Esophagus Diseases, Tests, Treatment
Esophageal Anatomy and Stenosis
The esophagus is a muscular (smooth muscle) tube that connects the pharynx (pharynx) in the neck and the stomach in the abdomen. Its average length is 25-30 cm. The average distance from the incisors to the stomach is 40 cm in men and 37 cm in women (measured with an endoscope). The esophagus is in front of the spine, behind the trachea and heart.
The most common disease of the esophagus is gastroesophageal reflux. It accounts for approximately 75% of all esophageal diseases. In this article, common esophageal diseases, esophageal tests, treatments and some terms related to esophageal diseases are presented in summary form. We hope that this article will be useful in understanding esophageal diseases as a whole.
Gastroesophageal Reflux Disease (GERD, Heartburn)
It occurs when stomach contents (acid) frequently leak back into the esophagus. This acid irritates the esophagus (esophagitis). Reflux may cause heartburn, retrosternal burning, cough, or hoarseness.
Many people notice acid reflux from time to time. For reflux to be considered a disease, there must be mild acid reflux at least twice a week or moderate to severe acid reflux once a week.
Most people can manage gastroesophageal reflux disease with lifestyle changes and medications. However, some patients may need stronger medications or surgery to relieve symptoms.
Esophagitis
Esophagitis is inflammation (inflammatory reaction) of the esophagus. Among the following causes, it is most commonly seen in gastroesophageal reflux (stomach acid).
Reflux esophagitis
Eosinophilic esophagitis (usually of allergic origin)
Lymphocytic esophagitis
Drug-induced esophagitis (especially swallowing medications without water, including painkillers such as aspirin, ibuprofen, naproxen sodium, antibiotics such as tetracycline and doxycycline, potassium chloride used to treat potassium deficiency, alendronate (Fosamax) used to treat weak and brittle bones (osteoporosis). bisphosphonates, quinidine used to treat heart problems
Infectious esophagitis: Bacterial, viral or fungal infection of the tissues in the esophagus can cause esophagitis. Infectious esophagitis is rare and common in people with weakened immune systems, such as people with HIV/AIDS or cancer. An infection called Candida albicans (a fungus normally found in the mouth) is a common cause of esophagitis. Such infections are often due to a weak immune system, diabetes, cancer, and steroid or antibiotic use.
Esophagitis can cause painful, difficult swallowing (dysphagia) and chest pain.
Treatment of esophagitis depends on the underlying cause and the severity of tissue damage. If left untreated, esophagitis can damage the esophageal mucosa, causing narrowing and shortening of the esophagus and making it difficult to pass food and liquids into the stomach.
Barrett's Esophagus
The esophageal mucosa, which is constantly exposed to acid, turns into the small intestinal mucosa (intestinal metaplasia), this is called Barrett's esophagus. Barrett's esophagus often develops in people with long-term gastroesophageal reflux disease (GERD).
In Barrett's esophagus, the risk of developing esophageal cancer increases. Although the risk is low, it is important to have regular examinations (endoscopy checks) for precancerous cells (dysplasia). If precancerous (before cancer) cells are discovered, they can be treated to prevent esophageal cancer.
Esophageal Ulcer
Esophageal ulcer is a type of peptic ulcer. Peptic ulcer is an ulcer caused by the action of acid. Esophageal ulcer is painful. In reflux, both acid and a bacterial infection called Helicobacter pylori cause esophageal ulcers. Rarely, fungal and viral infections can also cause esophageal ulcers.
Esophageal Stricture (Stenosis, Narrowing)
Esophageal stenosis develops in 3 disease groups.
1. Intrinsic Diseases (Esophageal Wall): Diseases that narrow through inflammation (esophagitis), fibrosis or neoplasia (cancer), congenital (esophageal atresia), caustic acid, iatrogenic (anastomotic stenosis, sclerotherapy), radiotherapy.
