week 1: esophagus

what are the ddx for achalasia

Esophageal Cancer Gastric cancer scleroderma peptic stricture GERD amyloidosis esophageal perforation

what is the gold standard to dx gerd but is never done

Manometry

when a pt has been on PPI definitely give

PROBIOTICS for 1-2 mo to reverse dysbiosis consider DEXA scan if 40-50yo

when dysphagia is worsening with bread and meat odynophagia midsternal pain, discomfort, pressure or burning unintensional weight loss hoarseness, hiccups and pneumonia

esphageal cancer

pneumatic dilation

esophagus with balloone up to 4 cm recommended tx: 70-80% success small risk for perforation 5% done q 3-6 mo

what are the naturopathic tx for GERD

food allergy/sensitivity panels - clean up diet and avoid LES triggering foods small frequent meal dont lay down after eating avoid late night eating or overeating do not drink large amounts of fluids with meals

what is safe for infants

food elimination slippery elm DGL fish oils

Traction

forces pull from outside of the esophagus d/t an inflamamtory process like LA

Calcium stimulates production of

gastrin from the stomach and duodenum neutralizing aspect wears off there is a rebound acid production

HCL

have some relief: GERD can very well stimulate esophageal spasm in some pt

baretts esophagus s/sz

heartburn regurgitation waterbrash dysphagia globus functional dyspepsia

what is the pathophysiology of GERD

hypotensive or incompetent LES : inappropriate relaxation times Anatomic disruption of esophageal or stomach junction: hiatal hernia increased intra abdominal pressure pregnancy or obesity

barrets screening should be doen

if GERD is untx and pt can be taken off acid suppressing drugs after 2-5 years

when do we consider manometry

if dysphagia is present

when do we refer to ENT

if larynx, hoarseness, sinuses or ear are involved

Lecithin / choline

increase LES prssures

PPI

increase risk of bone fracture - likely due to lack of calcium absorption increased risk for C.diff dysbiosis increase risk for community acquired pneumonia

orophayngeal DDX

infections: such as retropharyngeal abcess stroke

how to dx esophagitis

*EDG* bx to rule out brretts and infection Barium contrast upper GI series

DDX for esophageal webs

- Achalasia, esophageal leiomyoma/tumor, Graft vs. Host disease, toxicity/caustic ingestion, stricture, pill-induced esophagitis/ulcer, other rare conditions

DGL chewables

1-2 tab before meals

what is the measurement of the esophagus

10-13 in long 3/4 in diameter

Diffuse/distal esophageal spasm

20% or more uncoordinated contractions pressure greater 30 mmHg

Radiation

70% of pt releif from dysphagia

how is GERD diagnosis

80% cases: history of heartburn Give antacids and see if sx improve other ddx like ulcers aren't dx placebo in 20% of pt negative for h.pylori EGD: dx of reflux esophagitis helps dx NERD, Barrets, ulcers there is no correlation with symptions bx for H.pylori, barretts, infections

what are the ddx for esophageal diverticulum

Achalasia Cancer, motility disorders, spasm, stricture GERD Zenker diverticulum

What are the complication to allopathic tx

Decreased QOL esophageal tears aspiration and peuomonia Cancer deterioration may occur over time

impaired relaxation of the LES and loss of peristaltic contractiosn of the esophagus resulting in dilation

Achalasia Dysphagia to liquid and solids regurtiation of food without acid or bile, up the nasal cavity Heartburn, cough (aspiration) and weight loss this is due to degeneration of inhibitory neurons via vagus nerve which normally releases NO and VIP (vasoactive intestinal peptide) relaxes smooth mm 1/100K people: rare age 25-60 idiopathic viral and autoimmune symptons avg: 5 years prior dx Histology: lymphocytic inflammatory infiltrate resulting in hypothesis of Autoimmune, viral or neurodegenerative:

what are the ddx for esophageal cancer

Achalasia esophageal web ring or stricture peptic stricture from GERD benign Esophageal Tumor

