Swallowing Difficulty & Pain
Tim Farrell, MD
Tom Egan, MD
Assumptions
• Students understand the anatomy,
physiology, and pathophysiology of
the swallowing mechanism and the
esophagogastric junction.
Objectives
Students will understand:
• Differential diagnosis for a patient with dysphagia.
• Symptoms and treatment of GERD.
• Pathophysiology and treatment of achalasia and diffuse
esophageal spasm.
• Etiology and treatment of esophageal diverticula.
• Common symptoms and management of hiatal hernias.
• Management of adenocarcinoma of the E-G junction.
• Presenting symptoms, etiology and treatment of
esophageal rupture.
Case 1
• An 80-year-old man presents with a
trouble swallowing for a year. He
regurgitates after meals, has heartburn,
but no other pain and is in good health
otherwise.
• He is thin, without neck mass. His chest is
clear and his abdomen is soft and without
masses.
Case 1
• What is the differential diagnosis?
Anatomic
Tumor, Stricture, Compression, Foreign Body
Functional
GERD
Motility Disorder (achalasia, scleroderma)
Neurologic (Parkinson’s, bulbar paralysis)
Psychological
Globus Hystericus
Case 1
• What test should be done, in what order,
and why?
Anatomic Assessment
Upper GI Series
EGD
Biopsy
Functional Assessment
24-hr pH
Esophageal Manometry
GES
GERD - Definition
Protracted
exposure of
the
esophageal
lining to
stomach
juice
GERD - Causes
• Lower esophageal sphincter
– Incompetent valve
– Inappropriate relaxations
• Hiatal Hernia
• Abnormal motility
– Impaired esophageal clearing
• Delayed gastric emptying
• Defective cytoprotection
GERD - Symptoms
Typical Symptoms
Atypical Symptoms
Heartburn
Asthma
Cough
Hoarseness
Chest Pain
Regurgitation
Trouble Swallowing
GERD - Complications
• Peptic Stricture
• Esophagitis / Ulcers
• Barrett's Esophagus
Indications for further Dx-Rx
•
•
•
•
•
•
•
Persistent or frequent symptoms
Dysphagia
Frequent vomiting
Early satiety
Weight loss
Significant respiratory complaints
Age < 45
GERD - Diagnosis
• Barium Swallow
• Upper Endoscopy
• Esophageal Manometry
• 24-Hour Ambulatory
Esophageal pH
• Gastric Emptying Study
GERD - Diagnosis
Barium Swallow
GERD - Diagnosis
Upper Endoscopy
GERD - Diagnosis
Manometry
GERD - Treatment
• Environmental
• Medical - OTC
– Antacids
– H2-Blockers
• Medical -Prescription
– Proton-Pump
Inhibitors
• Endoscopic
• Surgical
– Fundoplication
Dietary Modifications
• Avoid large meals
• Limit foods which decrease LES pressure
– Fatty foods, chocolate, mints, and alcohol
• Avoid irritating foods and beverages
– Citrus, tomatoes, pepper, etc.
• Limit caffeine and carbonated beverages
– Increases acid production
– Increased gastric distension
• Candy or gum to increase saliva
– Alkaline saliva neutralizes acid
– Increases motility and clearance
Lifestyle Modifications
• Weight Loss
• Avoid smoking
– Decreases LES pressure
• Avoid lying down for 2-3 hours
after meals
– Limits supine reflux
• Sleep with elevated head of bed
– Improves esophageal clearance
Medications Worsening Reflux
– Calcium channel blockers
– Anticholinergics
– Theophylline
– Progesterone
– β2-antagonists, α-antagonists
– Nitrates
– Meperidine
– Diazepam
GERD - Medical Treatment
Medications may be used to:
• Neutralize acid
• Increase LES tone
• Improve gastric emptying
OTC H2 Blockers
• Lower-dose formulations
• Acute treatment or prophylaxis
• Slower onset than antacids
• Longer duration of acid inhibition
Proton Pump Inhibitors
Endoscopic Treatment Modalities
Thermal (Stretta®)
Thermal energy Mechanical / Neural
Endoscopic Treatment Modalities
Endoscopic Suturing
• Suturing or plication
EndoCinch ®
Endoscopic Treatment Modalities
Biocompatible Material
Enteryx ®
GERD - Surgical Treatment
GERD - Surgical Treatment
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
Nissen Fundoplication
Technique
GERD - Surgical Treatment
Results
• Procedure - 2 Hours
• Need to Open <1%
• Hospital - 1-2 Days
• Need for Blood <1%
• Full Activity - 2 weeks • Off Medications - 95%
• Full Diet - 3 weeks
• Off Steroids - 50%
• Need 2nd Procedure - 5%
Effects of Fundoplication
Fundoplication
– augments LES resting pressure
– lessens frequency of transient LES relaxations
– reestablishes anatomy of the LES and crura
– may improve esophageal clearance
– may improve gastric emptying
Case 2
• A 61-year-old man presents with progressive
difficulty swallowing. He has history of
indigestion and heartburn. Until 12 months ago,
food would come up into his throat when he was
supine, with a sour taste and sometimes a
cough. About 12 months ago, these symptoms
improved but he developed progressive
dysphagia.
