ESOPHAGEAL PROBLEMS
Educational Objectives
| The goal of this program is to improve the management of disorders of the esophagus. After hearing and assimilating
this program, the clinician will be able to:
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 | 1. Diagnose and treat achalasia.
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| 2. Distinguish achalasia from other esophageal motility disorders.
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| 3. Recognize the indications for dilating esophageal strictures and the risk factors for stricture recurrence.
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| 4. Discuss the different types of ablation therapy for Barrett’s esophagus.
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| 5. Describe treatment challenges associated with high-grade esophageal dysplasia.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the following has been
disclosed: Dr. Vaezi receives research funding from AstraZeneca and TAP; Dr. Sampliner has received grants from
Barrx Medical and TAP, and is on the Speakers’ Bureaus for TAP and AstraZeneca. The planning committee reported
nothing to disclose.
Acknowledgements
Dr. Vaezi spoke at Gastroenterology Update 2007, held September 28, 2007, in Nashville, TN, and sponsored by the
Vanderbilt University School of Medicine, Division of Gastroenterology, Hepatology, and Nutrition. Dr. Sampliner
spoke at the 32nd Annual Texas Program, held September 14-16, 2007, in Grapevine, TX, and sponsored by the Texas
Society for Gastroenterology and Endoscopy, the American College of Gastroenterology, and the SGNA Texas Regional
Societies. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
| ESOPHAGEAL MOTILITY DISORDERS —Michael F. Vaezi, MD, PhD, Professor of Medicine, Clinical Director,
Divison of Gastroenterology and Hepatology, and Director, Clinical Research and Center for Swallowing and Esophageal
Disorders, Vanderbilt University School of Medicine, Nashville, TN
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| Normal esophageal function: swallowing triggers peristalsis; lower esophageal sphincter (LES) relaxes with
each swallow and stays relaxed until bolus clears esophagus (in reflux disease and transient LES sphincter relaxation,
relaxation occurs without swallowing)
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| Classification of esophageal disorders: based on manometry findings; inadequate LES relaxation—classic achalasia;
atypical disorders of LES relaxation; uncoordinated contraction—diffuse esophageal spasm; hypercontractile
conditions—nutcracker esophagus; isolated hypertensive LES—another classification; hypocontractile
contractions—ineffective esophageal (nonspecific) motility disorders
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| Achalasia: esophagus dilates; LES does not relax; patients typically have dysphagia for solids and liquids and are
usually young to middle-aged; cause unknown; diagnosis based on observation of 10 swallows in which LES
does not relax or relaxes inappropriately during simultaneous isobaric esophageal contractions (peristalsis does
not occur); solid food dysphagia that occurs first, progressing to dysphagia to liquids and solids, is probably
not achalasia, but consider it; regurgitation may occur; weight loss uncommon, but rapid weight loss may signal
pseudoachalasia (malignant condition; rule out with endoscopy); patients may also experience heartburn
(may be misdiagnosed as gastroesophageal reflux disease [GERD])
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| Treatment: goal to open LES; standard of care pneumatic dilation or surgical myotomy; botulinum toxin not recommended
in young patients, with no heart or lung disease; pneumatic dilation—long-term results superior to
those obtained with botulinum toxin; most effective nonsurgical treatment for achalasia; relieves obstruction
and results in clinical improvement; balloons may be 3.0, 3.5, or 4.0 cm in diameter; achieves intraluminal myotomy
(risk for perforation); surgical myotomy—longer and more controlled than dilation; goal of any treatment
to “empty the barium” (ie, resolve dysphagia); pneumatic dilation more likely to fail in younger men than
in younger women or women in general, due possibly to thicker musculature (start with 3.5-cm balloon, or
take patient directly to surgery); complications—perforation (national average rate 5%; key to have surgical
backup ready if perforation does occur)
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| Efficacy: in retrospective studies, similar for dilation and myotomy
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| Treatment algorithm: dilation contraindicated for patients who are high surgical risks, due to need for surgery if
