C) Ineffective esophageal motility and hypotonic LES D. REFLUX TESTING (PH MONITORING) Involves inserting a pH probe into the patient’s nose and this monitors the esophageal pH over time (usually 24 hours) Helpful in making a diagnosis of GERD where it is otherwise unclear The machine records the amount of time the esophageal pH goes below 4 and if values exceed 5% is indicative of GERD Figure 6. Esophageal cancer invading surrounding mediastinal structures. III. ESOPHAGEAL DISORDERS Table 1. Esophageal Disorders Trauma/ Inflammatory Motility Structural Iatrogenic Achalasia Diverticulum Corrosive GERD esophagitis Esophageal Rings/ webs Eosinophilic spasm Pill-induced esophagitis Tumors esophagitis Infectious Mallory-Weiss esophagitis tear Foreign body Figure 4. pH monitoring catheter We can group esophageal disorders into 4 categories: → Inflammatory disorders Page 2 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. → Motility disorders ▪ functional disorders wherein there is abnormality in esophageal peristalsis or mobility to get food down into the stomach → Structural disorders ▪ abnormalities in the anatomy of esophagus cause symptoms; for example, if there is something occluding or obstructing the passage of contents into the stomach → Traumatic/Iatrogenic disorders IV. INFLAMMATORY DISORDERS A. GASTROESOPHAGEAL REFLUX DISEASE (GERD) PATHOPHYSIOLOGY Poorly functioning esophagogastric (EG) junction composed of Figure 7. Los Angeles Classification Grading System lower esophageal sphincter (LES) and crural diaphragm, coupled Table 2. Los Angeles Classification Grading System with impaired esophageal clearance and altered mucosal integrity Grade Description → Normally, in the esophagus, located on its distal end is the lower esophageal sphincter – usually closed, except during A ≥ 1 mucosal break ≤ 5 mm not extending between folds swallowing to allow food to enter to the stomach B ≥ 1 mucosal break > 5 mm not extending between folds With GERD, there is weakness of LES sphincter (and it is also ≥ 1 mucosal break between folds but involves < 75% of C open) that allows acid and gastric contents to reflux into the the circumference of the esophageal lumen esophagus causing unpleasant symptoms like heartburn and ≥ 1 mucosal break that involves at least 75% of the regurgitation D circumference of the esophageal lumen SYMPTOMS → In the recent American College of Gastroenterology Guidelines, Typical: heartburn and regurgitation only Grades B, C, D are diagnostic of GERD Atypical: dysphagia, chest pain, cough → Grade A is not sufficient due to interobserver variability and sometimes can be seen in normal patients during upper GI DIAGNOSIS endoscopy for symptoms other than GERD There is NO gold standard Reflux Monitoring → Based on these 4 parameters: combination of symptoms, → It is done if the patient has symptoms of GERD, yet EGD endoscopic findings, reflux testing and response to treatment showed no evidence consistent with GERD (normal or at least Grade A) Combination of Symptoms → Positive test = if pH < 4 in more than 5% of the time measured → Common symptoms: heartburn and regurgitation is indicative of GERD → In ER, usually chest pain like heart attack but NOT anginal in ▪ pH probe remains in the esophagus for 24 hours character ▪ If after 24 hours, the machine records ph < 4, in 1.2 hours, ▪ Anginal: characterized as heavy, substernal location, that is a positive reflux test sometimes radiating over the left side of the chest and is usually triggered by exertion ▪ Keep MI as a differential → Patients could also complain of dysphagia, and water brash, which is a result of hypersalivation due to the recurrent reflux of gastric content into the proximal esophagus → Symptoms are worse in supine (at rest): reason why they would present nocturnal asthma and coughing at night → ALARM symptoms: dysphagia, odynophagia, weight loss, anemia, overt GI bleeding, age > 50, hoarseness/changes in voice, tobacco use ▪ If alarm symptoms are present, investigate before labeling as having GERD based on symptoms alone. Endoscopic Evaluation (Upper GI Endoscopy or EGD) → Endoscopic hallmark: erosive esophagitis Figure 8. Algorithm proposed by ACG in the management of GERD ( GERD) (see appendix A) 🚩focus in terms of → Los Angeles Classification for erosive esophagitis is the most → In patients presenting with typical symptoms without alarm widely accepted and validated tool used for endoscopic signs, an 8-week trial of Proton pump inhibitors (PPI) once grading. daily