Esophageal stricture Dr. - PowerPoint Presentation

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Esophageal stricture

Dr.

Mohd

Azam

Haseen

Associate Professor

D/O

Cardiothoracic surgery

J.N.Medical

College,AMU,Aligarh

Slide2

Introduction

Anatomy/physiology

Causes

Individual entities

Questions

Slide3

Anatomy

Muscular tube

25cm

Cricopharyngeus

to LES

Mainly posterior

mediastinum

Outer longitudinal & inner circular muscles

Upper 1/3 striated , lower half smooth muscle

Two sphincters; UES-

cricopharyngeus

muscle, LES lower 1-2 cm of esophagus

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Lies in midline, with a deviation to the LEFT in the lower portion of neck and upper portion of thorax

Returns to midline in midportion of thorax near bifurcation of the trachea

Surgical Approach: Cervical

 Left, Upper Thoracic Right, Lower Thoracic  Left

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Three anatomic constrictions:

-

Cricopharyneus

-Aortic arch/left

mainstem

bronchus

-

Gastroesophageal

junction

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Anatomy

Blood supply:

inferior thyroid artery

branches from thoracic aorta, bronchial A.

branches from left gastric and inferior

phrenic

arteries

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Anatomy/Physiology

Venous; submucosal plexus drains into plexus outside of esophagus

Outer plexus to :

Inferior thyroid

Azygos

Coronary

Gastric venous system

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Defination

A

ny loss of lumen area within the esophagus

The normal esophagus measures 20 mm in diameter

P

redominant symptom of strictures is dysphagia, which is usually when the lum

i

nal diameter is less than 15 mm

.

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Etiology

Intrinsic strictures

Acid peptic

disorder (GERD)

Foreign body induced

Chemical/lye

ingestion

Iatrogenic -

Post-nasogastric tube

,post endoscopy ,

Sclerotherapy

Infectious esophagitis

Radiation-induced

Esophageal/gastric malignancie

s

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Etiology

Extrinsic strictures

Pulmonary/mediastina

l

malignancies

Anomalous vessels and aneurysms

Metastatic submucosal infiltration (breast cancer, m

e

sothelioma, adenoeareinoma of gastric eardia)

Diverticula

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Intrinsic strictures are most common, with acid/ peptic cause accounting for the majority of cases (60%-70%)

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Clinical picture of Esophageal

stricture

Heartburn

D

ysphagia

O

dynophagia

F

ood impaction

W

eight loss

C

hest pain.

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Diagnostic work up in Esophageal

stricture

Barium swallow

ENDOSCOPY

Esophagoscopy

–rigid/flexible

Biopsy

CECT

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Endoscopy

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Rigid

esophagoscopy

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Esophageal stricture treatment

Dilation. The esophagus is stretched by passing a dilator or air-filled balloon is passed through a endoscope.

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Ballooon dilatation

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Esophageal stricture treatment

Surgery

is

needed

if

repeated dilations do not keep these strictures from returning.

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Esophageal bypass grafting

(Esophagoplasty)

Total colonoesophagoplasty

Total gastroesophagoplasty

Total jejunoesophagoplasty

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Swallowed FB

Peds 80% of all cases

Prisoners, psych, edentulous adults

Adults=meat and bones

Peds = coins, toys, crayons, pen caps

Psych and prisoners = unlikely objects, spoons, razors

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Swallowed FB

Most pass spontaneously

10-20% require some intervention

1% surgical

Most are at “anatomic

narrowings

”

Cricopharyngeal

(C6) most commonthoracic inlet(T1

)

aortic

arch(T4

)

tracheal

bifurcation(T6

)

hiatal

narrowing(T10-11)

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Pathophysiology

Once object passes pylorus, usually passes out with stool.

Irregular or sharp edges may lodge anywhere though

.

Neglected Foreign bodies can lead to stricture formation

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Esophagitis

Inflammatory: can progress to ulceration, scarring,

stricture

Med induced-NSAIDs, KCL, doxy,

clindamycin

,

tetracycline,iron,alendronate

Infectious:

immunosuppression; AIDSCandida, HSV, CMV,

aphthous

ulceration

Fungal,

varicella

, EBV.

