Evaluation and Management of Dysphagia - Chicago … · Evaluation and Management of Dysphagia ... Anticoagulation (bleeding ~4/1000) 3. ... • Strictureplasty –Needle-knife

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Ikuo Hirano, MDGastroenterology DivisionNorthwestern University Medical School

CSGNA Fall into GI Conference

Evaluation and Management of Dysphagia

Dysphagia Management

1. Evaluation of dysphagia

2. Dilation methods: pros and cons

3. Specific disease examples

1. Schatzki ring

2. Achalasia

3. Eosinophilic esophagitis

4. Refractory strictures

Dysphagia

Structural

Solid DysphagiaSolid & Liquid

Dysphagia

Motility

Esophageal

Dysphagia

Dysphagia localized to

chest or neck, food

impaction

Dysphagia localized to

neck, nasal regurgitation,

aspiration, associated ENT

symptoms

Oropharyngeal

Dysphagia

Esophageal Dysphagia:

Motility Disorders

Achalasia

Diffuse Esophageal Spasm

Scleroderma

Polymyositis

Esophageal Dysphagia Structural Etiologies

Schatzki ring

Eosinophilic esophagitis

Peptic stricture

Iatrogenic (radiation, surgery,

endoscopic therapy)

Esophageal neoplasm

Caustic injury

Esophageal diverticula

Esophageal web

Congenital esophageal stenosis

Diagnostic Testing for Esophagus

• Upper GI Series/Esophagram/Barium swallow

• Endoscopy

• Esophageal manometry

• Esophageal impedance manometry

• Impedance planimetry

• Endoscopic ultrasonography

2

UGI Study

0 15 Seconds1.5

3.35.06.6

8.5

13.

0

Fluoroscopy

Esophageal Manometry High resolution manometry

20 seconds

Swallow

Esophageal peristalsis

LES deglutitive relaxation

Upper esophageal sphincter

Lower esophageal sphincter

0

5

10

15

20

25

30

35

Pharynx

Stomach

Cm

140

120

100

80

60

40

30

20

10

0

150mmHg

Predilation Considerations

Stricture characteristics

1. Proximal vs distal location

2. Long vs short stricture

3. Estimated stricture diameter

4. Active mucosal inflammation/ulceration

5. Concomitant fistula/diverticulum

Patient characteristics

1. Comorbidities. Can patient tolerate complication

2. Anticoagulation (bleeding ~4/1000)

3. Antibiotics (endocarditis prophylaxis if high risk)

Predilation Considerations

A. Pre Procedure Esophagram

Complex strictures (radiation, surgery)

B. Intraoperative Fluoroscopy

Tight stricture that scope cannot traverse;

Angulation

Pneumatic dilation

C. Choice of Equipment (1 mm=3 Fr)

1. Maloney:

PRO: Blind, Tactile, Reusable

CON: Blind passage, Axial + Radial force

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Predilation Considerations2. Savary:

PRO: Wire-guidance, Reliable diameter, Reusable,

Some tactile sensation

CON: Axial+radial force, patient comfort

3. Hydrostatic Balloon (TTC,TTS, CRE):

PRO: Pt tolerance, Axial, +/- wire, variable diameter

& length, visualize results of each successive dilation

CON: cost, long strictures, no tactile sensation

4. Pneumatic Balloon: Achalasia, Post fundoplication

dysphagia

Fixed diameter (3,3.5,4 cm)

D. Steroid injection for refractory stricture

“Rule of Threes”

No more than 3 consecutive dilations once

resistance is encountered

Eminence and not evidence based

Based on passage of Maloney dilators that have

best tactile response

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Case Presentation

A 62 yo male presents to the ER at 1 am

complaining that a piece of meat is trapped in

his throat. He states that while eating a late

dinner at a local restaurant, a piece of his

steak “did not go down” (he points at his mid

sternum). He tried to wash down the meat

with water but vomited only the water. This

same problem has been happening a few

times a year for several years.

Schatzki Ring

• Described by Schatzki & Gary and by Ingelfinger & Kramer in 1953

• Localized to esophageal squamocolumnar junction and almost invariably coexist with a hiatal hernia

• Found in 4-15% (mean 10%) of radiographic studies. Autopsy study by Goyal reported a prevalence of 9%

Schatzki, AJR 1963

Dysphagia vs Ring Diameter

Repeated dysphagia

Isolated dysphagia

No dysphagia

3 mm

12 mm

20 mm

40 mm

Schatzki ring

Schatzki’s Ring

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Schatzki’s Ring• Primary Treatment:

– Maloney, Savary or balloon dilator.