is in order Page 3 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. → If after 8 weeks of treatment there is complete relief of → Allergic vasculitis symptoms, then the diagnosis of GERD is highly likely and Pathogenesis: Immune Mediated (Some form allergy) PPIs can be continued (verbatim as per doc during → Predominantly seen in males synchronous session) → In children, it was associated with: → If after the 8 week trial, there is NO relief, request for an EGD ▪ Asthma, Rhinitis and Eczema in 53% of cases (to check for erosive esophagitis which is the hallmark for ▪ If diet restriction is done, resolution of symptoms GERD) provided that the patient is off any PPI for at least 2 happened in 98% of cases weeks → In adults → If in the endoscopy, you see LA Grade B, C, D, GERD is ▪ Connection between allergy and EOE is not really confirmed, continue PPI impressive → However, if the EGD is normal or LA Grade A, proceed with ▪ But atopy is found in 78% of cases and IgE for food pH testing/pH studies or reflux monitoring and patient should allergen is found in 82% of patients be off any PPI therapy → If after the 8-week PPI trial, there is complete resolution of PATHOPHYSIOLOGY GERD symptoms then GERD is highly likely and may opt to An allergen that will go to the esophagus produces a reaction from discontinue PPI after 8 weeks T-helper cells that in turn will release cytokines and interleukins that will recruit eosinophils in the area. Eosinophils congregate in the 🚩Notes from face-to-face lecture: esophagus; this will be seen in the biopsy as eosinophilic infiltration. The congregations produce fibrosis and lead to the esophageal 🚩 Patient is supposed to take the PPI for 8 weeks straight rings that are typically seen in EOE during endoscopy. 🚩The assessment if the PPI trial is effective is after the 8 regardless of presence or absence of symptoms weeks, not during the 8 weeks If the patient has complete relief, regardless of whether the patient eats spicy food, fatty food, there are no symptoms but it’s GERD We advise patients to avoid spicy & fatty food and dairy products in order to avoid symptoms, even if these patient avoid these food stuff and takes PPIs and yet there is no relief of symptoms, proceed with EGD Barrett’s esophagus is a complication of long standing GERD (metaplasia in the lining of the esophagus) TREATMENT Weight loss in overweight and obese patients (strongly recommended for these patients) Proton pump inhibitors (PPIs) (Gold standard of treatment) Figure 9. Pathophysiology of EOE H2RA (ranitidine, famotidine for pregnant patients) → Given only in selected cases, however PPI is still superior SYMPTOMS PPIs > HR2A for healing of erosive esophagitis, administered 30-60 Similar to GERD but minutes before a meal (empty stomach) → Food impaction and dysphagia is common because of the B. EOSINOPHILIC ESOPHAGITIS (EoE) formation of esophageal rings Chronic immune mediated disorder of the esophagus associated with esophageal symptoms: DIAGNOSIS → Dysphagia Diagnosis of EOE relies on the following test: → Regurgitation → Esophagogram → Chest pain ▪ On barium swallow, you may see ring-like structures along → Same symptoms seen in GERD (very similar to GERD) the body of the esophagus which can cause significant Biopsy: Intense eosinophilia in the absence of other causes of narrowing of the esophagus causing some strictures eosinophilia (>15/hpf) Other causes of eosinophilic infiltration of the esophagus: (should giving rise to dysphagia and food impaction which EOE be ruled out when considering EoE) commonly presents with. → GERD - close differential → Parasites, Fungi → Inflammatory Bowel Disease → Hodgkin’s Disease → Scleroderma → Drug injury Page 4 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Esophageal dilation with a balloon → Done in Patients who are symptomatic C. INFECTIOUS ESOPHAGITIS As a result of increased immunosuppression from organ transplant, with epidemic of HIV/AIDS, there has been increased in esophageal infections Although rarely, these esophageal infections can also happen in patients who are immunocompetent. All infectious esophagitis presents with odynophagia (painful swallowing) See Appendix B for the tabulated summary of infectious esophagitis Figure 10. Esophagogram of EOE CANDIDA ESOPHAGITIS Most common etiology of infectious esophagitis → Upper GI Endoscopy immunocompromised individuals can also affect immunocompetent ▪ Linear furrows (crepe paper like), esophagus may appear Diagnosis trachea