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Esophagus: Anatomy Terminology Esophageal and Gastric Conflicts of Interest: Motility Disorders: A case • None based approach Gokul Balasubramanian, MD Assistant Professor Director of Gastrointestinal Motility Lab Division of Gastroenterology, Hepatology and Nutrition The Ohio State University Wexner Medical Center Overview • Esophageal anatomy • Dysphagia-case based approach • Reflux disease-case based approach Dysphagia-Case • Gastric physiology based approach • Gastroparesis-case based approach 1 Esophagus: Anatomy Terminology • 25 cm muscular tube. • Dysphagia: derived from the Greek word dys (difficulty, disordered) and phagia (to eat). • Extends from upper esophageal sphincter to stomach. • Odynophagia: painful swallowing. • Proximal 1/3rd consist of striated muscles while distal • Globus Sensation: Sensation of lump in throat 2/3rd is formed by smooth muscles. between meals. • Lined squamous epithelium. History Dysphagia Assessment Oropharyngeal Esophageal Fluoroscopic • Oral: • Food stuck in examination ‒ Drooling of saliva suprasternal notch or ‒ Food spillage retrosternal region ‒ Sialorrhea ‒ Piecemeal swallows • Motility: ‒ Associated dysarthria ‒ dysphagia to solids and liquids • Pharyngeal: ‒ Associated with ‒ Choking/cough during heartburn or chest pain. swallow • Mechanical: ‒ Associated dysphonia Endoscopic Manometric ‒ progressive dysphagia to examination examination solids; may involve liquids at later stages 2 Case Study 1: Case Study 1: 78-year-old female with no significant medical history presenting with: ‒ Dysphagia to both solids and liquids ‒ Chest pain ‒ Denies any heartburn • Mean DCI:2380 ‒ 50 lb weight loss • Mean LES IRP:32 mm Hg • Mean DL: 3.8 sec • Epiphrenic diverticulum • Epiphrenic diverticulum • Resistance at GEJ • Beaking at GEJ Case Study 1: Achalasia • Post extended myotomy and diverticulectomy • Rare esophageal motility • Fairly doing disorder • Esophageal aperistalsis • Impaired LES relaxation Loss of inhibitory neurons secreting VIP and NO leads to unopposed excitatory activity and failure of LES relaxation DA Patel. An Overview of Achalasia and Its Subtypes. Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 3 Achalasia: Subtypes Achalasia: Treatment Algorithm Type I is characterized by a quiescent esophageal body, type II has pan-esophageal pressurization, and type III is characterized by simultaneous contractions. DA Patel. An Overview of Achalasia and Its Subtypes. DA Patel. An Overview of Achalasia and Its Subtypes. Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 Achalasia: Treatment Options Case Study 2: Treatment Options Pros Cons • On Demand Medications(CaCB/Nitrate • Minimal risk • Least effective 24-year-old s) • For non-operative • Not durable female presented candidates • Good option for with dysphagia to nonoperative • Durability of 6–12 solids and Botulinum toxin injection candidates months liquids. • Short procedure time • Most effective • Mean DCI:NA nonsurgical option • Mean LES IRP:24 mm Hg • Short recovery time • Perforation (1%– Pneumatic dilation • Mean DL: NA • Durability 2–5 years 5%) • Procedure time <30 Diagnosis?? minutes • General anesthesia • Durability 5–7 years required Surgical myotomy • Procedure time 90 ∼ • Hospital stay of 1–2 minutes days Type 2 Achalasia. Patient • High morbidity and Esophagectomy • For end-stage disease mortality sent for myotomy 4 Case Study 3: Opioid-induced esophageal dysfunction 64-year-old female with CAD, chronic backache on morphine is presenting dysphagia Opioid-induced esophageal and spasmodic pain in dysfunction is often characterized the neck and chest. by EGJ outflow obstruction and type III achalasia pattern. • Mean DCI:2765 • Mean LES IRP:18 mm Hg • Mean DL: 3.8s Diagnosis?? Opioid induced esophageal dysfunction Ratuapli S, et al.Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids. Am J Gastroenterol 2015; 110:979–984; Achalasia syndromes beyond the CC v3.0 GERD-Case based approach Kahrilas, P. J. et al. (2017) Advances in the management of oesophageal motility disorders. in the era of high-resolution manometry: a focus on achalasia syndromes. Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2017.132 5 Gastroesophageal Reflux Risk factors: Disease Definition • Obesity GERD is a condition that develops • Family history for GERD when the reflux of gastric content • Tobacco smoking causes troublesome symptoms or • Alcohol consumption complications. • Associated psychosomatic complaints • Mild symptoms once in > 2 days/week • Moderate/Severe once in >1 day/week Vakil N, van Zanten SV, Kahrilas P, et al. Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Locke GR, et al. The American Journal of Medicine. 