1 & 2. Esophageal Physiology & GERD Flashcards
define globus
feeling of fullness in the upper throat; typically improves w swallowing.
pt will report feeling like there is a marble in their throat.
usually caused by anxiety.
pyrosis: definition? what is it usually cuased by?
substernal ascending burn. heartburn
mostly caused by reflux, NOT spasm!
water brash: definition?
spontaneous salivation as a result of reflux.
vagally mediated.
anatomic causes for pyrosis?
enlarged vasculature (aorta, pulminary vasculature)
mediastinal mass
“Red Flag” symptoms associated with dyspagia?
Weight loss, anemia, melena, hematemesis
See these and think more of cancer
Transfer dysphasia: definition?
Due to what?
“High” dysphasia: usually up in the throat.
difficulty initiating a swallow, food sticks in the throat, nasal regurg, coughing during swallowing.
Usually due to NM conditions/stroke.
Transport dysphagia: def?
Due to what?
“low” dysphagia. trouble getting food down the esophagus.
May be due to achalasia (failure to relax the LES), may be anatomic (ring, stricture, extrinsic compression), may be functional (spasm, motor failure)
The steps involved in swallowing?
- A bolus of masticated food is pushed backward
- Soft palate elevates, and nasopharynx closes
- Larynx elevates, vocal cords close, and epiglottis tips forward
- UES opens, the LES opens, and the pharynx contracts
- Peristalsis is then initiated
what is a structural cause of oro-pharyngeal dysphasia that we may see in the elderly?
what causes it?
Zenker’s diverticulum
esop herniates between the inferior constructor and the cricopharyngeus –> blebs out –> diverticula
Studies to assess esophageal function (4)?
- Barium swallow
- Endoscopy
- Manometry
- pH studies (bravo v pill thing)
Esophageal Manometry: define? how does it work?
Tests LES function, evaluates esophageal perostalsis.
Patient drinks water and swallows, we watch the pattern of contraction
Normal pattern is below
notable about this normal manometry study?
- S = initiation of swallow. Pharynx opens and contracts as food passes –> + pressure
- UES opens, (pressure goes down), then closes (pressure goes up)
- UES + LES open at the same time –> both drops to 0 pressure (won’t see the LES relaxation in achalasia; over time lose the esophageal body as well due to motor failure)
- LES opens even before the esophageal body starts doing its contractions. LES stays open until food passes, and then it contracts after the food passes
(Lots of dysphagia = LES failure to open at the right time.)
Manometry findings:
name 2 hypercontractile states?
name 2 hypocontractile states?
Hyper:
Achalasia (LES doesn’t open-> distension, bird-beak)
Diffuse esophageal spasm (corkscrew esop)
Hypo:
Scleroderma/CREST (fibrosis)
Transient LES Relaxations (cause of GERD, valve opens more than needed)
what is a possible pathophys of achalasia (theory)?
possibly degeneration of vagal fibers/loss of NO-containing neurons. therefore no signal to the LES to relax with swallowing.
(relaxation and contraction of the LES reflect a balance between acetylcholine and NO)
food piles up in the esop and causes it to dilate (can dilate to the size of the chest!)
achalasia: what is seen on CXR?
- dilated esophagus
- air fluid levels in the esophagus
- absent gastric air bubble
achalasia: what is seen with barium swallow?
symmetrically tapered distal esophagus, birds beak
also dilated esophagus, can see that it contains food
On manometry, what will be signs that a pt has achalasia?
- incomplete relaxation of the LES
- LES resting pressure will be elevated
- Aperistalsis
- with vigorous achalasia, there may be high amplitude simultaneous contractions, then muscles will have motor failure due to death of ganglion cells. (like burnout)
why would i do an endoscopy on a pt i suspect of having achalasia?
what might I see?
need to r/o pseudo-achalasia (secondary achalasia) or mechanical obstruction.
-this is not used to diagnose achalasia but rather to r/o other things
will see a pinpoint opening of the LES!
