Esophageal cancer

Barrett esophagus is metaplasia of the distal esophageal squamous lining into intestinal columnar epithelium driven by chronic GERD, and it is the established precursor of esophageal adenocarcinoma. Diagnosis requires endoscopy showing salmon-colored mucosa above the gastroesophageal junction confirmed by biopsy showing intestinal metaplasia with goblet cells, and management, from surveillance interval to endoscopic ablation, is dictated entirely by the graded dysplasia.

GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.

Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.

Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.

Esophageal rupture is a full-thickness tear of the esophageal wall, most often iatrogenic after endoscopy or spontaneous (Boerhaave syndrome) from forceful vomiting, that spills contaminated contents into the mediastinum and causes rapidly fatal mediastinitis and sepsis without emergent source control. CT with oral water-soluble contrast or a contrast esophagram confirms the leak, and treatment combines resuscitation, broad-spectrum antimicrobial therapy, and either emergent surgical repair or endoscopic stenting depending on the size, location, and time since perforation.

Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.