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Swallowing Difficulty & Pain. Tim Farrell, MD Tom Egan, MD. Assumptions . Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction. Objectives. Students will understand:

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Swallowing Difficulty & Pain

Tim Farrell, MD

Tom Egan, MD


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Assumptions

  • Students understand the anatomy, physiology, and pathophysiology of the swallowing mechanism and the esophagogastric junction.


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Objectives

Students will understand:

  • Differential diagnosis for a patient with dysphagia.

  • Symptoms and treatment of GERD.

  • Pathophysiology and treatment of achalasia and diffuse esophageal spasm.

  • Etiology and treatment of esophageal diverticula.

  • Common symptoms and management of hiatal hernias.

  • Management of adenocarcinoma of the E-G junction.

  • Presenting symptoms, etiology and treatment of esophageal rupture.


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Case 1

  • An 80-year-old man presents with a trouble swallowing for a year. He regurgitates after meals, has heartburn, but no other pain and is in good health otherwise.

  • He is thin, without neck mass. His chest is clear and his abdomen is soft and without masses.


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Case 1

  • What is the differential diagnosis?

    Anatomic

    Tumor, Stricture, Compression, Foreign Body

    Functional

    GERD

    Motility Disorder (achalasia, scleroderma)

    Neurologic (Parkinson’s, bulbar paralysis)

    Psychological

    Globus Hystericus


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Case 1

  • What test should be done, in what order, and why?

    Anatomic AssessmentFunctional Assessment

    Upper GI Series 24-hr pH

    EGD Esophageal Manometry

    Biopsy GES


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GERD - Definition

Protracted exposure of the esophageal lining to stomach juice


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GERD - Causes

  • Lower esophageal sphincter

    • Incompetent valve

    • Inappropriate relaxations

  • Hiatal Hernia

  • Abnormal motility

    • Impaired esophageal clearing

  • Delayed gastric emptying

  • Defective cytoprotection


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Atypical Symptoms

Asthma

Cough

Hoarseness

Chest Pain

Typical Symptoms

Heartburn

Regurgitation

Trouble Swallowing

GERD - Symptoms


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GERD - Complications

  • Peptic Stricture

  • Esophagitis / Ulcers

  • Barrett's Esophagus


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Indications for further Dx-Rx

  • Persistent or frequent symptoms

  • Dysphagia

  • Frequent vomiting

  • Early satiety

  • Weight loss

  • Significant respiratory complaints

  • Age < 45


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GERD - Diagnosis

  • Barium Swallow

  • Upper Endoscopy

  • Esophageal Manometry

  • 24-Hour Ambulatory Esophageal pH

  • Gastric Emptying Study


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GERD - DiagnosisBarium Swallow


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GERD - DiagnosisUpper Endoscopy



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Environmental

Medical - OTC

Antacids

H2-Blockers

Medical -Prescription

Proton-Pump Inhibitors

Endoscopic

Surgical

Fundoplication

GERD - Treatment


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Dietary Modifications

  • Avoid large meals

  • Limit foods which decrease LES pressure

    • Fatty foods, chocolate, mints, and alcohol

  • Avoid irritating foods and beverages

    • Citrus, tomatoes, pepper, etc.

  • Limit caffeine and carbonated beverages

    • Increases acid production

    • Increased gastric distension

  • Candy or gum to increase saliva

    • Alkaline saliva neutralizes acid

    • Increases motility and clearance


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Lifestyle Modifications

  • Weight Loss

  • Avoid smoking

    • Decreases LES pressure

  • Avoid lying down for 2-3 hours after meals

    • Limits supine reflux

  • Sleep with elevated head of bed

    • Improves esophageal clearance


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Medications Worsening Reflux

  • Calcium channel blockers

  • Anticholinergics

  • Theophylline

  • Progesterone

  • β2-antagonists, α-antagonists

  • Nitrates

  • Meperidine

  • Diazepam


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GERD - Medical Treatment

Medications may be used to:

  • Neutralize acid

  • Increase LES tone

  • Improve gastric emptying


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OTC H2 Blockers

  • Lower-dose formulations

  • Acute treatment or prophylaxis

  • Slower onset than antacids

  • Longer duration of acid inhibition



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Endoscopic Treatment Modalities Thermal (Stretta®)

Thermal energy Mechanical / Neural


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Endoscopic Treatment Modalities Endoscopic Suturing

  • Suturing or plication

    EndoCinch ®


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Endoscopic Treatment ModalitiesBiocompatible Material

Enteryx ®











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Procedure - 2 Hours

Hospital - 1-2 Days

Full Activity - 2 weeks

Full Diet - 3 weeks

Need to Open <1%

Need for Blood <1%

Off Medications - 95%

Off Steroids - 50%

Need 2nd Procedure - 5%

GERD - Surgical TreatmentResults


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Effects of Fundoplication

Fundoplication

  • augments LES resting pressure

  • lessens frequency of transient LES relaxations

  • reestablishes anatomy of the LES and crura

  • may improve esophageal clearance

  • may improve gastric emptying


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Case 2

  • A 61-year-old man presents with progressive difficulty swallowing. He has history of indigestion and heartburn. Until 12 months ago, food would come up into his throat when he was supine, with a sour taste and sometimes a cough. About 12 months ago, these symptoms improved but he developed progressive dysphagia.