What is the tx for schatzki rings 39 min

Allopathic : balloon dilation PPI , H2 Antagonist to control acid reflux ND: diet: softer foods, small pieces, slow eating ensure hydration with meds, dont lie down after drinking or eat for 30 min Treat: gerd and remove allgies from diet supplementation with anti inflammatory, antioxidant and antihistomaine nutrients, herbs Fish oils avoid sugar trans fats highly saturated fats white grane s consider: stool culture and parasitology

What is the allopathic tx for esophageal spasm vs the Nature cure way

Allopathic: calcium channel blockers Botulinum toxin Nitriates: sublingual nitro TCA *Dilation* myotomy esophagectomy PPI dilizem 60-90mg QID Hot water peppermint oil similar to achalasia Nature cure Elimination diet,FAT: food allergies Avoid irritants: foods: tomatoes spicy, coffee, caffeine, chocolate, citrus, EtOH, tobacco Magnesium/Ca/K: up to 800 mg MAG QD TBT Spasmolytic herbs Asses for M/E: anxiety, fear and depression - refer to EMDR, EFT, guilded imagery Homeopathy

treatment for esophageal varices

Allopathic: No bleeding beta blockers variceal ligation edoscopyic sclerotherpay if bleeding: refer to ER for NG tube and sclerotherpay ND tx: Tx liver dz: astringent herbs increase integrity of the veins

what are the ddx for esophageal spasm

Angina MI GERD achalsia esophageal cancer esophagitis stricture diverticulum, Motility, stricture, webs, rings scleroderma

homeopathy throat inflammation esophagus

Ars phos rhus tox nit-ac

Homeopathy Throat spasms and esophagus

Bar-c Bapt merc-c

What study is dx for Schatzkis ring

Barium study or video fluorscopy or EGD definitive follow up with endoscopy

how is dx of esophageal webs done

Barium swallow EGD less sensitive CBD with diff

how do you dx zenkers diverticulum

Barium swallow or esophagoscopy

how is dx of achalasia done

Barium swallow: initial imaging for investigation Bird beaking narrowing of the distal esophgus with dilation PE does not help blood work doesn;t help must rule out esophageal and gasteric cancer

in infants who we suspect with GERD dx what do we do

Barium swallow: infants: we rule out anatomical defects in pre and post operative eval. id: normal functioning

precancerous condition - metaplasia white squamous non mucosa lining of esophagus changed into red, columnar mucus secreting cells: similiar to stomach

Barretts esophagus 10-15%pt with GERD who have erosive esophagitis - chronic irritation most pt are asx increase risk with age 60+ caucasian highest incidence

what is the tx for mallory weiss syndrome

Blood transfusion 40-70% cases endoscopic band ligation or hemoclipping sclerotherapy to control bleed electrocoagulation: contact thermal modality use with an epi injection PPI/H2RA therapy usually bleeding stops 80-90% of pt alone fasting will help stop the bleeding following endoscopy most pt can eat clear and full liquid deits regular diet within 48 hours

ND tx for mallory weiss syndrome

Botanicals Homeopathics

David hoffman formula

Chamomile (1 part), calendula (1 part), marshmallow (2 parts), comfrey (2 parts), 3-5 mls TID

etiology for esophageal adenocarcinoma formation

Chronic GERD White, male Obesity Tobacco and smoking increase cancer risk Ulcer or stricture on the proximal esophagus

grade 3 esophagitis

Circular confluent erosion

What are some risk factors for LES specifically food

Coffee or tea milk chocolate perppermint and spearmint EtOH Nicotene carbonate citrus fruits tomato based foods vinegar onions lifestyles factors Weight gain : BMI greater 30 smoking eating prior to recumbency/ bending fowrd high fat meals or large meals stress hypochlorydria

Varices herbs

Colinsonia horse chestnut butchers broom hamamelis do not use tincture for those in liver failure

what are the ddx for GERd

Coronary artery dz cholelithiasis gastric cancer esophageal cancer esophageal spasm PUD IBS chronic gastritis esophagitis achalasia

