Esophageal Disorders

Dr. H. Rustam Effendi YS,SpPD-KGEH

Divisi Gastroenterologi dan Hepatologi
Departemen Ilmu Penyakit Dalam FKUSU/
RSUP H. Adam Malik - RSU Dr. Pirngadi Medan

15 Oktober 2012
 Kelainan pada Esofagus
• Odinofagia.
• Disfagia
• Gangguan passage oesophagus.
• Striktura oesophagus
• Varises oesophagus
• Gangguan motilitas oesophagus /reflux
• oesophagitis.
• Corosive lesions of oesophagus
 Kelainan Esofagus
1.Dysphagia:( Disfagia)
– Kesulitan menelan.

2.Odynophagia:
– Painful swallowing, is characteristic of nonreflux
esophagitis (particularly monilial), herpes, and
pill-induced esophagitis.

– may occur with peptic ulcer of the esophagus

(Barrett's ulcer),carcinoma with periesophageal
involvement, caustic damage of the esophagus,
and esophageal perforation
 Kelainan esofagus(lanjutan)
• Phagophobia : rasa takut menelan, dan menolak untuk
menelan.
Bisa terjadi pada hysteria, rabies, tetanus, dan
paralysis faring.
• Aphagia : obstruksi esofagus yg komplit,biasanya akibat
sangkutnya bolus dan merupakan suatu darurat medik.
• Globus pharyngeus/globus sensation(globus hystericus) :
Perasaan adanya gumpalan yang mondok di
kerongkongan,tapi tidak ada kesulitan menelan. Dijumpai
kontinu tapi tdk berhubungan dgn menelan. Bisa hilang
sementara waktu menelan.
• Penyebab umum globus sensation :
( GERD,anxiety disorder, Early hypopharyngeal cancer,
goiter.
 Heartburn, or pyrosis
• Ditandai rasa terbakar retrosternal, rasa tidak
enak, bisa menjalar keatas/kebawah dada, spt
gelombang.
• - Bila berat, bisa menjalar kesebelah dada,leher, dan
sudut rahang.
• - Heartburn adl. Keluhan khas dari reflux
esophagitis dan bisa berhubungan dengan
regurgitation rasa adanya cairan hangat naik
ketenggorok. Akan bertambah berat bila ada
tekanan, atau berbaring dan makin berat
sesudah makan.
 KELAINAN ESOFAGUS
ODYNOPHAGIA
a severe sensation of burning, squeezing pain
while swallowing caused by irritation of the
mucosa or a muscular disorder of the esophagus.
Aetiology :
1.Infection (fungal and bacterial,viruses/herpes),
2.Acid reflux/GERD (form of esophageal disease),
3.Exposure to radiation /Chemical Irritation,pill
4.Tumor,Achalasia
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
 Esophagitis
1.CAUSTIC INGESTION
Acid
Alkali (lye, Drano)
2.PILL-INDUCED ESOPHAGITIS
Antibiotics (especially doxycycline)
Potassium chloride, slow release
Quinidine
Iron sulfate
Zidovudine
NSAIDs
 AETIOLOGY (cont)
3.Radiation Esophagitis
4.Infectious Esophagitis
5.Healthy persons
Candida albicans
Herpes simplex
6.HIV patients
Fungal (Candida, histoplasmosis)
Viral (herpes simplex, cytomegalovirus, HIV, Epstein-Barr
virus)
Mycobacteria (tuberculosis, avium-complex)
Protozoan (Cryptosporidium, Pneumocystis carinii)
7.Idiopathic ulcers
8.Severe Ulcerative Esophagitis Secondary to GERD
9.Esophageal Carcinoma,Achalasia
 Dysphagia

