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Toronto Notes 2019
Esophagus
Gastroenterology G9
Esophageal Diverticula
Definition
• outpouchingsofoneormorelayersoftheesophagealtract
Clinical Features
• commonlyassociatedwithmotilitydisorders
• dysphagia,regurgitation,retrosternalpain,intermittentvomiting,maybeasymptomatic
Classification
• pharyngoesophageal(Zenker’s)diverticulum
■ most frequent form of esophageal diverticulum
■ posterior pharyngeal outpouching most often on the left side, above cricopharyngeal muscle and
below the inferior pharyngeal constrictor muscle
■ symptoms: dysphagia, regurgitation of undigested food, halitosis (bad breath)
■ treatment: small and asymptomatic: no treatment required, large and symptomatic: endoscopic or
surgical myotomy of cricopharyngeal muscle ± surgical excision of sac
Peptic Stricture (from Esophagitis)
• presentsasdysphagiaalongsidealonghistoryofrefluxsymptoms,butrefluxsymptomsmaydisappear as stricture develops
• diagnosedwithendoscopyorbariumstudyifendoscopycontraindicatedorunavailable
Treatment
• endoscopicdilatationandindefinitePPI
Esophageal Carcinoma
• seeGeneralSurgery,GS15 Webs and Rings
• web=partialocclusion(upperesophagus)
• ring=circumferentialnarrowing(loweresophagus)
Clinical Features
• asymptomaticwithlumendiameter>12mm,providedperistalsisisnormal • dysphagiawithlargefoodboluses
• Schatzkiring
■ mucosal ring at squamo-columnar junction above a hiatus hernia ■ causes intermittent dysphagia with solids
■ treatment involves disrupting ring with endoscopic bougie
Infectious Esophagitis
Definition
• severemucosalinflammationandulcerationasaresultofaviralorafungalinfection
Risk Factors
• DM
• chemotherapeuticagents
• immunocompromisedstates
Clinical Features
• characteristicallyodynophagia,lessoftendysphagia • diagnosisisviaendoscopicvisualizationandbiopsy
Appearance
• Candida(mostcommon):whitish-yellowplaqueswithoutvisibleulcerationorinflammation • Herpes(secondmostcommon),CMV:focalulcers
Investigations
• diagnosisviaendoscopicvisualizationandbiopsy
Treatment
• Candida:nystatinswishandswallow,ketoconazole,fluconazole • Herpes:oftenself-limiting;acyclovir,valacyclovir,famciclovir
• CMV:IVganciclovir,famciclovir,ororalvalganciclovir
Plummer-Vinson Syndrome Triad
• Iron deficiency anemia
• Dysphagia
• Esophageal webs
* rare (prevalence <1 in 1,000,000) but good
prognosis when treated with iron and esophageal dilatation
Eosinophilic Esophagitis
• Eosinophils infiltrate the epithelium of the esophagus
• Causes odynophagia, dysphagia, common cause of bolus food impaction
• Usually primary, but can be part of the spectrum of eosinophilic gastroenteritis, secondary to drugs, parasites etc.
• Often associated with allergies
• Most characteristically occurs in young
men
• Diagnosis established by endoscopic
biopsy, suggested by mucosal rings seen in
the esophageal mucosa at endoscopy
• Treatment: (a) diet, (b) swallowed
corticosteroid nasal spray (fluticasone), (c) swallowed viscous corticosteroid (budesonide mixed with sucralose)