– Most commonly 50-51 Fr (17 mm)

• Alternative Tx: – Disruption of ring with cold biopsy forceps in 4 quadrants

• Long-term follow up following dilatation with 46-58Fr dilator (Eckardt DDS 1992)

– 68% of patients are free of dysphagia at 1 year

– 35% at 2 years

• PPI Therapy may prevent recurrence (Sgouros Am J Gastro 2005)

– Recurrence 47% with omeprazole vs 7% with placebo at 3 years

Case Presentation

57 yo female referred for evaluation of dysphagia.

• Onset of dysphagia 6 months ago.

• Both liquids and solids

• Localizes to his lower sternal region

• Frequent regurgitation of food / saliva

• Nocturnal coughing/aspiration

• 8# weight loss

Achalasia

QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

High Resolution Manometry in Achalasia

20 seconds

Swallow

Failed LES deglutitive relaxation

90

80

70

60

50

30

20

1050

-10

100

mmHg

40

Upper esophageal sphincter

Lower esophageal sphincter

0

5

10

15

20

25

30

35

Pharynx

Stomach

Cm

Failed esophageal peristalsis

Therapy of Achalasia

• Smooth muscle relaxants

• Botulinum toxin

• Pneumatic dilation

• Per oral endoscopic myotomy (POEM)

• Esophageal stent

• Percutaneous gastrostomy tube

• Heller myotomy

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Boston Scientific RigiflexPneumatic dilation3.0, 3.5, 4.0 cm diameters

Before

After

Timed barium swallow Pooled Estimates of Response Rates of Achalasia Treatments

Therapy Total Weighted mean Weighted Weighted

n response mean mean

p±SE % follow-up perforation

Botulinum toxin 638 78 ± 33 1 mo NA

412 58 ± 36 6 mo

225 49 ± 23 12 mo

Pneumatic dilation 374 85 ± 30 20 mo 2.6

(Rigiflex)

Heller myotomy

Thoracotomy 1221 84 ± 20 5 yr NA

Laparotomy 732 85 ± 18 7.6 yr NA

Laparoscopy 365 91 ± 13 1.4 yr NA

Boeckxstaens N Engl J Med 2011Boeckxstaens N Engl J Med 2011

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Boeckxstaens N Engl J Med 2011

Effectiveness of pneumatic dilation is comparable to laparoscopic Heller myotomy IF allow for

repeated dilations and accept risk of esophageal perforation

Case Presentation• 42 year old male presents with 12 years of intermittent

dysphagia for solids that localizes to his mid sternum. Symptoms have been progressive; now occurring on a daily basis. He has had repeated food impactions after eating meat or bread that last up to 1 hour. He was seen in the ER on 2 occasions for endoscopic disimpaction.

It takes the patient over an hour to complete his meals. He is embarrassed when he needs to leave the table during meals to vomit up food that he cannot swallow.

The patient was previously diagnosed with GERD and esophageal spasm.

PMH includes childhood asthma and allergic rhinitis.

Eosinophilic Esophagitis 2011

Liacouras et al. Eosinophilic Esophagitis Updated Consensus Recommendation.

J Allergy Clin Immunol 2011

EoE is a clinicopathologic disease

• Clinically, EoE is characterized by symptoms related to

esophageal dysfunction

• Pathologically, 1 or more biopsy specimens must show

eosinophil-predominant inflammation. With few exceptions,

15 eos/hpf is considered a minimum threshold for the

diagnosis of EoE

• The disease is isolated to the esophagus, and other

causes of esophageal eosinophilia should be excluded

EoE is increasing over past 2 decades in both children and adults worldwide

Prasad Clin Gastro Hepatol 2009; Hruz J Allergy Clin Immunol 2011;

DeBrosse J Allergy Clin Immunol 2010; Dellon Aliment Pharm Ther 2015

Olmstead County, MN (peds/adults) Olten County, Switzerland

Hamilton County, OH (peds) Denmark

Epidemiology of EoE in USHealth insurance database 2009-11 of 11.5 million;

Prevalence based on ICD9 (530.13) 57/100,000

Dellon Clin Gastro Hep 2014; 12 (4): 589

Eosinophilic Esophagitis

Clinical Features in Adults

• Male predominant ~70%

• Age at diagnosis: 35-40

• Atopy (asthma, allergic rhinitis, atopic dermatitis): ~70%

• Primary symptoms: dysphagia, food impaction

• Secondary symptoms: heartburn, chest pain

• Symptom duration prior to diagnosis: 5 years

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Etiology of Dysphagia Retrospective Study 1371 Adults Undergoing EGD for dysphagia

Kidambi, Toto, Hirano World J Gastro 2012

1999 2009

EoE

GERD GERD

The 2 am “Wake up” Call!