2. Extrinsic Diseases (External Compression etc.): Invasion of another cancer (thyroid, stomach, lung cancer) or enlarged lymph node compression.
3. Diseases that Impair Lower Esophageal Sphincter (LES) Function: Achalasia, Nutcracker esophagus.
Peptic strictures account for 70-80% of all esophageal stricture cases.
Esophageal Motility Disorders
Achalasia (Achalasia)
Achalasia results from progressive degeneration of ganglion cells in the myenteric plexus, a network of nerves located between the lonlitudinal (outer) and circular muscle layers of the esophagus. As a matter of fact, it is determined that ganglion cells are reduced in pathology. Ganglion degeneration results in the inability of the lower esophageal sphincter to relax and loss of peristalsis in the distal esophagus. It is a rare disease (occurring in one in 10 thousand of the population). The ratio of men and women is equal. It is seen between the ages of 25-60.
The most common symptoms in patients with achalasia are dysphagia for solids (91%) and dysphagia for liquids (85%) and regurgitation of soft undigested food or saliva (76-91%). Achalasia begins insidiously and progresses slowly. Patients often live with these symptoms for years before receiving a diagnosis (an average of 4.7 years). These patients are mistakenly diagnosed with gastroesophageal reflux disease (GERD), psycholosomatic, and other diagnoses.
Achalasia Diagnosis:
Direct radiographs show mediastinal widening and the absence of gas in the gastric fundus.
Barium esophageal radiographs show enlargement of the esophagus (megaesophagus; >6 cm), elongation and openings in the esophagus, sigmoid appearance, bird's beak appearance (a gradual, pointed thinning) at the esophago-gastric junction, loss of peristalsis (aperistalsis), and delay in the passage of barium to the stomach.
In upper gastrointestinal system endoscopy, food residues in the esophagus, enlarged esophagus, and a lower esophageal sphincter that does not open spontaneously with air are observed.
Distal in esophageal manometry? Loss of peristalsis, inability to relax the lower esophageal sphincter, and high resting pressure are detected in the lower esophageal section.
Achalasia Treatment: Treatment aims to reduce the pressure of the lower esophageal sphincter.
Endoscopic pneumatic dilatation (with balloon)
Surgical esophago-cardio-myotomy (open, laparoscopic) + fundoplication
Per Oral Endoscopic Myotomy (POEM), its full effectiveness has not yet been proven
Botulinum toxin injection (botox)
Drug therapy (nitrates and calcium channel blockers)
Diffuse (Distal) Esophageal Spasm (DES)
It is characterized by simultaneous contractions in the distal esophagus that do not have a certain order. Normally, esophageal contractions follow each other in a coordinated manner (like a screw pump) to move food forward. In conventional manometry, DES is defined by simultaneous contractions of 20 percent or more (amplitude >30 mmHg). Although most patients with DES generally have normal relaxation of the LES, high resting pressure or incomplete relaxation is detected in approximately one-third of patients. This disease causes dysphagia and chest pain.
Nutcracker Esophagus (Hypertensive Peristalsis, Spastic Nutcracker, Hypercontractile (jackhammer) Esophagus)
In the nutcracker esophagus, there are normal sequential (coordinated) contractions, but the amplitude (severity) and duration of the contractions are long. In conventional manometry, nutcracker esophagus is defined by high-amplitude peristaltic contractions exceeding 220 mmHg in the distal 10 cm of the esophagus after swallowing liquid. Many patients with nutcracker esophagus also have hypertensive LES. Unlike diffuse esophageal spasm, it is usually asymptomatic.
Hypertensive Lower Esophageal Sphincter
Hypertensive LES is a LES resting pressure above 45 mmHg in the mid-respiratory phase (mid-respiration) on conventional manometry. Unlike diffuse esophageal spasm, it is usually asymptomatic.