like → Endoscopy: Show white plaques/exudates that when we try ▪ Whitish plaques could also be seen flush it out would reveal friability of mucosa underneath → Biopsy: candida hyphae Treatment: → Oral fluconazole 400 mg the first day, followed by 200 mg twice a day for 14-21 days Figure 11. Endoscopic findings EOE. Linear Furrows pointed by the arrows (Left). Whitish Plaques (Right) → Biopsy ▪ Numerous intraepithelial eosinophils must be >15/hpf Figure 13. Endoscopy of Candida esophagitis showing white plaques HERPES SIMPLEX ESOPHAGITIS Seen mostly in immunocompromised patients but can also affect immunocompetent. Diagnosis → Endoscopy: Reveals vesicle or small superficial ulcerations because it only affects the superficial mucosa → Biopsy: Must be done to clinch the diagnosis. Biopsy will reveal ground glass nuclei and eosinophilic Cowdry type A inclusion bodies Treatment → Acyclovir 200 mg once a day for 5 days / IV Acyclovir for Figure 12. Histopathology of EOE severe odynophagia TREATMENT PPI effective in reducing inflammation Elimination diet based on the skin testing, wherein offending foods are identified Topical glucocorticoids (Fluticasone, Budesonide) → Effective in only 50-80% cases. Recurrence after short term treatment Page 5 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. 🚩Notes from face-to-face lecture: Normally, the LES is closed and when we swallow food the LES is supposed to open to allow entry of food into the stomach. In patients with achalasia, when they swallow food the LES contracts or tightens. Symptoms/History: → Dysphagia (most common): usually to both solids and liquids → Regurgitation Figure 14. Small ulcerations seen HSV esophagitis endoscopy → Chest pain → Vomiting CMV ESOPHAGITIS → Weight Loss: because they can’t eat properly Occurs primarily in immunocompromised patients Diagnosis → Endoscopy: Large serpiginous ulcers → Biopsy: Cytoplasmic inclusion bodies (OWL EYE appearance) which is pathognomonic Treatment → Ganciclovir for 3-6 weeks / Valganciclovir given until ulcer healing is seen Figure 15. Large serpiginous ulcers seen in CMV esophagitis endoscopy Figure 16. Typical gross, endoscopic and x-ray findings of achalasia V. ESOPHAGEAL MOTILITY DISORDERS NATURAL HISTORY OF ACHALASIA Due to esophageal neuromuscular dysfunction Early Stages Primary: → Progressive esophageal dilation → Achalasia → Prominent symptom: chest pain → Diffuse Esophageal Spasm Late Stages → Jackhammer Esophagus → More dilated, sigmoid-shaped esophagus Secondary: caused by a systemic disease process → Chest pain may disappear → Chagas Disease: endemic in South America; caused by a bite → Prominent symptom: dysphagia and regurgitation of a reduviid bug that transmits T.cruzi → Scleroderma: connective tissue disorder → Pseudoachalasia (aka secondary achalasia): caused by a tumor in the stomach A. ACHALASIA Most common among the rare primary esophageal motility disorders Rare idiopathic disease of esophageal motility All esophageal motility disorders are actually rare relative to others but primary achalasia is a bit more common Characterized by: → Insufficient LES relaxation → Loss of esophageal peristalsis Figure 17. Natural HIstory of Achalasia Page 6 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Eckardt Scoring System → Assessment of symptom severity → Scored depending on the severity of weight loss, dysphagia, retrosternal chest pain, and regurgitation → The higher the score, the more severe the disease Figure 21. Esophageal Motility Disorders Flow Diagram With high-resolution esophageal manometry, several parameters is Figure 18. Eckardt Scoring System considered like integrated relaxation pressure (IRP) It is also important to check whether there is peristalsis in the DIAGNOSTIC TESTS esophagus in order to identify the specific esophageal motility An assessment of esophageal motor function is essential in disorder a patient has diagnosing Achalasia and all esophageal motility disorders Abnormal IRP: consider Esophagogastric Junction Outflow Obstruction (EGJOO); achalasia falls under this category High-Resolution Esophageal Manometry (HREM) Normal IRP: consider Disorders of Peristalsis → Gold standard in the diagnosis of esophageal motility Details about the other disorders shown in the diagram are beyond disorders the scope of the lecture because it is highly specialized. → Clinically, it is difficult to differentiate one motility disorder from another Upper Gastrointestinal Endoscopy → Remember: Barium esophagogram and