Slide34

Caustic Injury

Caustic ingestion can result in severe injury to the esophagus and stomach.

Most ingestions occur accidentally in the pediatric population and the remainder in suicidal, psychotic, and alcoholic adults

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Caustic Ingestion

Esophagus, pharynx, larynx

Bases ( most severe injuries )

Drain cleaners

Dishwasher soap

Acids

Bleaches

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Mechanism of injury

Alkalis – pH > 7

Liquefaction necrosis

Acids – pH < 7

Coagulation necrosis

Bleaches – pH = 7

Irritants

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Severity of burn

Type

Amount

Concentration

Time of

contact

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Signs and symptoms

Pharyngeal or laryngeal

Odynophagia

Mucosal

erythema

, ulceration

Drooling

Tongue edema

Stridor

Hoarseness

Esophageal

Dysphagia

Odynophagia

Chest or back pain

Gastric

Epigastric

pain or tenderness

Vomiting

Hematemesis

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Esophagoscopy

Esophagoscopy

in virtually all patients at 24-48 hours

post-ingestion

Signs and symptoms are not entirely predictive of esophageal injury

48-72 hrs – structural weakness in esophageal

wall

< 24 hours – underestimation of injury> 48-72 hours with risk of iatrogenic perforation – barium swallow

Rigid vs. flexible debatable

Endoscopy to upper limit of severe burn

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Radiography

Radiologic exam

Chest & neck

radiographs - WNL

Barium swallow

Will not reveal 1

st

and 2

nd

degree injuries

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Immediate Treatment

Lye or other alkali

neutralized with half-strength vinegar, lemon juice, or orange juice

Acid

neutralized with milk, egg white, or antacids

sodium bicarbonate is not used because it generates CO2, which might increase the danger of perforation

Emetics are contraindicated

vomiting renews the contact of the caustic substance with the esophagus

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Management of caustic injury

No evidence of burns at endoscopy

Keep under observation

Oral nutrition resumed when patient can painlessly swallow saliva.

First degree burn

Observation for 24-48 hrs.

Oral nutrition resumed when patient can painlessly swallow saliva.

Barium swallow at 24 hrs.

Repeat endoscopy & barium swallow at 1,2 and 8 months.

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Management of caustic injury

Second & third degree burns

Resuscitation is aggressively pursued

NPO, IV fluid, PPI, Antibiotics, steroids.

Conservative management if no perforation.

Perforation/full thickness necrosis – exploratory

thoracotomy

/

laparotomy.

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Management of Chronic phase

Aimed at managing strictures & fistulas.

Stent placement

during acute phase to prevent stricture formation. Stent removed at 3 weeks &

bougie

dilatation continued to achieve adequate lumen (40 French).

Reconstructive surgery

at 6 month to 1 year.

Esophagectomy with gastric pullup

Esophagectomy

with

jejunal

interposition

Esophagectomy

with

colonal

interposition

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Surgical Intervention

complete

stenosis

in which all attempts have failed to establish a lumen

marked irregularity and pocketing on barium swallow

development of a severe

periesophageal

reaction or

mediastinitis

with dilatation

fistula

inability to dilate or maintain the lumen above a 40F

bougie

a patient who is unwilling or unable to undergo prolonged periods of dilation

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Surgery

Esophageal Substitute

Colon

Stomach

Jejunum: free/transfer grafts based on the superior thyroid artery or internal mammary artery

Slide48

Schatzki ring:

most common cause of intermittent

dysphagia

with solids

Fibrous stricture near GE junction in 15 % of population

Pts frequently present with food impacted after poorly chewed meat

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SCHATZKI

’

S RING

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Tt:

Treatment consists of dilation with bougienage and possibly acid suppression

Many of these patients require more than one treatment session to obtain a desired esophageal lumen of 15 mm

They are also at higher risk of painful deep mucosal tears

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Esophageal webs

Thin strictures of mucosa and

submucosa

Often mid or proximal esophagus

Congenital or acquired

Plummer-Vinson syndrome, with iron deficiency anemia

Tx

is dilatation

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External compression -

Diverticula

can be found throughout

esaphagus

Zenker

; progressive

outpouching

of pharyngeal mucosa above UES. d/t increased pressure when swallowing.