• He smokes 1 PPD and drinks two beers at
dinner.
• Exam is unremarkable except for barrel chest.
Case 2
• What is the differential diagnosis?
Anatomic
Tumor, Stricture, Compression, Foreign Body
Functional
GERD,
Motility Disorder (achalasia, scleroderma)
Neurologic (Parkinson’s, bulbar paralysis)
Psychological
Globus Hystericus
Case 2
• How would you evaluate this patient?
Anatomic Assessment
Upper GI Series
EGD
Biopsy
Functional Assessment
24-hr pH
Esophageal Manometry
GES
Case 2
• What are the treatment options for benign
esophageal stricture?
• Medications
• Endoscopic Dilation
• Surgery
Case 2
• What are the treatment options for
carcinoma of the esophagus?
– Esophagogastectomy
• Ivor-Lewis
• Transhiatal
Barrett’s Esophagus
Epidemiology
• Affects 10% of patients with severe GER
• 40-fold increased risk of cancer
• Patients require endoscopic surveillance
• Esophagectomy for severe dysplasia/cancer
Barrett’s Esophagus
Endoscopic Appearance
Barrett’s Esophagus
Pathologic Diagnosis
• Normal squamous epithelium transforms
to intestinal-type (columnar) epithelium
40x increased cancer risk
No increased cancer risk
PPI-Induced Regression?
Peters FT, et al., Gut 1999;45:489-94.
Surgery-Induced Regression?
• 56 Barrett’s patients had antireflux surgery
• Annual flexible endoscopy
24 Barrett’s regressed
8 cm
4 cm
9 Barrett’s progressed
6 cm
10 cm
23 No change
Sagar: Br J Surg 1995;82:806-10.
Barrett’s Esophagus
Development of Cancer Based on Grade
• No dysplasia
3%
• Low-grade dysplasia
18%
• High-grade dysplasia
28%
Morales and Sampliner, Arch Int Med 1999;159:1411-16.
Barrett’s Esophagus
Following Patients Without Dysplasia
• Studies of cost-effectiveness are mixed
• Few cancers found during surveillance are
node-positive, versus >50% otherwise
• Optimal surveillance interval debated, but
data suggest q2-3 years
Barrett’s Esophagus
Patients With Low-Grade Dysplasia
• Repeat endoscopy to avoid sampling error
• Surveillance q6 mo. x 1 year then q12 mo.
• May regress allowing increased interval
Barrett’s Esophagus
Patients With High-Grade Dysplasia
• Must confirm the diagnosis
• Treatment is controversial
• Some advocate aggressive biopsy protocol
• Some advocate esophagectomy
Barrett’s Esophagus
Patients With High-Grade Dysplasia
Case for Aggressive Surveillance (q3-6 mos.):
• Regression may occur (25%)
• Most patients will not progress to cancer
• Cancers remain surgically curable
• Esophagectomy carries morbidity (up to
40%) and mortality (3-6%)
Barrett’s Esophagus
Patients With High-Grade Dysplasia
Case for Esophagectomy:
• 40% may already have cancer
• Surveillance delays definitive treatment
• Risk of esophagectomy low in highvolume centers
Barrett’s Esophagus
Specific Treatment
Ablative Techniques
• laser
• electrocautery
• photodynamic therapy (PDT)
Resective Techniques
• Endoscopic mucosal resection (EMR)
Barrett’s Esophagus
Take-Home Points
• Barrett’s esophagus is not a
contraindication to antireflux operation
• Medical or surgical therapy does not
eliminate need for Barrett’s surveillance
• Management of high-grade dysplasia is
evolving away from esophagectomy
Case 3
• A 53-year-old patient presents with a
history of difficulty swallowing for years.
More recently she is having increasing
trouble swallowing, and has been
regurgitating undigested food. Exam is
unrevealing, but on chest film there is an
air fluid level seen behind the heart in the
mid chest.
Case 3
• Describe a differential diagnosis and
diagnostic evaluation.
Case 3
• Discuss the management options for a
patient with achalasia.
