Diseases of esophagus

diseases of esophagus

1. Dr Amit Jha 1 st year PG resident ENT-HNS National medical college

2. Diseases of oesophagus Moderator Dr Inclub Dhungana Lecturer , ENT –HNS National Medical college

3. Diseases of esophagus Other Faculty of ENT-HNS : Dr Ram Kumar Pradhan , HOD Dr Md kamaluddin Rain , Lecturer

4. Clinical Presentation It has 50 Slides and it will take around 45 minutes System – Gastrointestinal System

5. Specific objectives : To understand about diseases of esophagus

6. General Objectives : To know about benign diseases of esophagus To know about malignancy of esophagus To know about Foreign Body esophagus To know about Perforation / Rupture of esophagus To know about motility disorders of esophagus

7. Contents : Perforation/Rupture of esophagus Corrosive Burns of esophagus Benign strictures Motility disorders Gerd Barret's esophagus Achalasia Cardia Benign diseases of esophagus Malignancy of esophagus Plummer Vinson syndrome Zenkers Diverticulum Hiatus Hernia Foreign Body esophagus

8. ⦿ Etiology ⦿ Iatrogenic – instrumental trauma during oesophagoscopy/biopsy/dilatation ⦿ Malignancy ⦿ Penetrating injuries – pointed FB, cut throat, gun shot ⦿ Spontaneous rupture – mostly lower 1/3 rd during vomiting. Boerhave’s syndrome – all layers ⦿ C/F ⦿ Cervical oesophagus rupture – pain in neck, supraclavicular region, dysphagia, odynophagia, emphysema, fever ⦿ Thoracic oesophagus rupture – more dangerous. Retrosternal pain,chest pain, high fever, shock , emphysema

9. ⦿ Hamman’s sign – Crunching sound over heart because of air in mediastinum ⦿ Diagnosis ⦿ X Ray Chest/Neck – surgical emphysema/ widening of mediastinum/ pneumothorax/ gas under diaphragm/ pleural effusion ⦿ Barium swallow – 3-4 days later to localise ⦿ Treatment ⦿ NG tube feed/ gastrostomy ⦿ IV antibiotics ⦿ Cervical – conservative, drainage if suppuration

10. ⦿ Thora c i c – surgical r e pai r i f withi n 6 hrs, after 6 hrs – no repair possible ⦿ Drainag e of pleura l ca v ity ⦿ Com p lication ⦿ Deat h du e t o mediasti n i t i s / s e pti c aem i a ⦿ If treatment delayed more than 24 hrs - > 50% mortality due to mediastinitis

11. ⦿ Etiology ⦿ Ac c ident al – children ⦿ Suicidal/alcoholic/psychiatric – adults ⦿ A c ids / alka l i e s (mo r e dest r uctiv e ,pen e tra t e deep) ⦿ Se v e r it y depend s on na t ure , amou n t, concentration and duration ⦿ Stag e s – acut e necr o sis -> gran u lat i ons -> strictures

12. ⦿ C/F ⦿ B u rns on l i ps , o r a l ca v it y , o r opharynx ⦿ Dysp h agi a /odynophagia ⦿ Dr o o l in g of s aliva ⦿ Hoa r seness / s t rid o r ⦿ Sho c k ⦿ Mediasti n i t i s ⦿ D iagnosis ⦿ X Ra y chest/ n e c k ⦿ Barium /o e sophagosc o p y ( n ot immediat e but 2 days)

13. ⦿ T re a tment ⦿ Im m edi a te ⦿ ICU/I V fluids ⦿ NG feed / gastr o sto m y ⦿ Wash and irrigate eyes and mouth with cold water ⦿ Ant i biotics/ s ter o ids/ a nalg e s i c s – parentral ⦿ T ra c heostom y i f stridor ⦿ Only f o r mil d b urns – ne u traliz e wit h w e ak acid or alkali (within 6 hrs)

14. ⦿ Delayed ⦿ Oesophagoscopy within 2 days and repeat every 2 weeks – to know site and extent. Perforation ⦿ Dilatatio n of strictures ⦿ Oes o ph ageal r e c o ns truction

