Summary for Esophagus Diseases

Achalasia Pathogenesis Symptoms & Signs Investigation Differential Diagnosis 1) degenerative disease of neurons 2) infection of the neurons * Peristalsis: absent * LOS: hypertensive & fail to relax in response to swallowing 96% Dysphagia ( in early stage to liquids , late both solids 7 liquids) 60% Regurgitation (may lead to aspiration) 40% Heartburn & Chest pain 1- Endoscopy: the first test performed to rule out mechanical obstruction 2- Barium: narrowing at the GE junction (bird’s beak) + slow emptying of contrast + a dilated sigmoid esophagus 3- Esophageal manometry (gold standard) : absence of peristalsis + hypertensive LES. Classification:Type 1: classic with minimal pressurization Type 2 : achalasia with esophageal compression Type 3 : achalasia with spasm ⮚ ⮚ ⮚ Complications 1. 2. 3. 4. Diffuse Esophageal Spasm (DES) Peristalsis: repetitive, non-coordinated , spontaneous , high amplitude + long duration LOS: Normal but If its associated with achalasia Stricture - Intermittent chest pain (most common) - Dysphagia 1- Barium: segmental spasm, areas of narrowing & irregular uncoordinated peristalsis ( corkscrew esophagus) - epiphrenic diverticulum 2- Manometry: a) alternation of esophageal peristalsis & simultaneous contractions b) normal LES function or abnormal 3- Ambulatory 24H pH monitoring: To diagnose GERD * When chest pain is a predominant symptom , a complete cardiac workup is done. Esophageal carcinoma * Once heart disease is excluded, ambulatory pH must be performed to rule Infiltrating tumor of GE junction out GER. (secondary or pseudo-achalasia) * Manometry is the only test that *endoscopic US & CT scan to differentiate distinguishes DES from other disorders. Benign strictures due to GER Aspiration of retained food Pneumonia Esophageal SCC Adenocarcinoma( after dilation or myotomy) ● ● Regurgitation & aspiration leading to repeated episodes of pneumonia Epiphrenic diverticulum Treatment Pathogenesis Symptoms & Signs Investigation 1) Palliative + relief of symptoms + medical therapy (calcium-channel blockers) 2) Endoscopic: Intrasphincteric injection of botulinum toxin, Pneumatic dilation of LES (most effective) Or POEM 3) Surgical: laparoscopic Heller myotomy & partial fundoplication. If failed esophagectomy is done 1) Palliative + relief of symptoms + medical therapy (calcium-channel blockers) 2) Endoscopic: Intrasphincteric injection of botulinum toxin, Pneumatic dilation 3) Surgical: laparoscopic Heller myotomy & partial fundoplication. If failed esophagectomy is done * also calcium blocker post-operative Nutcracker Esophagus Zenker Diverticulum Not known - chest pain (most common) - dysphagia 1- manometry: key test a) normal propagation of the peristalsis waves , very high amplitude & duration in distal esophagus. b) normal LES function or abnormal in achalasia & DES 2- Ambulatory 24H pH monitoring Epiphrenic Diverticulum Due to: lack of coordination b/w pharyngeal contraction & the opening time of UES Or hypertensive UES. * hernia through the posterior Killian triangle * it’s a false & pulsion diverticulum Dysphagia (most common) Regurgitation Halitosis GERD - in the distal 10 cm of esophagus - It’s a consequence of underlying motility disorder. - it’s a false & pulsion diverticulum 1) Barium : show the position & size of the diverticulum OR a prominent cricopharyngeal bar without diverticulum. 2- Manometry: shows a) lack of coordination b/w pharynx & cricopharyngeal muscle b) hypertensive UES c) hypotensive LES d) abnormal peristalsis 3- Ambulatory 24H pH monitoring *endoscopy is dangerous it may cause perforation. 1- chest radiograph: air fluid level 2- Barium : show the position & size of the diverticulum 3- endoscopy to rule out malignancy 4- Manometry: shows the underlying motility disorder - Asymptomatic - Symptoms due to underlying motility & to diverticulum per se. Differential Diagnosis Same as DES Esophageal stricture Achalasia Esophageal cancer Complications Same as DES Aspiration & lung abscess ( most serious ) * Small diverticula (< 2cm) myotomy * 3-6 cm transoral endoscopic approach Treatment 1) conservative + medical therapy (calcium-channel blockers) 2) myotomy + calcium blocker post-operative. Paraesophageal hernia 1- resection of the diverticulum 2- long myotomy 3- anti-reflux measurements ( partial fundoplication ) Notes: * Hypertensive lower esophageal sphincter is a rare disorder is characterized by hypertensive LES which relax in response to swallowing & normal esophageal peristalsis - If the question was to write the clinical findings of any of the above, you have to write symptoms & signs + complications - The difference b/w achalasia, corkscrew and nut cracker as regard Peristalsis & LOS.