perforation occurs (use botulinum toxin, nitrates, or calcium channel blockers); if patient good surgical candidate,
choose either procedure, depending on level of expertise; for pneumatic dilation in younger men (<45 yr of age),
start with 3.5-cm balloon; for older men (>50 yr of age), perform serial dilation with 3.0, 3.5, and 4.0-cm balloons
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| Pattern recognition: diffuse esophageal spasm (DES)—resembles achalasia, but peristalsis occurs (patient can
swallow); rarely progresses to achalasia; may convert to normal; nutcracker esophagus—pressure >180 mm Hg
during peristalsis; hypertensive LES—hypertension at LES; sphincter sometimes does not relax completely; nonspecific
or ineffective motility disorder—includes low persistaltic pressure (12-26 mm Hg), simultaneous or nontransmitted
contractions; usually mixed with normal swallows; patients complain of dysphagia and chest pain; cause and
clinical significance unknown (treatment often does not relieve pain); manometry establishes diagnosis;
management—rule out heart disease and malignancy; relieve patient’s anxiety; treatment consists of GERD therapy,
nitrates, or calcium channel blockers for high-amplitude peristaltic waves; antidepressants for anxiety and
sleep disturbance; mixed outcomes of myotomy or pneumatic dilation for DES; nitrates or calcium channel blockers
for achalasia patients who are not surgical candidates (warn patients of possible side effects; try botulinum toxin
first); some evidence that antidepressants (eg, trazodone, imipramine) reduce symptoms and anxiety
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| DIFFICULT ESOPHAGEAL STRICTURES —Richard E. Sampliner, MD, Professor, Department of Medicine, and
Chief, Gastroenterology Section, University of Arizona College of Medicine, Tucson
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| Definitions: stricture—abnormal narrowing of duct or passage; stenosis—narrowing or stricture of duct
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| Trends: in study of >19,000 patients, ≈12% decrease in rates of dilation and recurrence of strictures from 1998 to
2003; may reflect increased use of proton pump inhibitors (PPIs)
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| Indications for dilation: presence of dysphagia and narrowed lumen
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| Proton pump inhibitors: most effective agents for treating benign esophageal strictures; in study of patients with
solid-food dysphagia, esophageal healing occurred in all patients on PPIs, 94% experienced relief of dysphagia,
and dilation rate significantly decreased, compared to H2 -receptor antagonists
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| Esophagitis: as important as stricture diameter in causing dysphagia; often difficult to determine which contributes
more to symptoms
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| Predictors of stricture recurrence: in study of 87 consecutive patients, 36 needed repeat dilation within 1 yr;
nonpeptic risk factors—radiation, anastomotic stricture, diameter <13 mm); peptic risk factors—persistent heartburn
(unrelieved reflux) and hiatal hernia
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| Malignancy: suspect when patient needs frequent dilation due to symptom persistence or recurrence; rule out with
biopsy, endoscopic ultrasonography, and computed tomography
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| Indications for barium esophagography: anticipated complex stricture; history of esophagogastrectomy or radiation
therapy (increased risk for high complex strictures)
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| Biopsy before dilation: speaker does routinely; prefers Savary dilator to through-the-scope balloon; choose dilator
with diameter larger than estimated lumen size; dilate times three with resistance; stop when large amount of
blood on dilator (more than from biopsy)
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| Eosinophilic esophagitis: always rule out before dilation, especially in younger adults with unexplained dysphagia;
endoscopic hallmarks include furrows, corrugations, multiple rings, and whitish plaques; esophageal caliber
may be “impressively small”; diagnose with distal- and mid-esophageal biopsies; patients have high risk for perforation
during endoscopy; treat first with PPIs, then progress to therapy aimed at eosinophils if PPI therapy unsuccessful
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| Rigid vs balloon dilators: in recent randomized study of 251 patients with peptic strictures or Schatzki rings, no
significant difference between dilators in immediate relief or need for repeat dilation; place patient on PPI after dilation