15. ⦿ Etiology – whe n muscul a r layer i s damaged ⦿ T rauma – FB/ i n j u ry ⦿ Iatr o genic – surger y , N G t ube , pills ⦿ Co r r o sive b u rns ⦿ Infe c tions ⦿ Ulce r s – r e flux, dipt h e r i a, typ hoid ⦿ Drug s – ant i diureti c , ant i arthritic ⦿ Congen i ta l – lo w e r 1/ 3 rd

16. ⦿ C/F ⦿ Impacti o n of FB ⦿ Dysp h agi a 1 s t wit h solids ⦿ P ain ⦿ R egurgitati o n / c o ug h i ng ⦿ Mal nourished/a n a emia ⦿ Diagnosis – barium swallow/ oesophagoscopy / Chest X Ray

17. ⦿ T re a tment ⦿ Gastrost o my ⦿ O e sophag o sc o p y an d r e peat e d endos c opic dilatation with bougies under direct vision ⦿ C h evalie r Ja c ks o n bougies ⦿ Balloon dilatation/wire guided rigid dilatation ⦿ Excision and reconstruction – excise the stricture segment and reconstruct with stomach/colon/jejunum

18. ⦿ Hy p ermot i lity disorde r s ⦿ Cr i copharynge a l s p asm – failure o f U ES to relax ⦿ D iff u se oeso p hage a l s p asm – no n pe r istaltic contractions of oesophagus due to degeneration of nerve process. ⦿ Barium swallow – r o sary bea d or c o rk sc r ew type of appearance ⦿ Nu t c r acker oesophagus – peristaltic contractions of oesophagus

19. ⦿ Hypom o tilit y disord e r wit h ab no r ma l r e flux of gastric contents through oesophagus into laryngopharynx causing laryngeal and pharyngeal symptoms ⦿ Mc cause of laryngitis, non productive cough and non cardiac chest pain ⦿ Etiology ⦿ Inappropriate functioning of LES (low tone) ⦿ T oba c c o /alcohol/fatty food/chocolates/drugs ⦿ P r e gn a ncy ⦿ Hiatus hernia/ post nasal drip/ psychological

20. ⦿ C/F ⦿ Hear t burn ⦿ R egurgitati o n ⦿ Dysphagi a /od y nophag i a ⦿ Ang i n a like ches t pai n w o rsens aft e r sublingual nitroglycerine ⦿ Extra o e sophageal r e flux symptoms – FB sensation throat, hoarseness of voice, dental erosion, throat clearing ⦿ Sign s – pos t la r yng i ti s – c o ngeste d arytenoids, interarytenoids, nasal congestion

21. ⦿ T ypes ⦿ N o n e r osive r eflu x – only symptoms, n o s i gns ⦿ R eflu x o e sophagit i s - mucosa l cha nges ⦿ Bar r ett ’ s o e sophagus ⦿ Diagnosis ⦿ Cli n ical ⦿ Oesophagoscopy/laryngoscopy ⦿ 24 hrs double ph monitoring of pharynx and oesophagus ⦿ Barium swallow ⦿ C h es t X Ray

22. ⦿ T re a tment ⦿ Lif e style modifi c ations ⦿ Antacids – liq u id ⦿ Proton pump inhibitors – rabeprazole (80%) ⦿ H 2 re c epto r an t agonist s - raniti d i ne ( 5 0% ) - healing ⦿ Pro kinetic drugs – domperidone (increase clearance) ⦿ Surgery – nissen’s fundoplication ⦿ Complicati o n s – o e sophagit i s , laryngi t i s , OME, aspiration pneumonia, carcinoma

23. ⦿ P re c ancer o u s c o nd i tio n aff e ctin g distal oesophagus due to change in its normal stratified epithelium to intestinal columnar epithelium ⦿ Ca n lead t o adenoca r cinom a (i f > 8 c m long) ⦿ Se e n i n GER D du e t o seve r e inflammation ⦿ Sm o ke r s ⦿ Diagnosis – bariu m swall o w/ oesoph a goscopy ⦿ T re a tmen t – an ti r e flux/ r e gular endosc o py to detect adenocarcinoma early

