Benign Esophageal Disease Matthew Hartwig, MD, MHS, FACS Associate Professor of Surgery Duke University Health System Disclosure Slide • Consultant for Mallincrodkt and Quark Pharmaceuticals unrelated to this talk. • Research funding from Torax for GERD treatment in lung transplant recipients. Introduction • Esophageal anatomy and physiology • Gastroesophageal Reflux Disease (GERD) • Hiatal and Paraesophageal Hernia • Esophageal motility disorders • Other benign esophageal diseases Esophageal Anatomy • Muscular tube – Starts at pharynx – Ends at cardia of stomach • Cervical Esophagus – 5 cm – UES • Thoracic Esophagus – 20 cm • Abdominal Esophagus – 2 cm – LES Cervical Esophagus • Starts below cricopharyngeus muscle • Continuation of inferior constrictor of pharynx • C6 – T1 • Killian’s triangle – Zenker’s diverticulum Esophageal Muscle • Striated muscle – Cricopharyngeal sphincter & most proximal 1-2 cm of cervical esophagus – Vagus/recurrent laryngeal nerves • Smooth muscle – Thoracic & abdominal esophagus – Inner circular & outer longitudinal layers – Esophageal plexus Lower Esophageal Sphincter • Protects acid-sensitive esophageal mucosa • Two modes of failure, both impact proximal esophagus – Failure to relax (achalasia) – Failure to remain closed (GERD) • No anatomical landmarks – high pressure zone – Function determined by length, pressure, and position What is GERD? Normal LES - closed LES in reflux - GERD GERD • Significant public health concern • Most common upper GI disease • Accounts for 5 million office visits per year • PPI’s are the most effective management of GERD • 100 million PPI prescriptions and 14 billion dollars in sales in 2010 alone. GERD Symptoms • Persistent heartburn • Regurgitation • Chest pain • Sore Throat/Laryngitis • Chronic Cough/Asthma • Pain or trouble swallowing • Strictures • Esophagitis/Barrett’s Esophagus GERD Why? • No one knows for sure • Lifestyle factors can contribute • Hiatal hernia makes it easier for acid to reflux GERD – Lifestyle Factors • Alcohol use • Obesity • Large or late night meals • Pregnancy • Smoking • Stress • Weight training GERD – Food Triggers • Citrus fruits • Chocolate • Drinks with caffeine • Fatty and fried foods • Garlic and onions • Mint flavorings • Spicy or tomato based foods GERD • Diagnosis and treatment will be covered in a subsequent presentation Hiatal and Paraesophageal Hernia • All paraesophageal hernias are hiatal hernias, but not all hiatal hernias are paraesophageal • Hiatal hernia: herniation of abdominal contents through the hiatus • Paraesophageal hernia: upward herniation of the gastric fundus through a defect in the phrenoesophageal membrane Hiatal and Paraesophageal Hernia • Hiatal hernias: – Type 1: Sliding hernia, GEJ above the hiatus, fundus below the GEJ. 95% of HH’s – Type II/III/IV PEH: • Type II: Gastric fundus herniates through hiatus, but GEJ remains fixed. • Type III: GEJ and fundus herniated, with fundus above the GEJ. 90% of PEH’s • Type IV: Presence of any organ other than stomach in the hernia sac. Hiatal and Paraesophageal Hernia • Clinical Presentation: – Asymptomatic – Heartburn – Regurgitation – Dysphagia – Chest pain/odynophagia – Nausea – Anemia (Cameron’s Ulcers) Hiatal and Paraesophageal Hernia • Differential Diagnosis: – Esophagitis – Motility disorder – Severe GERD – Functional dyspepsia – Coronary artery disease Achalasia and Pseudo-Achalasia • Achalasia is the prototypical esophageal motility disorder • The only esophageal motility disorder shown to be a true disease • Primary achalasia: degeneration of myenteric plexus neurons in esophageal smooth muscle Achalasia • Primary-idiopathic • Secondary: Chagas’ disease, GE junction/proximal stomach malignancy (pseudoachalasia), paraneoplastic syndrome, others Achalasia-Clinical Features • Any age, M=F, 1/100,000 per yr incidence • Longstanding, slowly progressive solid + liquid dysphagia • Weight loss • Nocturnal sxs (cough, choking, regurgitation) • Pulmonary sxs • Chest pain (vigorous achalasia) • Heartburn ~ 40% (different pathophysiology) Carcinoma • Risk of cancer many times greater in setting of achalasia, even after treatment1 • Population based (Sweden) cohort study • >16-fold increased risk • Mainly squamous cell CA • Also adenoCA (Barrett’s pathway) • Incidence greater in men Sandler RS. JAMA 1995 Carcinoma • Annual surveillance after the 1st year: 406 exams in men, 2220 in women to detect one cancer • Other studies: 7-33x increased risk • Unclear whether treatment affects this risk or not • Duration of symptoms of achalasia reported as at least 15 years Carcinoma-Surveillance • ASGE: Insufficient data to support routine surveillance • If surveillance considered, start 15 yrs after onset of symptoms • Subsequent surveillance interval not defined Diffuse Esophageal Spasm • Rare • Non-peristaltic, simultaneous contractions • ? Early stage of myenteric plexus denervation • 3-5% evolve into formal achalasia Diffuse Esophageal Spasm • Present with chest pain and dysphagia • Dysphagia can be at rest or with swallow • Ba Sw can be normal or “cork- screw” • Dx on manometry • Rx with meds – Ca Channel Blockers – Nitrates – Phosphodiesterase inhibitors – Low dose TCA for chest pain • Try not to operate Hyperdynamic (Nutcracker) Hyperdynamic (Nutcracker) • Non-cardiac chest pain or dysphagia • More common in psychiatric d/o’s • Manometric diagnosis • Rx similar to DES. – RCT showing Diltiazem efficacious Scleroderma • Smooth mm atrophy with scar replacement • LES weakens, peristalsis dysfunctional • Typically upper 1/3 of esophagus striated and functioning. Esophageal Diverticulum • Classification – Zenker’s • Above UES through Killian’s Triangle • Open or endoscopic therapy https://throatdisorder.com/swallowing-disorders/zenkers-diverticulum/ Esophageal Diverticulum • Classification – Zenker’s • Above UES through Killian’s Triangle • Open or endoscopic therapy – Traction • Mid esophagus • Assc with TB, sarcoid, etc Esophageal Diverticulum • Classification – Zenker’s • Above UES through Killian’s Triangle • Open or endoscopic therapy – Traction • Mid esophagus • Assc with TB, sarcoid, etc – Epiphrenic • Distal esophagus • Assc with stenosis or motility disorders Conclusions • Benign esophageal disorders are very common, cost billions of dollars each year to diagnose and treat, and can be the source of great morbidity in our patients..