Good morning, everyone, and thank you to Dr. Tierney and the ASB for inviting me here to speak on the diseases of the esophagus and the stomach, and I understand I met some of you virtually during your Las Vegas meeting where I was bigger than life on a screen, and as you can see, I'm much smaller in person, and you've seen this disclosure. What I'm hoping to do with my time is to review with you esophageal anatomy structure and function, how that relates to structural disorders that you might hear about, including hiatal hernias and esophageal rings. We'll put that into clinical context with gastroesophageal reflux disease. You'll hear more about EOE tomorrow. We'll highlight a little bit about motility disorders and some miscellaneous disorders of the esophagus. Now, I'm focusing on the esophagus because it's a much cooler organ than anything else that you'll hear. I'm a little biased, but if there's time, I will also talk about some gastric things. So what you heard earlier from Dr. Lightdale regarding esophageal anatomy is the esophagus is a long muscular tube that separates the oropharynx from the stomach. There is a muscle up at the top called the cricopharynx, and a muscle at the bottom called the lower esophageal sphincter. In terms of an anatomy, it is sandwiched here between the trachea and the spine for a while before it dives down into the stomach through the diaphragm. And at one point, it's sandwiched here between the trachea and the aorta and the spine. And that anatomy will become more relevant as I go through some of these disorders. Proper esophageal functioning allows you to swallow, and it prevents backflow of gastric contents into the esophagus. When things don't work, that's when people have symptoms. So I'm just going to go through a glossary of symptoms with you, things that you'll hear, things that we talk about, things that patients may tell you. So heartburn, what is heartburn? This is the most common esophageal symptom. That is a discomfort or a burning sensation behind the sternum. Regurgitation is an effortless return of food or fluid into the pharynx without nausea or retching. Dysphagia, which is very common in AOE, is a feeling of food sticking or even lodging in the chest. Odynophagia is pain caused by or exacerbated by swallowing. Globus is a perception of a lump or fullness in the throat felt even without swallowing. And water brash is excessive salivation, which is a compensatory response to reflux. So you may hear this speckle throughout the talk. Esophageal symptoms can be transit-related, meaning antegrade or moving down. Those are food impactions and dysphagia. They can be retrograde or moving back up, regurgitation and aspiration. And they can be perception-related, which is discomfort, chest pain, pressure, and heartburn. Now what causes these esophageal symptoms? Well, there can be structural abnormalities, and that usually causes dysphagia to solid food, feeling like solid food is getting stuck in the esophagus. That is picked up by endoscopy. Now these are the many things that can cause dysphagia from rings, strictures, AOE, and all the other things I mentioned here, which we'll go into some detail. You can have propulsive or motility disorders, which you heard a little bit about from Dr. Lightdale. They usually have dysphagia for solids and liquids or even reflux symptoms. These are picked up by functional esophageal tests, like manometry. And there are various esophageal disorders, such as aparistalsis, the achalasia that you heard about, esophageal spasm, to name a few. You can also have sensory abnormalities of the esophagus, where you feel symptoms with both solids and liquids. Oftentimes the endoscopy is normal here. We think that this could be a functional cause related to some psychological factors. And of course, there can be an overlap in all of these disorders. So it's a little bit difficult to tease out sometimes in your patients. So what are some of these structural disorders that can cause symptoms? And I'm focusing mostly not on AOE today, because we'll talk a lot about that in later talks. But the first thing is a hiatal hernia. You saw a little bit about normal anatomy, where you have the esophagus coming down through the diaphragm muscle, and then you see the stomach here. If you have herniation of the viscera or stomach into the mediastinum through this hiatus, that is called a hiatal hernia. And the most common type is a type 1, or a sliding hiatal hernia. We see this in about 95% of all hernias. And this can obviously predispose you to acid reflux, because that barrier is no longer there. There are other types of esophageal hernias. Just for your own knowledge, to go through briefly, that hiatal hernia is up here, that type 1. There can be a type 2, where there's just a stomach coming up into the chest. There's a type 3, with both the hiatal hernia and some of the stomach coming up into the chest. And a type 4, where almost the whole stomach