Dr Vikas Singla, Director & Head, Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi
Patients' preference for lack of scars, and the lesser complications, has moved the treatment of various diseases towards lesser invasive approaches. Open surgery has given way to the laparoscopic technique for various disorders such as gall bladder stones, obesity and appendicitis. Recent advances in the endoscopy, has opened the doors for the total endoscopic treatment by the natural orifices such as mouth and anus for various disorders. The key benefits are total absence of scar and possibly early recovery.
Treatment of esophageal or food pipe disorders has seen paradigm shift and is continuously evolving towards the least invasive manners. Esophagus is an organ which transfers the food from mouth to the stomach. Various disorders of the esophagus can now be cured with the endoscopy.
Achalasia Cardia
A ring of muscle called the lower esophageal sphincter(LES) encircles the lower oesophagus just above the stomach. This sphincter muscle when contracts, closes the oesophagus. When the sphincter is closed, the contents of the stomach cannot flow back into the oesophagus. After swallowing or drinking, LES opens up, allowing passage of food or liquids in the stomach. In patients with achalasia cardia, this valve fails to open, causing difficulty in swallowing food. Individuals with achalasia cardia feel that food has stuck in the central part of chest and does not travel down. Food may collect in food pipe during the day time and may enter the nose in the night. Patient may also have pain in central part of chest and rapid weight loss due to reduced food intake.
While advanced techniques are available to prompt diagnosis of the condition, endoscopy is essential to rule out malignancy and peptic strictures. Achalasia cardia can be diagnosed by high resolution esophageal manometry in which a probe having multiple pressure sensors to measure the pressure of esophagus and the LES, is passed down the throat in the esophagus. During the test, patients are advised to swallow small amount of water. In patients with achalasia cardia, LESpressures are high and are not reduced after the swallows. Another test known as barium swallow can also help in diagnosis of achalasia cardia.
Treatment of achalasia cardia, is careful cutting of muscle of the tight valve. Thanks to the new technique of Per Oral Endoscopic Myotomy (POEM) the whole procedure of the cutting of tight valve can be performed endoscopically without any incision or scar on the skin. If performed by expert hands, the POEM procedure is highly safe and totally painless as it is performed under the general anesthesia. In addition to treating achalasia cardia, similar techniques are very effective for the treatment of esophageal tumor, known as leiomyoma.
Gastroesophageal reflux disease (GERD)
In contrast to achalasia cardia, patients with GERD have loose esophageal valves that lead to reflux of gastric acid into the esophagus. Usual complains include of burning sensation in the chest, return of acid in the mouth on benign forward or during rest, and chest pain, chronic cough, sticky sensation in the throat and dental caries. GERD can be diagnosed clinically with a good history taking and tests such as endoscopy and 24-hour pH study are performed to diagnose the condition. During the endoscopy, there may be ulceration in lower esophagus suggesting the diagnosis of GERD.
24-hour pH study – A new test known as 24-hour pH study has emerged as the best test for the diagnosis of GERD. During the test, a small wire like catheter is passed down the throat into the esophagus, and is kept for 24 hours. Catheter has the sensors for the pH which measures the number and time duration of acid reflux episodes, and helps in diagnosis of GERD. Most of the patients can be treated with the life style modification such as weight loss and dietary restrictions, medicines to reduce the acid formation are also advised in the patients with GERD. In few patients who has persistent symptoms or required medicines for long duration, tightening of loose valve between food pipe and stomach is advisable.
Earlier surgery was the only option to tighten the valve but with recent advancements, endoscopic methods can be used to tighten the loose area. Endoscopy methods are safe and efficacious. Recent studies have shown that, more than 70% of patient can be benefited with such procedures. The whole procedure can usually be performed in less than one hour, and patients are discharged with in 48 hours.
Oesophageal Cancer
As most of the esophageal cancers are diagnosed in the late stage, treatment and cure becomes difficulty The most common risk factors for esophageal cancer are smoking, alcohol, obesity and GERD. GERD can lead to change in inner lining of esophagus, known as Barrett's esophagus, which predispose to cancer. Most common symptoms are difficulty in swallowing food and liquids. Weight loss is abrupt in these patients because of poor oral intake. Two innovations are likely to change the management of esophageal cancer.
Image enhanced endoscopy, which is very helpful in early diagnosis of esophageal cancer. During this endoscopic procedure, early stage cancers, which could have been missed with the conventional endoscopes, can be diagnosed accurately. Areas with Barrett esophagus are scanned very carefully, as they may have hidden areas for the cancer.
If the cancer is diagnosed in early stage, this may be treated with novel endoscopic technique known as endoscopic submucosal dissection. During ESD, layer of esophagus containing the cancer is very carefully removed with the help of endoscopy, and esophageal cancer can be cured without the need of surgery or chemotherapy.
Advances in medical sciences aim to cure the various disorders, evolution of endoscopic procedure has added that dimension in treatment of various food pipe disorders.
