Prof KHALED HEMIDA Ain Shams University

قال الله تعالي : يرفع الله الذين آمنوا منكم و الذين أوتوا العلم درجات. قال رسول الله ( صلي الله عليه و سلم ): إن الملائكة لتضع أجنحتها لطالب العلم رضاً بما يصنع.

Heartburn Barrett`s Esophagus Erosive esophagitis NERD Functional Heartburn Endoscopy pH monitoring 10 %30 % 60 %

The LA Classification system Endoscopic assessment and classification of esophagitis

Grade A One (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds Lundell et al 1999

Grade B One (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds Lundell et al 1999

Grade C One (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference Lundell et al 1999

Grade D One (or more) mucosal break that involves at least 75% of the esophageal circumference Lundell et al 1999

Complications of GERD Esophageal Extra esophageal Prolonged exposure of the esophagus to gastric refluxate can cause metaplasia, malignancy, ulceration or strictures. Movement of gastric refluxate through the esophageal/pharyngeal /laryngeal/pulmonary axis can cause, or exacerbate, several disorders.

Possible extraesophageal manifestations of GERD Asthma Sinusitis Dental erosions Reflux laryngitis Vocal cord ulcers Subglottal/tracheal stenosis Laryngospasm Jailwala & Shaker 2000; Richter 2000; Ulualp et al 1999

Esophageal complications of GERD Erosive/ulcerative esophagitis Esophageal (peptic) stricture Barrett’s esophagus Adenocarcinoma

GER Complications Esophageal stricture secondary to GERD: radiography and endoscopy Barrett’s esophagus: endoscopy and histology Normal Barrett’s Normal Stricture

Complications Barrett’s Esophagus Acid damages lining of esophagus and causes chronic esophagitis Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma EE BE Cancer

1- Erosive/ulcerative esophagitis

Erosive/ulcerative esophagitis Erosive esophagitis(EE) develops in chronic GERD patients when acid irritation and inflammation cause extensive injuries to the esophagus. The longer and more severe the GERD the higher the risk for developing erosive esophagitis.

Erosive esophagitis Responsible for 30-40% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitis

Esophageal stricture Result of healing of erosive esophagitis May need dilation

Risk Factors : GERD >1year Male gender Regular ETOH Smoking(current or previous)

Clinical presentation: Odynophagia ( painful swallowing) Bleeding: Bleeding may occur in about 8% of cases. A- Haematemesis & melena. B- Iron deficiency anemia in chronic mild cases This condition can occur without heartburn or other warning symptoms, or even without obvious blood in the stools ( occult blood +ve)

2- Peptic Stricture

Occurs in % of patients with untreated esophagitis * Dysphagia is usually the most common symptom May require dilation Chronic PPI therapy required to decrease the risk of stricture reformation * Murphy et al. Endoscopy

Peptic Stricture Barium Swallow Endoscopy

Esophageal stricture

Management of strictures

Dilating Devices

TTS Balloon Dilation of a Peptic Stricture

3- Barrett’s Esophagus

Squamous epitheliumColumnar epithelium Sampliner A change in the esophageal epithelium of any length that: -Can be recognized at endoscopy ( NBI). -Is confirmed by biopsy to have intestinal metaplasia (Goblet and mucous secreting cells) -Excludes intestinal metaplasia of the cardia Definition:

It is premalignant Condition Prevalence of BE increases as symptom & duration of GERD increases Prolonged acid and bile exposure, compared to pt’s with GERD Barrett’s epithelium is less sensitive to acid, so patients who report a decrease in sx’s after long-standing GERD may be developing Barrett’s No antireflux therapy has been shown to reduce the risk of adenocarcinoma or the extent of BE.

Aggressive acid suppression can decrease both acid and bile reflux Patients with chronic GERD sx’s are those most likely to benefit from endoscopy to rule out BE. Once-in-a-lifetime endoscopy to exclude Barrett’s? About 10% of patients with symptomatic GERD have BE. In some cases, BE develops as an advanced stage of erosive esophagitis

The prevalence of Barrett’s esophagus increases with the duration of reflux symptoms <11–55–10>10 Duration of symptoms (years) Prevalence of endoscopic Barrett's esophagus (%) Lieberman et al 1997

Diagnosis of BE Endoscopy & Biopsy Chromo endoscopy Narrow Band Imaging

Classification of Barrett’s Esophagus: Short segment – <3cm above GEJ (more prevalent) Long segment – >3cm above GEJ(more likely to have intestinal metaplasia)

Barretts Esophagus Long Segment Short segment

Enhansed Magnification Endoscopy

Chromo endoscopy

Narrow Band Imaging(NBI)

- Risk factors for Barrett's esophagus - Age : >50 years, White race - Men: Women (4:1) - Only the persistence of GERD symptoms indicates a higher risk for BE. - Obesity, alcohol use, and smoking have all been implicated as, their role remains unclear.

BE treatment Goals Control of reflux symptoms Healing of esophagitis & mentainance therapy Promote healing of ablated mucosa Prevention of Dysplasia /cancer ( Chemoprevention) “ Symptom versus pH control”

BE Surveillance BE without dysplasiaBE with dysplasia Endoscopy every 3-5 yrs Low grade dysplasia Repeat endoscopy every 6-12 mon Then yearly if no progression Diagnosis confirmed by experienced pathologist High grade dysplasia Esophagectomy in fit pts < 50 yrs Or Intensive endoscopic surviellance in non fit pts Consider endoscopic ablative therapies for pts at high risk for surgical complications

Management options for high-grade dysplasia Esophagectomy. Endoscopic ablative therapies - Photodynamic Therapy (PDT) - Endoscopic mucosal resection( EMR)

EMR in BE

4- Cancer esophagus

Cancer esophagus The incidence of esophageal cancer is higher in patients with BE. (risk range from 40- to 125-fold higher than the general population). Most cases of esophageal cancer start with BE, and symptoms are present in less than half of these cases. Still, only a minority of BE patients develop cancer. There is some evidence that acid reflux may contribute to the development of cancer in BE.

Risk factors Barrett`s esophagus, GERD & hiatal hernia. Obesity( 3-4 fold risk). Smoking ( 2-3 fold risk) Increased esophageal acid exposure ( Zollinger –Ellison syndrome).

Diagnosis of Cancer esophagus Barium swallow Endoscopy & biopsy ( Definitive) Endoscopic US ( For staging) Bronchoscopy ( for fistula) CT scan ( staging) MRI ( staging) Positron Emission tomography(PET) scan ( For metastasis)

Barium Swallow

Endoscopy

Endoscopic ultrasound

Staging of Cancer

T- stage

N stage ( lymph node)

M- stage ( metastasis)

Treatment of cancer esophagus Endoscopic mucosal Resection (EMR) Surgery Chemotherapy Radiotherapy Combined-modality therapy Palliative therapy

EMR Indications T i s or T 1a defined as tumor involving the mucosa & not involving the submucosa

Surgery Indications : 1- Early stage ( stage 0,1 ) 2-Middle stage ( stage 2,3) 3- Tumor recurrence after radiotherapy ( with no distal metastasis) 4- Palliative treatment

Palliative therapy Photodynamic Therapy Laser therapy Esophageal stenting Colonic interposition External-beam irradiation

Esophageal stents Totally coverd Partially coverd stent

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