Homeopathics: stomach, vomiting and blood

Crot-h ferrum hamem china phos carbo-veg

how do you dx mallory weiss syndrome

DO NOT DO Barium Swallow!!! EDG usually single tear is present but multiple tears in 27% CBC: Hct and Hgb CMP: bun and creatinine Electrolytes for IV blood typing PTT antibodies - infusion

What is the location of esophageal rings

Distal

HREPT: high resolution esophageal pressure topography

Dx: esophageal spasm

DX

EDG with bx - white papules - microabscess proximal food allergy panel cbc eosinophilia skin prick test for IGE

antioxidants

EFA: 3-6 grams QD vitamin: A C E zinc carnosine for healing the gut Melatonin 3-6 mg qhs - mixed studies

Dx for esophageal varices

EGD esophagogastroduodenoscopy CBC CMP LFT BUN Arterial blood gas pH measurements Prothrombin US of liver DRE IFOBT

typically this is found in young children but can present at any age symptoms are similar to GERD and is commonly misdiagnosed higher prevalence in cold and arid zones in US mc: men 20-30 or young boys

Eosinophilic esophagitis dysphagia for solids and food impaction chest pain: doesn't respond to antacids GERD symptoms emesis, weight loss failure to thrive in children - feeding dysfunction: median age 2 yo there is a strong correlation with food allergies, environmental allergies, atopic dermatitis, urticaria, asthma and allergic rhinitis

What are the sx of mallery weiss syndrome

Epigastric pain hematemesis with bright red blood non bloody vomiting may precede

dysphagia with symptoms of: chest pain regurgitation food feels like it becomes stuck on the way down: localized to the chest or thrroat - stopping at suprasternal notch, but the issues my be further down

Esophageal dysphagia GERD: common Motor: difficulty with both: solids and liquids - due to decrease esophageal LES function - achalasia Obstructive: difficulty with solid only: due to smaller lumen circumference - bread and meat - first noticed = usually due to carcinoma, peptic stricture and lower esophageal ring or web

Portal vein obstruction with increase Portal venous pressure leading to gastroesophageal collateral veins developing to shunt the pressure

Esophageal varices Risk factors liver dz: NASH is the number 1 cause ETOH is the number 2 cause Hepatidities is the number 3 cause ascites Etoh intake PUD forcefull retching or emesis NASH Bleeding diathesis, endoscopic red color signs

Thin mucosal folds 2-3 mm that protrudes into the lumen and is covered with squamous epithelium in Upper esophagus

Esophageal webs most pt are asymptomatic 5-15 % have dysphagia dx: barium xray associated: plummer vinsion syndrome small percentage have dysphagia Risk: developing esophageal cacinoma

a primary condition or secondary to gastroesophageal reflex, hiatal hernia, recurrent vomiting, surgery, medications, lye, radiation

Esophagitis 50% of GERD pt develop esophagitis caused by: infection or irritation of the esophagus: pill eosphagitis, NSAIDS, fasamax, K, Chemotherapy, post radiation infection virus: herpes, EBV, VZV, HPV, polio parasites bacteria: myobacterium fungi: yeast: candida - aids, leukemia, lymphoma associated symptoms dysphagia odynophagia heartburn-reflux oral lesions - herpes N/V, fever, sepsis abdominal pain anorexia wt loss cought

h. pylori is not well associated with

GERD

perception of flow of gastric contents into mouth, hypopharynx

GERD may have a sense of lump in throat or hoarseness

What is the ddx for esophageal varices

GERD PUD Mallory weiss tears Gastric Cancer

A condition which develops when the reflux of stomach contects causes troublesome symptoms and or complciations greater than 2 heart burn episodes per week adversely affect an individual's well being with or without esophagitis

GERD Heart burn is simple: explain the term will result in more accurate symptom evaluation transient LES relaxation: TLESR Les is composed to radial and lontiduinal mm fibers natural phenomenon that occurs during the day and at night when sleep or after eating aggravated by slower stomach emptying

what is heightened bronchial reactivity

GERD and vagal nerve sensitivity make the bronchioles more reactive to other stimuli such as food allergens this is the reflex theory

