Motility Disorders and Esophagitis are must-know esophageal pathologies are NOT inherently malignant (cancerous), but may be associated with increased risk for malignancy.

 

 

Motility Disorders

  • Achalasia – failure of the lower esophageal sphincter (LES) to relax.
    • Pathophysiology:  ganglion cell and myenteric plexus breakdown, cholinergic nerve predominance leading to persistent contraction of muscle.
    • Cancer risk:  squamous cell esophageal cancer in those with >10 year history of achalasia.
    • Clinically:  dysphagia to solids and liquids, regurgitation of bland food; chest pain, weight loss.  No response to PPI.
    • Best initial test:  barium esophagogram (bird’s beak appearance!)
    • Confirmatory test:  manometry
    • EGD may be done to ensure there is no mass obstruction or concomitant pathology (e.g. ulcer, inflammation)
      • Mimicking condition:  malignant/benign tumors that invade nearby esophageal nerves (pseudoachalasia).
        • Consider when patient c/o weight loss and age > 60
    • Treatment:
      • Pneumatic dilation via upper endoscopy (slightly cheaper)
      • Surgical myotomy
      • Both aforementioned treatments have similar rates of success!
      • Injection of botulinum toxin via EGD has 50% relapse rate at/before 6 months.
      • Last line:  CCBs (nifedipine) or prolonged-release nitrates.
  • Diffuse Esophageal Spasm / Nutcracker Esophagus
    • Clinically:  chest pain similar to angina and dysphagia.
    • Pathophysiology:  unknown; concomitant high-amplitude (>30 mm Hg in DES; >220 mmHg in Nutcracker) esophageal muscular contractions.
    • Diagnosis:  barium esophagogram “corkscrew esophagus
    • Treatment:  CCBs, botulinum toxin, hydralazine, and/or anxiolytics.

Esophagitis

  • Infectious Esophagitis – bacterial, fungal, parasitic, viral.
    • Clinically:  painful swallowing and/or dysphagia.
    • Candida (albicans) – both immunocompetent and immunocompromised patients
      • EGD will show small white raised plaques.
      • Treatment:  Fluconazole PO
    • CMV – immunocompromised patients only.
      • EGD with biopsy of ulcer base (CMV base)
      • Treatment:  Ganciclovir and valganciclovir
    • HSV – both immunocompetent and immunocompromised patients
      • EGD with biopsy of ulcer edge (HSV edge)
      • Treatment:  Acyclovir
  • Pill Esophagitis
    • Direct mucosal irritation and inflammation
    • Risk factors:  non-peristalsis of esophagus, medications decreasing muscular function (e.g. opioids), diminished salivary output, direct pill damage.
    • Clinically:  dysphagia, odynophagia, chest pain – can occur a few hours after ingestion or days later.
    • Typical offenders:
      • Alendronate, ferrous sulfate, mexiletine, tetracycline, doxycycline, quinidine, potassium.
    • Worry about stricture progression with:
      • Alendronate, NSAIDs, potassium, ferrous sulfate.
    • Prevention is key!  Simply drink plenty of water/fluids when taking pill and sit UP greater than/equal to 30 minutes.
  • Eosinophilic Esophagitis
    • Squamous mucosal inflammation secondary to permeation of eosinophils.
    • Think of when seeing:  atopic man, near middle age, with dysphagia to solid foods and frequent food blockages.
    • Associated with asthma, eczema, food allergies.
    • Population studies:  54 per 100,000 people in the US.
    • Diagnosis:  EGD shows longitudinal furrows, stenosis of lumen, leukoplakia and white exudates, and rings.  BIOPSY shows eosinophils, >15 eos per HPF.
    • Must rule out GERD-induced esophageal eosinophilia via trial of PPI.
      • If repeat biopsy shows improvement post-PPI, you’ve diagnosed GERD-associated eosinophilia.
      • If no improvement with PPI, it is eosinophilic esophagitis!
    • Treatment:
      • Diet modification (stop eating foods that agitate esophagus)
      • Swallowed aerosolized glucocorticoids – budesonide or fluticasone
      • Oral prednisone (if above don’t work)
      • Treat any associated strictures with dilation.
      • CHRONIC process with high recurrence rate if treatment interruption.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 3-7
  • Image source:  http://www.wikiwand.com/en/Diffuse_esophageal_spasm

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