upper GI endoscopy → Findings: are only complementary tests to manometry in the diagnosis ▪ Dilated esophagus with retained saliva, liquid or and management of esophageal motility disorders undigested food particles in the absence of a stricture or tumor Figure 22. Dilated esophagus with retained saliva (left) Esophagography (Barium Swallow Test) Figure 19. An example of High-Resolution Esophageal Manometry reading → Findings: ▪ Bird’s beak appearance or rat-tail sign: barium fails to go down the esophagus ▪ Poor emptying of barium in long standing cases ▪ Esophageal dilation and tortuosity Figure 20. HREM findings of the three subtypes of primary achalasia; subtype II has the best prognosis while subtype III is the most difficult to treat Figure 23. “Bird’s beak appearance” or “rat-trail sign” on barium esophagogram Page 7 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. TREATMENTS Pharmacotherapy → Most common: Ca-channel blockers (e.g. Nifedipine) or Nitrates (e.g. Isosorbide dinitrate) - usual medication for hypertension and coronary artery disease → MOA: Relaxation of the smooth muscles of the blood vessels as well as smooth muscles of the esophagus Table 3. Pros and Cons of pharmacotherapy Pros Cons Cheap Not really effective Non- invasive balloon dilation 🚩Notes from face-to-face lecture: Figure 28. Standard treatments for Zenker’s Diverticulum In normal persons, the esophagus has peristalsis and its job is to B. ESOPHAGEAL RINGS AND WEBS propel food down into the stomach.. Structures that can partially occlude the esophageal lumen In patients with achalasia there is absence of peristalsis, and at the same time, the lower esophageal sphincter is tight. B-RING OR SCHATZKI RING Treatments for achalasia at the moment, only address the tight Usually located at the distal esophagus lower esophageal sphincter. Usually asymptomatic but can cause steakhouse syndrome wherein a patient would develop intermittent choking, especially after a VI. STRUCTURAL ESOPHAGEAL DISORDERS heavy meal Treatment is esophageal dilation for symptomatic individuals A. ZENKER’S DIVERTICULUM Sac-like outpouching of the mucosa and submucosa through the Killian’s triangle Located in the upper esophagus, just below the upper esophageal sphincter “False” diverticulum since there are no muscles in the diverticulum Prevalence: 0.01-0.11% Usually asymptomatic If symptomatic M>F, middle age to older adults in 7th/8th decade of life Figure 29. B-ring or Schatzki ring Common symptoms include halitosis, gurgling in the throat, mass in ESOPHAGEAL WEB the neck, regurgitation, dysphagia Complications are rare but watch out for aspiration, ulceration, Located proximally bleeding, fistula formation Usually asymptomatic Diagnosis is made through barium swallow combined with Can be associated with iron deficiency anemia continuous fluoroscopy where you can see an outpouching at the If seen in females, would constitute Plummer-Vinson or posterior aspect of the upper esophageal sphincter Paterson-Kelly Syndrome On EGD two lumina can be seen: one on the blind pouch, and the other is on the two lumen of the esophagus Figure 27. Barium swallow (Left) and EGD (Right) seen in a patient with Zenker’s Diverticulum. Standard treatment: Figure 30. Esophageal Web. → Surgical cricopharyngeal myotomy → Rigid septotomy → Endoscopic myotomy (ZPOEM/POEM) Transmaker’s notes: This part was specifically mentioned by Dr. Santi to not review anymore. Page 9 of 17 DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Lifted from Batch 2024 Trans. ESOPHAGEAL CANCER 8th most common type of cancer worldwide 6th leading cause of cancer deaths High mortality rate Poor prognosis at the time of diagnosis High incidence rates: Asia, China, Japan, Russia and Scotland Figure 33. Reddish areas indicative of early squamous cell carcinoma By switching to a special mode called the narrowband imaging, some reddish areas (as shown in Figure 33 above) can be seen that eventually become brown in color, indicative of early squamous cell carcinoma. These are small blood vessels dilated due to neovascularization that occurs during the development of cancer. Endoscopic treatment or endoscopic submucosal dissection is needed to completely remove the cancer. ADENOCARCINOMA OF THE DISTAL ESOPHAGUS Located at the distal esophagus Strongly linked to a long-standing GERD and Barrett’s Metaplasia Diagnosis can be clinched by EGD and biopsy Figure 31. Leading cause of cancer mortality SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS