Strictures

• Narrowing of esophagus from GERD (MC), esophagitis, radiation, caustic ingestion

• SSX: Gradually progressive (worsening) dysphagia (solids)

• DX: Barium esophagram shows narrowing at GE junction (MC)

  • Get endoscopy and biopsy to r/o esophagitis or malignancy

Webs

• Eccentric (not concentric like a ring) membrane protruding into lumen, usually in cervical esophagus

• Associated with Plummer Vinson syndrome

  • Webs ➔ dysphagia (solids), Fe deficiency anemia ➔ splenomegaly, angular cheilitis, koilonychia (spoon nails)

• Also associated with Zenker's Diverticulum, Bullous pemphigoid, and pemphigus vulgaris

• DX: Barium esophagram shows asymmetric protrusion

  • No need for endoscopy and there is risk of rupture when passing endoscope over webs

Rings

• Schatzki rings (not involving muscular layer) are associated with hiatal hernia and eosinophilic esophagitis

• SSX: Usually asx but can have intermittent dysphagia (solids) depending on how completely food is chewed

  • (when pt has the occasional steak... they notice the sx)

• DX: Barium esophagram shows concentric ridge above the esophageal hiatus

  • Get endoscopy and biopsy to r/o esophagitis

TX for strictures/webs/rings

• Chew food completely

• Push (bougie) or balloon dilation (will likely need multiple dilations)

• PPI's prevent recurrence (regardless of GERD)

• Refractory rings can get laser division, electrocautery division, or obliteration with biopsy forceps during EGD

Zenker's diverticulum

• Outpouching of mucosa and submucosa of esophagus through a weak spot

  • Killian's triangle: between thyropharyngeal and cricopharyngeal parts of the lower inferior constrictor muscle

  • Associated with SCC

• SSX: Food diverted into pouch ➔ oropharyngeal dysphagia (difficulty initiating swallowing, coughing/choking, nasal regurgitation)

  • Halitosis, gurgling, mass in throat, regurgitation, odynophagia from infection/inflammation

  • Fuller pouch ➔ complications: aspiration PNA, fistula connecting esophagus and trachea, vocal cord paralysis

• DX: Barium esophagram (lateral view) with dynamic continuous fluoroscopy shows collection of contrast at hypopharynx

  • Can get endoscopy and biopsy to r/o SCC

• TX: Surgery (diverticulotomy) when large

Achalasia

• SSX: Gradually progressive (worsening) dysphagia to solids then liquids

• Primary (idiopathic): Inflammation/degeneration of inhibitory neurons in myenteric (Auerbach) plexus of esophageal wall

  • Abnormal/no peristalsis in distal esophagus and lower esophageal sphincter (LES) fails to relax with swallowing

• Secondary: Malignancy, Chagas (Trypanosoma cruzi), amyloidosis, sarcoidosis

  • Difficulty belching, chest pain, regurgitation/heartburn

• DX: Esophageal manometry (High-resolution esophageal manometry is gold standard):

  • • High relaxation pressure, incomplete LES relaxation with swallowing, aperistalsis in distal esophagus

  • Barium esophagram shows dilated esophagus filled with contrast and region of persistent narrowing (bird's beak)

  • Endoscopy with biopsy to r/o pseudoachalasia due to a malignancy

• TX: ↓ LES resting pressure mechanically via pneumatic dilation, surgical myotomy, or peroral endoscopic myotomy (POEM)

  • or pharmacologically via botulinum toxin, or PO nitrates

Hypertensive/spastic motility disorders

• SSX: Intermittent, non-progressive (non-worsening) dysphagia to liquids and solids

  • Chest pain exacerbated by stress, hot and/or cold food/drinks, regurgitation/heartburn

Diffuse esophageal spasm (corkscrew) ➔ non-progressive waves (non-peristaltic)

• • DX: Esophageal manometry (gold)

    • Normal amplitude (normal pressure) but repetitive (not coordinated/premature) contractions

  • Barium esophagram shows rosary bead/corkscrew esophagus when in spasm

Hypercontractile (nutcracker) ➔ progressive waves but high contractility

• • Jackhammer is a subtype with highest amplitude

  • DX: Esophageal manometry (gold)

    • Hypertensive peristalsis: high amplitude (high pressure) with normal (coordinated) contractions

• TX: Control GERD, CCB (diltiazem) or TCA (imipramine)

  • Nitro can relieve spasm... So chest pain relieved with NTG is not diagnostic for cardiac chest pain 🤯