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Toronto Notes 2019 Esophagus
• esophagealmanometry(studyofesophagealmotility):indicatedinpatientswhohaveanormal gastroscopy but with chest pain and/or dysphagia
■ done to diagnose abnormal peristalsis and/or decreased LES tone, but cannot detect presence of reflux; indicated before surgical fundoplication to ensure intact esophageal function; exclude alternative diagnoses like scleroderma and achalasia
■ surgical fundoplication (wrapping of gastric fundus around the lower end of the esophagus) more likely to alleviate symptoms if lower esophageal pressure is diminished; less likely to be successful if abnormal peristalsis
• 24hpHmonitoring:mostaccuratetestforreflux,butnotrequiredorperformedinmostcases ■ most useful if PPIs do not improve symptoms
Treatment
• PPIsarethemosteffectivetherapyandusuallyneedtobecontinuedasmaintenancetherapy
• on-demand:antacids(Mg(OH)2,Al(OH)3,alginate),H2-blockers,orPPIscanbeusedforNERD
• diet helps symptoms, not the disease; avoid alcohol, coffee, spices, tomatoes, and citrus juices
• only beneficial lifestyle changes are weight loss (if obese) and elevating the head of bed (if nocturnal
symptoms)
• symptomsmayrecuriftherapyisdiscontinued
Complications
• esophagealstricturedisease–scarringcanleadtodysphagia(solids) • esophagitis
• ulcer
• bleeding
• Barrett’sesophagusandesophagealadenocarcinoma–gastroscopyisrecommendedforpatientswith chronic GERD or symptoms suggestive of complicated disease (e.g. anorexia, weight loss, bleeding, dysphagia)
Barrett’s Esophagus
Definition
• metaplasiaofnormalsquamousesophagealepitheliumtointestinalcolumnarepitheliumcontaining- type intestinal mucosa (intestinal metaplasia)
Etiology
• thoughttobeacquiredvialong-standingGERDandconsequentdamagetosquamousepithelium
Epidemiology
• inNorthAmericaandWesternEurope,0.5-20%ofadultsarethoughttohaveBarrett’sesophagus
• upto10%ofGERDpatientswillhavealreadydevelopedBEbythetimetheyseekmedicalattention • more common in males, age >50, Caucasians, smokers, overweight, hiatus hernia, and long history of
reflux symptoms
Pathophysiology
• endoscopyshowserythematousepitheliumindistalesophagus;diagnosisofBEreliesonbiopsy demonstrating the presence of specialized intestinal epithelium of any length within the esophagus
• BEpredisposesfirsttopremalignantchangescharacterizedasloworhigh-gradedysplasia,whichthen progresses to adenocarcinoma
Significance
• rateofmalignanttransformationisapproximately0.12%peryrforallBEpatientspriortodysplasia
• riskofmalignanttransformationinhigh-gradedysplasiaissignificantlyhigher;studieshavereporteda
32-59% transformation rate over 5-8 yr of surveillance
• increasedgastricacidsecretionismorefrequentlyassociatedwithBarrett’sesophagusasopposedto
reflux alone
Treatment
• acidsuppressivetherapywithhigh-dosePPIindefinitely(orsurgicalfundoplication)
• surveillancegastroscopyevery3yrifnodysplasia
• highgradedysplasia:regularandfrequentsurveillancewithintensivebiopsy,endoscopicablation/
resection, or esophagectomy produce similar outcomes; however, evidence increasingly favouring
endoscopic ablation with mucosal resection or radiofrequency ablation
• iflowgradedysplasia,bothsurveillance(every6mofor1yrthenannually)andendoscopicablation/
resection are satisfactory options
Gastroenterology G7
Side-Effects of Long-Term Use of Proton Pump Inhibitors
• Only some (pneumonia, Clostridium
difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, small bowel bacterial overgrowth) seem to be related to suppressing gastric acid whereas others (fractures, chronic kidney disease, dementia, death) have no apparent pathophysiological relationship
• Stopping proton pump inhibitors can increase gastric acid above baseline by a ”rebound effect” causing heartburn even in healthy volunteers
• These associations do not preclude long term use of proton pump inhibitors in patients with esophagitis and peptic ulcer, or those needing gastric protection when taking NSAIDs or anti-platelet drugs, but do emphasize the importance of being as definitive as possible when making these diagnoses and accurately assessing risk- benefit ratios (as is true for all drugs)
Up to 25% of patients with Barrett’s esophagus do not report symptoms of GERD
Should Patients with Barrett’s Esophagus Undergo Periodic Upper GI Endoscopy for Esophageal Cancer Screening?
Impact of Endoscopic Surveillance on Mortality From Barrett’s Esophagus - Associated Esophageal Adenocarcinomas
Gastroenterology 2013;145:312-319
There is no question that Barrett’s esophagus
(BE) increases the incidence of esophageal adenocarcinoma, which can be recognized early
on with a safe procedure, endoscopy. Indeed, because early cancer is often asymptomatic and curable, most clinicians recommend period upper endoscopy. Yet Corley et al. found no difference
in endoscopy rates in BE patients who died of esophageal adenocarcinoma compared to BE patients who died of other diseases. Perhaps this result is due to statistics, but as the accompanying editorial emphasizes (Gastroenterology 2013; 145:273-6) at the very least this finding should question the value of a screening program. In fact, there are multiple other lines of evidence indicating that endoscopic surveillance is of marginal benefit at most. Possible explanations for this disappointing finding include: most esophageal adenocarcinomas may not arise from BE, esophageal carcinoma is too rare a cause of death in BE, morbidity from esophageal cancer treatments, or that endoscopic screening is just not that effective in the real world. The situation is analogous to the disappointing value of serum PSA screening for prostate cancer. Therefore, adoption of screening programs require more than theoretical calculations.