and other organs, like the colon, is coming up into the chest. And you can imagine, just looking at these pictures, that if you were to have these types of hernias, patients may have chest pain. They may have dysphagia. They may have that regurgitation. Other structural things that are in our differential for EOE are esophageal rings and webs. Schottky ring is a very common one. It's a lower esophageal mucosal ring that you see here at the bottom part of the esophagus. It happens in about 15% of patients. It's usually asymptomatic, but only becomes symptomatic when that diameter is less than 13 millimeters across. Patients usually get this when they're over 40 years old. It's thought to be an acquired condition. And it's treated with esophageal dilation. And you can see here on a barium esophagram, where patients swallow barium and they take an X-ray, here is that Schottky ring. And you can see, similar to the strictures that you'll hear about in EOE later, it's really acting like a speed bump in the esophagus. So you can imagine why food is getting caught there. There can be other esophageal rings higher up in the esophagus. We talk about cervical webs. And that's cervical because it's in the cervical esophagus, so in your neck. This can be congenital or inflammatory in origin. This happens in about 10% of patients. They can have circumferential webs, so all the way around. And that can cause intermittent dysphagia that's usually treated with dilation. Other things that can cause difficulty swallowing and esophageal symptoms are diverticuli or pouches. You hear about diverticuli in the colon. You can also have diverticuli in the esophagus. So one of them is called a Zenker's diverticulum. It's a little pouch that happens in the upper part of the esophagus here, kind of pooches out in the back of the esophagus. And it's an area of weakness in that part of the esophagus that can happen. It's pretty rare, about 2 in 100,000 patients. This is more common in men than women. And it happens in older patients, so typically about a seventh or eighth decade. You can see here the X-ray too of that barium kind of pooling in that upper neck. Common symptoms, if you can imagine stuff pooling up here in your neck, can be aspiration, things kind of slipping back into that trachea, halitosis, regurgitation, a fullness in that neck sensation, and a gurgling sensation in the throat. There can be other types of esophageal diverticula, which are usually associated with motility disorders. And you can see here a traction diverticulum. It's a big pouch in the middle portion of your esophagus. And an epiphrenic diverticulum, which is just above that diaphragm muscle here. These are usually associated with motility disorders, such as achalasia. And symptoms include regurgitation and dysphagia. And sometimes, you can imagine, if this big pouch is in your chest, you can have some chest pain. What about gastroesophageal reflux disease, often attributed or heard of as GERD? This is reflux of stomach contents into the esophagus or mouth. And you can see here, again, just to refresh your memory, normal anatomy, your esophagus here, the diaphragm muscle, and your stomach down here. The lower esophageal sphincter creates some pressure to prevent that backflow. So normally, your lower esophageal sphincter is closed here. It keeps all the gastric contents into the stomach. If it relaxes, and it relaxes too frequently, you're going to get more of that gastric content up into that esophagus, and you're going to start getting those symptoms. What are the causes of reflux? You can get this in normal physiology. Everyone here will have episodes of reflux disease. Most people may not be symptomatic from them. You can have reflux in response to certain foods or food bolus, some anatomic abnormalities, like those hiatal hernias. Foods, alcohol, coffee, chocolate, amongst a few fatty foods, can trigger acid reflux, as well as medications. Any medication that may weaken that sphincter muscle there can also give you reflux. Symptoms of reflux, the most common are heartburn and acid regurgitation. Less common include dysphagia, a chronic cough, laryngitis, or asthma. Some people have a lot of throat clearing, too, attributed to this. What are treatments for reflux disease? Well, lifestyle modification, including elevating the head of the bed. And the real reason to do that is just to help gravity, help prevent things from going back up the esophagus. Weight loss, if someone is above their ideal body mass index. Avoiding exacerbating foods, making sure you don't eat three hours before you go to bed. If people need medication, proton pump inhibitors are typically prescribed. And in patients with severe disease or anatomic abnormalities, surgeries such as a Nissen fundoplication, where they take the stomach and wrap it around that esophagus to recreate that sphincter pressure that that patient may be missing. How about Barrett's esophagus? You heard about