Oesophagal Diseases Gastro-esophageal Reflux Disease (GERD) - PowerPoint Presentation

Slide1

Oesophagal Diseases

Slide2

Gastro-esophageal Reflux Disease (GERD)

ACG define – Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus which are Often chronic and relapsing.

Slide3

Pathophysiology

Slide4

Clinical Presentations of GERD

Heart burn is a classical symptom-

Substernal

burning or regurgitation, Postprandial, Aggravated by change in position, get

releif

by Antacid.

Potential Oral and

Laryngopharyngeal

Signs Associated with GERD - Edema and hyperemia of larynx,Vocal cord erythema, polyps, granulomas, ulcersHyperemia and lymphoid hyperplasia of posterior pharynx Interarytenyoid changes

Slide5

Clinical Presentations of GERD

Hoarseness, Laryngitis,

Pharyngitis

, Chronic cough,

Globus

sensation,

Dysphonia

, Subglottic stenosis, Laryngeal cancer.Pulmonary symptoms are Asthma, Aspiration pneumonia, Chronic bronchitis, Pulmonary fibrosis. Chest pain, Dental erosion

Slide6

Diagnostic Tests for GERD

Barium swallow

Endoscopy

Slide7

Ambulatory 24 hr pH monitoring.

Esophageal

manometry

-

Assess LES pressure, location and relaxation, Assist placement of 24 hr. pH catheter

Assess peristalsis - Prior to

antireflux

surgery

Slide8

Treatment Goals for GERD

Eliminate symptoms

Heal

esophagitis

Manage or prevent complications

Maintain remission

Slide9

Lifestyle modifications

Avoid large meals

Avoid acidic foods (citrus/tomato), alcohol,

caffiene

, chocolate, onions, garlic, peppermint

Decrease fat intake

Avoid lying down within 3-4 hours after a meal

Elevate head of bed 4-8 inches

Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS)Lose weight, Stop smoking. Acid Suppression Therapy- PPIAntireflux surgery

Slide10

Complications of GERD

Erosive/ulcerative

esophagitis

Esophageal (peptic) stricture

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Balloon Dilation of a Peptic Stricture

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Barrett’s Esophagus

Defined as the presence of >3 cm of Columnar lined esophagus.

Incidence 0.5-2%

Associated with the development of

adenocarcinoma

Slide13

Slide14

Motility Disorders

Achalasia

Diffuse esophageal spasm

Nutcracker esophagus

Scleroderma

Nonspecific esophageal

dysmotility

Slide15

Achalasia

Achalasia

means “failure to relax.” term coined in 1929

Epidemiology

1-2 per 200,000 population

usually presents between ages 25 to 60

male=female

Pathophysiology

-loss of ganglionic cells in the myenteric plexus (distal to proximal)----that affect relaxation of LES.Basal LES pressure rises

Slide16

Clinical presentationsolid

dysphagia

90-100% (75% also with

dysphagia

to liquids)

post-

prandial

regurgitation 60-90%

chest pain 33-50%,weight lossnocturnal cough and recurrent aspirationDiagnostic Work UpBarium esophagram (dilated esophagus with taper at LES) Bird peak , good screening test (95% accurate)

Slide17

Endoscopy (rule out GE junction tumors, esp. age>60)

Esophageal

manometry

(absent peristalsis,

 LES relaxation, & resting LES >45 mmHg

Slide18

Treatment of Achalasia

Nitrates and Calcium Channel Blockers- Reduces LES pressure.

Balloon

Myotomy

-Sequential dilation of LES with

intraluminal

ballons

of 30,35 & 40 mm under flurocopic control.Surgical Myotomy by either an Open or Laproscopic approach. A laparoscopic Heller myotomy and partial fundoplication is the procedure of choice for esophageal achalasia

.

Slide19

Diffuse Esophageal Spasm

Unknown etiology .

Nonprogressive

dysphagia

with solids and liquids and

nonexertional

chest pain that responds to nitroglycerin.

corkscrew on barium .The diagnosis by manometryperiodic occurrence of simultaneous high-amplitude contractions with intervening periods of normal peristalsis.Treatment:-Nitrates, and CCBs , Botulinum toxin injection, surgery does not have an established role.

Slide20

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

Slide21

Esophageal Webs

localized narrowing of the esophagus caused by

intraluminal

extension of the mucosa and part of the

submucosa

Congenital or acquired (mc), usually secondary to conditions such as

iron deficiency anemia/Plummer-Vinson syndrome and ulcerative colitis. Tt: endoscopic dilatation

Slide22

Pharyngoesophageal/

Zenker’s

Diverticula

From muscle

incoordination

that leads to

herniation

of the mucosa in prox esophagus.Dysphagia mc symptom, halitosis, regurgitation, throat discomfort, palpable neck mass, recurrent aspiration pneumonia.The best initial diagnostic tool is a barium swallow.

Slide23

Carcinoma Esophagus

Slide24

Epidemiology:-

Esophageal cancer is the 7

th

leading cause of cancer deaths, accounts for 1% of all malignancy & 6% of all GI malignancy.

Most common in China, Iran, South Africa, India and the former Soviet Union.

The incidence rises steadily with age, reaching a peak in the 6

th

to 7

th decade of life.Male : Female = 3.5 : 1Worldwide SCC responsible for most of the cases. Adenocarcinoma now accounts for over 50% of esophageal CA, due to association with GERD , Barretts’s esophagus & obesity.SCC usually occurs in the middle 3rd of the esophagus (the ratio of upper : middle : lower is 15 : 50 : 35).

Adenocarcinoma

is most common in the lower 3

rd

of the esophagus, accounting for over 65% of cases.

