FISIOLOGIA DIGESTIVA (BCM II)FISIOLOGIA DIGESTIVA (BCM II)Clase 3: Fisiopatología EsofágicaClase 3: Fisiopatología Esofágica

Dr. Michel Baró AlisteDr. Michel Baró Aliste

Acalasia EsofágicaAcalasia Esofágica

Endoscopic view of patient with achalasia of LES

Barium swallow in patient with achalasia of esophagus (A)

Barium swallow in patient with achalasia of esophagus (B)

Lateral radiograph of barium swallow in patient with achalasia of esophagus

Barium swallows of patient with secondary achalasia (A)

Barium swallows of patient with secondary achalasia (B)

Manometric tracing from patient with achalasia of esophagus

Pressure recording and fluoroscopy during barium swallow in achalasia

Onda de presión hidrostática

Epiphrenic diverticulum in patient with achalasia of esophagus

Ultrasound images of the lower esophageal sphincter (A)

Ultrasound images of the lower esophageal sphincter (B)

Pneumatic dilation of lower esophageal sphincter using Rigiflex Balloon

Otros Trastornos Motores del Otros Trastornos Motores del EsófagoEsófago

• Espasmo difuso del esófago• Esófago en cascanueces• Esclerodermia

Barium swallow study in patient with diffuse esophageal spasm

Diffuse esophageal spasm

Manometric appearance of diffuse esophageal spasm

Manometry and fluoroscopy of barium swallow in diffuse esophageal spasm

Contracción y compartamentalización del lumen

Nutcracker esophagus

Ondas peristálticas

Radiographic view of scleroderma of esophagus, stomach, duodenum

Dilated esophagus and patulous lower esophageal sphincter

Manometric tracing from patient with severe involvement of scleroderma

Esophageal function in woman with scleroderma and esophageal motor impairment (A)

Esophageal function in woman with scleroderma and esophageal motor impairment (B)

Esophageal function in woman with scleroderma and esophageal motor impairment (C)

Reflujo GastroesofágicoReflujo Gastroesofágico

Anatomy of two lower esophageal sphincters

Contribution of LES/crural diaphragm to esophagogastric junction pressure

Spontaneous, transient LES relaxation

diaphragmatic electromyography

Relationship between GER and GERD (A)

Relationship between GER and GERD (B)

Prevalence of heartburn in adult Americans

M / F = 3 / 1

Incidence of heartburn in northeast Scotland

Pathophysiology and etiology of reflux esophagitis

Reflux mechanisms

Reflux mechanisms

Antireflux mechanisms in ambulatory patients with GERD (A)

transient lower esophageal sphincter relaxation (TLESR)

swallow-associated prolonged lower esophageal sphincter relaxation (SAPLESR)

swallow-associated normal duration LES relaxations (SANLESR)

Antireflux mechanisms in ambulatory patients with GERD (B)

Esophageal luminal acid clearance mechanisms

Mechanisms of Esophageal Luminal Acid Clearance Bolus clearance Gravity Peristalsis Acid clearance Swallowed salivary bicarbonate-rich secretions Secreted bicarbonate-rich fluid from esophageal submucosal glands

Tiempo de aclaramiento del ácido esofágico en sujeto sano : 3-5 minutos

Esophageal luminal acid clearance mechanisms

Esophageal luminal acid clearance

Hiatal hernia

Bile salt concentrations in forms of reflux esophagitis

Components of tissue resistance against acid injury in esophagusPotential Components of Tissue Resistance Against Acid Injury in the Esophagus

Pre-epithelial defenses

Mucus layer

Unstirred water layer

Surface bicarbonate ion concentration

Epithelial defenses

Physical barriers

Cell membranes

Intercellular junctional complex

Tight junctions

Intercellular glycoconjugates or mucin

Functional components

Cellular defense against acidification

Apical membrane Na+ channel regulation

Intracellular pH regulation

Intracellular buffering

Basic proteins

Bicarbonate ions

Phosphates

Epithelial repair (basal layers only)

Epithelial restitution

Cell replication

Postepithelial defenses

Blood flow

Delivery of beneficial substances

Oxygen

Metabolic substrates (nutrients)

Bicarbonate ions (extracellular buffering)

Removal of noxious agents

CO2

H+

Metabolic byproducts

Cellular debris

Tissue resistance: structural and functional defenses

Tissue resistance: altering esophageal epithelium defense

Conditions and activities associated with GERD

Helicobacter pylori

Protective role of Helicobacter pylori

Erradicados

Infec. persistente

Characteristics of heartburn

Esophageal pathology in gastroesophageal reflux disease

Esophageal Pathology in Gastroesophageal Reflux Noninflammatory changes

Basal cell hyperplasia

Increased papillary height

Dilated intercellular spaces

Inflammatory changes

Acute

Vascular congestion with or without stasis

Mucosal edema

Polymorphonuclear leukocytic infiltration (neutrophils and eosinophils)