  • He smokes 1 PPD and drinks two beers at dinner.

  • Exam is unremarkable except for barrel chest.


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Case 2

  • What is the differential diagnosis?

Anatomic

Tumor, Stricture, Compression, Foreign Body

Functional

GERD,

Motility Disorder (achalasia, scleroderma)

Neurologic (Parkinson’s, bulbar paralysis)

Psychological

Globus Hystericus


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Case 2

  • How would you evaluate this patient?

    Anatomic AssessmentFunctional Assessment

    Upper GI Series 24-hr pH

    EGD Esophageal Manometry

    Biopsy GES


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Case 2

  • What are the treatment options for benign esophageal stricture?

    • Medications

    • Endoscopic Dilation

    • Surgery


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Case 2

  • What are the treatment options for carcinoma of the esophagus?

    • Esophagogastectomy

      • Ivor-Lewis

      • Transhiatal


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Barrett’s EsophagusEpidemiology

  • Affects 10% of patients with severe GER

  • 40-fold increased risk of cancer

  • Patients require endoscopic surveillance

  • Esophagectomy for severe dysplasia/cancer


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Barrett’s EsophagusEndoscopic Appearance


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Barrett’s EsophagusPathologic Diagnosis

  • Normal squamous epithelium transforms to intestinal-type (columnar) epithelium

40x increased cancer risk

No increased cancer risk


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PPI-Induced Regression?

Peters FT, et al., Gut 1999;45:489-94.


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Surgery-Induced Regression?

Sagar: Br J Surg 1995;82:806-10.


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Barrett’s EsophagusDevelopment of Cancer Based on Grade

  • No dysplasia 3%

  • Low-grade dysplasia 18%

  • High-grade dysplasia 28%

Morales and Sampliner, Arch Int Med 1999;159:1411-16.


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Barrett’s EsophagusFollowing Patients Without Dysplasia

  • Studies of cost-effectiveness are mixed

  • Few cancers found during surveillance are node-positive, versus >50% otherwise

  • Optimal surveillance interval debated, but data suggest q2-3 years


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Barrett’s EsophagusPatients With Low-Grade Dysplasia

  • Repeat endoscopy to avoid sampling error

  • Surveillance q6 mo. x 1 year then q12 mo.

  • May regress allowing increased interval


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Barrett’s EsophagusPatients With High-Grade Dysplasia

  • Must confirm the diagnosis

  • Treatment is controversial

  • Some advocate aggressive biopsy protocol

  • Some advocate esophagectomy


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Barrett’s EsophagusPatients With High-Grade Dysplasia

Case for Aggressive Surveillance (q3-6 mos.):

  • Regression may occur (25%)

  • Most patients will not progress to cancer

  • Cancers remain surgically curable

  • Esophagectomy carries morbidity (up to 40%) and mortality (3-6%)


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Barrett’s EsophagusPatients With High-Grade Dysplasia

Case for Esophagectomy:

  • 40% may already have cancer

  • Surveillance delays definitive treatment

  • Risk of esophagectomy low in high-volume centers


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Barrett’s EsophagusSpecific Treatment

Ablative Techniques

  • laser

  • electrocautery

  • photodynamic therapy (PDT)

    Resective Techniques

  • Endoscopic mucosal resection (EMR)


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Barrett’s EsophagusTake-Home Points

  • Barrett’s esophagus is not a contraindication to antireflux operation

  • Medical or surgical therapy does not eliminate need for Barrett’s surveillance

  • Management of high-grade dysplasia is evolving away from esophagectomy


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Case 3

  • A 53-year-old patient presents with a history of difficulty swallowing for years. More recently she is having increasing trouble swallowing, and has been regurgitating undigested food. Exam is unrevealing, but on chest film there is an air fluid level seen behind the heart in the mid chest.


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Case 3

  • Describe a differential diagnosis and diagnostic evaluation.


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Case 3

  • Discuss the management options for a patient with achalasia.