Botanicals the are astrignent

Geranium achillea yanan baiyao

Herbs that are astringent

Hamamelis collinonia aesculus ruscus Veinoblend: vitanica

resting LES pressure greater than 45 mmHG

Hypertensive LES

treatmetn for oropharyngeal dysphagia

ID the neurological or structural issue VFSS: video fluoroscopy

Phenergan suppository

If needed to stop continuous retching

Normal LES

LES at rest keeps a high pressure of 15-30 mmHG above intra-gastric pressure - LES relaxes prior to esophagus contacts, to allow food to come in to the stomach - after food comes in, the LES constricts again to prevent it from regurgitating into the esophagus

what is the ND theory behind GERD

LES is closed when there is enough acid produced if not enough acid is made, the sphincter might no close.

grade 2 esophagitis

Linear non confluent erosion

what is the risk factors for adenocarcinoma of esophagus

Lower esophagus usually due to GERD tobacco etoh obesity deit low in fruits, veggies, C , A, riboflavin this is increasing in the population

dissection of the distal esophagus and proximal stomach

Mallory weiss syndrome: tears associate with forceful retching: increase in intraabdominal pressure laceration result in bleeding from the submucosal arteries Pathogenesis: unknown cn account for 15% of cases of the upepr abdominal bleeding associated with: Hiatal hernia 40-100% of pt EtOH with vomiting: ASA intake age greater than 40 yo

how is the actual dx made then

Mamomety Aperistalsis in the distal two-thirds of the esophagus and incomplete lower esophageal sphincter (LES) relaxation are diagnostic findings of achalasia on conventional manometry. Elevated resting LES pressure is supportive of the diagnosis of achalasia, but is not diagnostic

what are the ddx of esophagus

NERD GERD H. pylori reflux esophagitis esophageal carcinoma esophageal ulcer hiatal herna globus sensation atypical asthma gastritis PUD duodenal ulcer

is the severity of heartburn a good predictor of the presence of esophagitis

NO pt with severe reflux symptoms may have normal endoscopies; however, a large number of patients will have EE

Arginine

NO precursor to relax mm

Drugs:

Nitroglycerin calcium channel blockers 10% pt benefit botulinin toxin: 85% pt improvement but relapse with dx voer 6-9 mo post injection

coordinated but very intese avg: pressure greater 220 during 10 + 5mL liquid swallows

Nutcracker esophagus

difficulty in initiating swallowing resulting in oral and nasal regurgitation, aspiration, coughing upon swallowing - poor bolus formation - liquids worse than solids

Oropharyngeal dysphagia Food sticks at the level of the throat - can clear throat common in neuromuscular disorders: -ALS, strokes, dementia, Parkinson, MS, MG, brain injury, Muscular dystrophy, dermatomyositis

allopathic tx for barrets esophagus

PPI agressively survallance for dysplasia no dysplasia: check q 2-3 years after 2 negative observance

which patients are likely to benefit from surgery

PPI intolerance persisten symptoms especially regurgitation

esophageal

esophagus Lower essophagus sphincter/ gastroestophagus junction

allopathic tx for achlasia vs ND tx

Pnuematic dilation drugs sugery ND: food allergy: elimination diet avoid irritating foods spasmolytic herbs assesme for M/E Homeopathy

Berries

Products heal capillary matrix

Gastri emptying study

Radioactive substance is eaten with meal and sensor measures how long it takes to leave the stomach

Acupunture

Ren 17 15-12 GB 34 REN 22with stim PC6 7 H 5 7 LU 9- for emotions

How do you gx Esophageal Spasm

Rosary bead or Corckscrew appearnce: xray Test: barium swallow study: then Manometry primary for Dx CT scan PE and blood work are not helpful Barium xray not sensitive nor specific: wide variety of findings

Thin delicate 3-5 mm stricture that partically or fully block lumen of the distal esophagus at the SCJ