24. ⦿ P at h ology ⦿ Absence o f peristalsi s i n bod y of o e sophag u s ⦿ High resting pressure in LES which dont relax ⦿ Spasm of LES leading to retention of food ⦿ Etiology ⦿ Her e ditary ⦿ Infe c tiv e – chaga s diseas e du e to trypanosomiasis (cardiomegaly, megacolon, achalasia) ⦿ Auto imm u ne ⦿ Degenerati o n of auerbach ’ s ple xus

25. ⦿ C/F ⦿ Age gp 30-60 yrs, both sexes equal ⦿ Dysphagia more for liquids than solids (as solids pass due to weight) ⦿ Regurgitation ⦿ Chest pain / retrosternal or epigastric fullness ⦿ Weight loss ⦿ IDL – pooling of saliva ⦿ Complications – nutritional deficiency/ pulmonary complications/ oesophageal malignancy

26. ⦿ Diagnosis ⦿ Barium swallow w it h fluo r os c opy ⦿ Sm o oth an d r egula r narr o win g of lo w er oesophagus – rat tail appearance/ bird beak appearance/ pencil tip appearance ⦿ Los s o f peristalsi s i n dista l o e sophag u s ⦿ Dilate d o e sophag u s ⦿ Manom e try ⦿ Lo w pressur e a t bod y of o e sophag u s, h igh pressure at LES ⦿ Flexible endosc o py

27. ⦿ T re a tment ⦿ Endoscopic pneumatic dilatation – tears LES muscle hence reduces LES pressure. Can cause perforation ⦿ Modifie d Helle r ’ s op e ration – i n cisio n of circular muscle fibres of lower oesophagus ⦿ In j botuli n u m toxi n i n LES ⦿ Calciu m cha n ne l blo c ke r s – r e lax smo o th muscles. ⦿ Nitrat e s

28. ⦿ Rare ⦿ Se e n i n y o u n ger ag e gp ⦿ Lei o myoma s – 66% . T r e atmen t – external surgical excision with thoracotomy. No endoscopic removal as can cause perforation... ⦿ Lipoma s /fibr o ma s/ ha e mangi o mas ⦿ M u c o sal polyps/cysts

29. ⦿ Common ⦿ Types and etiology ⦿ SCC (93%) – mostly involves upper and middle 1/3 rd of oesophagus ⦿ Age 50-70 yrs ⦿ Males ⦿ Smoking/alcohol/paan/supari ⦿ Hot and spicy food ⦿ Oesophageal conditions – strictures, corrosive injury, cardiac achalasia ⦿ Premalignant – plummer vinson syndrome (females), HPV ⦿ Adenocarcinoma – lower 1/3 rd – gerd/barrett’s oesophagus

30. ⦿ Spread ⦿ Direct – trachea, left bronchi, subglottis, RLN ⦿ Lymphatic – supraclavicular LN ⦿ Blood – lung, liver, bone, brain ⦿ C/F ⦿ Retrosternal discomfort ⦿ Gradually progressive dysphagia for solids first then liquids ⦿ Odynophagia ⦿ Iron def anaemia ⦿ Loss of weight ⦿ IDL – pooling of saliva (ca upper 1/3 rd ), paramedian vc (RLN)

31. ⦿ Diagnosis ⦿ Barium swallow – irregular narrowing and ulcerated edges. Rat tail appearance ⦿ Oesophagoscopy with biopsy ⦿ CT Scan ⦿ Chest X Ray ⦿ Treatment – poor prognosis as late presentation ⦿ SCC – RT / if early in upper 1/3 rd – total laryngo pharyngo oesophagectomy with gastric pull up ⦿ Adeno – surgery – oesophagogastrectomy with reconstruction (radioresistant) ⦿ Late stage – palliative – pain killers/gastrostomy

32. ⦿ Patterson brown kelly syndrome ⦿ Etiology ⦿ Iron def/ vitamin def ⦿ Autoimmune ⦿ Atrophy of mm of alimentary tract in lowest part of laryngopharynx ⦿ C/F ⦿ Gradually progressive dysphagia first for solids ⦿ Microcytic hypochromic anaemia ⦿ Angular stomatitis/ glossitis ⦿ Koilonychia (spooning of nails) ⦿ Web formation in cricopharynx/ splenomegaly

33. ⦿ Prognosis – can lead to ca buccal mucosa, tongue, pharynx, oesophagus, stomach, post cricoid region ⦿ Diagnosis ⦿ Haemogram ⦿ Barium swallow ⦿ Oesophagoscopy – web formation in post cricoid region ⦿ Treatment ⦿ Oral/parentral iron ⦿ Vit B6, B12 ⦿ Oesophageal dilatation of web with bougies........