Early stage: asymptomatic and curative treatment is possible Advanced stage: symptoms like dysphagia to solids, weight loss, anemia and hoarseness manifest, which indicates that the tumor has spread to adjacent and distant organs In countries where incidents of squamous cell carcinoma is high, screening EGD starts at age 40 and this could be much earlier in patients who belong to high risk groups: → Heavy smokers Figure 34. Barrett’s esophagus with foci of adenocarcinoma → Alcoholic beverage drinkers → History of head and neck malignancies Figure 34 above focuses on the foci of adenocarcinoma wherein the area is not just a mucosal break like esophagitis, but there are some ulcerations and nodularities. TREATMENT Early esophageal cancer - both squamous cell cancer carcinoma and adenocarcinoma can be treated endoscopically by mucosal resection. Advanced esophageal cancer should be treated by surgery and chemotherapy. VII. TRAUMA/IATROGENIC ESOPHAGEAL DISORDERS Figure 32. Early squamous cell carcinoma A. CORROSIVE ESOPHAGITIS The image of early squamous cell cancer above was detected Results from ingestion of caustic agents like alkali or acid either by during an EGD using high definition endoscopes with capability accident or attempted suicide. to do real time magnification in vivo. Ingestion of these substances can cause severe injury not only in Using these endoscopes, early detection of squamous cell the esophagus but in the stomach as well. cancer and endoscopic treatment can be performed. The mechanism of tissue injury is different depending on the nature of the substance ingested. Page 10 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Table 7. Mechanism of Tissue Injury Depending on Substance Ingested Alkali Ingestion Acid Ingestion Causes pain upon contact with the oropharynx Patient immediately vomits → Limiting the amount ingested Upper airway injury is common Can easily pass into the Liquefactive necrosis stomach Extends rapidly Can cause more damage in Transmural damage (entire the stomach wall is affected) superficial coagulation Esophagus > gastric necrosis Example: sodium/potassium thrombosis of mucosal vessels Figure 36. Grade III. Gray discoloration of the esophageal mucosa with linear ulcerations and /ammonium hydroxide, and consolidation of and active bleeding in a patient after ingestion of concentrated muriatic acid. Grade III toilet cleaners (lye) connective tissue forming esophageal injury with >75% risk of developing esophageal stricture later on. protective eschar Sufficient amounts concentrations of acid can and 🚩Notes from face-to-face lecture: cause perforation and Can be low grade where there is edema and redness peritonitis In severe cases, you can see ulcers that can be brown, black or Gastric > esophagus gray in color. Example: Muriatic Acid Table 9. Zargar Classification Representative Photos Upper gastrointestinal endoscopy Grade Endoscopic Findings → Used to grade the severity of injury. The more severe the injury, the higher risk of development of esophageal strictures. → Esophageal injury can be low grade with findings of edema and redness. → As the injury becomes more severe or high grade, hemorrhages, ulcerations, and grayish discoloration are seen. I 🚩These are indicative of necrosis if not perforation. Zargar Classification → Used to grade the endoscopic findings in Caustic Injury of the esophagus. Edema and erythema Table 8. Zargar Classification for Endoscopic grading of Caustic Injury Grade Endoscopic Findings I Edema and erythema IIA Hemorrhage, erosions, blisters, ulcers with exudate IIA IIB Circumferential ulceration Multiple deep ulcers with brown, black, or gray III discoloration IV Perforation Hemorrhage, ulcers with exudate IIB Circumferential ulceration Figure 35. Grade IIA. 33/F. Erosions and linear ulcers with whitish exudates in a patient after ingestion of lye (liquid sosa). Page 11 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. B. PILL-INDUCED ESOPHAGITIS This occurs when a pill (medicine, tablet, capsule) fails to traverse the esophagus and gets stuck within the esophageal lumen. → Remember that there are three anatomical esophageal III narrowings: upper esophageal sphincter, one in the main esophagus created by the indentation of the arch of the aorta, and lower esophageal sphincter. This is where we usually see pills and medicines getting trapped. Ulcers are deeper with black or gray discolorations Patients present with acute onset of odynophagia and chest pain. No