1. By George Vagujhelyi MD
Esophageal Disorders By
George Vagujhelyi MD

2. Cardinal symptoms Heartburn Bland or sour regurgitation Chest Pain
Dysphagia
Odynophagia

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

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

5. 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

6. 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)

7. 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

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

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

15. 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

18. 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

19. 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.

20. 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

21. 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

24. 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 mg QD-BID
Systemic steroids 2mg/kg/d 60 mg max for 4 wks course severe symptoms
Fluticasone 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)

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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