1. Esophageal Disorders Flashcards
Anatomic relationships of the esophagus
The cervical esophaguspasses through thethoracic inlet (formed by T1, the first ribs, and the costal cartilage between the first ribs and the manubrium of the sternum) to become the thoracic esophagus
The thoracic esophagussits posterior to the trachea and anterior to the vertebral column. It passes to the right of the thoracic aorta and thoracic duct before deviating to the left, passing through theesophageal hiatus at the level of T10, and sitting anterior to the aorta
Gross anatomy of the esophagus
Epiglottis - seals larynx to prevent aspiration of bolus
Upper Esophageal Sphincter - ring of skeletal muscle that regulates food entry from pharynx into esophagus and prevents bolus reflux
Lower Esophageal Sphincter - ring of smooth muscle that regulates food entry from esophagus into stomach and prevents acid reflux
Gastroesophageal Junction - point where distal esophagus joins the cardia of the stomach
Microscopic anatomy of the esophagus
(From inside the esophagus –> out)
1. MUCOSA
- Stratified Squamous Epithelium
- Lamina Propria - connective tissue containing lymph nodules
- Muscularis Mucosae - smooth muscle responsible for folds in wall
2. SUBMUCOSA
- Submucosal Glands - secretes bicarbonate to alkalinize esophageal contents
- Blood Vessels
- Submucosal Nerve Plexus - provides autonomic nerve supply to the muscularis mucosae
3. MUSCULARIS
- Inner Circular Layer of smooth muscle
- Myenteric Nerve Plexus - controls GI tract motility
- Outer Longitudinal Layer of smooth muscle
4. ADVENTITIA - connective tissue
Function of the esophagus
Propulsion of food from the pharynx to the stomach via peristalsis
Mechanics required for food to enter the stomach
For food to enter the stomach, it must to overcome intrathoracic and intraabdominal pressures in equilibrium with each other
Normal intrathoracic pressure is - 5 mm Hg
Normal intraabdominal pressure is + 5 mm Hg
The lower esophageal sphincter exerts pressure of 25 mm Hg to move food into stomach
Factors that contribute to reflux
Factors that decrease lower esophageal sphincter pressure
- Medications that cause LES smooth muscle relaxation (CCB, progesterone, beta agonists)
- Expiration - diaphragmatic relaxation decreases LES pressure
Factors that increase intraabdominal pressure
- Pregnancy
- Obesity
BARIUM SWALLLOW:
Procedure
Indications
Advantages
PROCEDURE:
Patient swallows barium tablets or liquid gastrografin which are followed with fluroscopy:
- Upper GI Series (UGI) - evaluates esophagus, stomach, duodenum
- Upper GI Series with Small Bowel Follow Through - evaluates esophagus, stomach, duodenum, jejunum, and ileum
- Modified Swallow - is conducted by speech pathology and evaluates pharynx/upper esophagus. Important if concerned for aspiration pneumonia
INDICATIONS:
First choice if suspecting:
- Motility Disorder
- Mechanical Obstruction
- GERD
UGI + SBFT is the test of choice for Crohn’s Disease
Modified Swallow is done on patients at risk for Aspiration Pneumonia
ADVANTAGES:
Noninvasive, good screening test
ESOPHAGOGASTRODUODENOSCOPY (EGD) aka UPPER ENDOSCOPY:
Indications
Advantages
INDICATIONS:
- Best to visually identify anatomy
- Best when tissue is needed for diagnosis
- Perform an endoscopic ultrasound if you suspect cancer or a mass
ADVANTAGES:
- Dilate strictures
- Treat bleeding
- Place stents
MANOMETRY:
Procedure
Indications
Advantages
PROCEDURE:
When you “give the man” local anesthetic, place a catheter intranasally, and measure pressures at various points.
INDICATIONS:
- Look at how well sphincter squeezes and relaxes
- Do this before any surgery on the esophagus
ADVANTAGES:
- No sedation
- 20-30 minute test
IMPEDANCE and pH MONITORING:
Procedure
Indications
PROCEDURE:
- NG catheter test detects changes in resistance to electrical current across electrodes.
- pH electrode can detect pH of reflux and the frequency and duration of each episode.
