10/5- Esophageal Diseases Flashcards
How often does a normal adult swallow?
600 times/24 hrs (unconsciously)
What are the two parts of swallowing?
- Voluntary/involuntary?
- Muscles involved
Oropharyngeal
- Voluntary + involuntary
- Striated ??
Esophageal
- Involuntary
- Smooth muscle of the esophagus
Describe the oropharyngeal phase of swallowing
- Initiation of swallow
- Nasopharynx
- Protection of airway
- Clearing
Involves 26 muscles and 5 CN
What is dysphagia?
Sensation of ingested material being hindered in tits normal passage from the mouth to the stomach
Where can problems occur during the oropharyngeal phase of swallowing?
- Difficulty initiating swallowing
- Nasopharyngeal regurgitation
- Pulmonary aspiration
- Residual
What innervates the esophagus?
Medulla
- Nucleus ambiguus (NA) controls skeletal muscle
- Dorsal motor nucleus (DMV) controls the smooth muscle
NTs are: ACh, NO, VP
Dual innervation:
- Vagal pathway: through the nodose ganglia to the nucleus solitarius of the medulla
- Sympathetic
Some pathways may overlap with those of the heart and respiratory system (chest pain may be a symptom of varied esophageal conditions)
Describe the anatomy of the esophagus (the plexi)
Myenteric plexus (Auerbach’s plexus):
- Motor innervation to both layers of the muscular layer
- Secretomotor innervation
- Sensory component
Submucosal plexus (Meissner’s plexus)
- P-sympathetic
- Sensory neurons
What are the 2 broad categories of things causing dysphagia?
- Structural lesions
- Abnormal motility
The patient might not have dyshpagia; they might be describing __?
Globus (problem with the lungs)
What are comorbidities of dysphagia?
- Collagen vascular disease
- Immunosuppression
- h/o trauma, radiation, surgery
What can cause odynophagia?
(Pain on swallowing)
- Pill esophagitis
- Infection (immunosuppressed)
What should you think of if the esophageal dysphagia is solid only and intermittent?
- Esophageal ring
- Eosinophilic esophagitis
What should you think of if the esophageal dysphagia is solid only and progressive?
- Peptic stricture (chronic heartburn)
- Malignancy (pt > 50, weight loss)
What should you think of if the esophageal dysphagia is solid and/or liquid and intermittent?
- Diffuse esophageal spasm (with chest pain)
What should you think of if the esophageal dysphagia is solid and/or liquid and progressive?
- Scleroderma (chronic heartburn)
- Achalasia (regurgitation weight loss)
Pathogenesis of esophageal pain (stimuli/pathway)?
- Acid hyperosmolarity -> chemoreceps
- Distention/contraction -> mechanoreceps
- ?
What are the diagnostic modalities for esophageal diseases?
- Endoscopy
- Endoscopic ultrasound (especially useful in staging esophageal cancer)
- Barium esophagram
- Manometry/pressure topography
- pH monitoring (for reflux testing; lies 5 cm above LES)
-
What are some esophageal diseases?
- Structural disorders
- Mobility disorders
- Eosinophilic esophagitis
- GERD
- ?
What is Zenker diverticulum?
Regurgitation of undigested food
- Bad breath
- Pharyngoesophageal diverticulum
- Located superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles (Killian’s triangle)
When to you treat a Zenker diverticulum?
When diverticulum is very large or symptomatic, can do:
- Endoscopic myotomy
- Surgery
What is a hiatus hernia? Types?
Hiatal hernia = stomach herniates upward through the esophageal hiatus of the diaphragm
- Sliding HH: GEJ is displaced upward
- P-esophageal: GEJ is normal; fundus protrudes into the thorax
What is Barrett’s esophagus?
- What causes it?
- What is it associated with?
Intestinal metaplasia: replacement of squamous epithelium with intestinal epithelium (columnar with goblet cells) in the distal esophagus
- Due to chronic inflammatory due to gastroesophageal reflux disease (GERD)
- Associated w/ esophagitis, esophageal ulcers, increased risk of esophageal adenocarcinoma
T/F: Many patients with Barett’s esophagus do not have dysplasia?
True
- Handle with surveillance and GERD treatment
Case 1)
- 45 yo WF
- Intermittent esophageal dysphagia to solids only
- Otherwise healthy
- No weight loss
- Esophagram shows narrowing in esophagus
- Endoscopy shows concentric ring of mucosal tissue
What is the diagnosis?