1999;106(6):642-649 Gastroenterol. 2006;101:1900–1920. Hampel H. Ann Intern Med. 2005;143(3):199-211. Impact of Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease Esophagitis Extra-esophageal Non-erosive GERD GERD (EGD negative) Stricture Bleeding ENT Impairs quality Barrett’s metaplasia Asthma of life & Adenocarcinoma Dental Irvine EJ, Hunt RH. Evidence-Based Gastroenterol. BC Decker Inc. Hamilton and London. 2001. 6 Goals for Treatment of GERD Life-Style Modifications include: • Eliminate symptoms • Elevate the head of the bed on 4" to 6" blocks. • Advise weight loss for obese patients. • Heal erosive esophagitis • Avoid recumbency for 3 hours after meals. • Avoid bedtime snacks. • Prevent the relapse of erosive • Avoid fatty foods, chocolate, peppermint, onions, and esophagitis and complications from garlic. GERD • Avoid cigarettes and alcohol. • Avoid drugs that decrease LES pressure and delay gastric emptying. Medical treatment options: Maintenance of Healing Erosive Esophagitis Proton Pump Inhibitors: • Higher healing rates in mild to moderately severe reflux esophagitis(80% to 100%). 100 Esomeprazole 40 mg 80 20 mg • Improves dysphagia. 10 mg 60 Placebo • Decreases the need for esophageal dilation in patients 40 who have peptic esophageal strictures. Remission In (%) 20 • About 70% may have nocturnal acid breakthrough that 0 0123 4 5 6 requires H2RA. Months Pooled from Johnson DA, et al., Am J Gastroenterol, 2001;96:27-34 and Vakil NB, et al., Aliment Pharmacol Ther, 2001;15:927-935. 7 Healing of esophagitis GERD Is a Chronic Condition Proton-pump inhibitor Likely to Relapse Superior to placebo (83% vs. 18%) at 8 wk; NNTB, 1.722 Superior to H2-blocker (83% vs. 18%)18; relative risk, 0.5122 Superior to H2-blocker (84% vs. 52%)17; relative risk, 0.512 100 No mucosal breaks Significant dose–response effect at 4 wk22 LA Grade A 80 Low dose vs. standard dose once daily: NNTB, 10 LA Grade B LA Grade C Standard dose vs. high dose once daily: NNTB, 25 60 H2-blocker (%) 40 Superior to placebo (41% vs. 20%) at 6 wk; NNTB, 522 20 No significant dose–response effect (standard dose vs. high dose twice daily) 22 Patients in Symptomatic Remission 0 0123456 Best practice Time After Cessation of Therapy (Months) recommendations for proven GERD consist of long-term therapy with the Lundell LR, et al. Gut. 1999;45:172-180. lowest dose of PPI that provides symptom control and/or healing of Kahrilas PJ, NEJM. GERD.2008 esophagitis. Resolution of heartburn† Maintenance therapy‡ Esophagitis Remission of esophagitis Proton-pump inhibitor superior to placebo (56% vs. 8%) at 4 Proton-pump inhibitor superior to placebo (93% vs. wk; NNTB, 2 to 323 29%)29 Proton-pump inhibitor superior to H2-blocker (77% vs. 48%) at 4 to 12 wk24 Low dose of proton-pump inhibitor sufficient in 35 to 95% H2-blocker superior to placebo (56% vs. 45%) at 12 wk25 of patients18 No significant dose–response effect for proton-pump inhibitor Remission of heartburn at 4 wk22 Acceptable symptom control with low-dose, intermittent Low dose vs. standard dose once daily: 75% vs. 79% therapy with proton-pump inhibitor in 83 to 92% of Standard dose vs. high dose once daily: 73% vs. 76% patients without esophagitis18 Patients without known esophagitis Proton-pump inhibitor superior to placebo (36.7% vs. 9.5%); NNTB, 3 to 423 Proton-pump inhibitor superior to H2-blocker (61% vs. 40%); Best practice NNTB, 526 recommendations for H2-blocker superior to placebo (relative risk, 0.77; 95% CI, 0.60 proven GERD consist of to 0.99)27 long-term therapy with the lowest dose of PPI that No significant dose–response effect for H2-blocker at 8 wk provides symptom control Standard dose vs. high dose twice daily: 45.8% vs. 44.8%28 and/or healing of esophagitis. Kahrilas PJ, NEJM. GERD.2008 Kahrilas PJ, NEJM. GERD.2008 8 Appropriateness of PPI use Decisions to start, properly dose, continue, or discontinue PPI therapy should be personalized based on indication, effectiveness, patient preferences, and risk assessment. Yadlapati and Kahrilas BMC Medicine (2017) 15:36 Yadlapati and Kahrilas BMC Medicine (2017) 15:36 Medical treatment options: Indications for anti-reflux surgery • Antacids and Alginic Acid: • Unwillingness to remain on medical therapy ‒ Temporarily relieve episodic heartburn ‒ Useful add on therapy • Intolerance of medical therapy • Medically refractory symptoms with objective • Histamine H2-Receptor Blocking Agents: evidence of GERD ‒ Safe and effective in mild esophagitis • GERD in the setting of a large hiatal hernia ‒ Not useful in severe esophagitis ‒ Useful for breakthrough symptoms ‒ Concern for tachyphylaxis • Prokinetic Agents: ‒ Limited efficacy and side effects in up to 30% • TLESR
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