Chronic

Mononuclear leucocyte infiltration (macrophages)

Increased macrophage activity Proliferation of fibroblasts

In-growth of vascular endothelium

Epithelial necrosis

Erosion

Ulceration

Epithelial repair

Granulation tissue

Fibrosis (stricture formation) Epithelial regeneration

Squamous replication

Columnar metaplasia (Barrett's esophagus)

Histopathology of reflux damage to esophagus

Histopathology of GERD (A)

control

control

Histopathology of GERD (B)

Esofagitis erosiva

Histopathology of GERD (C)

Esofagitis no erosiva

Histopathology, erosive esophagitis

EdemaInfiltración PMN, eosinófilos.Congestión vascular yextravasación.

Endoscopic view of erosive esophagitis

Endoscopic grading systems for reflux esophagitis

Endoscopic Grading System for Reflux Esophagitis Classification Grade Characteristics

Savary-Miller classification I Single lesion (erosive or exudative) involving only one longitudinal fold

II Multiple lesions (erosive or exudative) involving more than one longitudinal fold but not circumferential

III Circumferential (erosive or exudative) lesions

IV Chronic lesions: ulcer, stricture, or short esophagus ± lesions of grades I to III

V Barrett's epithelium ± lesion of grade I through IV

Los Angeles classification A One or more mucosal breaks (erosions) confined to the folds, each no

longer than 5 mm

B At least one mucosal break more than 5 mm long confined to the mucosal folds but not continuous between the tops of the mucosal folds

C At least one mucosal break continuous between the tops of two or more mucosal folds but not circumferential

D Circumferential mucosal break

Hetzel (Hetzel-Dent) classification O Normally appearing mucosa

I Mucosal edema, hyperemia, or friability

II Erosions that involve < 10&percnt; of the lower 5 cm of the esophagus

III Erosions that involve 10&percnt; to 50&percnt; of the distal esophagus

IV Deep ulceration or erosions that involve > 50&percnt; of the distal esophagus

Esophageal complications of reflux esophagitis

Esophageal Complications of Reflux Esophagitis Complication Prevalence, &percnt;

Esophageal stricture 4–20 Barrett's esophagus 8–20 Hemorrhage < 5 Perforation < 1

Esophageal stricture

Barrett's esophagus

Barrett's esophagus: 3 types of columnar epithelium

1-Epitelio de la unión (cardial)2-Epitelio fúndico atrófico

3-Epitelio especializado (intestinal)

Barrett

Barrett's esophagus increases with age

Rising incidence of adenocarcinoma of the esophagus

Frequency of cancer based on frequency, severity, duration of heartburn

Incidence of cancer based on frequency of heartburn or in Barrett's esophagus

Tests for diagnostic assessment of GERD, its mechanisms and consequences

Tests for Diagnostic Assessment of Gastroesophageal Reflux Disease, its Mechanisms, and its Consequences

Test for reflux

Upper GI series

Tuttle's (standard acid reflux) test

Continuous intraesophageal pH monitoring

Radionuclide (99Tc) scintigraphy Bile monitoring (Bilitec)

Esophageal impedence plethysmography*

Test to assess symptoms

Bernstein's (acid-perfusion) test

Continuous intraesophageal pH

Empirical trial of a PPI

Test to assess esophageal damage

Barium esophagogram or upper GI series

Upper endoscopy

Esophageal biopsy

Esophageal potential difference measurement*

Test to assess pathogenesis of esophagitis

Acid clearance test*

Radionuclide (99Tc) scintigraphy

Esophageal manometry

Gastric analysis

*Principally investigational.

Lifestyle modifications to lessen reflux esophagitis

Modification of Lifestyle to Lessen Reflux Esophagitis

Elevate the head of the bed 6 inches

Stop smoking

Stop consuming excessive alcohol

Reduce fat in diet

Reduce size of meals

Avoid eating at bedtime

Lose weight (if overweight)

Avoid wearing tight-fitting clothes

Avoid certain foods

Chocolate

Carminatives (eg, spearmint, peppermint)

Coffee (eg, caffeinated and decaffeinated)

Tea

Cola beverages

Tomato juice

Citrus juices

Avoid certain drugs, when possible

Anticholinergics

Theophylline

Diazepam

Narcotics

Calcium channel blockers

β-Adrenergic agonists (isoproterenol)

Progesterone (some contraceptives)

α-Adrenergic antagonists (phentolamine)

Endoscopic views of gastroesophageal reflux disease (A)

Endoscopic views of gastroesophageal reflux disease (B)

Endoscopic views of gastroesophageal reflux disease (C)

Endoscopic views of gastroesophageal reflux disease (D)

Dental erosion from chronic acid reflux disease

View of hypopharynx during upper gastrointestinal endoscopy

Fin