photo for perforation since endoscopy is Swallowing saliva can trigger odynophagia and chest pain. IV contraindicated. The most common location where these pills can get stocked is in the mid-esophagus where there is normal anatomical luminal Difference between IIA and IIB Classification is that in IIA, the narrowing formed by the indentation of the arch of the aorta. entire circumference is not affected, usually only half. But in IIB, Cause: Poor pill-taking habits such as: the entire circumference is affected. → Not taking sufficient amounts of water to swallow their medicine. One should drink approximately 100 mL of water per pill. MANAGEMENT → Lying down immediately after taking pills. Initial stabilization of patients with caustic ingestion at the ER, in Common medications implicated (precisely because these are large general, includes IV or fluid resuscitation, respiratory support, and tablets): pain control → Bisphosphonates (i.e. Alendronate) Assessment for acute life-threatening complications like → Antibiotics (i.e. Doxycycline) mediastinitis, peritonitis, respiratory distress and shock when → Potassium supplements detected should be addressed. → Ferrous sulfate Patients should be kept on NPO (nothing per orem) until the initial Endoscopic finding: evaluation has been performed and done. → Localized ulcerations (usually in pairs and facing each other, Gastric acid suppression with IV PPI is used to prevent stress ulcers hence called ‘kissing ulcers’ (not pathognomonic) in the stomach Broad spectrum antibiotics are reserved for patients with suspected 🚩 perforations and should be referred for surgery. Avoid: → NGT because it can induce retching and vomiting which can compound existing injuries in the esophagus. This may also lead to perforation. → Induce emesis → Neutralizing agents should not be administered neutralization releases heat that causes thermal injury to the ongoing chemical destruction of tissues → Use of corticosteroids not recommended because of lack of Figure 37. Kissing Ulcers demonstrable efficacy C. MALLORY-WEISS TEAR 🚩Notes from face-to-face lecture: Longitudinal mucosal lacerations in the distal esophagus developed 🚩→Avoid: due to forceful retching Most common presenting symptom is hematemesis often preceded Inserting a NGT because it can induce retching and by retching vomiting which can cause previously ingested alkali or acid Treatment to go back to the esophagus and cause further damage. → Usually self-limiting ▪ This may also lead to perforation since this is a blinded → If with protracted bleeding: endoscopic treatment with procedure. If the esophagus is already friable, you may adrenaline injection + clipping perforate it. → Do not induce emesis → Neutralizing agents should not be administered - neutralization releases heat due to production of enthalpy if acid and alkali is combined. You do not want to cause more heat since it may cause additional injury to the esophagus. → Use of glucocorticoids or corticosteroids not recommended because of lack of demonstrable efficacy Figure 38. Mallory-Weiss Syndrome. Pointed by the arrows are the longitudinal mucosal tears. Page 12 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Endoscopic removal is the procedure of choice and is successful D. FOREIGN BODY INGESTION in >90% of cases with 2.5 cm in size aortic arch, and LES) → if the ingested object is a coin in the esophagus since it can → Areas with anatomic abnormalities (webs, rings, EoE). obstruct the trachea which is adjacent to it Types of foreign body ingestion with high risk of complications: → Illegal drugs → Button/disc batteries → Multiple magnets → Sharp/pointed objects Approach to patient: → History taking ▪ Ask for the type of object ingested. Is it a coin? Fish bone? battery? blade? illicit drugs? ▪ Ask for the time when it occurred ▪ These information/factors will help us determine if the object needs to be retrieved urgently or if the patient can safely be managed by observation and follow-up. Figure 40. L - the endoscopic finding, R - the recovered foreign materials. Both were photos from a real patient who presented with acute symptoms of vomiting, hypersalivation, ▪ Ask for symptoms such as vague discomfort, chest pain, jitteriness, and hallucinations. The abdomen was tender but with no signs of peritonitis or hypersalivation, choking, hiccups, and retchings are perforation. Her vital signs were normal except for some tachycardia. EGD was done. common. Odynophagia when present may indicate a serious problem like esophageal laceration or perforation VIII. REFERENCES ▪ Challenging: When patients are unable or unwilling to Dr. Esperanza Grace Santi’s Face-to-Face Lecture provide details about these informations as in psychiatric Disorders of the Esophagus Batch 2024 Trans patients, infants, children, or prisoners. IX. REVIEW QUESTIONS DIAGNOSTICS X-ray: PA and lateral views of the chest (usually adequate), neck and abdomen (may be needed depending on clinical presentation) LECTURE → Usually the first step in diagnostics. → Findings include a radiopaque foreign body. 1. 