EoE identified in 11-55% of adults with food impaction

Desai Furuta Gastrointest Endosc 2005;61:795

Gonsalves Sanger Zhang Hirano Am J Gastro 2006;101, S66

Kerlin Jones Remedios Campbell J Clin Gastro 2007;41:256

Byrne Peterson Fang Dig Dis Sci 2007; 52: 717

Sengupta Lembo Aliment Pharm Therap 2015; 42; 91

Hirano Am J Gastro 2016

Role of Endoscopy in EoEClassify and grade severity of characteristic findings of

Edema, Rings, Exudates, Furrows, Strictures (EREFS)

Hirano Moy Heckman Thomas Gonsalves Achem. Gut. 2012.

Normal Eosinophilic Esophagitis

Edema (loss vascular markings)Grade 0: Distinct vascularityGrade 1: Decreased Grade 2: Absent

Rings (trachealization)Grade 0: NoneGrade 1: Mild (ridges)Grade 2: Moderate (distinct rings)Grade 3: Severe (not pass scope)

Exudate (white plaques)Grade 0: NoneGrade 1: Mild (<10% surface area)Grade 2: Severe (>10% surface area)

Furrows (vertical lines)Grade 0: NoneGrade 1: Mild Grade 2: Severe (depth)

StrictureGrade 0: AbsentGrade 1: Present

Grade 0 Grade 1 Grade 2 Grade 3EoE Endoscopic Reference Score (EREFS)

Hirano Gut. 2013

Complications of EoE:Narrow caliber esophagus

Hirano Aceves Gastro Clin North Am 2014;43(2):297-316.

EoE inflammation+ Fibrosis

EoE FibrosisEoE inflammation

. .

Normal

EGD

Histo

EoE: A Conceptual Model of Clinical Subtypes Based On Inflammation and Tissue Remodeling

DilationMedical/Diet Therapy

Hirano Aceves Gastro Clin North Am 2014;43(2):297-316.

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3 D’s of Treatment for EoE• Drugs

– Topical steroids

– Systemic steroids

– Leukotriene antagonists (montelukast)

– Mast cell stabilizers (cromolyn sodium)

– Immunomodulators (CRTH2 antagonist, azathioprine)

– Biologics (anti IL5, anti IL13, anti TNF, anti IgE)

• Dietary Therapy

– Empiric elimination diet

– Allergy testing directed elimination diet

– Elemental diet

• Dilation (Endoscopic therapy)

Suggested Algorithm for ManagementOf Eosinophilic Esophagitis

Suspected EoE

PPI x 8 wks

EGD with Bx

“PPI Responsive Esophageal Eosinophilia” (EoE vs GERD)

Symptom relief &Normal histology

EoE

> 15 Eos/hpf

Topical steroidDietary therapy

EGD with Bx

Elimination diet

↑ Dose topical

Systemic steroid

Biologic therapy ?

Persistent Symptoms and Pathology

Esophageal

dilation

Persistent dysphagiawith stricture

Consider Maintenance Therapy

Symptom relief &Normal histology

Hirano. Eosinophilic Esophagitis (Liacouras Ed). 2011

Esophageal Dilation in EoE Prior to 2008High risk of Esophageal Complications

8 cases; 3 dilations

1 perforation with EGD

5 dilations

5 large lacerations

with EGD or dilation

1 dilation

1 perforation

6 dilations

3 perforations

Esophageal Dilation in EoE 2012:Low risk of Esophageal Complications

474 dilations

0 perforations

70 dilations

0 perforations

15 dilations

0 perforations

293 dilations

3 perforations

• Retrospective study of 474 dilations in 207 adults

• 63 patients treated with dilation alone

• 93% of patients reported slight or no dysphagia after dilation

• Esophageal diameter increased from 11 mm pre to 16 mm post dilation

• 3 mm incremental dilation per session; median 2 sessions per patient (range 1-13)

• Median duration symptom improvement: 15 mos

• No perforations

Schoepfer AM, et al. Am J Gastroenterol 2010;105:1062-70

Esophageal Dilation in EoE: Effectiveness, Safety and Impact on Underlying Inflammation

121

104

0

50

100

150

(n=63)

Pre-Dilation

Post-Dilation

Peak e

osi

nophil

/ hpf

Esophageal Dilation Does Not Affect the Underlying Esophageal Inflammatory ProcessDilation without anti-eosinophil therapy


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Chest pain noted in 7% of patients based on chart reviewChest pain reported by 74% of patients based on survey

Esophageal Dilation in EoE: Chest Pain Retrospective Analysis of 474 dilations in 207 patients

38% of patients experienced moderate to severe

post dilation pain lasting less than 4 days in most


Dilation in EoE has a high degree of patient acceptance based on patient survey (n=42)

Esophageal Dilation in EoE:

Case Presentation

• 16 year old man with onset of severe dysphagia for solids of all consistencies following a several week hospitalization for complicated appendicitis.