INDICATIONS:
Most sensitive test to detect presence of acid in GERD (take patients off PPIs for 5 days)
GASTROESOPHAGEAL REFLUX DISEASE (GERD):
Definition
Epidemiology
Risk Factors
DEFINITION:
Gastric juice refluxes into the esophagus and oropharynx causing symptoms, tissue injury, or both
EPIDEMIOLOGY:
15 million people have heartburn daily
GERD is the #1 non-cardiac cause of chest pain
RISK FACTORS:
FACTORS THAT DECREASE LES PRESSURE BY RELAXING SMOOTH MUSCLE
- Smoking / Alcohol
- Medications (Beta Agonists, CCB, Progesterone)
- Foods (Caffeine, High Fat, Peppermint)
- Pregnancy
INCREASED INTRAABDOMINAL PRESSURE
- Hiatal Hernia
- Obesity
- Pregnancy
GERD:
Etiology
Clinical Presentation
Physical Exam Findings
ETIOLOGY:
- Dysfunctional LES (due to risk factors)
- Transient LES relaxation
Other components:
- Caustic gastric juice (acid, pepsin, bile, pancreatic enzymes)
- Sufficient duration of contact
- Possible immune reaction can cause mucosal changes
- Atypia of pain receptors in the esophagus plays a role in Reflux Hypersensitivity and Functional Heartburn
CLINICAL PRESENTATION:
TYPICAL:
- Heartburn
- Chest pain
ATYPICAL:
- Asthma/Aspiration
- Chronic Cough
- Chronic Throat Clearing
- Dysphonia
- Dysphagia
- Dental Disease
- Sleep Disturbances / Daytime Somnolence
PHYSICAL EXAM:
Generally normal, but may see:
- Overweight / obese / gravid abdomen
- Mild pain with deep palpation of epigastric area
GERD:
Spectrum
Physiologic –> Symptomatic –> Erosive Esophagitis –> Complicated Esophagitis
- Ulceration
- Hemorrhage
- Stricture
- Barrett’s Adenocarcinoma
GERD:
Initial Diagnostics
Indications for Further Diagnostic Testing
Further Diagnostic Tests
INITIAL DIAGNOSTICS:
Diagnosis is based on symptoms and complete response to medications
INDICATIONS FOR FURTHER DIAGNOSTIC TESTING:
- Concerning symptoms: Atypical Symptoms, Advanced Age, Weight Loss, GI Bleed, Anemia
- Proton Pump Inhibitor Failure
- Surgical Planning
FURTHER DIAGNOSTIC TESTS:
Endoscopy - used first if patient has persistent symptoms or complications of GERD
Manometry - used if endoscopy is normal
24 hour ambulatory pH monitoring - gold standard for persistent symptoms
GERD:
Lifestyle Modifications
- Quit smoking, alcohol, meds and foods that relax the LES sphincter
- Weight loss for overweight patients
- Elevate head of bed
- Avoid bedtime snacks
- Avoid recumbency after meals
GERD:
Medical Management
Medical Management for Refractory Symptoms
MEDICAL MANAGEMENT:
Antacids - neutralize acid
- Occasional / Rescue Use
H2-Receptor Blockers (Ranitidine (ZANTAC), Famotidine (PEPCID) - heal GERD symptoms and signs in 50-65% of patients in a few weeks
- First line for Mild/Intermittent GERD
Proton Pump Inhibitors (Omeprazole (PRILOSEC), Lansoprazole (PREVACID), Pantoprazole (PROTONIX), Esomeprazole (NEXIUM) - irreversibly bind to H/K ATPase in parietal cells to block acid production. Effective in 80% of patients
- Mainstay of GERD therapy
- Don’t take perpetually as there’s a risk of mortality
- Interacts with Protease Inhibitors and Plavix
- Adverse Events
- Hypochlorhydria
- Bacterial overgrowth –> gastritis, increased risk for gastric cancer
- Decreased B12 absorption
- Hypergastrinemia can cause rebound hyperacidity
- Hypochlorhydria
- Monitor Magnesium
MEDICAL MANAGEMENT FOR REFRACTORY SYMPTOMS:
- Alginates - buffer acid
- Bile Acid Sequestrants (Sulcrafate and Cholestyramine)
- Baclofen - antispasmodic
- Metoproclomide (REGLAN) - promotility agent
- SSRIs, SNRIs, Trazadone, TCAs - reflux hypersensitivity and heartburn
- Gum - salivation buffers acid and improves motility
GERD:
Candidates for Surgery
Surgical Management
CANDIDATES FOR SURGERY:
- Typical symptoms and failed medical therapy
