Acquired diseases-of-the-esophagus.pptxdgghjh

esophagus

1. Acquired Diseases Of The Esophagus Dr. Omongo

2. Surgical Anatomy Has upper and lower sphincters 3 constriction sites Has outer longitudinal and an inner circular layer Proximally only striated and distally smooth ms

3. Swallowing Physiology Oropharyngeal phase Esophageal phase Primary and secondary peristalsis Antireflux mechanism is composed of three components: Mechanically effective LES Efficient esophageal clearance, and Adequately functioning gastric reservoir

4. Gastroesophageal Reflux Disease(GERD) It is one of the most challenging diagnostic and therapeutic problems in clinical medicine The most simplistic approach is to define the disease by its symptoms but not specific

5. Pathophysiology of GERD Altered Antireflux mechanisms : Mechanically deffective LES: resting pressure , overall and intra-abdominal sphincter length D efective esophageal body function Inadequately functioning gastric reservoir and clearance Precipitating factors Chronic gastric distention due to emptying problem, overeating, large air swallowing Spicy or fatty foods, chocolate, alcohol, and coffee Hiatal hernia

6. Symptoms (GERD) Typical Heartburn - substernal burning type discomfort Regurgitation - the effortless return of acid or bitter gastric contents into the pharynx/ mouth Dysphagia -sensation of difficulty in the passage of food from the mouth to the stomach Atipical Chest pain Cough, hoarseness, asthma, and recurrent pneumonia.

7. GERD con…. Investigations 24-hour ambulatory esophageal PH monitoring Stationary and high-resolution manometry Esophageal impedance Upper gastrointestinal endoscopy Barium swallow with video- and cineradiography

8. Complications Associated with GERD Esophagitis Stricture Barrett’s esophagus (BE) Adenocarcinoma Respiratory complications Adult-onset asthma, pulmonary fibrosis

9. Metaplastic (Barrett’s Esophagus ) The squamous epithelium of esophagus replaced with intestinalized columnar epithelium (containing goblet cells) Occurs in 10% to 15% of patients with GERD Endoscopy with biopsy is diagnostic Complications of barrett’s esophagus : Barrett’s ulceration s tricture formation Dysplasia adenocarcinoma sequence 40 times than the normal population with annual conversion rate of 0.2 % to 0.5 %

10. Barrett’s Esophagus… endoscopy

11. Treatment of GERD Lifestyle modifications Medical Simple antacids, alginic acid High-dose PPI Surgical Nissen fundiplication Partial Fundoplications

12. Diaphragmatic ( Hiatal ) Hernias Hiatal hernia is a defect in the diaghragm that allows the abdominal contents to move into chest cavity Three types: Type I( the sliding hernia) Upward dislocation of the cardia Type II (the rolling or PEH- PhrenoEsophageal Hernia) Upward dislocation of the gastric fundus alongside a normally positioned cardia Type III :(the combined sliding-rolling or mixed hernia) Type IV :when an additional organ herniated as well

13. Hiatal hernia

14. Diaphragmatic ( Hiatal ) Hernias…… Incidence and Etiology True incidence is difficult to determine The incidence of a sliding hiatal hernia is seven times higher than that of a PEH PEH is also known as the giant hiatal hernia Higher prevalence of complications with PEHs Sliding type occurs relatively in younger (~48yrs) and PEH in older age groups(~61yrs) with more female predominance(4:1) Structural deterioration of the phrenoesophageal membrane over time is a possible pathology

15. Diaphragmatic ( Hiatal ) Hernias…… Clinical Manifestations Usually asymptomatic Heartburn and regurgitation Dysphagia Postprandial fullness or retrosternal chest pain Dyspnea and recurrent pneumonia Anemia Intermittent foregut obstruction/ vulvulus

16. Diaphragmatic ( Hiatal ) Hernias …. Diagnosis: Erect chest x-ray/ CT Barium swallow Esophagoscopy (UGI endoscopy) 24-hour esophageal ph monitoring –indirect Treatment : Watchful waiting of asymptomatic PEHs ?? Diaphragmatic repair +/- Fundiplication Primarily tissue or mesh repair

17. Diverticula The Pharynx And Esophagus Diverticula of the pharynx and esophagus may be characterized : By their location (proximal, mid-, or distal ) By the nature of concomitant pathology: Diverticula associated with motor disorders are termed pulsion diverticula and those associated with inflammatory conditions are termed traction diverticula

18. Zenker’s Diverticulum Out pouching of the mucosa of pharynx just above cricophryngeal muscle Rare and commonly seen in elderly Incomplete relaxation due to a loss of compliance of the cricopharyngeal sphincter muscle is thought to be the mechanism Presentation : Dysphagia Spontaneous regurgitation of undigested food Cough Halitosis

19. Zenker’s Diverticulum cont… Diagnosis Neck x-ray Barium swallow Treatment Cricopharyngeal myotomy Diverticulopexy Sutured in the inverted position to the prevertebral fascia Diverticulectomy Excessively large,thickened wall

20. Midesophageal diverticula Mostly traction diverticula Theorized by adhesions formed between the inflamed mediastinal nodes and the esophagus resulting traction Common in patients with T b, pulmonary fungal infections ( Eg ., Aspergillosis ), lymphoma, or sarcoid Rarely, when no underlying inflammatory pathology is identified, a motility disorder may be identified

21. Epiphrenic diverticula Arise from the terminal third of the thoracic esophagus and are usually found adjacent to the diaphragm. Associated with distal esophageal muscular hypertrophy, esophageal motility abnormalities, and increased luminal pressure. They are “ pulsion ” diverticula

22. Motility Disorders of the Esophagus Generally Classified into : Primary esophageal motility disorders Secondary esophageal motility disorders

23. Esophageal motility disorders Primary esophageal motility disorders Achalasia Diffuse esophageal spasm Nutcracker esophagus Hypertensive LES Unspecfic and Ineffective esophageal motility disorders Secondary esophageal motility disorders Collagen vascular diseases Chronic idiopathic intestinal pseudoobstruction Neuromuscular diseases Endocrine and metastatic disorders

24. Achalasia The best known and best understood primary motility disorder of the esophagus Primarily disorder of the LES relaxation Incidence is 6/ 100,000 population per year Typically affect adults above 25yrs of age Equal sex distribution

25. Achalasia cont…. Pathophysiology : Not well understood Neurogenic degeneration , which is either idiopathic or due to infection Failure of lower esophageal sphincter to relax on swallowing Elevation of intraluminal esophageal pressure, esophageal dilatation, and Subsequent Loss of progressive peristalsis in the body of the esophagus Vigorous achalasia :simultaneous contractions of esophageal body

26. Achalasia cont…. Presentation : Dysphagia Regurgitation Chest pain Cough Weight loss Diagnosis : Barium swallow---“bird's beak” tapering Endoscopy CT scan Manometry (esophageal motility study)

27. Treatment of Achalasia Medical Smooth ms relaxants( nitroglycerin,nifedipine ) Botulinum toxin injection Balloon dilation Heller myotomy +/- partial fundoplication Esophagectomy and replacement – for end stage

28. Heller myotomy + partial fundoplication

29. Thank you!!