that a little bit earlier today. This is the replacement of the normal lining of the esophagus with a lining similar to that of the small intestine. This is a complication of long-standing reflux disease. And what you can see here, you saw some pictures earlier about that squamous columnar junction. The white mucosa here is the esophageal mucosa. The pink mucosa is typically that gastric mucosa, and this is now the columnar epithelium. So pink going into white. So this is a precancerous condition. There is an increased risk of developing esophageal adenocarcinoma, although a very small risk. And oftentimes, these patients may not have symptoms. What about the diagnosis and progression of disease? We typically think that patients start off with a normal esophagus. With long-standing reflux, you can start to see this Barrett's esophagus here. Over time, it progresses to low-grade dysplasia, so added inflammation. And even high-grade dysplasia, you may start to see more polypoid, protruding lesions here. And then, of course, the dreaded complication over time of esophageal cancer. What is the treatment of Barrett's esophagus? Well, in addition to acid suppression, there can be what's called radiofrequency ablation. So with a little device here that goes down into the esophagus targeting the Barrett's segment, it sort of heat zaps that Barrett's mucosa, tries to kill off that Barrett's mucosa, and allows normal mucosa or normal lining to repopulate. And that's just an image of the post-burn that you see. It looks pretty ugly, but over time, it does repopulate normal mucosa. Other treatments include endoscopic mucosal resection. You heard a little bit about that with taking out polyps. Same can be true with Barrett's segment, is taking out that portion of the Barrett's. And you can see here that with the devices that Dr. Wood had showed you, putting in some saline in here, tenting up this mucosa and scooping out that area of abnormal Barrett's. We'll move on now to esophageal motility disorders, because they can also create some of these symptoms that we discussed. With esophageal motility disorders, we notice abnormal motility of the esophagus or peristalsis, like Dr. Lightgale showed you, in terms of how that esophagus squishes to push the food down. Symptoms include dysphagia, odynophagia, chest pain, and heartburn. It's picked up with a manometry catheter. So a manometry catheter is this long, skinny tube here. And along the tube, there are a lot of pressure sensors here. And those pressure sensors pick up on that peristalsis. The tube goes into the patient's nose and down into the esophagus. It sits there for about half an hour. I know it sounds really icky. But it does sound really icky. I can't lie about that. But it is very helpful in terms of picking up these esophageal motility disorders. It sits in that esophagus for half an hour. Patients swallow different volumes of water, and in some centers, different types and consistencies of foods. And it checks to see if that esophagus is actually coordinating in a coordinated fashion, if there are discoordinated contractions, if there are pressures that are just too high. So some of these esophageal motility disorders include achalasia, nutcracker esophagus, diffuse esophageal spasm, or scleroderma, to name a few. We'll highlight just a couple. So achalasia here, which was mentioned earlier, hallmarks of this disease are loss of that peristalsis, so the inability of that esophagus to contract, and a really tight lower esophageal sphincter, meaning the sphincter is not relaxing. The neurons that are supposed to go to that sphincter to say, hey, someone's swallowing. Let me relax. They're not working. So they stay tight. And as a result, the esophagus can get pretty stretched out up here. And this can lead to a functional obstruction of the esophagus. What are some of the treatments that were briefly mentioned earlier? Well you've heard about Botox. You can inject Botox into that sphincter muscle, and this is an example of that happening here. So this muscle, because it's not relaxing, can often be hypertrophied, meaning it's really thick. So if you can inject through the scope this Botox in different quadrants here, that helps relax that muscle. Pneumatic dilation is a very specific type of dilation done only in achalasia typically, where there's a very rigid balloon that goes across this lower esophageal sphincter. It gets insufflated or blown up, and that opens up the sphincter muscle, tries to break through this tissue to try and help swallowing and improve that obstruction down at the bottom part of the esophagus. Surgical myotomy has really been the definitive treatment for achalasia. We know that this muscle is really thick. It's not relaxing. So how can we make it work better? It's to cut it, kind of release some of that pressure and allow people to have better swallowing in that regard, and that they're not hitting that high-pressure zone when the food is