Achalasia
Incidence
• 0.5 new cases / 100,000 population / year
• Dysphagia, regurgitation, cough,
wheezing, aspiration, pulmonary infections
• 50% initially misdiagnosed
Achalasia
Pathophysiology
• Involves degeneration of Auerbach’s
plexus and elevated LES resting pressure
• Poor LES relaxation results in esophageal
dilation with progressive loss of peristalsis
Achalasia
Diagnosis
• Ba swallow:
– esophageal dilation / narrowing at GE junction
• EGD:
– patulous esophagus, retained food, thickening
• Esophageal manometry:
–
–
–
LES resting pressure
LES relaxation on swallowing
primary peristalsis
Achalasia
Treatment Options
• Non-Surgical options:
– Nitrates and Ca++-channel blockers
– Endoscopic injection of Botox
– Pneumatic balloon dilatation
• Surgical options:
– Heller myotomy (laparoscopic, thoracoscopic)
Heller Myotomy
Technique
Heller Myotomy
Technique
Heller Myotomy
Technique
Heller Myotomy
Outcomes
• 40 laparoscopic Heller myotomies
• No conversions, mean op time - 180 min
• Median hospital stay - 2 days
• One intraop mucosal injuriey repaired
• Dysphagia alleviated in > 95%
Case 3
• Discuss the management of a patient with
paraesophageal hernia.
Epidemiology
Hiatal Hernias
• Herniation of the stomach through the
esophageal hiatus
• Para-esophageal type - 5%
– Occurs in elderly patients (~ 65 years)
– Frequent co-morbid conditions
Classification
Hiatal Hernias
• Classification depends on location of GEJ
– Type I- “sliding” hiatal hernia
– Type II- true paraesophageal hernia
– Type III- “mixed” hernia- sliding hernia and
true paraesophageal hernia
– Type IV- intra-abdominal organ involvement
Sliding Hiatal Hernia
• Type I
• GE junction “slides”
into the mediastinum
• Most HH
• May be associated with
symptomatic GERD
• Surgery not indicated
True Paraesophageal Hernia
• Type II
• GEJ in the
abdominal cavity,
fundus in the
mediastinum
• 5% of all HH
• Risk of incarceration
and strangulation
Mixed Paraesophageal Hernia
• Type III
• GE junction and
gastric fundus are
located in
mediastinum
• 5% of all HH
• Risk of incarceration
and strangulation
Paraesophageal Hernia
Volvulus
Mesoaxial Volvulus
Organoaxial Volvulus
Paraesophageal Hernia
X-ray
Paraesophageal Hernia
Upper GI series
Type II
Type III
Paraesophageal Hernia
EGD
Paraesophageal Hernia
Treatment Options
• Observation
• Medical Therapy
• Surgery
Paraesophageal Hernia
Observation
• Assumes a low rate of gastric strangulation
• Allen et al.
– 23 of 147 patients followed for 12-268 mos
(median 78 mos).
– Only 4 pts had progressive symptoms and 2
had elective repair
– Estimate prevalence of one gastric
strangulation per 245 pts
J Thorac Cardiovasc Surg 1993;105:253
Paraesophageal Hernia
Medical Therapy
• One-third of patients have heartburn alone
– Acid inhibition
– Patient clearly informed of risk of gastric
strangulation and consequences
• Excessive (10-50%) mortality for surgical repair of
gastric strangulation
Paraesophageal Hernia
Principles of Operative Repair
• Hernia Reduction
• Hernia sac excision
• Crural repair
• Gastric fixation
• Fundoplication
controversial
Paraesophageal Hernia
Hernia Reduction
• Entire stomach and
at least 2 cm of
esophagus must be
intra-abdominal
Paraesophageal Hernia
Sac Excision
• Entire sac must be
excised to decrease
risk of recurrence
• Remnants of sac
along inferior border
of left crus lead to
recurrence
Paraesophageal Hernia
Crural Repair
• Primary repair alone
• Primary repair with
relaxing incision
• Mesh repair
Paraesophageal Hernia
Fundoplication
• Recent series report
high rate of GERD
without fundoplication
• Wrap provides bulk to
create “plug” at site of
crural repair
Paraesophageal Hernia
Surgical Outcomes
• Luketich et al.: 100 pts lap PH repair
– 12% intraop complications; technically demanding
– 3 conversions to open procedures
– 28% postop complication rate; 0% mortality
– 3% reoperation rate
– 91% satisfied, 2-day hospital stay
Ann Surg 2000;232:608
Paraesophageal Hernia
Take-Home Points
• Uncommon, rarely present with strangulation
• Repair advised for non-GER symptoms
• Repair is technically demanding
• Laparoscopic vs. open remains controversial
• Prospective study to determine recurrence
Case 4
• A 47-year-old woman has chest pain after
eating dinner at home 4 hours following
upper GI endoscopy for dilatation of her
achalasia.
• What is the presumed diagnosis?
Case 4
• What is the best means of making the
diagnosis?
Case 4
• What is the appropriate management?
Under what circumstances might you
manage this non-operatively?
• What might be an appropriate
management for a small perforation at the
GE junction with minimal soiling?