Esophageal Cancer
Most esophageal cancers are squamous cell carcinoma or adenocarcinoma (95%). Most esophageal cancers originate from the esophagogastric junction and cardia. The incidence in North and East Africa and East Asia is 16 times higher than in Central America. A diet low in vegetables, hot foods, smoked foods, smoking and alcohol are risk factors for Barrett's esophagus.
Esophageal cancer manifests itself with progressive difficulty in swallowing and weight loss. Sometimes occult bleeding causes iron deficiency anemia. In early stage esophageal cancer (T1-2, N0, M0), first surgery (esophagectomy) and then chemotherapy and radiotherapy are the appropriate options, while in T3-4 cancers, first chemoradiotherapy and then, if appropriate, surgery is a better option. Resection is not recommended for metastatic esophageal cancers (peritoneal, lung, bone, adrenal, brain and liver metastases).
Corrosive Esophagitis (Esophageal Burn, Caustic Drinking)
Caustic; It is a caustic, corrosive substance, usually a strong acid or base. Children drink caustic by mistake and stop when they realize its taste, so they drink small amounts. Young people or adults usually drink larger amounts of caustic because they drink it for suicide purposes. Acids (bases) are drunk in larger amounts, while acids are consumed less because they cause burns and pain in the mouth and pharynx. When caustic is consumed, it causes perforation in the esophagus and stomach in the acute phase. If perforation does not occur, esophageal stenosis may develop in the chronic period, causing difficulty in swallowing.
The damage caused by caustic depends on the following:
1. The amount of caustic,
2. Feature and concentration (density), D
3. contact time with schools.
The damage mechanisms of acids and bases are also different. Bases dissolve tissue and lead to easier perforation. Acids cause damage called coagulation necrosis, which limits the penetration of acid into the tissue and makes perforation more difficult.
When the base is drunk (e.g. bleach), vinegar, lemon juice or orange juice, it neutralizes the base and is beneficial. When acid is consumed, giving the patient milk, egg white or anti-icing syrup-tablet neutralizes the acid and is beneficial. The patient should not be induced to vomit because the esophagus will be exposed to the same chemical again. If esophageal or stomach perforation develops, surgery is required. In the chronic period, stenoses are treated with dilatation or surgery.
Mallory-Weiss Syndrome (Tear)
Mallory-Weiss syndrome develops due to severe vomiting. It is the development of longitudinal mucosal laceration (tear, intramural dissection) in the distal (end part) of the esophagus (esophagus) and in the proximal (beginning) part of the stomach. Tears often (70%) also cause bleeding (bleeding from submucosal arteries, in the form of hematemesis). Mallory-Weiss syndrome is the cause of 1-15% of upper gastrointestinal tract bleeding. Severe vomiting is most often caused by heavy alcohol use. There are also studies indicating that rupture is easier in people with hiatal hernia. Vomiting due to pregnancy, vomiting due to liver cirrhosis, straining, heavy lifting, severe coughing fits, nasogastric tube insertion and gastroscopy may cause Mallory-Weiss tears.
Symptoms of Mallory-Weiss Syndrome: Patients with Mallory-Weiss syndrome usually present with hematemesis (bloody vomit; red fresh blood or blood in the form of digested coffee grounds). Bleeding may be accompanied by chest and epigastric pain. When anamnesis is taken from the patient, they give a history of bloodless vomiting, retching, coughing and straining.
Diagnosis of Mallory-Weiss Syndrome: In endoscopy, a longitudinal mucosal tear (70%) or tears (30%) starting from the distal esophagus and extending to the cardia is seen, and hiatal hernia may accompany it. These tears heal within 24-48 hours. Therefore, they cannot be seen if endoscopy is delayed.
Treatment of Mallory-Weiss Syndrome: If bleeding is serious, the patient should be hospitalized for hemodynamic stabilization. If there is active bleeding during endoscopy, sclerotherapy is applied. As medical treatment, intravenous proton pump inhibitor (2x1) is used for severe bleeding, and outpatient oral proton pump inhibitor (2x1) is used for mild or stopped bleeding. If necessary, antiemetics are added to the treatment.