for healing without fibrosis; Savary system requires clear view of lumen (do not use otherwise); pass wire as
long as esophageal wall does not move (stop if movement occurs); new 4.9-mm endoscope useful for patients with
very narrow strictures; when endoscope in stomach, pass Savary wire through channel, then withdraw endoscope
and dilate; keep patient’s chin down or in neutral position; elevate dilator shaft parallel to axis of hypopharyngeal
lumen; ascertain that resistance comes from stricture, not pharynx
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| Intralesional steroids: option for patients who require repeated dilations; compared to saline, triamcinolone associated
with need for fewer dilations and significantly more dysphagia-free days in recent study; important to have
adequate dilation before injecting steroid
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| Self-expanding plastic stent: consider for refractory benign strictures (eg, caustic ingestion, irradiation, anastomotic);
removable; main drawback migration
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| BARRETT’S ESOPHAGUS UPDATE: IS IT TIME FOR PREVENTIVE ABLATION? —Dr. Sampliner
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| Ablation for nondysplastic disease: cancer risk 1 in 212 patient-years; thus, number needed to treat (NNT) to
prevent one case of cancer is 212 patients (considered excessive by most observers)
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| Goal of endoscopic therapy: elimination of all Barrett’s esophagus, ie, no residual columnar lining and no residual
intestinal metaplasia; careful biopsy protocol required; optimal number of endoscopies and biopsies for confirming
absence of Barrett’s esophagus and intestinal metaplasia unknown (suggested number, 3)
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| Types of ablation therapy
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| Thermal: most common; options include electrocoagulation, argon plasma coagulation (most widely used technique
worldwide), and radiofrequency ablation; cryoablation emerging (“antithermal”)
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| Photodynamic therapy (PDT): porfimer sodium—only photosensitizer available in United States; photosensitivity
lasts 6 to 8 wk; 5-aminolevulinic acid—available in Europe, can be taken orally; photosensitivity lasts only 48 hr;
not associated with strictures because injury not as deep; however, associated with slight risk for death from cardiac
arrhythmia within 1 to 2 days of use
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| Endoscopic resection: also considered ablation therapy
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| Argon plasma coagulation (APC): in study of 70 patients with nondysplastic disease treated with 90 watts APC
plus omeprazole, only 1 residual case observed at 12-mo follow-up; of 66 patients followed up to 51 mo, 11 had
no reflux symptoms and required no therapy (remainder on PPI therapy); annual histologic relapse rate only 3%;
suggests that esophagus develops durable new squamous lining; tissue may char on contact; probe may perforate
wall if excessive pressure used
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| Radiofrequency ablation: requires insertion of sizing balloon first (allows clinician to choose correct ablation catheter
size); focal device fits on tip of endoscope and easy to use; in early results from trial, aggressive (repeated)
use results in thorough ablation
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| Large randomized trial of PDT: 22 centers; largest randomized trial of any form of therapy for Barrett’s esophagus
(only 8 randomized trials ever conducted); this trial is basis for Food and Drug Administration (FDA) approval of
PDT for Barrett’s esophagus with high-grade dysplasia; at 5-yr follow-up, 77% of patients who received PDT
plus PPI had no high-grade dysplasia, compared to 39% of those receiving PPI alone; 15% of patients undergoing
PDT developed cancer, compared to 29% of those receiving PPI alone (NNT for reduction in cancer, 6);
conclusion—PDT reduces but does not eliminate risk of cancer; resistance to PDT increases with disease severity
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| Treatment challenges associated with high-grade dysplasia (HGD): patient may have cancer not detected
with endoscopy; in one recent series, 17% of surgical patients had cancer in resected specimen (consideration for
gastroenterologists who perform endoscopic ablation); PDT with porfimer sodium associated with 30% stricture
rate (difficult strictures that require many more dilations than peptic strictures), as well as common and persistent
photosensitivity; of 66 European patients with HGD or early adenocarcinoma who underwent PDT with oral 5-
