Spencer C. Knox, MD

Internal Medicine Resident Physician, PGY-3

Tag: dysphagia

Esophageal Metaplasia and Neoplasia

Esophageal cancer accounts for a jaw-dropping amount of cancer-related deaths, and is now classified as the 6th-highest cause of death in this group.  In this installment of the study guide series, I will discuss Barrett Esophagus (I learned this entity as Barrett Metaplasia) and esophageal cancer (neoplasia).

 

Barrett Metaplasia

  • Metaplasia:  columnar epithelium replaces the physiologic squamous epithelium in the distal portion of the food pipe.
  • PRE-MALIGNANT CONDITION
    • Cancer risk of 0.5% per year in those who have Barrett Esophagus.
    • Usual pathway (if progresses to ca):  intestinal metaplasia –> low-grade dysplasia –> high-grade dysplasia.
  • NO evidence that routine screening for BE based on GERD symptoms is helpful.
  • Clinically:
    • Think of this in an older obese white male with chronic reflux and a history of chain-smoking.
    • Protective = average wine consumption, fruits/veggies.
    • Barrett Esophagus occurs in the presence or absence of reflux!
  • Diagnosis:
    • Upper endoscopy showing typical intestinal metaplasia of distal esophagus.
      • Salmon-colored mucosa
      • Further classifications:  Short segment (< 3cm) or long segment (> 3cm)
  • Treatment:
    • PPI are useful for reflux symptom improvement, not preventing progression to dysplasia.
    • HIGH-grade dysplasia = destroy bad tissue with radiofrequency ablation or other resection.
  • Surveillance
    • EGD is primary modality.
    • Based on dysplasia grade:
      • none = repeat EGD 3-5 years.
      • low-grade = repeat EGD 6-12 months
      • high-grade = look for focal lesions, which may harbor more progressive disease; repeat EGD q3 months with resection/surgery.

Esophageal Carcinoma

  • Adenocarcinoma is most common type (#1) in US; SCC is also very common.
  • Typically presents in males, aged 50-60’s.
  • 5-year survival rate 15-25%, depending on stage at presentation.
  • Risk factors:
    • Adenocarcinoma = GERD, Barrett metaplasia, tobacco, radiation, male, old age, poor diet.
    • SCC = tobacco and alcohol, direct toxic injury, Zn and selenium deficiency, prior radiation to region, poor population, poor oral hygiene, HPV, nitrosamine exposure (occupational hazards), nonepidermolytic palmoplantar keratoderma.
  • Diagnosis:
    • #1 symptom = SOLID-food dysphagia
    • Weight loss, low appetite, low hemoglobin/hematocrit.
    • EGD is best way to diagnose.
    • Squamous Cell Carcinoma is proximal
    • Adenocarcinoma is distal
    • CT scan is useful to evaluate for metastatic disease; PET used for questionable lesions.
  • Treatment
    • Refer to Oncology, resection versus chemotherapy is stage dependent at time of diagnosis.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 9-12
  • Image source:  https://en.wikipedia.org/wiki/Barrett’s_esophagus
    • Intestinal metaplasia consistent with Barrett esophagus (left side of main image) and normal stratified squamous epithelium (right side), Alcian blue stain.

Introduction to Esophageal Problems

The very first entry in my GI & Hepatology study outline series will set the stage/define major descriptors of proximal GI (esophageal) symptoms and help with categorizing pathology.

Dysphagia = the sensation that food and/or liquid is not appropriately going through the mouth/throat/esophagus.  Typical symptoms:  “food is getting stuck / impeded.”

  • Oropharyngeal phase – food bolus from mouth into hypopharynx and proximal esophagus
    • “Transfer Dysphagia” – cannot START the swallow maneuver.
    • Symptoms:  coughing, food entering nares, choking; hoarseness and/or dysarthria (neuromuscular weakness/dysfunction)
    • At direct aspiration risk due to inability to clear food/liquid from epiglottis (look for perpetual pulmonary infections)
    • Examples:  cricoid webs, iron deficiency, mass compression, ALS, stroke, dementia, Myasthenia Gravis.
    • Best initial test = modified barium swallow (videofluoroscopy)
      • Test begins with liquid phase, proceeded by solid phase
      • If overall test is normal, symptoms are NOT oropharyngeal in nature.
    • Treatment
      • Dietary modification and swallow exercises (speech language pathology)
  • Esophageal phase – from proximal esophagus to stomach.
    • Symptoms:  lower chest discomfort, can be to solids (mechanical blockage) or liquids (motility issue) or both solids/liquids (motility).
    • Examples:  Achalasia, systemic sclerosis, strictures, cancer, vascular dysphagia, Schatzki ring, or webs
    • Best initial test = upper endoscopy (EGD)

Pyrosis = heartburn, or regurgitation of gastric (acidic) material into esophagus.  #1 GI complaint in the US.  Think about it if symptoms occur 1 hour after eating.  Must first rule out cardiac problems!

Odynophagia = PAIN with swallowing, related to inflammation and mucosal damage.

Globus feeling = symptoms include lump/ball in throat, can be constant when patient is not swallowing.  Consider barium swallow or nasal endoscopy to rule out organic disease.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 1-2
  • Image:  F. Netter Anatomy illustration

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