Esophageal Disorders

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• Oropharyngeal dysphagia = difficulty initiating a swallow
• • Associated with coughing, choking, nasopharyngeal regurgitation, and aspiration
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• Causes: Structural (Zenker’s diverticula, malignancy, goiter, stricture, radiation injury, infection), Neuromuscular (stroke, Parkinson disease, dementia, ALS, MS) Esophageal dysphagia: Difficulty swallowing several seconds after initiation; associated w/sensation of food getting stuck in esophagus
• • Foreign body: Inability to swallow solids and/or liquids, including oral secretions
  • Most common foreign body = food in esophagus 
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• Dysphagia to solids = mechanical obstruction
• • Progressive: esophageal stricture, peptic stricture, esophageal, cancer
  • Intermittent: esophageal ring/web, eosinophilic esophagitis (particularly in young pts)
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• Dysphagia to solids and liquids = motility disorder
• • Causes: achalasia, scleroderma, distal esophageal spasm (DES), hypercontractile (nutcracker) esophagus

Evaluation

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• If oropharyngeal dysphagia: videofluoroscopic modified barium swallow and fiberoptic endoscopic evaluation of swallowing (FEES)
• When to order barium esophagram:
  • Pre-endoscopy if clinical history suspicious for proximal esophageal lesion (i.e. Zenker’s) or known complex stricture (post-caustic injury or radiation)
    • Don’t order if a food impaction is suspected or if imminent endoscopy
  • Post-endoscopy if mechanical obstruction is still suspected (EGD can miss lower esophageal rings or extrinsic esophageal compression)
• EGD if concerns for mechanical obstruction
• Manometry for motility disorders

Management

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• Food impaction: IV glucagon to relax lower esophageal sphincter to allow food passage
  • Otherwise, requires urgent upper endoscopy for removal
• Additional management is specific to the final diagnosis

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• Pain with swallowing
• Associated with esophagitis

PIECE mnemonic for esophagitis:

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• Pill-induced: NSAIDs, ART, KCl, doxycycline, bisphosphonates
  • Discontinue culprit med or substitute with liquid formulation; prevent by taking culprit meds w/ 8oz water and sit upright for 30 mins after
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• Infectious: usually in immunosuppressed pts
  • Candida esophagitis: most common in HIV or heme malignancies, pts on antibiotics and steroid use
    • Can exist without OP thrush.
    • Diagnosis: white mucosal plaque-like lesions on EGD  biopsy and culture
  • HSV esophagitis. Occurs most commonly in solid organ, BMT transplant recipients, and immunosuppressed patients
    • Diagnosis: well-circumscribed ulcers on EGD, biopsy or brushings of ulcer edge
    • Rx: acyclovir 400mg PO five times daily for 14-21 days (immunocompromised) or acyclovir 5mg/kg IV q8h for 7-14 days if unable to tolerate PO; 200mg PO five times daily or 400mg PO three times daily for 7-10 days (immunocompetent)
• • CMV esophagitis: suspect in HIV pts w/ CD4<50
    • Diagnosis: linear/longitudinal ulcers on EGD, biopsy
    • Rx: ganciclovir 5mg/kg IV q12h for 21-42 days; change to PO once pt able to tolerate; If contraindication to ganciclovir (leukopenia, thrombocytopenia) can use foscarnet. PO valganciclovir can be used in patients who can tolerate and absorb oral medications. Treatment duration is 3-6 weeks based on expert opinion and response to disease
  • ​​​​​​​Eosinophilic esophagitis (see below)
  • Caustic: alkali-induced injury, acid-induced injury, acute period (several days) following esophageal radiofrequency ablation for Barrett’s.
• •  
  • GERD (see below)

Background

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• Condition that develops when reflux of stomach contents causes sxs and/or complications
• Classified base on appearance of esophageal mucosa on EGD
  • Erosive esophagitis: endoscopically visible breaks in distal esophageal mucosa + GERD
  • Nonerosive reflux disease: presence of sxs of GERD w/o  esophageal mucosal injury

Presentation

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• Esophageal symptoms: heartburn, regurgitation, chest pain, dysphagia, globus sensation, odynophagia
  • Extra-esophageal symptoms: cough, hoarseness
  • Complications: Esophageal stricture, Barrett’s esophagus, esophageal adenocarcinoma

Evaluation

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• Dx can often be made clinically in pts with classic heartburn and/or regurgitation
• If dx uncertain, can perform ambulatory pH monitoring + impedance
• EGD indicated for the following:
• • Presence of alarm features (dysphagia, persistent vomiting, GI cancer in 1º relative, odynophagia, GI bleeding, weight loss, iron deficiency anemia, ≥age > 60 y/o with new-onset GERD symptoms)
  •  Risk factors for Barrett’s esophagus (duration of GERD at least 5-10 years [must be present], >50 yo, male, white, hiatal hernia, obesity, nocturnal reflux, tobacco use, first-degree relative w/ Barrett’s and/or adenocarcinoma)
  • Abnormal UGI tract imaging (i.e. luminal abnormalities).
  • Continued sxs despite adequate PPI therapy

Management

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• Lifestyle and dietary modifications in all pts (weight loss; elevate HOB; avoid precipitants such as fatty foods, caffeine, alcohol, spicy foods, large meals, late night meals)
  • Mild/intermittent sxs (<2 episodes/wk) and no erosive esophagitis  step-up therapy q4-8 wks until sxs are controlled, then continue for at least 8 wks:
  • Low-dose H2RA prn  standard dose H2RA BID (min 2 wks)  discontinue H2RA and start daily low dose PPI  standard dose PPI
• Frequent sxs (>2 episodes/wk, and/or severe sxs that impair QOL)  step-down therapy in order to optimize sx relief
  • Standard-dose PPI daily (8 wks)  low-dose PPI daily  H2RA (if mild/intermittent sxs)  stop if asymptomatic
    • PPIs should be prescribed at lowest dose and for shortest duration appropriate
    • Taper if taking for >6 months and plan to discontinue

Additional Information

• Erosive esophagitis and Barrett’s esophagus:
  • Require maintenance acid suppression with a standard dose PPI daily given likelihood of recurrent sxs and complications if stopped
• Recurrent Symptoms (2/3 of pts with nonerosive reflux disease relapse when acid suppression is discontinued):
  • If ≥3 months after discontinuing  repeat 8 week course
  • If <3 months of discontinuing  EGD (if not already performed) to r/o other etiologies or complications
• Medications:
  • Low dose H2RA: famotidine 10mg BID
  • Standard dose H2RA: famotidine 20mg BID
  • Low dose PPI: omeprazole 10 mg daily
  • Standard dose PPI: omeprazole 20 mg daily