Usually seen after age 50HalitosisFeeling of a neck masscommonly associated with motor dysfunction

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Zenker’s

itself can either be

resected

or suspended

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Traction Diverticulum

a “true diverticulum”

usually lies

lateral

, and is in

midesophagus

due to inflammation, granulomatous disease, or tumor

Rx: excision and primary closure, may need palliative therapy if due to invasive Ca

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Hiatus hernia

Important cause of reflux and

esophagitis

Types –true

paraesophageal

hernia(rolling hernia)

--mixed type is most common

C/F –

dysphagia,chest pain -- strangulation,gastric perforation

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EOSINOPHILIC ESOPHAGITIS

Also known as

“

allergic

esophagitis

”

.

Predominant symptom is

dysphagia

.

Increasing incidence over past two decades.

Occurs in both children and adults with majority being males. In adults, majority are in their 20

’

s and 30

’

s.

High percentage have allergic issues including asthma, food allergies, hives, hay fever.

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EOSINOPHILIC ESPHAGITIS (CONT)

Findings can include multiple rings, narrowed esophagus, whitish nodules, furrows, & strictures in upper esophagus.

Some cases have involved several family members.

Etiology may relate to food allergies, additives, pollen, reflux?

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FURROWS

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TREATMENT

Trial of anti-reflux medication-PPI.

Allergy testing and diet changes. Elemental diet

Avoidance of six most frequent allergenic foods (eggs, soy, wheat, cow-milk protein, peanuts, and seafood). SFED

Steroid inhaler- swallowing rather than inhaling the medication.

Fluticasone

propionate.

Oral Prednisone- higher incidence of side effects.

Dilatation-

risks of perforation.

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ACHALASIA

Achalasia

is well recognized as a cause of swallowing difficulty.

Distal esophageal sphincter does not relax with a swallow and the muscle of the lower esophagus does not propel the food or liquid downwards i.e. abnormal peristalsis.

Result is

dysphagia

, occasionally chest pain and regurgitation, and weight loss

X-rays can reveal a dilated esophagus.

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ACHALASIA (CONT.)

On endoscopy often see retained food and secretions in esophagus even though patient has been NPO.

Characteristic “yield” of LES to the scope being advanced.

“

Pseudo-achalasia

”

Slide71

X-RAYS OF ACHALASIA

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ACHALASIA TREATMENT

Three common treatment options

Pneumatic forceful balloon

dilitation

with

Rigiflex

balloon. May not work; uncomfortable for patient; 3-5% risk of perforation.

Botox injection. Not always successful. Tends to lose effect in 6-12 months requiring reinjection. Good option for poor surgical candidates.

Surgery-laparoscopic

myotomy

. Cut the sphincter and add partial fundoplication.

Rarely, Calcium Channel blockers or Nitrates.

Slide73

Esophageal Varices

All patients with cirrhosis should have EGD screening for varices.

No varices- rescope in couple years.

Small varices- consider NSBB in these patients

Large varices- low risk group probably use NSBB. High risk group (red wale signs, advanced liver disease) can choose between NSBB and EVL. Add PPI after EVL (ulceration)

Sclerotherapy not warranted for primary prevention of bleeding.

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Esophageal Varices

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Esophageal Varices

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CA Esophagus

common cause of both types.

95 %

squamous

cell

Male : female , 3:1

Fast progression from solids to liquid

dysphagia

Pts >40 yo with dysphagia assume neoplasm. Need expedient work up to rule out malignancy

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A 74 year old male presents with dysphagia, gurgling sounds in his neck, and regurgitation of undigested food. What is the most likely diagnosis?

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Case Presentation

18 y/o female in excellent general health awakens in the morning with rather severe substernal chest pain when she swallows anything even saliva. Has never had similar problems in the past.

Her only medication is doxycycline which she has taken for acne for 2 years.

WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

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Treatment of Pill Ulcers

No evidence that any medication speeds healing. Typically resolves in a few days.

Pain meds.

May need parenteral support in rare cases.

Can try suspension of sucralfate (Carafate) or topical anesthetic (xylocaine).