Schatzki B ring dysphagia: solids asx: chw food well etiology: damage from reflux inflammation/eosinophilic cells in ring consider: GERD, meds, food allergies, Caustic ingestion, trauma, radiation, chronic inflammation 97% had accompanying Hiatal hernia

Grade 4 esophagitis

Stricture or Barrett's esophagus

Tx for zenkers diverticulum

Surgery : diverticulectomy tx the condition resulting with diverticula this is the ND way

Tincture: ginger, coleus, ammi, humulus

TIC 2 dropper full with meal

Vomiting Bright red blood or blood int eh stool venous blood of varices is darker

This is not an ER unlike Esophageal varies it will heal repair: 48 hours

What is plummer vinson syndrome

Triad: Fe def anemai dysphagia esophageal webbind glossitis cheilitis webs and weakenss RARE: white women 60-70 yo Scandinavian when anemia is tx: clears

what is the mechanism for GERD resulting in asthma

Vagally mediated reflex bronchospasm high acid in esophagus reodes away the mucous lining, exposing the vagal nerve ending: further acid exposure transmits a signal to the bronchial tubes to constrict

what are some Spasmolytic herbs

Valerian Piper -Kava Scutellaria Piscidia Dioscorea Chamomila Zingiber Curcumin Coleus Forskohlii Ammi Vishnaga Humulus

herbs that increase integrity of veins

Vitamin C centella Bilberry Biovlavinoids 3000 mg/dary rutin qercitin 3000 mg QD citrus bioflavinoids B6: 100-2 mgQD

High dose nutrient to heal tissue

Vitamin C Zinc Carotenoids

blind sac that is due to herniation of the posterior hypopharynx mm well

Zenker diverticulum above upper esophageal sphincter lead to retention of food elements: liquied and solids mc: men 60+ esophageal diverticulum further distal also possible this is due to increase in oropharyngeal pressure against a closed esophageal sphincter in the back of the mouth not yet in the esophagus Transient dysphagia: solids and liquids Aspiration pneumonia, halitosis, cough, gurgling in throat, regurggiation of food into the mouth and has a neck mass

what is the complication of oropharyngeal dysphagia

Zenkers diverticulum outpounching of the tissue superiorally in the esophagus

motor esophageal dysphagia: due to decrease in esophogeal and LES function

achalasia

what are the risk factors for squamous cell esophageal cancer

achalasia webs mets from scc of neck and head *smoking, etoh,*

what are the ddx for esophagitis

angina MI GERD PUD PE Pericarditis Aortic aneurysm stricture

what is the MAO of GERD

antacids neutralize Hcl PPI block acid at its source in the proton pump H2RA's blook the histamine receptor interfering with one of the stimulation pathways

homeopathy for GERD Throat pain burning esophagus

arsenicum nex-v phos sulphur ignatia

What are the complication of zenkers diverticulum

aspiration pneumonia

what are some drugs which may damage the esophageal mucosa

aspirin and nsaids tetracycline quinidine bisphosphonates

what are some cues that GERD may be causing asthma

asthma - first time in adulthood worse after meals or lying down or exercise worse at night obese body worse after peppermine, chocolate, high fat diet cough wheeze dyspnea associated with GERD symptoms

how do you dx esophageal cancer

barium swallow upper endoscopy and biopsy CT endoscopic U/S- eval cancer spread brochoscopy: bronchial lesion PET scan thorascopy and labaroscopy: remove nearby lymph nodes and see if surgery is advisable

what is the reflex theory

esophagus and bronchial tree share common innervation via the vagus nerve and share common reflexes

what are the complications of GERD

barretts esophagus esophageal strictures laryngitis laryngeal cancer sinus or middle ear infections swollen adenoids - children esophagitis chronic pain asthma: 35-80% of asthmatics have GERD and up to 50% have silent gerd without classic reflux dx tooth decay lung damage: asthma, aspriation pneumo, pulmonary fibrosis strictures: healed ulcers form scars leading to shrink into strictures