Esophageal Varicose Veins
Varicose veins mean enlarged, elongated, thinned veins (usually veins, veins). Esophageal varices, especially the lower part of the esophagus. It develops in the liver and as a result (complication) of liver cirrhosis. Normally, venous blood from the gastrointestinal tract flows to the liver. After this blood is processed in the liver (after passing through the liver), it is poured into the inferior vena cava (this is the main vein into which all the veins of the trunk and legs flow). In chronic liver disease (liver cirrhosis), fibrosis develops in the liver tissue (scarring). Liver fibrosis also blocks the capillary network through which blood from the intestinal system circulates within the liver (sinusoid; is the capillary system of the liver tissue). As a result, the pressure in the venous structure of the entire gastrointestinal system increases, which we call portal hypertension. Portal hypertension can cause dilation and varicose veins in all gastrointestinal system vessels, but it is important because varicose veins under the esophageal and gastric mucosa can bleed.
Symptoms of Esophageal Varices: Esophageal varices do not cause any symptoms unless they bleed. When esophageal varicose veins bleed, hematemesis (bloody vomiting), melena (bloody defecation), and shock due to blood loss may develop (first weakness, then loss of consciousness and coma may develop, which can be fatal). If varicose veins are due to liver cirrhosis, symptoms of cirrhosis are also observed (jaundice, bleeding diathesis (easy injury and bleeding), malnutrition, weight loss, abdominal ascites (causing swelling in the abdomen), confusion and coma.
Diagnosis of Esophageal Varicose Veins: It is detected during endoscopy checks in patients with liver cirrhosis. Ultrasonography and computed tomography also show enlargement of the splenic (spleen) vein and portal vein.
Treatment of Esophageal Varicose Veins: It can be summarized as preventing bleeding before it occurs and stopping bleeding if it occurs.
Prevention of Bleeding (Prophylaxis): Varicose veins that are thought to bleed during endoscopy checks are ligated endoscopically (endoscopic band ligation). The patient uses medications called beta blockers to reduce portal pressure.
Stopping Bleeding:
Endoscopy: Both diagnosis is made and band ligation is performed.
Drug Treatment: Sandostatin (octreotide) reduces portal vein flow and pressure.
TIPS (Transjugular Intrahepatic Portosystemic Shunt): The liver vein is entered through the internal jugular vein in the neck. From here, the portal vein is passed through the liver stool. A thin catheter is placed between these two veins. This procedure is performed by an interventional radiologist.
Liver transplant
Esophageal Web (Curtain)
Esophageal webs are ring-shaped, membrane-like structures (less than 2 mm thick) that partially obstruct the esophageal lumen. Esophageal webs are usually asymptomatic (they do not cause symptoms). Symptomatic patients typically present with occasional dysphagia to solids (difficulty swallowing). It usually originates from the core of the cervical esophagus.
Esophageal Ring (Schatzki Ring)
The esophageal ring is the concentric (all-around), 2-5 mm thick tissue that narrows the esophageal lumen (i.e., it is thicker and symmetrical than the web). They are usually located in the distal esophagus. Schatzki rings are usually of mucosal origin, rarely of muscular origin (due to muscular hypertrophy of the lower esophageal sphincter). The most common esophageal ring is the Schatzki ring, a mucosal ring located at the squamocolumnar junction (Z line). According to some studies, hiatal hernia was also detected in 97% of those with Schatzki ring.
Plummer-Vinson Syndrome (Paterson-Brown-Kelly Syndrome, Sideropenic Dysphagia)
The classic triad of this syndrome is as follows; iron deficiency anemia, dysphagia (difficulty swallowing) and cervical esophageal web (web). The following components may also be present in this syndrome: glossitis, angular (commissural) cheliitis (sore around the mouth), koilonychia (pitted nail), splenomegaly, goiter. Plummer-Vinson Syndrome is a risk factor for esophageal and pharyngeal squamous cell cancer, so its recognition and treatment is important. After iron supplementation, dysphagia usually resolves before the anemia resolves. If the stenosis is very serious, esophageal dilatation is performed (with an endoscopic balloon or dilator).
