Q21) Which one of the following is not a management option in early esophageal cancer?
a) Photodynamic therapy
b) Endoscopic Mucosal resection
c) Argon plasma coagulation
Q22) Which of the following is the least common symptom of nutcracker esophagus?
a) Pain in chest
Q23. All are true about Nissen's fundoplication except?
a) It is a 360 degree fundoplication
b) Gas bloat syndrome is a common complication
c) Nissen's fundoplication can be done by both thoracic and abdominal approach
d) Usually three sutures are taken to hold the wrap
21 d Esophagectomy
There is a recent term Endoscopically suspected Esophageal metaplasia (ESEM) seen with white light high resolution endoscopy. Management is PPI and repeat evaluation after 6-12 months
Once Barrett's esophagus is diagnosed, the further management depends on weather its a low grade or high grade dysplasia.
No dysplasia and barrett's segment < 3 cm - Endoscopic surveillance 5 years
No dysplasia and barrett's segment > 3 cm - 3 year surveillance with four quadrant biopsy every 2 cm
Indefinite dysplasia - Biopsy repeat 3-6 months
Low grade dysplasia - 6-12 months endoscopic surveillance
HIgh grade dysplasia/Early esophageal cancer-
i) age younger than 30 years at the time of Barrett's diagnosis
ii) a family history of Barrett's esophagus or esophageal cancer,
iii) a segment of circumferential Barrett's esophagus greater than 6 cm
Endoscopic ablative therapy can be considered
Dysplasia and Invasive carcinoma
- No submucosal invasion - EMR followed by ablative management
- T1b or more (submucosal invasion) -Esophagectomy
EMR, PDT and APC can be done for T1a lesion
Nutcracker esophagus is a hyper contractile disorder of the esophagus in which there is excessive contractility of the esophagus. There are high amplitude peristaltic contractions in the body of esophagus.
It is the most common motility disorder of the esophagus.
It can occur in all age groups and is of equal distribution in both sex.
Nutcracker esophagus symptoms
- Chest pain
- Painful deglutition (Odynophagia)
Acording to the Chicago classification
There is subjective complaint of chest pain with at least one swallow showing a distal contractile integral greater than 8000 mm Hg with single or multipeaked contractions on HRM. The LES pressure is normal, and relaxation occurs with each wet swallow
- Avoid trigger inducing foods such as caffeine
- Calcium channel blockers, Nitrates, Antispasmodics
- Esophageal dilatation in some cases
Nissen fundoplication is only an abdominal procedure in which total fundoplication is done. it is a 360 degree wrap. It might have short term dysphagia but is durable in the long run.
Gas bloat syndrome is a very common complication in which belching is not possible. If gas bloat is excessive and disabling conversion to a partial fundoplication is done.