34. ⦿ Hypopharyngeal diverticulum/ upper oesophageal diverticulum ⦿ Etiology ⦿ Age > 60 yrs ⦿ Hypopharyngeal mucosa herniates through killian’s dehiscence (weak area between thyropharyngeus and cricopharyngeus) ⦿ Sac formed has mouth wider than oesophageal opening so food gets collected in it ⦿ C/F ⦿ Dysphagia – increases after few swallows as pouch filled with food

35. ⦿ Regurgitation of food ⦿ Halitosis ⦿ Voice change ⦿ Gurgling sound on swallowing ⦿ Loss of weight ⦿ Aspiration pneumonia ⦿ O/E ⦿ Swelling on left side of ant triangle of neck which is soft and gurgles on palpation (Boyce’s sign) ⦿ IDL – pooling of saliva ⦿ Diagnosis – Barium swallow. ⦿ Oesophagoscopy C/I as risk of perforation

36. ⦿ T r e atment ⦿ Excision of pouc h ( dive r ticulect o m y ) ⦿ Cricopharyngeal myotomy (cervical approach) ⦿ Dohlman ’ s pr o c e dur e – endosc o pi c d iat h e r my to divide partition wall between oesophagus and pouch ⦿ Endoscopic laser treatment with CO2 laser using operating microscope to divide partition wall between oesophagus and pouch

37. ⦿ Displacemen t of stomach int o c hes t t hr o ugh diaphragm ⦿ Age > 5 y r s ⦿ T ypes ⦿ Sliding (mc ) 85 % - r e flux o e sophagit i s , heart burn – in line of oesophagus ⦿ P ara o es o ph ageal 5 % - n o r e flux, external dyspnoea – by side of oesophagus ⦿ Mixe d 10%

38. ⦿ Diagnosis ⦿ Barium swallow ⦿ X Ra y C h es t – gas sh a do w behi nd heart ⦿ T reatment ⦿ Conser v ativ e – r e duc e r e flux ⦿ Surgical – r e ductio n of herni a an d r epai r o f diaphragmatic opening

39. ⦿ Pharynx ⦿ Tonsil, base of tongue, vallecula, pyriform fossa ⦿ Tonsil – fish bone, needle – tongue depressor and forceps........ ⦿ Base of tongue/vallecula – fish bone, needle – IDL ⦿ Pyriform fossa – fish bone, needle, dentures, meat bone – rigid endoscopy ⦿ Oesophagus – coin (mc), meat bone (adults), dentures, safety pin , battery (tissue necrosis) ⦿ Sites – cricopharyngeal sphincter (mc), broncho aortic constriction and lower sphincter

40. ⦿ Risk factors ⦿ Children – tendency to put ⦿ Oesophageal strictures, carcinoma ⦿ Psychosis ⦿ Loss of consciousness – seizures, alcohol, deep sleep ⦿ C/F ⦿ Choking/gagging at time of ingestion ⦿ Pain/discomfort ⦿ Dysphagia/odynophagia ⦿ Drooling of saliva ⦿ Resp distress/hoarseness/stridor – if compresses trachea ⦿ IDL – pooling of saliva ⦿ Laryngeal crepitus absent

41. ⦿ Diagnosis ⦿ X Ra y Ne c k AP an d Latera l – radio opaq u e ⦿ Radiolucen t – preve r tebra l wideni n g, displacement of trachea ⦿ X Ray Chest lateral and PA view ⦿ X Ra y Ne c k t o pelvi s – childre n t o rule o ut multiple FB ⦿ Barium st u d y – full stu d y ca n disfig ure the oesophagus. So a small cotton pledget soaked in barium can be swallowed and it get stuck at FB – for radiolucent FB

