David Markowitz, MD. Physicians and Surgeons

Transcription

1 Esophageal Motility David Markowitz, MD Columbia University, College of Columbia University, College of Physicians and Surgeons

2 Alimentary Tract Motility Propulsion Movement of food and endogenous secretions Mixing Allows for greater contact of food with digestive enzymes and absorptive surface Reservoir

3 Determinants of GI Tract Motility Myogenic control Neurogenic control Endocrine factors

4 Myogenic Control Basic Electrical Rythym: intrinsic rhythmic fluctuation of smooth muscle membrane potential Pacemaker Cells: set BER for the entire organ Slow waves: spread from cell to cell via gap junctions

5 Enteric Nervous System Afferent and efferent arms Numerous interneurons in the ENS are highly integrated and receive input from: CNS efferent arm of ENS Afferent neurons receive input from ENS interneurons and these affect: smooth muscle blood vessels secretory cells

6 Swallowing Oropharyngeal Phase Involuntary & Voluntary Phases Extremely rapid Dx test: Video esophagram Esophageal Phase Slow Stereotyped Dx test: t Esophageal Manometry

7

8 Oropharyngeal Phase of Swallowing Moves ingested food and fluid into upper esophagus Prevents aspiration or regurgitation of the bolus Voluntary movement by the tongue of the bolus into the pharynx triggers the involuntary phase of swallowing

9

10

11

12 Dysphagia Esophageal Disease Symtpoms Oropharyngeal Dysphagia Esophageal Dysphagia Pain Odynophagia Atypical Chest pain GE Reflux disease (GERD)

13 Dyspahgia Oropharyngeal Difficulty transferring bolus out of mouth Associated w/ coughing & aspiration Esophageal Sense of bolus sticking in chest Mechanical causes Motility disorders

14 Esophageal Dysphagia Mechanical Causes Typically occurs with solid foods Frequently progressive, especially with malignancy Food impaction (w/ forced regurgitation) common Prominent weight loss only w/ malignancy

15

16 Schiatzki Ring

17 Schiatzki Ring

18 Esophageal Strictures

19 Esophageal Stricture

20 Esophageal Dilators

21 TTS Ballons

22 Esophageal Carcinoma

23 Esophageal Carcinoma

24 Esophageal Carcinoma

25 Esophageal Stents

26 Esophageal Stents

27 Barrett s Esophagus

28 Barrett s esophagus definition iti A change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed to have intestinal metaplasia by biopsy Sampliner. Am J Gastroenterol 1998

29 Barrett s Esophagus

30 Barrett s esophagus is a premalignant lesion for esophageal adenocarcinoma Normal Endoscopy-negative reflux disease Erosive esophagitis? Barrett s esophagus? Dysplasia Esophageal adenocarcinoma

31 Esophageal Dysphagia Motor Disorders

32 Esophageal Manometry Normal Study

33 Achalasia

34 Achalasia

35 Achalasia

36 Achalasia

37 Achalasia

38 Achalasia

39

40 Scleroderma

41 Sl Scleroderma

42 Scleroderma

43 Esophageal Dysphagia Esophageal Dysphagia Mechanical Motor Benign Malignant Achalasia Scleroderma Webs Rings Strictures Adeno ca. Sq. cell ca.

44 Spastic Motility Disorders

45 Diffuse Esophageal Spasm

46 Atypical Chest Pain

47 Candida Esophagitis

48 GE Reflux Normal Physiology

49 GERD The sequellae of prolonged exposure of esophageal mucosa to caustic gastric refluxate

50 GERD: Pathogenesis

51 Defective Esophageal Clearance Ineffective peristalsis Reduced salivary secretion Reduced secretion from esophageal submucosal glands

52 LES dysfunction Inappropriate and prolonged transient relaxations Reduction in basal LES pressure/tone

53

54 Hiatal hernia May trap a reservoir of gastric contents above the diaphragm, increasing reflux May compromise LES function

55 Delayed gastric emptying May result in an increase in the volume of gastric contents available for reflux into the esophagus Exact role in GERD remains to be clarified

56

57 Bravo Capsule

58 Bravo Capsule

59

60 Nissen Fundoplication

61 Stretta procedure Step 1 Step 2 Step 3

62 Mechanism of action of refluxate in GERD Acid-peptic attack leading to a widening of and thus allowing acid weakens cell junctions cell gaps penetration Tight cell Acid Nerve ending junction Pepsin Bicarbonate Orlando. Am J Gastroenterol 1996 Widened cell junction

63 Mechanism of action of Penetration of acid and pepsin allows contact of acid with nerve endings refluxate in GERD and disrupts intracellular mechanisms leading to cell rupture and damage Acid cd Pepsin Bicarbonate Nerve ending Orlando. Am J Gastroenterol 1996

64