Obesity

bending forward and lying down after meals maybe hiatal hernia esophageal conractions

what are some medications which impair LES function

beta adrenergic agonists theophylline anticholinergics tricyclic andtidepressants progesterone alpha adrenergic antagonists diazepam calcium channel blockers OCP DA

digestive enzymes before meals

betaine HCL gentian scutellair a sweetish bitters apple cider vinegar

H2 histamine antagonist

bind to HR to prevent acid release Cimetidine - tagamet famotidine - pepcid ranitidine - zantac nizatidine - axid

waterbrash

bitter or sour taste in mouth pain less when eating dysphagia odynophagia

blood in stools loik like

black tarry or bloody stoole

increase risk associated with PPI

c.diff aspiration pneumonia hip fractures fundic gland polyps absorption issues due to changes in pH b12, calcium , proteins, Iron

Aluminum ones

can result with constipation

bravo capsule

capsule is a wireless pH monitoring device that has been shown to be more tolerable, accurate and sensitive than the transnasal catheter-based pH monitoring Confirms diagnosis

what are some atypical or supraesophageal s/sx for GERD

chest pain laryngitis asthma sinusitis *chronic cough greater 8 weeks* aspiration pneumonia tooth decary

vomiting blood due to liver dz looks like

coffee grounds

c

confluent break less than 75% circumferential

D

confluent breaks greater than 75% circumferential

if food is stuck above the suprasternal notch

could indicate a problems from the pharynx tot eh gastroesophageal junction

what are some anti inflammatory and anti allergy hergs

curcumin zingiber boswellia quercitin citus bioflavinoid

Magnesium can cause

diarrhea

dysphagia

difficulty swallowing

epipherinic

distal esophagus and lower 6-10 cm : increase pressure during contractions agaisnt a close LES rare dx

low grade dysplasia

do nothing check q6 mo then for 1 year

certain pills can cause ulceration and strictures such as

doxycyline NSAIDS quinidine

GERD

drink only water or non-mint herbal tea away from measl can drink: licorice, ginger or slippery elm tea also

what are the alarm signs of GERD

dysphagia odynophagia weight losss GI bleeding family hx of upper gi cancer Anemia Advanced age

dx for barretts esophagus

edg with bx: may first do double contrast esophagophagry golbet cells, abnormal pink lining replaces the normal white esophageal lining

grade 1 esophagitis

erythema

squamous cell or adenocarcinom

esophageal cancer african american men servival rate: less than one year

Surgery

esophagomytomy: if dilation fails 85% success

Barrett's esophagus

is a metaplastic change of the tissue lining the esophagus,from squamous epithelium into columnar epithelium.66 It is also called 'intestinal metaplasia', as columnar epithelium is usually found in the lining of the stomach. Approximately 10-15% of patients with GERD will go on to develop Barrett's esophagus.7 As described on the following slides, these patients may have greater levels of acid exposure than those who remain free of the lesion.67,68

PPI proton pump inhibitors

lansoprazole - prevacid esomeprazole - Nexium Omeprazole - Prilose Pantoprazole - Protonix Rabeprazole - Aciphex

fundoplication

laparoscopic surgery in which the stomach is wrapped around the esophagus 80% relief for 5-10 years and most need meds

what happens if Varies rupture

leads to hemorrhage and hypovolemic shock 1/3 recurrences are fatal 70% recurrence

Stretching:

lift arm up stright then bend down so that the hand touch the back of neck, back fixation can reflex neurologically to the esophagus R/O cervical and thoracic fixations

obstructive esophageal dysphagia: difficulty with solid foods due to smaller lumen.

may be due to carcinoma peptic stricture lower esophageal ring lower esophageal web

Esophageal spasm: dysmotility

mc: white women rare: children non peristaltic, uncoordinated contractions inhibitory innervation resulting in increase or decrease amplitude of mm contraction 3 types: diffuse/distal esophageal spasms 20% nutcracker esophagus - very intense Hypertensive LES *non cardiac chest pain* pain last sec to min: very intesne dysphages: *solids and liquids* - very hot/cold foods/liquids - loud noises - stress can exacerbate regurgitation *lump in the throat* heartburn commonly: anxiety and depression

what is more common with complication of GERD

microaspiration of gastric acid resulting in bronchspasm triggering asthma attacks in the middle fo the night when the pts are supine