Slide25

Risk Factors : Squamous

Cell Carcinoma

Smoking and alcohol (80% - 90%)

Dietary factors

N-

nitroso

compounds (animal carcinogens)

Pickled vegetables and other food-products

Toxin-producing fungi Betel nut chewing, Ingestion of very hot foods and beverages (tea) Underlying esophageal disease (such as achalasia and caustic strictures)Genetic abnormalities:p53 mutationRisk Factors: AdenocarcinomaAssociated with Barretts’s esophagus, GERD

&

hiatal

hernia.

Obesity (3 to 4 fold risk)

Smoking (2 to 3 fold risk)

Increased esophageal acid exposure such as

Zollinger

-Ellison syndrome.

Slide26

Clinical Features

Associated with the symptoms of

dysphagia

, wt. loss, pain, anorexia, and vomiting

Symptoms often start 3 to 4 months before diagnosis

Dysphagia

- in more than 90% pt.

Odynophagia

- in 50% of pt.Wt. loss – more than 5 % of total body wt. in 40 – 70% pt. associated with worst prognosis. Complications:Cachexia, Malnutrition, dehydration, anaemia,.Aspiration pneumonia.Distant metastasis.Invasion of near by structures: e.g. Recurrent laryngeal nerve → Hoarseness of voice Trachea → Stridor

& TOF→ cough, choking & cyanosis

Perforation into the pleural cavity →

Empyema

Slide27

Pathological Classification

Preinvasive

Neoplasia

Esophageal intraepithelial

neoplasia

Glandular epithelial dysplasia/

AdenoCA

in situ in Barrett's mucosaInvasive Malignant Neoplasia Squamous cell carcinoma Adenocarcinoma, Adenoid cystic carcinoma Mucoepidermoid carcinoma

Adenosquamous

carcinoma

Small cell carcinoma

Carcinoid

tumor

Malignant melanoma & Sarcomas

Slide28

AJCC TNM classification

Slide29

Staging

TNM Stage

Stage

Tis

N0 M0 0

T1 N0 M0 I

T2 N0 M0 IIA

T3 N0 M0

T1 N1 M0 IIBT2 N1 M0T3 N1 M0 IIIT4 any N M0Any T any N M1 IV

Slide30

Diagnostic Workup

Detailed history & Physical examination:

Confirmation of diagnosis:

EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumor from incisor, presence of Barrett’s esophagus.

Early, superficial cancer

Circumferential ulceration esophageal cancer

Malignant stricture of esophagus

Slide31

Staging: CT chest and abdomen:

Slide32

Endoscopic

Ultrasonography

Slide33

Barium swallow:

can delineate proximal and distal margins as well as TEF

Helpful for correlation with simulation film.

Bronchoscopy

:

rule-out fistula in

midesophageal

lesions.Routine Investigations: CBC, chemistries, LFTs.Rat tail appearance

Cancer lower 1/3

Filling defect (ulcerative type)

Apple core appearance

Slide34

PET Scan:-

most recently, proven to be valuable staging tool

can detect up to 15–20% of metastases not seen on CT and EUS

low accuracy in detecting local nodal disease compared to CT / EUS

Value in evaluating response to Chemo Therapy & Radio Therapy

Slide35

SURGICAL MEASURES

Patients with esophageal CA are considered candidates for esophageal resection

(1) there is no evidence of the spread of

thetumor

to structures next to the esophagus, such as the

tracheobronchial

tree, the aorta, or the recurrent laryngeal nerve;

(2) there is no evidence of distant

metastases;and (3) the patient is fit from a cardiac and respiratory point of view.An esophagectomy can be performed by using (1) an abdominal and a cervical incision with blunt dissection of the thoracic esophagus through the esophageal hiatus (transhiatal esophagectomy) or (2) an incision into the abdomen and the right side of the chest (transthoracic

esophagectomy

).

After removing the esophagus,

continuity of the gastrointestinal tract is reestablished by using either the stomach or the colon.

The morbidity

rate of the operation is approximately 30%

Slide36

NONSURGICAL MEASURES

Neoadjuvant

therapy based on a combination of radiation therapy and chemotherapy(5 FU,

Cisplatin

,

Vinblastin

,

Leucovorin

) has been attempted to improve both the local control, via radiation therapy,and the distant control of the disease, via chemotherapy.. Nonoperative therapy is reserved for patients who are not candidates for surgery because of local invasion of the tumor, metastases, or a poor functional status. The goal of therapy in these patients is palliation of the dysphagia, which will allow them to eat.

Slide37

The following treatment modalities are available to achieve this goal:

(1) Expandable, coated, metallic stents can be deployed by endoscopy under fluoroscopic guidance to keep the esophageal lumen open.

(2) Laser therapy (

Nd:YAG

laser) relieves

dysphagia

in up to 70% of patients. However, multiple sessions are usually required.

(3) Radiation therapy is successful in relieving

dysphagia in about 50% of patients.Prognosis The overall 5-year survival rate for esophageal cancer remains approximately 25–30%.

Slide38

ESOPHAGEAL ATRESIA &TRACHEOESOPHAGEAL FISTULA

Prevalence 1 in 3000 live

births,M

=F.

Infants with these conditions are often premature, and

polyhydramnios

is commonly diagnosed prenatally.

Classification & Incidence

:-Atresia with distal TEF 85.4%Atresia without TEF 7.3%TEF without atresia 2.8%Atresia with proximal & distal TEF 2.1%Atresia with proximal TEF < 1.0%

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Slide40

ReferencesScott-Brown’s

Otorhinolaryngolology

, Head and Neck Surgery, Vol-2 ,7

th

edition.

Cummings ,

Otorhinolarngology

Head and Neck Surgery, Vol-2 ,4

th edition.