42. ⦿ Treatment ⦿ Oesophagoscopy and removal under GA ⦿ Cervical oesophagotomy – impacted FB ⦿ Trans thoracic oesophagotomy ⦿ Thoractomy/external approach ⦿ IV antibiotics ⦿ Stomach – passes with stools so watch, normal diet, no purgatives. Operate if pain and tenderness in abdomen, no progress, if FB > 5 cm in a child < 2 yrs age ⦿ Complication – resp obstruction/oesophageal perforation, stenosis, strictures/TOF/ cellulitis and abscess in neck/perforation of aorta

43. ⦿ RIGID OESOPHAGOSCOPY ⦿ Indications ⦿ Diagnostic ⦿ Dysphagia, odynophagia, regurgitation ⦿ FB throat ⦿ Oesaphageal disorders ⦿ Haematemesis ⦿ Metastatic neck node ⦿ As part of panendoscopy ⦿ Therapeutic ⦿ Removal of foreign body ⦿ Removal of benign neoplasm/ treatment of diverticulum ⦿ Dilatation of oesophagus – stricture, webs, stenosis ⦿ TEP after total laryngectomy ⦿ Injection sclerosing agent for oesophageal varices

44. ⦿ C/I ⦿ Coagulopathy/bleeding disorder ⦿ Perforation of oesophagus/acute burns ⦿ Cervical spine/mandible lesions/severe trismus ⦿ Aneurysm of aorta ⦿ Advance heart, kidney, liver disease ⦿ Pre op ⦿ BT, CT ⦿ Stop NSAID – 2 to 5 days before ⦿ Stop aspirin – 7 to 10 days before ⦿ NBM 6-8 hours ⦿ Barium swallow ⦿ Antibiotic

45. ⦿ Oes o ph agos c ope ⦿ C h evalie r Ja c ks o n – dista l illum i nati o n ⦿ N e gus – oblique light ⦿ The handl e a t pr o ximal en d indicate direction of bevel at distal end

46. ⦿ Anaesthesia – GA ⦿ Position – Boyce’s position- head extended at atlanto occipital joint, neck flexed on chest ⦿ Once cricopharyngeal sphincter reached all extended ⦿ Technique ⦿ Lubricate – protect lips and teeth – hold in right hand and introduce through right side of tongue- identify epiglottis and arytenoids ⦿ Lift the scope with left thumb to open hypopharynx ⦿ Slow gentle pressure on tip at cricopharyngeal sphincter opening. If sphincter dont open give a muscle relaxant or 4% lignocaine drops through scope ⦿ Guide the scope into oesophagus. Now hands switched over and hold with left hand ⦿ Advance to see cardiac end . extension ⦿ Inspect the oesophagus while withdrawing

47. ⦿ Post op care ⦿ Look for features of oesophageal perforation – pain in intrascapular region, surgical emphysema, high fever ⦿ Complications ⦿ Injury to lips, teeth, pharynx ⦿ Oesophageal perforation – cricopharyngeal sphincter ⦿ Injury to arytenoids ⦿ Bleeding ⦿ Rupture of aortic aneurysm ⦿ Injury to cervical vertebra ⦿ Compression of trachea in children leading to resp obstruction – immediately withdraw the scope

48. ⦿ Advantages ⦿ OPD procedure ⦿ LA – spray/SLN block ⦿ Less morbidity ⦿ Can be done in jaw, spine disorders ⦿ Can examine stomach and duodenum ⦿ Good illumination and magnification ⦿ Disadvantages ⦿ Limited removal of FB ⦿ Cant examine laryngopharynx ⦿ Need voluntary swallowing to advance scope ⦿ Procedure ⦿ Air or water insufflation is done to open the lumen of oesophagus

49. Questions ?

50. References : Scott and Brown’s Otolaryngology 8 th edition vol I ,vol II Operative otolaryngology Head and Neck – Eugene N Myers vol I Diseaes of Nose ,Throat , Ear – Logen Turner Text book of Otolaryngology and head and neck surgery - Byron &Bailey An atlas of head & neck surgery- Lore’ 3 rd edition

51. Thank You