going down. It can be done in a typical surgical fashion. Or now there's newer, whoops, I think I'm going to go ahead and then come back here, because I think this got misaligned. There are newer techniques called a peroral endoscopic myotomy, or a POEM procedure. And this is a less invasive option than that heller myotomy, where through the camera, through the endoscope, there is a little incision into the submucosal space through the esophagus. There's a creation of a little tunnel here with the scope, as you can see, going down to where this muscle is. And then once the scope is in here through the tunnel, it starts cutting through this muscle. So it's called peroral endoscopic myotomy, or POEM, and it's a less invasive mechanism to do the same thing. Sorry, we're going a little backwards. Moving on into other types of disorders of the esophagus, things that can result in symptoms that would mimic EOE, infectious esophagitis. So candidal esophagitis is the most common. It can cause odynophagia, painful swallowing, or dysphagia. You see these white plaques or little speckles in the esophagus. Sometimes it looks like a picture of EOE even. CMV is an antifungal medication, oral fluconazole, for 14 days. Herpetic esophagitis, this can be caused by the virus HSV-1 or 2. These are typically punched out lesions here that you can see in the esophagus. The treatment is self-limited. Usually it gets better on its own, but you can treat with acyclovir or valcyclovir for that course of therapy. And as you can imagine, with these types of lesions here, it can be quite painful to swallow. CMV is another virus. This typically happens in immunocompromised patients. They have these linear or these serpiginous ulcerations along the length of the esophagus that's also treated with an antiviral medication called ganciclovir. Hill esophagitis is another thing that can cause difficulty swallowing, but more often painful swallowing. And I'm going to bring you back to that anatomy here just to help you understand why. This occurs when a swallowed pill lodges in the esophagus. The mid-esophagus is the most common location, and the reason it's the most common location is you can see here it's compressed a little bit by that aorta, a little bit by that trachea. So there's always a little bit of an indentation when you look on the camera in the esophagus in that spot. Implicated medications include a lot of antibiotics, doxycycline, tetracycline, quinidines, phenytoin, and some older medications, bisphosphonates, which are used for osteoporosis or osteopenia. The classic thing that patients will tell us is they have a sudden onset chest pain or painful swallowing. This usually gets better on its own, although it can be treated with an acid-suppressing medication or PPI and something called sucrofate. And you can see here, these are some of the lesions there. While the mid-portion of the esophagus is the most common place to have this, sometimes in the lower esophagus, particularly in patients who have strictures, you can also see inflammation there. All right. I guess I will give the stomach a little bit due diligence here. I have some time. We'll talk about just one thing, peptic ulcer disease. This happens when you get ulcers or mucosal breaks in the GI tract. And you can see here the schematic with some inflammation, both in the stomach and the small intestine. Those are the most common locations for these ulcers. Most common causes of ulcers are bacterial infection called H. pylori. And sometimes you can get your stomach biopsy and stain it for these organisms. And you can see here these rod-like areas here that are staining for the H. pylori. Ulcers have really become the most common reason for having ulcers. So people who have been taking things like ibuprofen and Motrin and things like that for aches and pains, you can see these ulcers form. Symptoms include abdominal pain and discomfort. You can have GI bleeding with throwing up of blood or seeing black, tarry, sticky stools. If you have long-standing ulcerations, that can create some fibrosis. And you may have gastric outlet obstruction, which can lead to nausea and vomiting. And sometimes if the ulcers are really deep and significant, you can have perforations. And that can present with severe acute abdominal pain. It's usually diagnosed with an endoscopy. So with the camera going into the stomach, you'll see this break in this mucosa. So rather than it being smooth and salmon-colored, you see this opening here with this little scar tissue. And that is a picture of an ulcer. Treatment includes, if the patient does have that bacteria, eradicating that H. pylori with a course of antibiotics. And if they don't have the H. pylori but just have the ulcer, treating with an acid-suppressing medication, which will help heal that ulcer. And with that, I end with a lot of time left over. I didn't go over. Thank you.

diseases

esophagus

stomach

GERD

Barrett's esophagus

achalasia