Esophageal Diverticules
Zenker Diverticula (Pharyngoesophageal Diverticul)
Zenker's diverticulum is the protrusion (protrusion) of the mucosa and submucosa, forming a pouch, from the weak area between the cricopharyngeal muscle and the inferior pharyngeal constrictor muscle. The weak area here is called the Killian triangle. Symptomatic Zenker diverticula are 5 times more common in men. It is seen in middle age and in the 70s-80s. Zenker diverticulum is a traction (pressure) diverticulum and a false diverticulum (it is not full thickness and does not contain a muscle layer).
Traction Diverticula of the Esophagus
It is in the middle part of the esophagus. It is a true diverticulum (It includes all esophageal layers; mucosa, submucosa, muscle layers.) The esophageal wall undergoes full-thickness shrinkage due to mediastinal lymphadinitis caused by tuberculosis or other reasons. It usually causes no symptoms and no treatment is required.
Epiphrenic Diverticula
It is on the right, just above the lower esophageal sphincter. They are traction (pressure) diverticulum and false diverticulum (not full thickness, does not contain a muscle layer). Epiphrenic diverticulum is often seen with Achalasia. Therefore, Heller myotomy should be performed along with diverticulectomy (esophago-cardiomyotomy).
Esophagus Tests
Upper Gastrointestinal System (GIS) Endoscopy (EGD (esophagogastroduodenoscopy): A flexible tube with a camera and light at its end is inserted through the mouth (endoscope). The endoscope allows you to examine the esophagus, stomach, and duodenum (duodenum).
Esophageal pH Monitoring: A probe that monitors acidity (pH) for 24 hours is inserted through the nose into the esophagus. Monitoring pH is used to diagnose gastroesophageal reflux and monitor response to treatment.
Barium Esophageal Stomach Duodenum Radiograph: The person drinks a barium syrup that has the consistency of boza. Barium does not transmit X-rays and appears white on films. The passage of barium through the esophagus is monitored with an X-ray device (scopy; it can also be recorded as a video) and films are taken from time to time. Most often, it is used to find the cause of difficulty swallowing (dysphagia) and to diagnose gastroesophageal reflux and hiatal hernia.
Esophageal Manometry: Manometry means pressure measurement. Esophageal manometry testing is used to determine if an esophageal motility disorder is present (achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive LES (lower esophageal sphincter))
Some Treatments and Definitions Used in Esophageal Diseases
H2 blockers: Histamine stimulates the release of acid in the stomach. Some antihistamines, called H2 receptor antagonists, reduce stomach acid and may improve gastroesophageal reflux (GERD) and esophagitis.
Proton Pump Inhibitors: These drugs prevent the acid production pumps in the gastric mucosa from working. Thus, stomach acid decreases, reduces gastroesophageal reflux (GERD) symptoms and treats ulcers.
Esophagectomy: Surgical removal of the esophagus. It is generally applied in esophageal cancer.
Esophageal Dilatation: A balloon is passed through the esophagus and inflated to widen a stricture, web, or ring that prevents swallowing. Sometimes this procedure is performed with special esophageal plugs (expanders) called Maloney dilators.
Tape Ligation for Esophageal Varicose Veins: Additional attachments are attached to the endoscopy device, and esophageal varicose veins are banded (tied) with small rubber buckle-like tapes. Taping results in necrosis and sloughing of the varicose vein. The area blocked by the tape heals with fibrosis (scarring), and varicose veins do not develop again in the same place, and the bleeding in the bleeding varicose vein is stopped.
Endoscopic Biopsy: During endoscopy, small pieces are removed with tools advanced through the working channel of the endoscope and sent to the pathology department (microscopic examination of tissues is performed).
