Causes of oropharyngeal dysphagia
Neuromuscular
- Central: stroke, brain stem tumour, PD
- Peripheral: Motor neuron dz (ALS), peripheral neuropathy, MG, myopathies - myotonic dystrophy, polymyositis, dermatomyositis
- Post infection: poliomyelitis, syphillis
Mechanical
- intraluminal: eso web, pharyngeal pouch (Zenker divert)
- luminal: tumour, abscess
- extraluminal: anterior mediastinal masses - 4Ts
Oesophageal dysphagia differentials
Neuromuscular:
- pri motility disorder: achalasia, spastic motility - diffuse eso spasm, nutcracker esophagus, hypertensive LES
- sec motility disorder: scleroderma, multiple sclerosis, Sjögren syndrome, DM
Mechanical
- intra-luminal: lower eso rings, eso web (Plummer vinson), FB
- luminal: tumour, strictures (reflux esophagitis, radiation, caustic ingestion, malignant), eosinophilic esophagitis
- extra-luminal: anterior med masses, bronchogenic CA, vascular ab (thoracic aortic aneurysm, LA dilatation)
Causes of anterior mediastinal masses
thymus, thyroid, teratoma, terrible lymphoma
What is CREST syndrome
calcinosis raynauld esophageal spasm sclerodactyly telangiectasia
Plummer vinson syndrome
- triad
- a.w
- cx
triad of
- post cricoid dysphagia
- fe deficiency anemia
- cervical oesophageal webs
a/w
- glossitis
- angular chelitis
- koilonychia
- splenomegaly
- enlarged thyroid
risk of eso CA, pharyngeal SCC
Achalasia triad
- aperistalsis of eso (alt in ganglia of Auerbach plexus)
- increased LES tone/ pressure (hypertensive LES)
- failure of LES to relax with swallowing
Causes of achalasia
Pri: idiopathic
Sec: diabetic autonomic neuropathy, lesions of dorsal motor nuclei (polio, sx ablation), chagas dz
Pseudo: Ca
Tx of achalasia
Med:
- CCB (nifedipine) and nitrates (nitroglycerine)
- endoscopic injection of botulinum toxin
Endo:
- per oral endoscopic myotomy
- pneumatic balloon dilatation
Sx:
- lap Heller esophagomyotomy with anterior fundoplication
RF for GERD
- hiatal hernia
- increased ab pressure: pregnancy, masses, chronic cough, ascites
- dec LES pressure: smoking, alcohol, caffeine, alpha blockers, nitrates, ccb, bb, antiAch
- delayed gastric emptying: lying down after meal
- eso motility disorder: scleroderma
Scoring to diagnose GERD on ph probe
De Meester score >14.72 indicates reflux
Mamometry findings suggestive of reflux risk
pressure <6mmhg
overall length <2cm
abdominal length <1cm
Severity grading of esophagitis
Los Angeles Classification
Savary Miller Classification
When to do OGD for pt with GERD
- progressive symptoms despite medical therapy
- recurrent symptoms despite endoscopic/ sx therapy
- dysphagia, odynophagia
- LOW, LOA
- regurgitation
- UGBIT, anemia
- found a mass on imaging
- screen for Barrett (use narrow-band imaging on OGD)
Non sx mgx of GERD
Lifestyle:
- stop smoking, alcohol, chocolate
- stop medications that decrease LES pressure
- lose weight, avoid tight garments
- don’t lie down after meals, sleep at an angle
- eat small frequent meals
Meds:
- acid suppression: antacids, PPI, H2 receptor antagonists
- pro kinetics to increase gastric clearance: metoclopramide
when to do sx for GERD
- med therapy failing, recurrent progressive symptoms
- severe GERD with cx: barret, erosive esophagitis
- poor compliance to med
- manometric evidence of defective LES
Types of sx for GERD
fundoplication (wrap funds ard GEJ)
- 360: nissen
- partial: anterior 90, anterior 180, posterior 270 (toupet)
Cx of Nissen fundoplication
GA risks Intra op risks: hemorrhage, perforation Post op: - infection - dumping syndrome - gas bloat syndrome - too loose: recurrent symptom - too tight: dysphagia - slipped nissen: wrap slides down, GEJ retract into chest
What is Barretts?
intestinal metaplasia: esophageal stratified squamous epithelium converted to mucus secreting columnar epithelium with goblet cells above z line
how will you mgx Barrett esophagus
- tx underlying reflux
- GERD mgx - endoscopic surveillance - freq depends on severity
a. length of segment: Prague classification C,M
b. deg of dysplasia: Seattle protocol - 4quad biopsy every 2cm
c. other RF: gender, smoking - tx by biopsy grading
- intestinal metaplasia - 0% (OGD every 2 yr)
- low grade dysplasia (ablation)
- high grade dysplasia
- nodule: EMR > ablate
- no nodule > ablate - malignancy - CRT>sx
haloradiofrequency ablation
RF for oesophageal SCC
alcohol, smoking caustic injuries nitrosamine ingestion achalasia others: PV syndrome, Tylosis (AD), eso diverticula and webs
non mod: age>60, male, fam hx
RF for oesophageal adenoCA
chronic GERD
barrett esophagus
obesity
smoking
non mod: age>60, male, fam hx
esophageal SCC vs adenoCA
SCC: anywhere, typically middle 3rd
- CA in situ > invasive progression
- lymphatics (widespread tumour infiltration beyond apparent margins)
AdenoCA: distal 3rd
- b/g chronic GERD, barrett
layers of GI wall
mucosal - epithelium, lamina propria, muscularis mucosa
submucosal - meissner plexus
muscularis propria - circular muscle, Auerbach (myenteric) plexus), longitudinal muscle
adventicia/ serosa
Curative tx for oesophageal cx
localised: endoscopic mucosal resection
higher stage tumour:
- neoadjuvant CT/RT
- sx
- trans thoracic: Ivor lewis (intra thoracic anas)/ mc keown (cervical anas)
- trans hiatal (cervical anas)
