By George Vagujhelyi MD Esophageal Disorders By George Vagujhelyi MD

Cardinal symptoms Heartburn Bland or sour regurgitation Chest Pain Dysphagia Odynophagia

Atypical Symptoms Dyspepsia(epigastric burning and fullness) Nausea and Vomiting Hematemesis Globus Coughing Throat clearing Throat pain Hoarseness Wheezing/stridor Dyspnea Apnea Halitosis

Esophageal disorders Gastroesophageal Reflux Disease Barrett’s Esophagus Eosinophilic Esophagitis Intrinsic Structural disorders Systemic Disorders Iatrogenic

Gastroesophageal Reflux Most common esophageal disorder This is where gastric contents refluxes into the esophagus TLESR( transient lower esophageal sphincter relaxation) <1 min inhibition of the tone LES Decrease contraction of circular muscle of esophagus Cessation of diaphragmatic Contraction of the longitudinal esophageal muscle. Requires an intact vagal nerve Triggered by abd distension, awake and in postprandial state All this is a normal physiological response to venting

GERD People with GERD develop more acid reflux during TRLES and extended further proximally Compounding factors: Obesity Conditions that increase pressure difference between the abd and thoracic cavity Delayed emptying Delay in clearance of acid contents ( salivary production, peristalsis)

GERD Most commonly diagnosed GI disorder 9 million o/p visits annually Occurs in all ages 40 % of adults have an event monthly 18% report weekly Actual organ damage in fewer then 50% of patients who present with symptoms Of those who have EGD 10 % have esophagitis,3-4% Barrett’s, Adeno CA

GERD risk factors Obesity Hiatal hernia Smoking NSAIDS Aging IBS Anxiety/depression FHx HP and Chronic atrophic gastritis (inverse association)

GERD complications Esophagitis and ulceration Strictures Peptic Distal location near GEJ Erosions, ulcerations and Barrett’s Higher Pill Neoplasia EoE

GERD complications Barrett’s Esophagus demonstrates salmon-colored mucosa and the biopsy shows intestinal metaplasia with goblet cells. Prevalence is about 1-2 % Half don’t report typical GERD symptoms Risk factors Erosive esophagitis Male White Heavy ETOH Hiatal hernia Low LES Dysfunctional peristalsis

Extra esophageal manifestation of GERD These structures are not normal exposed to acid reflux Thus no neutralizing mechanism No clearance mechanism Asthma Aspiration pneumontitis/pul fibrosis Laryngitis/vocal cord lesions Chronic cough Dental erosions Sinusitis Otitis media

Therapy Lifestyle changes Medical therapy Surgery PPI once a day prior to the first meal Twice a day dosage for those with erosive disease for a period of time only to be titrated down to control symptoms Non erosive reflux disease Consider short course therapy to control symptoms Surgery Initial results are good but then symptoms of dysphagia and gas-bloat may off set About half of the patients will require repeat surgery or medical therapy.

Eosinophilic Esophagitis Is an esophageal dysfunction accompanied by pathological evidence of predominantly eosinophilic inflammation in the esophagus The eosinophilic infiltration is about 15/high powered field Prevalence <1 per 1000 It seems to be increasing Diagnosis is less in the winter months More prevalent in Male non-Hispanic whites

EoE Clinical presentation Endoscopic findings Solid food dysphagia Most common diagnosis in young people with food impaction May have other atopic conditions ( eczema, allergic rhinitis,food allergy) Endoscopic findings Corrugated mucosa Longitudinal mucosal furrows Whites spots/plaques Focal rings and strictures Diffusely small-caliber esophageal lumen Fragile mucosa Try to involve an allergist

EoE Therapy Removal food impactions Dilation which may need to be repeated, may results in rents and odynophagia However unless there is not a dominant stricture driving the dysphagia Defer dilation try avoidance of the food Medical therapy PPI therapy 20-40 mg QD-BID Systemic steroids 2mg/kg/d 60 mg max for 4 wks course severe symptoms Fluticasone 880-1760 mcg/d risk of candida esophagitis Elemental diet great for kids, expensive poorly tolerated do to feeding tube Six food elimination( wheat,milk,eggs,soy,peanuts,fish,shell) Targeted elimination based on allergy test ( low response rate)

EoE Associated conditions GERD Eosinophilic gastritis Celiac disease IBD Drug reactions Hypereosinophilic syndromes Infections Autoimmune disorders

Systemic Disorders Diabetes Predispose to GERD Type 2 DM Obese Hyperglycemia increase TLESR response to gastric distension Delayed gastric emptying Less sensitive to abnormal amounts of reflux Reflux esophagitis common finding in DKA Candida esophagitis

Systemic disorders Connective tissue disorders Systemic sclerosis Mixed connective tissue Reduced LES Atrophic smooth muscle Delayed gastric emptying Sjogrens syndrome Reduced saliva Risk for iatrogenic causes secondary to immunosuppression, pill injury and bisphosphonates

Dermatological disorders There is squamous epithelial tissue in the esophagus thus several systemic disease that affect the skin can manifest in the esophagus as well Epidermolysis bullosa Bullous phemphigoid Pemphigus vulgaris Steven-Johnson Lichen planus

iatrogenic Pill induced ASA,NSAIDS Bisphosphonates KCL Doxycycline/tetracycline Ascorbic acid Ferrous sulfate They cause symptoms of worsening heartburn, chest pain , dysphagia and/or odynophagia Medications Inhibit smooth muscle tone and contractility Calcium channel blocker Theophylline Beta-agonist Anticholinergic properties radiation

Diagnosis For patients with classical symptoms Heartburn( substernal postprandial burning with upward radiation) High likelihood they have GERD Trail of PPI therapy good response no further testing Odynophagia, dysphagia Need EGD Alarming symptoms Wt loss FFt Vomiting Hematemesis

Therapy failures Improper timing Inadequate dosage Rapid metabolizer Non compliance Improper timing Inadequate dosage Rapid metabolizer Nocturnal acid breakthrough False positive GERD Another esophageal disorder( achalasia,EoE) Functional disorder Z-E syndrome EoE Celiac disease Medication induced Infection Delayed gastric emptying