26/F complains of heartburn and regurgitation for 2 weeks. No → Will help determine the object, its location, and possible weight loss nor overt bleeding. She denies smoking, alcohol intake complications. and family history of any cancer. What is the best treatment? CT-Scan: for radiolucent foreign body (food, plastic, wood, or glass) a. Acyclovir that are not seen on routine X-ray and if complications (i.e. b. Glucocorticoids perforation) are suspected. c. H2RAs → High sensitivity for detecting foreign body d. Proton pump inhibitors → Very useful for detecting complications such as perforation 2. 40/M complains of odynophagia associated with fever and weight loss. He denies vomiting. He is on anti-retroviral treatment but is poorly compliant. What is your clinical diagnosis? a. Achalasia b. Candida esophagitis c. GERD d. Mallory-Weiss syndrome 3. 23/M came to the ER due to hematemesis. He had a drinking spree the night before and claims to be intoxicated. He had several episodes of retching prior to vomiting blood. What is the diagnosis? a. Achalasia b. Candida esophagitis c. GERD d. Mallory- Weiss Syndrome Figure 39. Radiopaque ingested foreign material as seen in X-ray. 4. 33/F was brought to the ER due to loss of consciousness. She drank approximately 200mL of muriatic acid an hour before. VS BP TREATMENT 110/80, HR 101, RR 22, T 36.8. PE showed erythematous but buccal If the airway is stable and there are no developing complications, mucosa. Chest and abdominal findings were unremarkable. What is the treatment and management is guided by the type of the foreign the next best step? body, location, and degree of obstruction. a. Induce emesis b. Insert NGT and do gastric lavage Page 13 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. c. Neutralize the acid 6. Which of the endoscopic findings suggest the presence of d. NPO and IV hydration eosinophilic esophagitis? 5. What is the endoscopic classification used to grade severity of a. Dilated esophagus erosive esophagitis? b. Multiple rings c. Mucosal tear within a hiatal hernia 6. 84/F was brought to the ER due to ingestion of 200cc of Zonrox. d. Presence of ulcers EGD was done. What is the grading of severity? 7. What is the treatment for a 72 year old lady with odynophagia, oral thrush and yellow-white plaques on the upper esophagus? a. Hydrocortisone b. Fluconazole c. Clindamycin d. Acyclovir 8. To assess mucosal severity, a patient who accidentally ingests bleach should undergo upper endoscopy within this time period from ingestion? a. More than 24 hours b. b. Upon arrival at the ER c. Within the first 6 hours d. Between 12 to 24 hours 9. Which of the following is considered a TRUE diverticula? Figure 41. a. Zenker’s b. Pulsion c. All of the above d. Epiphrenic PAST EXAM 2023 10. A 57 year old, chronic heavy alcoholic, male patient was brought to the emergency room for vomiting of fresh blood, jaundice, and increased abdominal girth. After initial resuscitation, which of the 1. Differential diagnosis in a 45-year-old woman with intermittent following is the next best step in management? dysphagia to solids alone include which of the following? a. Request for CT scan a. Ring b. Refer for Surgery b. Esophageal cancer c. Observation with antiemetics c. Peptic stricture d. Schedule for urgent upper endoscopy d. Achalasia 11. To prevent rebleeding in a cirrhotic patient treated previously 2.Upper endoscopy is immediately warranted in a patient with acute with rubber band ligation, which of the following is initiated? heartburn in the presence of which of the following? a. Propranolol a. Dysphagia b. Somatostatin b. Body weakness c. Antibiotics c. Nausea d. All of the above d. Fever 3. Extraesophageal GERD manifestation includes which of the following? a. Emphysema b. Conjunctivitis c. Laryngitis PAST EXAM 2024 d. Pneumonia 4. A 52-year-old obese, male, smoker presented to you for chronic 1. Which of the following is used to assess symptom severity in a heartburn. Endoscopy showed a 3.5 cm tongue-like island of patient with achalasia? salmon pink mucosa in the distal esophagus with biopsy findings of a. Eckardt score intestinal metaplasia. What is the diagnosis? b. Upper GI endoscopy (UGIE). a. Erosive esophagitis c. High resolution esophageal manometry (HREM). b. Gastroesophageal reflux disease d. Barium swallow c. Peptic stricture 2. Which of the following modalities is most sensitive in the d. Barrett’s esophagus diagnosis of achalasia? 