Kesukaran dalam menelan.Biasanya os mengeluh makanan

tersangkut antara mulut, faring atau esofagus

• Salah arah dari makanan menyebabkan nasal

regurgitation, laryngeal dan aspirasi paru waktu
menelan, merupakan tanda khas dari oropharyngeal
dysphagia.
• Lesi peradangan yang sakit yg menyebabkan
odynophagia bisa juga menyebabkan penolakan
untuk menelan.
• Ada pasien yang dapat merasakan turunnya
makanan ke esophagus. Sensitifitas seperti ini tidak
berhubungan dgn suatu food sticking atau obstruksi.
Esophageal Motility Disorders

Dr. H. Rustam Effendi YS,SpPD-KGEH

Divisi Gastroenterologi dan Hepatologi
Departemen Ilmu Penyakit Dalam FKUSU/
RSUP H. Adam Malik - RSU Dr. Pirngadi Medan

15 Oktober 2012
 Esophageal Disorders
• Motility
• Anatomic & Structural
• Reflux
• Infectious
• Neoplastic
• Miscellaneous
Esophageal Motility Disorders
Esophageal Anatomy

Upper Esophageal
Sphincter (UES)

Esophageal Body 18 to 24 cm
(cervical & thoracic)

Lower Esophageal
Sphincter (LES)
 Normal Phases of Swallowing
• Voluntary
– oropharyngeal phase – bolus is voluntarily moved into the pharynx
• Involuntary
– UES relaxation
– peristalsis (aboral movement)
– LES relaxation
• Between swallows
– UES prevents air entering the esophagus during inspiration and
prevents esophagopharyngeal reflux
– LES prevents gastroesophageal reflux
– peristaltic and non-peristaltic contractions in response to stimuli
– capacity for retrograde movement (belch, vomiting) and
decompression
 Normal Swallowing
Cortical Swallowing Areas
Frontal cortex

Swallowing Center

Brainstem
Motor Nuclei

Oropharynx & Esophagus

 Motility Disorders
• upper esophageal
– UES disorders
– neuromuscular disorders
• esophageal body
– achalasia
– diffuse esophageal spasm
– nutcracker esophagus
– nonspecific esophageal
dysmotility
• LES
– achalasia
– hypertensive LES
• primary disorders
– achalasia
– diffuse esophageal spasm
– nutcracker esophagus
– nonspecific esophageal
dysmotility
• secondary disorders
– severe esophagitis
– scleroderma
– diabetes
– Parkinson’s
– stroke
Motility Disorders
Normal Manometry
• diagnostic tools
– cineradiology or
videofluoroscopy
(MBS)
– barium
esophagram
– esophageal
manometry
– endoscopy
 Esophageal Motility Disorders
Upper ES
• cause oropharyngeal dysphagia
(transfer dysphagia) •cricopharyngeal hypertension
– patients complain of difficulty –elevated UES resting tone
swallowing
– tracheal aspiration may cause –poorly understood (reflex
symptoms due to acid reflux or
• pharyngoesophageal distension)
neuromuscular disorders
– stroke •cricopharyngeal achalasia
– Parkinson’s –incomplete UES relaxation
– poliomyelitis
– ALS
during swallow
– multiple sclerosis –may be related to Zenker’s
– diabetes diverticula in some patients
– myasthenia gravis
– dermatomyositis and
polymyositis
• upper esophageal sphincter
(cricopharyngeal) dysfunction
UES Disorders

• clinical manifestations
– localizes as upper (cervical) dysphagia
– within seconds of swallowing
– coughing, choking, immediate regurgitation, or
nasal regurgitation
• diagnosis: swallow evaluation & modified
barium swallow
Esophageal Motility Disorders

