02-13 Esophageal Physiology, Motility Disorders & GERD Flashcards
define dysphagia
difficulty swallowing
define: odynophagia
pain w/ swallowing
define globus
A sensation of fullness in the upper throat; typically improves with swallowing
define pyrosis
heartburn
define water brash
spontaneous salivation from reflux
define rumination
“chewing one’s cud”
dysphagia aortica
“mechanical dysphagia caused by compression of the esophagus by the dilated aorta, and it occurs mainly in elderly women with short stature, hypertension and kyphosis”
From: Song, Sang-Wook, Ju-hye Chung, and Se-Hong Kim. “A Case of Dysphagia Aortica in an Elderly Patient.” International Journal of Gerontology 6.1 (2012): 46-48.
dysphagia lusoria
“difficulty in swallowing caused by aberrant right subclavian artery” [Wiki]
types of muscle in the esophagus
- upper 5%, circular (striated) muscle only
- middle 1/3 is both
- lower 1/2, longitudinal (smooth) muscle only
REVIEW: which structures pass through the aorta at which thoracic level (mnemonic = ?)
I 8 - IVC
10 Eggs - Esophagus
At 12 - aorta & azygous
Forces that contribute to normal resting LES pressure
- intrinsic pressure of the LES
- pressure from diaphragm
- pressure from phrenoesophageal ligament
UES is made up of?
cricopharyngeal muscle
REVIEW: 4 histo layers of esophagus
- mucosa (strat squam epithel)
- submucosa
- muscularis propria (inner = circular; outer = longitudinal)
- outermost adventitia
**no outer serosal lining (unlike rest of GIT)
Blood supply to esophagus
- Upper: inf. thyroid a.
- Middle: L & R bronchial aa.
- Lower: small brs. of aorta + esophageal br. of L gastric a.
R.O.S. questions for dysphagia
- How long have symptoms been present?
- Are the symptoms intermittent, constant, progressive?
Is it difficult to move the food from the back of the throat or through the chest?
- Nasal regurg or cough?
- What kind of food elicits symptoms?
- If both liquids and solids, was it solids first and then liquids?
- Heartburn present or past?
- “Red flag” symptoms? (weight loss, anemia, melena, hematemesis)
Where do Zenker’s diverticula occur?
inf to inf. constrictors
sup to cricopharyngeal
S/Sx + DDx of Oro-pharyngeal dysphagia
Oro-Pharyngeal (Transfer) Dysphagia
S/Sx
- Difficulty initiating a swallow
- “sticks in throat”, nasal regurg, cough during swallowing
DDx
- Neuro
- Stroke/TIA, CN palsy
- ALS, MS, PD, HD
- Wilson’s
- neurosyph (tabes dorsalis)
- polio
- botulism, tetanus, diptheria
- Muscular
- PM/DM, metab myopath
- MG
- myotonic dystrophy
- oculopharyngeal dystrophy
- amyloidosis
- Structural
- tumor
- Zencker’s
- inflammation
- post surg/rad
- compression from other structure
Esophageal Dysphagia
- S/Sx
- DDx
Esophageal Dysphagia
S/Sx:
- Food “sticks in chest”
- not necess. where patient thinks b(/c innerv not specific)
- R/O red flags: wt loss, anemia, melena, hematemesis
DDx
- intra-luminal obstruction
- structural
- ring
- stricture
- extrinsic compression at one of 4 places:
- pharynx
- aortic arch
- L main bronchus
- diaphragm
- functional
- spasm
- motor failure (e.g. achalasia)
Steps in swallowing
- bolus pushed back as tongue thrusts up + back
- soft palate elevates closes nasopharynx
- larynx elevates, vocal cords close, epiglottis tips up
- UES opens, LES opens
- pharynx contracts
- peristalsis is initiated.
^Takes approximately 1s, although actual passage of food to stomach may take 3-8s.
- Once started, peristalsis is auto, governed by SMM muscle of esophagus.
3 types peristalsis
- Primary peristalsis of the esophagus is initiated by a swallow
- secondary peristalsis can be initiated anywhere in the esophagus by luminal distention
- Tertiary contractions may be seen in some people – these are ineffective, non-peristaltic contractions.
Tests for motility include EGD, barium swallow and manometry. Classify manometry findings in dysphagia
Hypercontractile
- Achalasia (at LES)
- Diffuse Esophageal Spasm
- Nutcracker esophagus
Hypocontractile
- scleroderma/CREST
- achalais (in upper section)
- Hypotensive LES, Transient LES Relaxations (TLESrs)
27 yo medical student presents with 9 months of progressive dysphagia to solids and liquids. Has lost 14 pounds due to decreased po intake. Has nocturnal cough in recumbency, and some post-prandial chest fullness and pressure. No pyrosis or odynophagia.