5. A 42 year old presents with progressive dysphagia. An a. CT Scan endoscopy revealed dilated esophagus with a normal-appearing but b. Barium swallow tight lower esophageal sphincter. To confirm the diagnosis, which c. HREM of the following is recommended? d. UGIE a. High-resolution manometry 3. An 80/M complains of intermittent dysphagia for 3 years b. CT scan of the chest associated with halitosis and regurgitation. He has no weight loss, c. Any of the above vomiting nor chest pain. PE was unremarkable. Barium swallow d. Barium swallow Page 14 of 17  DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. revealed an outpouching at the posterior aspect of the vomited blood. He is a non-smoker but a moderate alcoholic pharyngoesophageal junction. What is the diagnosis? beverage drinker. On PE, vital signs were normal, palpebral a. Achalasia conjunctivae were pink and the abdominal findings were b. Epiphrenic diverticulum unremarkable. What is the diagnosis? c. Zenker’s diverticulum a. Squamous cell carcinoma d. GERD b. Mallory-Weiss syndrome 4.Which of the following is an example of a true diverticulum? c. Corrosive esophagitis a. Epiphrenic d. Pill-esophagitis b. Zenker’s c. Midesophageal 5.A 32/M suddenly developed dysphagia and choking while eating unlimited samgyeopsal. The same symptoms occurred a year ago while he was eating in a buffet. What is the diagnosis? De La Salle Medical and Health Sciences Institute a. GERD College of Medicine b. B-ring c. Esophageal web BATCH 2025 d. Achalasia 6. A 46/M with HIV on antiretroviral treatment consulted due to painful swallowing. Which of the following conditions is most likely? a. GERD b. Candida esophagitis c. Achalasia d. Zenker’ diverticulum 7. Which of the following is the endoscopic hallmark of GERD? a. Mucosal erythema b. Esophageal diverticular opening c c. Linear furrows d. Erosive esophagitis 8. Histologic confirmation of eosinophilic esophagitis requires how many eosinophils per high power field? a. 10-14 b. 15 d. 6-10 9. A 26/M with HIV came in due to odynophagia. EGD showed white plaques with friable esophageal mucosa. What is the treatment of choice? a. Pantoprazole b. Ganciclovir c. Fluconazole d. Fluticasone 10.A 30/F consulted due to intermittent heartburn, regurgitation and water brash for 2 years. She is non alcoholic and a non smoker. She denies weight loss, overt GI bleeding nor dysphagia. PE was unremarkable. What is the next best step in the management? a. Schedule for an EGD b. Give PPI for 8 weeks c. Do esophageal pH testing d. Give H2RA for 2 weeks 11. A 56/F consulted due to heartburn and coffee ground vomiting. She was given H2RA in a clinic with provided no relief. On PE, vital signs are normal. She is pale. The rest of the examination was unremarkable. What is the next best step in terms of management? a. Schedule for an EGD b. Do CT of the chest c. Give PPI for 8 weeks d. Do esophageal pH testing 12. A 26/M arrived at the ER due to one episode of hematemesis. The came from a party where he had several drinks. His friends noticed that he was retching earlier in the evening before he Page 15 of 17 DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Page 16 of 17 DISORDERS OF THE ESOPHAGUS Internal Medicine - E.G. Santi, M.D. Appendix B Infectious Esophagitis Summary Causative Affected patient UGI Endoscopy Appearance Biopsy Treatment organism ORAL FLUCONAZOLE BOTH Candida WHITE PLAQUES 400mg on 1st day immunocompromised and CANDIDA HYPHAE albicans with increased friability followed by 200 mg immunocompetent Twice a day for 14-21 days ACYCLOVIR GROUND 200 mg once a day GLASS for 5 days VESICLES NUCLEI MOSTLY immunocompromised HSV SMALL SUPERFICIAL but also immunocompetent IV ACYCLOVIR ULCERATIONS COWDRY (SEVERE TYPE A ODYNOPHAGIA) INCLUSIONS GANCICLOVIR OR CYTOPLASMIC VALGANCICLOVIR LARGE, INCLUSION for 3-6 weeks SERPIGINOUS BODIES CMV Immunocompromised ULCERS (owl eye VALGANCICLOVIR appearance) (given until ulcer healing is seen) Page 17 of 17