- Severe esophagitis on upper endoscopy
- Strictures
- Barrett’s epithelium without dysplasia or carcinoma
SURGICAL MANAGEMENT:
- Nissen Fundoplication
- LINX - magnets used to close LES immediately after swallowing
- Stretta - radiofrequency applied to tighten LES
GERD:
Complications
- Ulceration
- Hemorrhage
- Stricture
- Barrett’s Adenocarcinoma
HIATAL HERNIA:
Definition
Types
Clinical Presentation
Management
DEFINITION:
Stomach herniates into chest at the hiatus
TYPES:
Sliding - GEJ moves above the diaphragm
Para-esophageal - GEJ at/below diaphragm, fundus above diaphragm
CLINICAL PRESENTATION:
TYPICAL GERD SYMPTOMS
- Heartburn
- Chest Pain
ATYPICAL
- Chest Pain
- Dyspnea
MANAGEMENT:
- Same as GERD
- Nissen Fundoplication
ESOPHAGEAL STRICTURE:
Etiology
Clinical Presentation
Management
ETIOLOGY:
- GERD
- Trauma
- Malignancy
- Radiation
CLINICAL PRESENTATION:
- +/- history of GERD
- Dysphagia
- +/- Weight Loss
MANAGEMENT:
- Dilatation with Biopsy
If symptoms persist, consider steroid injections or stenting
- Chronic PPI use if GERD related
- Treat malignancy
BARRETT’S ESOPHAGUS:
Epidemiology
Pathophysiology
Clinical Presentation
Diagnosis
Management
EPIDEMIOLOGY:
- M:F ~2:1
- 1-2% of those undergoing routine EGD
- 10% if erosive esophagitis present
- 30% if strictures present
- Familial clusters present
PATHOPHYSIOLOGY:
- Reflux injures squamous epithelium
- Squamous replaced by columnar epithelium during healing as its more protective against gastric acid
CLINICAL PRESENTATION:
- Can’t differentiate from GERD by symptoms
DIAGNOSIS:
- Usually an incidental finding on EGD
- If (+), confirm by a 2nd pathologist
- No dysplasia - repeat 3-5 years
- Low-grade dysplasia - repeat 6-12 months, treatment an option
- High-grade dysplasia - treat or repeat in 3 months
MANAGEMENT:
- PPIs recommended if patient has esophagitis
- Anti-reflux Surgery (regression possible and may not prevent cancer)
- Endoscopic (RFA, PDA) vs Esophagectomy for high grade disease (regression possible and may obscure new metaplasia)
BARRETT’S ESOPHAGUS:
Indications for Screening
ALL societies recommend against screening in general GERD population
CANDIDATES FOR SCREENING:
- White
- Male
- Age 50+
- Elevated BMI
- Chronic GERD
- Hiatal Hernia
ESOPHAGEAL ADENOCARCINOMA:
Definition
Etiology
Clinical Presentation
Diagnostic Evaluation / Staging
Management
Prognosis
DEFINITION:
Cancer at the GEJ
ETIOLOGY:
Related to Chronic GERD and Barrett’s esophagus
CLINICAL PRESENTATION:
- Dysphagia (Eating Less, Taking Smaller Bites)
- Weight Loss
DIAGNOSIS:
- Barium Swallow
- Endoscopy
- Biopsy
- Esophageal Ultrasound
- CT Chest/Abdomen/Pelvis
- PET - tumor activity, mets
MANAGEMENT:
SYMPTOM CONTROL:
- Esophageal dilatation and stenting for dysphagia
- Jejunal/Gastrostomy tube for nutrition
CURATIVE:
- Endoscopic surgery for superficial cancer
- Esophagectomy +/ chemo & radiation (5-FU, Cisplatin, Epirubicin are common 1st line regimen)
PALLATIVE:
- Surgery
- Brachytherapy
- RT
PROGNOSIS:
- Localized (Stage I and some Stage II): 43% have a 5 year survival if treated
- Metastatic (Stage IV) - SC nodes, lungs, liver, peritoneum, bones: 5% have a 5 year survival rate
ESOPHAGEAL SQUAMOUS CELL CARCINOMA:
Definition
Etiology
Clinical Presentation
Diagnostic Evaluation / Staging
Management
Prognosis
DEFINITION:
Esophageal cancer that occurs higher in the esophagus than adenocarcinoma
ETIOLOGY:
- Smoking, Opiate Smoking
- Alcohol
- Nitrites, Lye, Hot Tea
- Dietary Deficiency
CLINICAL PRESENTATION:
- Dysphagia (Eating Less, Taking Smaller Bites)
- Weight Loss
- Dysphonia
DIAGNOSIS:
- Barium Swallow
- Endoscopy
- Biopsy
- Esophageal Ultrasound
- CT Chest/Abdomen/Pelvis
