Management of Oesophageal Diseases

Oesophageal diseases encompass a wide spectrum of conditions, ranging from functional disorders (like motility problems) to structural issues (like hernias and diverticula), as well as inflammatory, infectious, and malignant conditions.

1. Classification of Oesophageal Diseases

2. General Management Principles

Initial Evaluation

• Detailed history: Dysphagia, odynophagia (painful swallowing), reflux, weight loss, chest pain.

• Physical examination

• Diagnostic tests:

  • Upper GI endoscopy (EGD)

  • Barium swallow

  • Esophageal manometry

  • 24-hour pH monitoring

  • CT/MRI or PET scans (for suspected malignancy)

3. Medical (Non-Surgical) Management

Gastroesophageal Reflux Disease (GERD)

• Lifestyle Modifications:

  • Weight loss

  • Elevate head of bed

  • Avoid late-night meals

  • Limit fatty/spicy foods, caffeine, alcohol

• Medications:

  • Antacids – short-term symptom relief

  • H2 blockers – e.g., famotidine

  • Proton Pump Inhibitors (PPIs) – omeprazole, pantoprazole (first-line therapy)

  • Prokinetics – e.g., metoclopramide (less common, used for gastroparesis)

Eosinophilic Esophagitis

• Elimination diets (e.g., 6-food elimination diet)

• Swallowed topical corticosteroids (e.g., fluticasone or budesonide)

• PPIs

• Endoscopic dilation if strictures develop

Infectious Esophagitis

• Candida: Oral or IV antifungals (fluconazole)

• Herpes simplex virus (HSV): Acyclovir

• Cytomegalovirus (CMV): Ganciclovir or valganciclovir

4. Endoscopic Management

Diagnostic & Therapeutic Uses of Endoscopy:

• Biopsies for diagnosis

• Dilating strictures or rings

• Treating bleeding lesions

• Managing Barrett’s Esophagus or early cancer

Specific Endoscopic Treatments:

Barrett’s Esophagus

• Surveillance endoscopy (for non-dysplastic cases)

• Radiofrequency ablation (RFA) – for dysplasia

• Endoscopic mucosal resection (EMR) – for localized lesions

Achalasia

• POEM (Peroral Endoscopic Myotomy) – minimally invasive endoscopic treatment for achalasia

Esophageal Varices (in liver disease)

• Endoscopic band ligation

• Sclerotherapy

• Beta-blockers (non-endoscopic)

5. Surgical Management

Surgery is indicated when:

• Medical/endoscopic treatment fails

• Severe anatomical abnormalities

• Cancer is present

• Complications like perforation, severe bleeding, or obstruction

Common Surgical Procedures:

6. Management of Esophageal Cancer

Treatment is typically multimodal and depends on the stage:

Early Stage (T1–T2):

• Endoscopic resection (EMR or ESD)

• Surgical resection (Esophagectomy)

Locally Advanced (T3–T4 or N+):

• Neoadjuvant chemoradiotherapy followed by surgery

• Definitive chemoradiation (if surgery not possible)

Metastatic:

• Palliative chemotherapy

• Immunotherapy (e.g., PD-1 inhibitors)

• Palliative stenting (for obstruction)