Achalasia: treatment? (meds, interventions, surgeries)
Meds: nitrates, Ca channel blockers, botox injection
Interventions: pneumatic dilation to stretch the muscle fibers
Surg: myotomy (open the external muscles to decr pressure); POEM = microinvaseive surgery, diving below the mucosa to cut the circular fibers from inside the esop.
If I see a corkscrew esophagus, what dx should I think?
What study should I do?
What meds are good?
Diffuse Esophageal Spasm
Manometry will show normal peristalsis but also diffuse random muscle spasms
Meds: to relax the esop. Specifics not given.
what patients have some of the worst LES findings (motor failure, acid damage) of any patients?
Scleroderma-CREST patients. due to dysfunction of smooth muscle/fibrosis.
On manometry: LES hypotension.
Esophageal Dysphasia: what are the 3 most common structural causes?
Esophageal Rings (speed bump in esop)
Eosinophilic Eophagitis (allergic rxn)
Tumors
What are the 2 types of Esophageal rings?
A ring: (associated with Plummer-Vinson sx/Idon deficiency anemia). Mucosal webs that stick out.
B ring (Schatzki): usually at site of hiatal hernia
What is Eosinophilic Esophagitis?
Appearance on imaging?
Treatment?
Ridges inside esophagus.
Treatment: get rid of the source of acid
can use topical steroids (can try to use inhaled steroids like an asthma inhaler but have patient swallow them instead of breathing)
If I see a shelf on imaging, what pathology should I think of?
What is the likely cause?
Esophageal adenoma.
Due to Barrett’s Esop
Esophageal cancer: what are the possible primary therapies? what is the general idea of treatment?
Therapy options: surgery, radiation, chemo.
General idea is to prevent this, because the cure rates are low.
Esop cancer: some secondary treatment options?
Dilation
Stenting
Ablation by laser, injection…
Not a cure, but will give pt a few more months to live. Bad prognosis overall.
If I see spiculation on imaging, what diseases should I consider? What patient population is prone to these?
Spiculation on imaging with odynodysphasia –>Candida esophagitis.
Top cause of esophageal disease in HIV patients (also HSV, CMV)
Why does a pt get GERD?
What has gone wrong to allow this?
What kinds of foods will cause opening of the LES?
Everyone gets some reflux: reflux disease occurs when there is more acid contact time than normal (normal is 4-5 min/day).
Cause is not usually due to a weak LES: rather due to transient LES relaxation.
May also be due to delayed stomach emptying, dry mouth (lack of bicarb which normally will neutralize any food bolus that rises into esophagus)
Fatty food will open the LES; spicy food does not. Caffeine has different effects in different people
What are some aggravating factors of GERD?
Pregnancy: due to increased progesterone
Hiatal hernia
EtOH, tobacco
Meds: Ca channel blockers can open the LES, theophylline, valium, diazepam
Foods: Fat, chocolate, acidic juices can also open the LES and contribute to GERD.
Diagnostic testing for GERD?
Barium swallow
Endoscopy
Manometry
pH capsule
Describe the pH capsule system for diagnosing GERD?
Capusule is applied 2’ proximal to LES
Sits in your esophagus for 10 days, then is defecated out. Reads pH every 6 sec and uploads to a BRAVO unit.
can monitor conditions for 40 h
GERD: therapeutic options?
Lifestyle changes
Meds: PPIs, Prokinetics (push things out of the stomach faster), H2RAs
Surgery (Lap Nissen fundoplication)
What are the 2 med options for acid suppression?
H2RAs (histamine 2 receptor antagonists): cimetidine, nizatidine etc
PPIs (proton pump inhibitors): omeprazole
what is the process by which Barrett’s Esop can progress to edophageal adenocarcinoma?
Intestinal metaplasia in the esophagus (squamous -> chronic inflammation)
- > changes in tumor suppressor
- > dysplasia
- > invasive adenocarcinoma
