Esophageal Disorders

Esophageal Disorders – Caroline Barrett

Dysphagia

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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

 

 

Odynophagia

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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.
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    • GERD (see below)

 

 

GERD

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

 

 

Eosinophilic Esophagitis

Background

  • Pt usually with a hx of asthma/allergies/eczema
  • Dysphagia (most commonly to solid foods), food impaction, central chest pain, GERD/refractory heartburn, upper abdominal pain

 

Evaluation

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  • Diagnostic criteria
    • Sxs related to esophageal dysfunction
    • EGD with >15 eos/hpf on biopsy and exclusion of other causes (no longer requires PPI trial as pts who are PPI-responsive do not appear to be clinically distinct from those who are PPI-nonresponsive)
    • Exclusion of other causes that may be responsible for or contributing to sxs and esophageal eosinophilia
      • 50-60% pts will have elevated serum IgE lvl, peripheral eosinophilia can be seen but is generally mild.

 

Management

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  • Standard dose PPI for 8 weeks +/- elimination diet if still symptomatic after 4 weeks, increase PPI to BID if responsive, continue PPI at lowest dose possible for sx control
  • Alternative treatment is swallowed budesonide or fluticasone
  • Intermittent dilation of strictures to relieve dysphagia, but no effect on underlying inflammation
  • Should undergo evaluation by allergist, given strong association with allergies