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AchalasiaIncidence

  • 0.5 new cases / 100,000 population / year

  • Dysphagia, regurgitation, cough, wheezing, aspiration, pulmonary infections

  • 50% initially misdiagnosed


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AchalasiaPathophysiology

  • Involves degeneration of Auerbach’s plexus and elevated LES resting pressure

  • Poor LES relaxation results in esophageal dilation with progressive loss of peristalsis


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AchalasiaDiagnosis

  • Ba swallow:

    • esophageal dilation / narrowing at GE junction

  • EGD:

    • patulous esophagus, retained food, thickening

  • Esophageal manometry:

    • LES resting pressure

    • LES relaxation on swallowing

    • primary peristalsis


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AchalasiaTreatment Options

  • Non-Surgical options:

    • Nitrates and Ca++-channel blockers

    • Endoscopic injection of Botox

    • Pneumatic balloon dilatation

  • Surgical options:

    • Heller myotomy (laparoscopic, thoracoscopic)


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Heller MyotomyTechnique


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Heller MyotomyTechnique


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Heller MyotomyTechnique


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Heller MyotomyOutcomes

  • 40 laparoscopic Heller myotomies

  • No conversions, mean op time - 180 min

  • Median hospital stay - 2 days

  • One intraop mucosal injuriey repaired

  • Dysphagia alleviated in > 95%


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Case 3

  • Discuss the management of a patient with paraesophageal hernia.


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EpidemiologyHiatal Hernias

  • Herniation of the stomach through the esophageal hiatus

  • Para-esophageal type - 5%

    • Occurs in elderly patients (~ 65 years)

    • Frequent co-morbid conditions


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ClassificationHiatal Hernias

  • Classification depends on location of GEJ

    • Type I- “sliding” hiatal hernia

    • Type II- true paraesophageal hernia

    • Type III- “mixed” hernia- sliding hernia and true paraesophageal hernia

    • Type IV- intra-abdominal organ involvement


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Sliding Hiatal Hernia

  • Type I

  • GE junction “slides” into the mediastinum

  • Most HH

  • May be associated with symptomatic GERD

  • Surgery not indicated


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True Paraesophageal Hernia

  • Type II

  • GEJ in the abdominal cavity, fundus in the mediastinum

  • 5% of all HH

  • Risk of incarceration and strangulation


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Mixed Paraesophageal Hernia

  • Type III

  • GE junction and gastric fundus are located in mediastinum

  • 5% of all HH

  • Risk of incarceration and strangulation


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Paraesophageal HerniaVolvulus

Mesoaxial Volvulus

Organoaxial Volvulus



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Paraesophageal HerniaUpper GI series

Type II

Type III



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Paraesophageal HerniaTreatment Options

  • Observation

  • Medical Therapy

  • Surgery


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Paraesophageal HerniaObservation

  • Assumes a low rate of gastric strangulation

  • Allen et al.

    • 23 of 147 patients followed for 12-268 mos (median 78 mos).

    • Only 4 pts had progressive symptoms and 2 had elective repair

    • Estimate prevalence of one gastric strangulation per 245 pts

      J Thorac Cardiovasc Surg 1993;105:253


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Paraesophageal HerniaMedical Therapy

  • One-third of patients have heartburn alone

    • Acid inhibition

    • Patient clearly informed of risk of gastric strangulation and consequences

      • Excessive (10-50%) mortality for surgical repair of gastric strangulation


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Paraesophageal HerniaPrinciples of Operative Repair

  • Hernia Reduction

  • Hernia sac excision

  • Crural repair

  • Gastric fixation

  • Fundoplication controversial


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Paraesophageal HerniaHernia Reduction

  • Entire stomach and at least 2 cm of esophagus must be intra-abdominal


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Paraesophageal HerniaSac Excision

  • Entire sac must be excised to decrease risk of recurrence

  • Remnants of sac along inferior border of left crus lead to recurrence


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Paraesophageal HerniaCrural Repair

  • Primary repair alone

  • Primary repair with relaxing incision

  • Mesh repair


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Paraesophageal HerniaFundoplication

  • Recent series report high rate of GERD without fundoplication

  • Wrap provides bulk to create “plug” at site of crural repair


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Paraesophageal HerniaSurgical Outcomes

  • Luketich et al.: 100 pts lap PH repair

    • 12% intraop complications; technically demanding

    • 3 conversions to open procedures

    • 28% postop complication rate; 0% mortality

    • 3% reoperation rate

    • 91% satisfied, 2-day hospital stay

      Ann Surg 2000;232:608


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Paraesophageal HerniaTake-Home Points

  • Uncommon, rarely present with strangulation

  • Repair advised for non-GER symptoms

  • Repair is technically demanding

  • Laparoscopic vs. open remains controversial

  • Prospective study to determine recurrence


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Case 4

  • A 47-year-old woman has chest pain after eating dinner at home 4 hours following upper GI endoscopy for dilatation of her achalasia.

  • What is the presumed diagnosis?


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Case 4

  • What is the best means of making the diagnosis?


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Case 4

  • What is the appropriate management? Under what circumstances might you manage this non-operatively?

  • What might be an appropriate management for a small perforation at the GE junction with minimal soiling?


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