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Updated: 03/12/08 02:37 PM |
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| HOME | HEAL | EDUCATE | RESEARCH | DIRECTORY | OUTREACH |
Author: C.E. Pope ♦
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G. Approaches to Therapy
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1. Gastroesophageal Reflux Disease
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To allow squamous epithelium to heal in reflux esophagitis, one could either limit the reflux of gastroduodenal contents into the esophagus; alter the character of the refluxed fluid so that it is less noxious, or strengthen the ability of the esophageal mucosa to resist digestion.
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Simple Measures |
To limit reflux of material, one should avoid going to bed with a full stomach. Elevation of the head of the bed by placing 6 to 8 inch blocks under the head end of the bed puts gravity at your service and is an effective form of treatment if the patient will tolerate such an elevation. Avoiding fat, alcohol, and onions will often diminish symptoms of reflux. Theoretically, a pharmacologic agent which would strengthen the lower esophageal sphincter would be expected to be of benefit. They unfortunately do not help the most severely affected patients. If transient LES relaxations after meals could be blocked, total time of regurgitation of gastric contents into the esophagus would be decreased. No currently used medication can do this.
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Antacids H2 blockers Proton pump inhibitors |
The most common form of therapy involves alteration of the gastric contents so that they will be less harmful. Neutralization of gastric acid with antacids has long been the mainstay of therapy. From the casual Tums or a shot of "bicarb" to more meticulous therapy with aluminum hydroxide - magnesium hydroxide antacids, relief is only a swallow away. The need to repeat antacid doses frequently makes long-term therapy more difficult. Another approach which has been shown to be effective is the inhibition of gastric acid secretion by an H2-blocking agent. When given in full dosage, this causes significant decrease in clinical symptomatology in patients with heartburn. Unfortunately, upon cessation of the drug, return of symptoms is often rapid. Proton-pump inhibitors (PPI) are more effective blockers of acid secretion than H2-inhibitors. Although healing of erosive esophagitis occurs with PPIs, prompt relapse is the rule unless some form of maintenance therapy is employed. If it has been necessary to employ PPIs for relief, then long-term use of PPIs (perhaps at a lower dose) will usually be necessary.
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Figure 7 SZ - Squamous zone BZ - Basal zone Note how the basal zone here is thicker than the basal zone in Figure 2. The dermal pegs reach up towards the lumen. |
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2. Fundoplication
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If esophagitis is a severe problem despite maximal medical measures, some form of surgical treatment should be considered. In the past, most such surgery has been aimed at the reduction of the often coexisting hiatal hernia. A number of ingenious methods of reducing the hernia have been developed, but objective evaluation of patients after such surgery often shows persistence of reflux. The procedure of fundoplication (Nissen operation) involves moving the lower esophageal sphincter into the abdominal cavity. The fundus of the stomach is wrapped around the esophagus, thus creating a valve. Studies of such patients have shown that postoperative reflux is uncommon. The operation can now be performed laparoscopically with less surgical morbidity than in the past.
If the squamous epithelial disease has progressed to stricture formation, luminal diameter can be increased by careful endoscopic dilation, using dilators traveling over a guiding wire. Careful dilation followed by PPI therapy can often restore good function to an esophagus whose lumen has been compromised by stricture. In extremely complicated and severe cases of stricture formation, total esophageal resection and interposition of a segment of small or large bowel can be considered. This is a formidable procedure but is sometimes the only recourse. |
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3. Esophageal Cancer
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The therapy of carcinomatous lesions of the esophagus has been fairly disappointing. Lesions are usually not discovered until local or distal metastases have made the possibility of cure unlikely. The problem is more that of palliation than cure; lesions in the lower one- third of the esophagus are usually amenable to surgical resection. The remaining esophagus is joined to the stomach which is brought up partially into the chest. Radiation can be used to shrink lesions of the middle and upper third of the esophagus where surgery presents more difficult technical problems. Long-term survival is rare after surgery or irradiation, although preoperative irradiation or chemotherapy may increase the survival rate. Palliation of an inoperable cancer may be achieved by endoscopic dilation and insertion of a stent to keep the lumen open.
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4. Neuromuscular Disorders
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| Treatment of neuromuscular diseases of the esophagus is efficacious in achalasia but disappointing in most other neuromuscular disorders. The ideal therapeutic goal in achalasia is to disrupt the function of the lower esophageal segment only partially so that food may enter the stomach more easily without concomitantly causing severe reflux of gastric contents into the esophagus. In over half of such patients, this can be done effectively by balloon dilatation of the lower esophageal segment, performed endoscopically. In the rest of the patients, results are less satisfactory and some require surgical incision of the muscle fibers of the lower esophageal segment (Heller operation). This offers good relief of dysphagia and food retention, but usually produces some degree of reflux and heartburn. Fortunately the latter is rarely a significant problem to the patient. There is no effective therapy for other neuromuscular dysfunction at the present time. | ||
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Next Section (H): Dysphagia Algorithm » |
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