- PET - tumor activity, mets
MANAGEMENT:
SYMPTOM CONTROL:
- Esophageal dilatation and stenting for dysphagia
- Jejunal/Gastrostomy tube for nutrition
CURATIVE:
- Endoscopic surgery for superficial cancer
- Esophagectomy +/ chemo & radiation (5-FU, Cisplatin, Epirubicin are common 1st line regimen)
PALLATIVE:
- Surgery
- Brachytherapy
- RT
PROGNOSIS:
- Localized (Stage I and some Stage II): 43% have a 5 year survival if treated
- Metastatic (Stage IV) - SC nodes, lungs, liver, peritoneum, bones: 5% have a 5 year survival rate
Motility Disorders and their Common Clinical Presentation
MOTILITY DISORDERS:
- Achalasia
- Diffuse Esophageal Spasm
- Scleroderma
COMMON CLINICAL PRESENTATION:
- Dysphagia to both solids and liquids
ACHALASIA:
Etiology
Pathophysiology
Clinical Presentation
Diagnostic Evaluation
Management
ETIOLOGY:
PRIMARY - idiopathic
SECONDARY -
- Gastric cancer
- Chagas Disease
- Viral Infections
- Neurodegenerative Disorder
PATHOPHYSIOLOGY:
- Lack of intramural neurons
- Lack of normal peristalsis
- Failure of LES relax (opposite of GERD)
CLINICAL PRESENTATION:
- Modest Weight Loss early on
- Chest Pain (globus sensation)
- Dysphagia to both solids and liquids that is aggravated by hurried eating and is better with valsalva
DIAGNOSTIC EVALUATION:
- Bird’s Beak esophagus found on Barium Swallow
- LES or GEJ closed on EGD
MANAGEMENT:
Think: BEC MEN
- Balloon Dilatation
- Endoscopic Botox
- CCB
- Myotomy +/- Fundoplication
- Esophagectomy (severe cases)
- Nitroglycerin sublingual
DIFFUSE ESOPHAGEAL SPASM:
Etiology
Pathophysiology
Clinical Presentation
Management
Natural Progression
ETIOLOGY:
Patchy neural degeneration
PATHOPHYSIOLOGY:
Loss of inhibitory neurons leads to non-peristaltic contractions
CLINICAL PRESENTATION:
- Dysphagia to both solids and liquids
- +/- Chest Pain (mimicking an MI)
MANAGEMENT:
- CCB
- Nitrates
NATURAL PROGRESSION:
Achalasia
- *SCLERODERMA:**
- *Pathophysiology**
Clinical Presentation
Diagnostic Evaluation
Management
PATHOPHYSIOLOGY:
Atrophy and fibrosis of esophageal wall
CLINICAL PRESENTATION:
- Dysphagia to both solids and liquids
- GERD-type symptoms
DIAGNOSTIC EVALUATION:
Stove-pipe Esophagus on Barium Swallow
MANAGEMENT:
- Soft foods
- Aggressive GERD therapy
Types of Inflammatory Esophagitis
TYPES OF INFLAMMATORY ESOPHAGITIS:
- Pill-Induced
- Radiation
- Infectious
- Corrosive
- Eosinophilic
PILL-INDUCED ESOPHAGITIS:
Etiology
Management
ETIOLOGY:
- Bisphosphonates (Boniva)
- Antibiotics
- NSAIDs
MANAGEMENT:
- Take pills upright
- Drink lots of water
RADIATION-INDUCED ESOPHAGITIS:
Management
MANAGEMENT:
- Stop radiation
- Viscous Lidocaine
- Indomethacin
- Dilatation +/- Feeding Tube
INFECTIOUS ESOPHAGITIS:
Etiology
Clinical Presentation
Diagnostic Evaluation
Management
ETIOLOGY in immunocompromised:
- Most Common: Candida, CMV, HSV
- Other Viruses: HIV, HPV, EBV
- Fungi: Histo, Blasto, Mucor
- Parasites: Crypto, PCP
- Bacterial esophagitis is rare, but TB and MAC possible
CLINICAL PRESENTATION:
- Acute onset
- Odynophagia
- Dysphagia
- Chest Pain
- Systemic Symptoms
DIAGNOSTIC EVALUATION:
- Barium Swallow
- EGD with Biopsy
MANAGEMENT:
- Antimicrobial Therapy
- +/- Steroids
- Hydration
CORROSIVE ESOPHAGITIS:
Pathophysiology
Management
PATHOPHYSIOLOGY:
- Heals by scarring (stricture)
MANAGEMENT:
- Dilatations
- Possible Esophagectomy
EOSINOPHILIC ESOPHAGITIS:
Etiology
Clinical Presentation
Diagnostic Evaluation
Management
ETIOLOGY:
- Environmental or Food Allergies
- Asthma/Atopy
CLINICAL PRESENTATION:
- Caucasian, male kids/teenagers
- GERD symptoms
- Dysphagia
DIAGNOSTIC EVALUATION:
Biopsy shows >15 eosinophils/high power field
MANAGEMENT:
- PPIs
- Steroids
- Dietary Elimination