Body esophagus & LES

• symptoms: usually dysphagia (intermittent and
occurring with liquids & solids)
• diagnostic tests
– barium esophagram
– endoscopy
– esophageal manometry
• disorders
– achalasia
– diffuse esophageal spasm (DES)
– nutcracker esophagus
– hypertensive LES
– nonspecific esophageal dysmotility
• hypomotility
• hypermotlity
 Achalasia
• first clinically recognized
esophageal motility disorder
• described in 1672, treated
with whale bone bougie
• term coined in 1929
• dual disorder
– LES fails to appropriately relax
• resistance to flow into stomach
• not spasm of LES but an
increased basal LES pressure
often seen (55-90%)
– loss of peristalsis in distal 2/3
esophagus
 Achalasia
• epidemiology
– Rare chronic disorder, affects all ages and both genders
– 1-2 per 200,000 population
– usually presents between ages 25 to 60
– male=female
– Caucasians > others
– average symptom duration at diagnosis: 2-5 years
• pathology
– loss of ganglionic cells in the myenteric plexus (distal to
proximal)
– vagal fiber degeneration
– underlying cause: unknown
• autoimmune? (antibodies to myenteric neurons in 50% of patients)
 Achalasia
Etiology and Pathophysiology
• Peristalsis of lower two thirds of esophagus
absent
– Impairment of neurons that innervate esophagus
– Unopposed contraction of LES
• LES pressure ↑
• Incomplete relaxation of LES
• Obstruction occurs at/near diaphragm
• Food and fluid accumulate in lower
esophagus
• Result: Dilation of lower esophagus
 Achalasia
Clinical Manifestations
• Symptoms
• Symptoms (cont’d)
– solid dysphagia 90-
100% (75% also with – Weight loss
dysphagia to liquids) –nocturnal cough and
– Globus sensation recurrent aspiration
– post-prandial – Globus sensation
regurgitation 60-90%
– Inability to belch
– chest pain 33-50%.
Substernal chest pain – GERD
• During/after a meal – Regurgitation
– Halitosis
– pyrosis 25-45%
 Achalasia
Diagnostic Studies
• Radiologic studies
• Manometric studies of lower esophagus
• Endoscopy
•diagnosis
–plain film (air-fluid level, wide mediastinum, absent gastric
bubble, pulmonary infiltrates)
–barium esophagram (dilated esophagus with taper at LES)
•good screening test (95% accurate)
–endoscopy (rule out GE junction tumors, esp. age>60)
–esophageal manometry (absent peristalsis,  LES relaxation,
& resting LES >45 mmHg)
 Achalasia
• treatment - reduce LES pressure and increase emptying
– nitrates and calcium channel blockers
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects
– botulinum toxin (prevents ACH release at NM junction)
• 90% initial response; 60% at 1 year
– pneumatic dilation (disrupt circular muscle)
• 60-95% initial success; 60% at 5 years
• recent series suggest 20-40% will require re-dilation
• risk of perforation 1-13% (usually 3-5%); death 0.2-0.4%
– surgical myotomy (open or minimally-invasive)
• >90% initial response; 85% at 10 years; 70% at 20 years (85% at 5
years with min. inv. techniques)
• <1% mortality; <10% major morbidity
• 10-25% acutely develop reflux, up to 52% develop late reflux
 Achalasia
Collaborative Care
• Cause unknown
• Goals
– Relieve symptoms
– Improve esophageal emptying
– Prevent development of megaesophagus
 Achalasia
Collaborative Care
• Endoscopic pneumatic dilation
– Outpatient procedure
– LES disrupted using balloons of progressively
larger diameters
– Repeat dilations are often required
Pneumatic dilation to Treat Achalasia

Fig. 42-10
 Achalasia
Collaborative Care
• Surgical therapy
– Heller myotomy
• Done laparoscopically
• LES surgically disrupted
• Often has antireflux surgery at same time
• 1 to 2 weeks for recovery
 Achalasia
Collaborative Care
• Drug therapy
– Smooth muscle relaxants
– Botulinum toxin injection
• 1 to 2 years relief
• Symptomatic relief
– Semisoft bland diet
– Eating slowly
– Drinking with meals
– Sleeping with HOB elevated
 Spastic Motility Disorders of the
Esophagus
• “lumper” approach
– normal
– achalasia
– spastic motility disorder
• “splitter” approach (radiology and manometry)
– diffuse esophageal spasm
– nutcracker esophagus
– hypertensive LES
– nonspecific esophageal dysmotility
• “splitting” has not resulted in a clinical benefit
 Diffuse Esophageal Spasm

