Esophageal Disorders

Esophageal Bleeding


  • Retching/vomiting with hx of etOHism (MC), hiatal hernia, bulimia ➔ longitudinal mucosal lacerations/erosions

  • SSX: Upper GI bleed (hematemesis, dark stool) with chest/back pain

  • DX: EGD (upper endoscopy)

  • TX: Supportive with PPIs (most heal spontaneously)

    • Severe ➔ EDG with epi injected at site (↓ bleeding), or balloon, or band ligation

Boerhaave Syndrome (spontaneous esophageal perforation)

  • ↑ intrathoracic pressure (retching, prolonged coughing/vomiting, weightlifting, childbirth) ➔ transmural perforation (all the way through)

  • Iatrogenic perf MC from EDG

  • SSX: Dyspnea, chest pain, dysphagia ± upper GI bleed

    • MC on left side ➔ air in mediastinum ➔ subq air (crepitus)

  • DX: Esophagram with gastrografin swallow

    • CXR/chest-CT shows air - subQ emphysema, pneumo-mediastinum/thorax/peritoneum

  • TX: Airway, IVF resuscitation, NPO


      • Mild sx and meets criteria ➔ medical management: NPO 7d, parenteral support, broad spectrum ABX, PPIs

        • Contained within neck or mediastinum or between mediastinum and visceral lung pleura

        • Contrast able to flow back into esophagus, perforation IS NOT in neoplastic tissue, IS NOT proximal to obstruction,

        • Institution can get contrast studies and has on-call GI surgeon

      • Sick ➔ surgery

Esophageal varices

  • Cirrhosis ➔ portal HTN (↑ splanchnic arteriolar vasodilation with resistance to outflow)

    • Varices develop when hepatic and portal vein pressure > 10mmHg (normal <5mmHg) - relieves pressure within portal system

  • SSX: Upper GI bleed (hematemesis, melena) in etOH/cirrhotic pt

  • DX & TX with EGD (upper endoscopy) active bleeding ➔ endoscopic variceal ligation or endoscopic sclerotherapy

    • Airway, IVF resuscitation, octreotide or vasopressin (↓ portal pressure) and broad spectrum ABX

    • Transjugular intrahepatic portosystemic shunt (TIPS) if tx EDG fails

    • PPX with propanolol or carvedilol (non-selective β-blockers)

      • Blocking β1 ➔ ↓ HR, blocking β2 ➔ ↓ portal inflow, blocking ⍺1 ➔ intrahepatic vasodilatation