• Local GI EGD demonstrated a severe 3-4 mm stricture at 20-37 cm. TTS dilation x 4 to 12 mm without benefit

Refractory Esophageal Strictures• Proposed Definition (Kochman GIE 2005)

– Refractory: Inability to successfully establish diameter of 14 mm during 5 sessions at 2-week intervals

– Recurrent: Inability to maintain luminal diameter for 4 weeks once the target of 14 mm achieved

• Most common etiologies:– Radiation

– Caustic ingestion

– Peptic

– Surgical anastomosis

– Narrow caliber esophagus (EoE)

Siersema Wijkerslooth Gastroint Endosc 2009

Refractory Esophageal Strictures

Treatment Options


• Repeated dilation– Bougie (Maloney, Savary)

– TTS Balloon

• Intralesional injection (steroid, mitomycin C)

• Strictureplasty– Needle-knife

– Endoscopic scissor

– Argon Plasma Coagulation (APC)

• Stent therapy – Advantages: Long-term, continuous dilation

– Disadvantages: migration, chest pain, durability

• Self bougienage

• Surgery

Suggested Algorithm for ManagementOf Refractory Esophageal Strictures

Benign Esophageal Stricture

Esophageal dilation Symptom relief

Dilation with

intralesional steroidStrictureplasty Esophageal

stent

Serial

Dilations

“Refractory” StrictureRule out esophageal inflammation (LP, EoE, bullous),

esophageal dysmotility, oropharyngeal dysphagia

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Intralesional steroid injection• First used by Holder in 1969

• Used by dermatology: keloid, burns

• Theoretically reduces collagen and fibrin deposition

• Most commonly triamcinolone 40-80 mg injection


Esophageal Stents


• PC-SEMS: partially-covered metallic

• FC-SEMS: fully-covered metallic

• SEPS: fully-covered plastic

De Wijkerslooth, Siersema, Am J Gastroenterol 2011;106:2080.

• Biodegradable


16 yo M with refractory mid-distal stricture 20-37

cm. Failed 4 dilations OSH and 4 dilations NMH

with steroids. Alimaxx


Esophageal Stents for Benign Stricture


• Conceptual advantages for benign

strictures

– Temporary (usu 4-12 weeks), continuous,

gradual dilation to allow for stricture remodeling

• Practical disadvantages• Migration (25-50%)

• Chest pain

• Durability of response

• Bleeding

Van Halsema World J Gastrointest Endosc 2015

De Wijkerslooth, Siersema, Am J Gastroenterol 2011;106:2080

Stents for Benign Esophageal StricturePooled analysis of 232 patients with refractory strictures

n (%)

Stricture etiology

Anastomotic 69 (30)

Peptic 58 (25)

Radiation 36 (16)

Caustic 29 (13)

Technical success

Overall 229 (98.7)

Fully covered SEMS 85 (100)

SEPS 67 (95.7)

Biodegradable 77 (100)

Clinical success

Overall 56 (24.2)

Fully covered SEMS 12 (14.1)

SEPS 19 (27.1)

Biodegradable 25 (32.9)


Stents for Benign Esophageal StricturePooled analysis of 232 patients with refractory strictures

n (%)

Stricture etiology

Anastomotic 69 (30)

Peptic 58 (25)

Radiation 36 (16)

Caustic 29 (13)

Technical success

Overall 229 (98.7)

Fully covered SEMS 85 (100)

SEPS 67 (95.7)

Biodegradable 77 (100)

Clinical success

Overall 56 (24.2)

Fully covered SEMS 12 (14.1)

SEPS 19 (27.1)

Biodegradable 25 (32.9)


Given risks and uncertain sustained benefits,

use of esophageal stenting for benign strictures

should be individualized.

Randomized trials awaited.

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Management of

Esophageal Strictures

Steroid injection and stents may reduce frequency of dilation for benign stricture

Esophageal stents are an option for refractory strictures but sustained resolution in < 25%

Pneumatic dilation is highly effective for treatment of achalasia and equivalent to surgical myotomy IF allow for aggressive dilation protocol

Esophageal dilation is safe and effective for esophageal strictures in eosinophilic esophagitis

Documents

Evaluation and Management of Dysphagia - Chicago … · Evaluation and Management of Dysphagia ... Anticoagulation (bleeding ~4/1000) 3. ... • Strictureplasty –Needle-knife