M

minimal change: erythema/turbidity

what is the gold standard but it is never done

monometry for pH monitoring

what plexus is affected with achalasia

myenteric plexus ganglion cells of the esophageal body and the LES

when a pt is well maintained on medical therapy for GERD is sugery beneficial

no

B

non confluent mucosal break greater than 5 mm

A

non confluent mucosal break less then 5 mm

NERD

non erosive reflex disease esophatitis common with GERD may be classified as erosive or nonerosive with the severity based on the number and location of the mucosal breaks

N

normal mucosa

with cancer tx for esophageal ca surgery is curative

only in early stages pt most pt are not early stages 25% death in surgery

VFSS: video fluoroscopy

oropharyngeal dysphagia

oropharyngeal

oropharynx larynx Upper esophagus sphincter

dx of GERD

pH monitoring - manometry: atypical cases failure to respond to PPI negative EGD

odynophogia

painful swalling

chemotherapy

palliative pre-operative with radiation

what are the symptoms of blood loss

pallor cyanosis lightheadedness hypotension dyspnea tachycardia

morbidity of esophagitis diagnosis

percursor to barretts esophagus stricture formation perforation / bleeding - rare

phtodynamic therapy

photsensitizing drug and certain types of light when exposed to wavelenght they form oxygen that kills cells In the first step of PDT for cancer treatment, a photosensitizing agent is injected into the bloodstream. The agent is absorbed by cells all over the body but stays in cancer cells longer than it does in normal cells. Approximately 24 to 72 hours after injection (1), when most of the agent has left normal cells but remains in cancer cells, the tumor is exposed to light. The photosensitizer in the tumor absorbs the light and produces an active form of oxygen that destroys nearby cancer cells (13). In addition to directly killing cancer cells, PDT appears to shrink or destroy tumors in two other ways (14). The photosensitizer can damage blood vessels in the tumor, thereby preventing the cancer from receiving necessary nutrients. PDT also may activate the immune system to attack the tumor cells. The light used for PDT can come from a laser or other sources (2, 5). Laser light can be directed through fiber optic cables (thin fibers that transmit light) to deliver light to areas inside the body (2). For example, a fiber optic cable can be inserted through an endoscope (a thin, lighted tube used to look at tissues inside the body) into the lungs or esophagus to treat cancer in these organs. Other light sources include light-emitting diodes (LEDs), which may be used for surface tumors, such as skin cancer (5). PDT is usually performed as an outpatient procedure (6). PDT may also be repeated and may be used with other therapies, such as surgery, radiation therapy, or chemotherapy (2).

individual who develop BE have a

predisposition usually not a result of antural progression of GERD through erosive esophagitis risk: white males greater 45 y/o central obesity achalasia metabolic syndrome low antioxidants high meat and fast food diet b- agonist drugs eradication of H.pylori

PGE2

pro inflammatory markers due to increased peroxide and decrease calcium stores

What is the location of esophageal webs

proximal

burning in retrosternal area post meals, radiating upward or into chest worse at night

pyrosis : heartburn GERD

Esophageal intramural pseudodiverticulosis

rare and acquired numerous very small outpouching form the esophageal wall

if the larynx hoarseness sinuses or ears are involved we

refer to ENT

so what then is our treatment protocol

remove food sensitivities and allergies leave pt on PPI add in slipper elm add in : licorice or DGL if the PPI +3mo then add in probiotic 20 billion daily RTC: 1 mo if they have reduced or stopped their medications if not and they are feeling better you reduce it continue protocol leaving them on demulcents for 2-3 mo PPI always need to be weaned off slowly or you risk rebound acidity

