2. Achalasia Cardia
โข Abnormal dilatation of esophagus
โข Degeneration of NO producing
inhibitory neurons
โข loss of ganglionic cells in the
myenteric plexus (distal to
proximal)
โข Non relaxation of LES
โข Basal LES pressure rises
3. Symptoms
โข Dysphagia more for liquids than solids
โข Chest Pain
โข Regurgitation
โข Nocturnal cough
โข Recurrent aspiration
4. Diagnosis
โข Plain x ray (air-fluid level, wide
mediastinum, absent gastric
bubble)
โข Barium Swallow (dilated
esophagus with taper at LES)-
BIRD BEAK appearance
โข Endoscopy-tight cardia & food
residue in esophagus
โข Esophageal manometry -absent
peristalsis, ๏ฏ LES relaxation, &
resting LES >45 mmHg)
5. TREATMENT
โข Isosorbide dinitrate
โข CCBs-Nifedipine
โข Botulinum Toxin
- prevents ACH release at NM junction
-Endoscopic injection into LES
-needs repetitive sessions
Pneumatic
Dilatation
โข Balloon dilatation of
cardia
โข Disruption of circular
muscle
โข Complication- perforation
7. GERD Gastro-Esophageal Reflux Disease
โข Reflux of contents from
stomach into the lower
esophagus.
โข Due to loss of competence
of the Lower esophageal
sphincter
โข May be associated with
hiatus hernia
โข Alcohol,smoking,stress
9. โข Diagnosis- Endoscopy
24 hour pH monitoring โ GOLD STANDARD
โข Complications of GERD:
1. Chronic esophagitis โ bleeding & strictures
2. BARRETS ESOPHAGUS- columnar metaplasia of lower part of
esophagus which predisposes to ADENOCARCINOMA OF
ESOPHAGUS.
10. Management of GERD
โข Lifestyle changes: control of obesity
stop smoking & alcohol
Avoid tea,coffee,chocolate
โข Medical Management :
โข PPIs โ Omeprazole 20 mg BD for 3-6 months
โข Prokinetic drugs-
Metoclopramide,Domperidone
โข Surgical management : Laparoscopic
Fundoplication
11. BARRETs Esophagus
โข Metaplastic change in mucosal lining
of esophagus in response to chronic
GERD
โข Columnar epithelium
โข Hallmark-presence of mucus
secreting Goblet cells (intestinal
metaplasia)
โข Increased risk of Adenocarcinoma of
Esophagus
12. โข Classic Barrettโs โ 3cm or more columnar
epithelium
โข Short segment Barrettโs- < 3 cm columnar
epithelium
โข Cardia Metaplasia โ intestinal metaplasia at
the GE junction without any macroscopic
change at endoscopy
โข TREATMENT โ treat the underlying GERD
13. Perforation
โข Can be caused
1. Spontaneously (Boerhaeves syndrome) OR by
2. Instrumentation - most common cause
3. Foreign bodies
4. Penetrating injuries โ bullets,knives
โข May lead to mediastinitis,septic shock or subcutaneous emphysema
14. Mallory Weiss Tear
โข Mucosal tear at the cardia due to forceful
vomiting
โข Vigorous vomiting produces a vertical split in
gastric mucosa immediately below the squamo-
columnar junction at the cardia.
โข Hemetemesis
โข TREATMENT- conservative management
-endoscopic injection therapy for severe
hematemesis.
15. Boerhaave Syndrome
โข Occurs when a person vomits against a closed glottis, leading to
โข Rapid increase in esophageal pressure
โข Esophagus bursts at its weakest point in lower third
โข Sending a stream of material into mediastinum & pleural cavity
โข Leading to mediastinitis,pleuritic
โข Severe chest pain following meal
โข Shortness of breath
16. โข Chest X ray- air in mediastinum, pleura or peritoneum
โข Contrast swallow or CT needed
โข MANAGEMENT โ mostly conservative
nasogastric suction
broad spectrum i/v antibiotics
SURGICAL MANAGEMENT required when patients
โข Are unstable due to sepsis or shock
โข Have heavily contaminated mediastinum,pleura or peritoneum.
โข Have widespread intrapleural or intraperitoneal extravasation of contrast
material.
17. โข Direct repair preferred if perforation
is recognized early ( first 4-6 hours)
โข For delayed presentation- Creation of
a controlled fistula & distal enteral
feeding by placing T-tube into
esophagus with drains & feeding
jejunostomy.
18. Plummer Vinson syndrome
โข Paterson Kelly syndrome or
Sideropenic Dysphagia
โข Post cricoid web in esophagus
โข Iron deficiency anemia
โข Glossitis
โข Koilonychia
โข Treatment โ Balloon Dilation