Esophageal Motility and Esophagitis

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