• frequent non-peristaltic
contractions
– simultaneous onset (or too
rapid propagation) of
contractions in two or more
recording leads
– occur with >30% of wet
swallows (up to 10% may
be seen in “normals”)
 Nutcracker Esophagus

• high pressure
peristaltic contractions
– avg pressure in 10
wet swallows is
>180 mm Hg
• 33% have long duration
contractions (>6 sec)
• may inter-convert with
DES
 Nonspecific Esophageal
Hypertensive LES
Dysmotility

• high LES pressure • abnormal motility

– >45 mm Hg pattern
• normal peristalsis • fits in no other category
• often overlaps with – non-peristalsis in 20-30%
other motility of wet swallows
disorders – low pressure waves (<30
mm Hg)
– prolonged contractions
 Spastic Motility Disorders of the
Esophagus
• epidemiology
– any age (mean age 40)
– female > male
• symptoms
– dysphagia to solids and liquids
• intermittent and non-progressive
• present in 30-60%, more prevalent in DES (in most studies)
– chest pain
• constant % across the different disorders (80-90%)
• swallowing is not necessarily impaired
• can mimic cardiac chest pain
– pyrosis (20%) and IBS symptoms (>50%)
– symptoms and manometry correlate poorly
Spastic Motility Disorders of the Esophagus
• diagnosis
– manometry
– barium esophagram
– endoscopy
– pH monitoring
• treatment
– reassurance
– nitrates, anticholinergics, hydralazine - all unproven
– calcium channel blockers - too few data with negative
controlled studies in chest pain
– psychotropic drugs – trazodone, imipramine and
setraline effective in controlled studies
– dilation - anecdotal reports, probable placebo effect
 Manometry in Esophageal
Symptoms
Non-Cardiac Chest Pain Dysphagia

Normal
ACH 48%
HLES ACH
DES 19%
NED Normal
9% 75%

HLES
NE 1%
12%
DES
7%

NED
20% NE
5%

JE Richter, Ann Int Med, 1987

 Hypomotilty Disorders
• primary (idiopathic)
– aging produces gradual decrease in contraction
strength
– reflux patients have varying degrees of
hypomotility
• more common in patients with atypical reflux symptoms
• usually persists after reflux therapy
– defined as
• low contraction wave pressures (<30 mm Hg)
• incomplete peristalsis in 30% or > of wet swallows
 Hypomotilty Disorders
• secondary
– scleroderma
• in >75% of patients
• progressive, resulting in aperistalsis in smooth-muscle region
• incompetent LES with reflux
– other “connective tissue diseases”
• CREST
• polymyositis & dermatomyositis
– diabetes
• 60% with neuropathy have abnormal motility on testing (most asx)
– other
• hypothyroidism, alcoholism, amyloidosis
 Nonischemic Chest Pain
• remains poorly understood (functional chest pain)
• enthusiastic investigation finds numerous associations in studies
– psychiatric disorders (depression, panic or anxiety disorder…)
– esophageal disorders (GERD, motility disorders…)
– musculoskeletal disorders
– cardiac disease (microvascular, MVP, tachyarrhythmias…)
• GERD is by far the most common, diagnosable, esophageal cause
– 50-60% of patients have heartburn or acid regurgitation symptoms
– 50% have abnormal esophageal pH studies (not always correlating to sxs)
– very low incidence of endoscopic findings
– “PPI Test” may be best and most cost-effective approach
• a small subset of patients with non-GERD NCCP display a variety of esophageal
motility disorders
– symptoms and motility findings correlate poorly
– esophageal hypersensitivity/hyperalgesia may explain the symptoms