- Diagnosis?
- Pathophysiology
- Testing?
- Treatment?
Dx → Achalasia
Pathophys
- Cause unknown: ?genetic, ?inflamm of myent. plex, ?s/sp infx, ?auto-imm, ?degen
- Best evidence so far: Injured ganglion cells in myent. plexus → loss of NO-producing neurons → LES can’t relax + no peristalsis
- Messes up the ACh/NO balance controlling contractility
Testing
- CXR → air fluid level, no gastric bubble
- barium → dilated eso., aperistalsis, bird beak [pic here], no gastric bubble
- occurs slower than tumor which would happen too fast for bird beak to develop
- Manometry = gold std
- aperistalsis
- LES hypertense
- Endoscopy
- use to exclude pseudo-achalasia (tumor at GE jct)
- would see: bunch of food, pinhole LES that’s hard to push thru
Tx
- pneumatic dilation
- myotomy
- POEM = PerOral Endoscopic Myotomy
- drugs: BoTox, CCBs, nitrates
A 72 y/o man presents w/ intractable chest pain accompianed by reflux. Cardiac work-up is benign. [Barium image below]
- Dx?
- Pathophys?
- Work-Up
- Tx options?
Diffuse Esophageal Spasm
- neuromuscular d/o
Work-Up
- barium swallow → corkscrew
- manometry → crazed variety but key finding is “excess numbers of simultaneous contractions in the distal esophagus” (UpToDate)
Tx (per UptoDate)
- Supported by clinical trials
- CCB (eg, diltiazem)
- Antidepr (eg, trazodone, imipramine)
- Positive anecdotal results
- Nitrates (eg, nitro, isosorbide)
- Anticholinergics (eg, dicyclomine)
- dilatation
- BoTox
- PDE inhibs (eg, sildenafil)
Nutcracker Esophagus, briefly
“high amplitude peristaltic contractions in the distal 10 cm of the esophagus, with average distal esophageal peristaltic pressures > 220 mmHg” (UptoDate)
esophageal webs and rings, briefly
Web - Mucosa & Submucosa only
- (E.g. Plummer-Vincent = Fe++ def w/ muc ring)
- “B” or “Schatzki’s” ring = mucosal web above hiatal hernia
- Technically a web! [eMedcine]
Ring - all 3 esophag. layers (incl muscle)
- “A” ring = muscular ring
Name this finding.
- Dx?
- A.K.A.?
- Endoscopy would show?
- Biopsy shows?
Eosinophilic esophagitis (a.k.a. feline esophagitis)
- Endoscopy shows these rings (image here, looks like cat’s esophagus)
- Biopsy shows > 15 eos/hpf
35 y/o HIV+ pt. complains of odynophagia and presents w/ this barium finding.
- What’s your ddx?
- If dx were most common cause, what would endoscopy show?
*
Infectious esophagitis in HIV
- Candidiasis (50%) endoscopy attached here
- HSV (~12%)
- CMV (~12%)
Dysphagia flow chart
GERD Spectrum
- Typical
- ENRD - Erosion-Negative Reflux Disease
- Erosive RD
- Atypical RD
- asthma
- cough
- laryngitis
- c.p.
- globus
- dental erosions
- Complicated RD
- Stricture
- Ulcer
- Barrett’s (Metaplasia)
- Cancer (adeno-ca)
Pathophy of GERD
Multiple Causes, from top down:
- ↓ HCO3-/saliva production
- mucosal problem
- hiatal hernia
- TLESRs/↓ LES basal tone
- excess H+ prod
- delayed gastric emptying
Aggrevated by:
- preg/posture/obesity
- smoking/EtOH
- caffeine/chocolate/juices
- drugs that open LES (theophyllin, diazepam)
Dx possibilties for GERD
- Barium swallow/UGI
- Upper endoscopy
- Esophageal Manometry
- Bravo pH capsule
- test of choice to answer “Is there reflux?”
- done OFF meds
- Impedance catheter
- test of choice “why meds not working?”
- done ON meds
- Bilitec probe
- uses bilirubin as a marker for the detection of duodeno-oesophageal reflux
What is this? Expected histo findings?
Barrett’s metaplasia
Stratified squamous → simple columnar w/ goblet cells