aminolevulinic acid, only 8 local recurrences requiring retreatment occurred, with no tumor-related deaths
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| Experience with endoscopic resection: in one study of 100 patients with low-risk adenocarcinoma (<20 mm), calculated
5-yr survival rate 98%; however, in another series of 56 patients, complete reversal of intestinal metaplasia
occurred in 93%, but 38% developed symptomatic strictures (median of 4 dilations required); procedure
gaining popularity due to quality of specimens obtained (submucosa as well as mucosa), with “true T staging;”
also has potential therapeutic role
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| Future trend: combination therapy consisting of endoscopic resection for visible lesions, with superior recognition
of focal lesions made possible by newer imaging technologies; ablation of all residual intestinal metaplasia, because
HGD and early cancer often multifocal at multiple levels; followed by yet-to-be identified form of thermal
ablation
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| Resection plus PDT vs esophagectomy for HGD: mortality in both groups 9% (no cancer deaths); esophagectomy
patients had longer mean length of Barrett’s esophagus; patients undergoing endoscopy had more cardiac disease
and comorbidity; conclusion—“it’s time to treat high-grade dysplasia and early cancer in Barrett’s esophagus
endoscopically”; HGD should not elicit automatic referral for esophagectomy; pendulum swinging from surgery to
endosocopic therapy
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| Staging for ablation: endoscopic resection for T staging more accurate than endoscopic ultrasonography (EUS);
however, EUS still important for for N staging of mediastinal and celiac axis nodes; fine needle aspiration; limit endoscopic
therapy to intramucosal lesions (T1a; not beyond muscularis mucosa); once into submucosa (T1b), 25%
of lesions lymph node-positive
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| Ideal candidate for ablation: patient with pre-HGD and 5-yr risk for esophageal cancer >25%, based on age,
gender, length of Barrett’s esophagus, body mass index, smoking status, and biomarker panel (not yet known); currently,
endoscopic reversal requires >1 session and ideally, with >1 modality; patient will still have risk for residual
intestinal metaplasia and cancer and will require continuing surveillance
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| Questions and answers: should all patients be on bid PPI therapy? treatment with PPI to point of symptom control
(not necessarily bid) decreases risk of developing dysplasia (effect on cancer development still unknown); PPI recommended
for symptom control; speaker keeps patients on PPI therapy throughout course of ablation therapy; do
you routinely use narrow band in your practice for surveillance, particularly for short-segment Barrett’s? yes; helps in
identification of squamocolumnar junction; high resolution scopes will be answer to recognition of changes
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Suggested Reading
Ell C et al: Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest Endosc
65:3, 2007; Farhoomand K et al: Predictors of outcome of pneumatic dilation in achalasia. Clin Gastroenterol
Hepatol 2:389, 2004; Khatami SS et al: Does diffuse esophageal spasm progress to achalasia? A prospective cohort
study. Dig Dis Sci 50:1605, 2005; Kochhar R, Makharia GK: Usefulness of intralesional triamcinolone in
treatment of benign esophageal strictures. Gastrointest Endosc 56:829, 2002; Nayar DS et al: Esophageal manometry:
assessment of interpreter consistency. Clin Gastroenterol Hepatol 3:218, 2005; Potter JW et al: Eosinophilic
esophagitis in adults: an emerging problem with unique esophageal features. Gastrointest Endosc 59:355, 2004; Rastogi
A et al: Incidence of esophageal adenocarcinoma in patients with Barrett’s esophagus and high-grade dysplasia:
a meta-analysis. Gastrointest Endosc 67:394, 2008; Said A et al: Predictors of early recurrence of benign
esophageal strictures. Am J Gastroenterol 98:1252, 2003; Sampliner RE et al: Effective and safe endoscopic reversal
of nondysplastic Barrett’s esophagus with thermal electrocoagulation combined with high-dose acid inhibition: a
multicenter study. Gastrointest Endosc 53:554, 2001; Sharma P et al: A randomized controlled trial of ablation of
Barrett’s esophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid
suppression: long term results. Gut 55:1233, 2006; Wani S, Sharma P: Another strike against esophagectomy for
high-grade dysplasia in Barrett’s esophagus? Clin Gastroenterol Hepatol 6:128, 2008.
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