Chapter 4-04: Diseases and Pathophysiology in Gastroenterology

ESOPHAGUS

Gastroesophageal reflux disease (GERD)

• Pathophysiology: Decreased lower esophageal sphincter (LES) tone; may also have decreased esophageal motility, gastric outlet obstruction, and/or hiatal hernia

• Clinical features: Heartburn (i.e., burning sensation in the retrosternal area), regurgitation (i.e., perception of refluxed gastric content flowing up into the mouth or hypopharynx)

• Diagnosis: Treat empirically. Typically only perform EGD and/or ambulatory pH monitoring in patients who have refractory or alarm symptoms (e.g., new onset GERD at age >60 yr, dysphagia/odynophagia, weight loss, anorexia, GIB or iron-deficiency anemia, persistent vomiting, or GI malignancy in a first-degree relative)

• Treatment:

  • - Mild: Lifestyle modifications (e.g., weight loss, eliminate dietary triggers, avoid lying down after eating, use of a wedge pillow)

  • - Moderate: Add an H2 blocker

  • - Severe: Switch to a PPI.

    • Potential side effects of PPI use: Increased risk of C. diff infection, osteoporosis, vitamin B₁₂ deficiency

    • Consider the use of a long-term PPI in patients with refractory symptoms, recurrent GI bleeds, Zollinger-Ellison syndrome, Barrett’s esophagus, severe esophagitis

  • - Refractory: If no improvement with empiric treatment after 8 weeks, recommend EGD. Surgical options: Laparoscopic fundoplication or bariatric surgery if obesity is contributing.

• Complications: Erosive esophagitis, stricture, Barrett’s esophagus, increased risk of esophageal cancer

Barrett’s esophagus

• Pathophysiology: Normal squamous epithelium that lines the esophagus changes to columnar epithelium with goblet cells like intestinal cells, typically due to repeated exposure to stomach acid from GERD. Can progress to esophageal adenocarcinoma.

• Diagnosis: Guidelines from various societies differ; overall, should consider screening patients with multiple risk factors for adenocarcinoma (male sex, older age, white, chronic GERD, obesity, hiatal hernia, smoking, first-degree relative with GI malignancy).

• Treatment:

  • - PPI indefinitely

  • - If no dysplasia present: Surveillance EGD every 3–5 yr

  • - If low- or high-grade dysplasia present: Remove with radiofrequency ablation, photodynamic therapy, cryotherapy or endoscopic resection. Perform repeat endoscopy for surveillance within 3–12 months (timing based on severity and whether the dysplasia was deemed to be eradicated)

Esophageal motility disorders

• Classification: First differentiate oropharyngeal dysphagia (difficulty initiating a swallow) vs. esophageal dysphagia (sensation of obstruction several seconds after swallowing)

• Clinical features:

  • - Dysphagia with solids only is often due to a mechanical obstruction

    • Intermittent: Esophageal rings or webs (Plummer-Vinson syndrome, Schatzki’s ring), eosinophilic esophagitis

    • Progressive with chronic heartburn/GERD, no weight loss: Peptic stricture

    • Progressive, age >50 yr, weight loss: Esophageal carcinoma, Zenker’s diverticula

  • - Dysphagia with solids and liquids is often due to a motility problem

    • Intermittent: Esophageal rings

    • Intermittent, with chest pain (similar to angina pain): Diffuse esophageal spasm (DES)

    • Progressive, with heartburn/GERD and skin tightening: Scleroderma

    • Progressive, with regurgitation of food and saliva, weight loss: Achalasia

• Diagnosis:

  • - Barium swallow. Perform an EGD prior if the patient has a history of radiation, caustic injury, esophageal cancer, or stricture to avoid the risk of perforation

  • - EGD: Used to detect structural abnormalities

  • - Esophageal manometry: If the barium swallow ...