Tx for esophageal webs

same as esophgeal rings usually rutpured during EGD: recurrence rate is common dilation if necessary Fe repletion if associated with anemia Treatment: None in asymptomatic pts - not the best advice, mostly MD's Eat soft food, eat smaller pieces of solid food, eat slowly Ensure oral medications are cut into small size so are not caught in esophagus. Take with 8 oz water and do not lie down afterwards for 30 minutes. Esophageal dilation if necessary. Treat causative problem, like GERD. May wish to do food allergy testing and push anti-inflammatory foods/supplements: fish oils, no sugar/trans fats/high sat fats, no white grains. Anti-inflammatories, anti-allergies: turmeric, ginger, boswellia, quercitin, citrus bioflavinoids, etc. May also do stool culture/parasitology Food allergy testing

Antacids

short acting TUMS - CaCO3 maalox, mylanta Mg(OH)3 Rolaids Alka seltzer (NaHCO3)

Valerian extact

shown to have a strong effect prior to meals

nature cure for barretts esophagus

similar to gerd diet elimination no nitrates no etoh tobacco nitrosamines excellent general diet plan assess for food allergies and remove them antioxidants 6 mo Vit E vit A natural Cartenioids vit c selenium folic acid EFA3-6 mg AD fish oil mushroom formula green first berry product quercitin curcumin at high doses selenium green tea good muli flavinox anti inflamamtory botanical

upper 1/3 esophagus has what type of mm

skeletal

demulcents

slippery elm gruel 1-1.5 tsp in ¼ cup cold water makes paste, then add 1 cup boiling water. Let cool and drink. Can add to oatmeal, apple sauce, etc. That's one dose. Sits too long = mucousy. Robert's Formula (slippery elm, marshmallow, echinacea), DGL Plus (1-2 caps TID) do not add to food and eat it: it will not work as well

must wean off pharmaceutical

slowly rebound effect

lower 2/3 esophagus has what type of mm

smooth mm

what types of cells are found in the esophagus

squamous cells

GERD accupuncture

stomach fire st:36 44 P6 Li5 11 ren 15 14 ren 17 if chest sx

nd tx for esophageal cancer

support cancer tx support immune system prevention: cancer are due to lipid peroxidation and increase ROS so push ANTIOXIDANTS green or rooibos teas turmeric onions garlic shitake vitamin A, C, E carotenoids, selenium anticarogenic: dially sulfide compuond in garlic, onion, radishes, garden cress fish oil boswellia quercitin Decrease PGE2 and Leukotriene 4 to prevent/treat esophageal cancer:

GERD

treat for 1 mo then if no change then consider gastro referral

treatment for esosinophilic esophagitis

tx: dietary elimination topical corticosteroids similar to GERD food allergies and sensitivities anti histamin supplemnets anti oxidants - barrets vit C quercitin urtica bromelain

botainical: vulnerary: wound healing demulcents

ulmus althea chamomile aloe gel/juice calendual DGL chewable tabs slipper elm gruel: 1-1.5 tsp in 1/4 cup cold water makes past then add 1cup boiling water. let ool and drink can add to oatmeal, apples sauce

allopathic GERD tx

uncomplicated gerd: initial trial: empiric therapy of lifestyle modification and or PPI is appropriate Lifestyle modification omeprazole: 20-40 mg/day for 3mo reduced asthma sx by 57% Asthma meds surgery- laparoscopic fundoplication PPI test does not confidently include or exclude GERD

lifestyle modification for GERD

weight loss - all pts tailored to individual circumstances elevated head of bed if nocturnal symptoms at lead 4-8 in avoid precipitating foods decrease water and fluid will meals eat smaller meals do not eat late at night avoid drugs the lower LES tone remain upright after eating no bending forward wear loose cloths stop smoking chew gum: increases saliva and bicarbonate and increases swallowing

Abnormal LES

when LES relaxes at inappropriate times and allows food and acid to reflux up into the esphagus regurgitate: acid, pepsin and bile associated with h. pylori infection in the stoamch

if food is stuck below the suprasternal notche

you can feel confident its an esophageal pathology