A. Radiation-induced stricture
B. Schatzki’s ring
C. Esophageal adenocarcinoma
D. Achalasia Treatment?
What is the diagnosis?
A. Radiation-induced stricture
B. Schatzki’s ring
C. Esophageal adenocarcinoma
D. Achalasia Treatment?
- Classic presentation is intermittent
Treatment:
- Various dilators to stretch airways
- Balloon to break up ring
- Acid suppression
Case 2)
- 54 yo WM
- 12 yr hx of heartburn rx’d with intermittent tums and H2 blockers
- 2 yr hx of progressive esophageal dysphagia to solids
- Heartburn better in last few months
- No weight loss
- Esophagram shows widening and then narrowing
What is the correct diagnosis?
A. Radiation-induced stricture
B. Peptic stricture
C. Eosinophilic esophagitis
D. Achalasia
Treatment?
What is the correct diagnosis?
A. Radiation-induced stricture
B. Peptic stricture
C. Eosinophilic esophagitis
D. Achalasia
Treatment:
- Manage acid reflux
- Various dilators to stretch airways
Case 3)
- 63 yo WM
- Chronic heartburn rx’d with tums
- 2 mo h/o progressive esophageal dysphagia to solids
- Unquantified weight loss (clothes are loose)
Diagnosis?
A. Candida esophagitis
B. Peptic stricture
C. Esophageal adenocarcinoma
D. CMV esophagitis
Treatment?
Diagnosis?
A. Candida esophagitis
B. Peptic stricture
C. Esophageal adenocarcinoma
D. CMV esophagitis
Treatment:
- Staging: CT, EUS
- Rx based on staging: surgery, chemo, radiation, palliative stent
Case 4)
- 59 yo WM
- 1-2 yr h/o progressive dysphagia to solids and liquids, currently with every meal
- Nocturnal regurgitation and cough
- 20 lb weight loss in last 6 mo
- Esophagram shows dilation and then narrowing (?)
- Manogram shows aperistalsis (no motility); no relaxation of LES
- Endoscopy doesn’t show a lot of inflammation, but is very narrow due to lack of relaxation of LES
What is the diagnosis?
A. Distal esophageal spasm
B. Jackhammer esophagus
C. Ineffective esophageal motility
D. Achalasia
Treatment?
A. Distal esophageal spasm
B. Jackhammer esophagus
C. Ineffective esophageal motility
D. Achalasia
Treatment:
- Botox
- Pneumatic dilation
- Heller myotomy
Case 5)
- 25 yo WF
- 3 mo h/o intermittent esophageal dysphagia to solids and liquids
- Intermittent chest pain
- Manometry shows really high amplitude, strong, uncoordinated contractions in the esophagus
Diagnosis?
A. Eosinophilic esophagitis
B. Jackhammer esophagus
C. Ineffective esophageal motility
D. Achalasia
Treatment?
Diagnosis?
A. Eosinophilic esophagitis
B. Jackhammer esophagus
C. Ineffective esophageal motility
D. Achalasia
Treatment:
- Ca channel blocker
- Nitrates
- Sildanafil
- Botox
Case 6)
- 27 yo WM
- Intermittent esophageal dysphagia to solids only
- Food impaction a few months ago
- H/o asthma
- No weight loss
- Esophagram shows “fractalization” of esophagus
- Endoscopy shows concentric rings or white spots in the esophagus
Diagnosis?
A. Corrosive esophagitis
B. GERD
C. Eosinophilic esophagitis
D. Achalasia
Treatment?
A. Corrosive esophagitis
B. GERD
C. Eosinophilic esophagitis
D. Achalasia
- Pretty common in pediatric population
Treatment:
- Elimination diet (allergy testing)
- Acid suppression
- Steroids: topical, systemic
- Careful esophageal dilation if no response to treatment (can cause perforation)
Case 7)
- 41 yo AA F
- 1 w h/o dysphagia fors olids > liquids
- Odynophagia
- Diabetic
- Recently finished course of antibiotics for UTI
Diagnosis?
A. Candida esophagitis
B. Pill esophagitis
C. Erosive esophagitis
D. Caustic ingestion esophagitis
A. Candida esophagitis
B. Pill esophagitis
C. Erosive esophagitis
D. Caustic ingestion esophagitis
Case 8)
- 72 yo WF
- 3 d h/o odynohpagia, dysphagia, chest pain
- Multiple prescribed medications
- Prn NSAIDS (arthritis)
Diagnosis?
A. Candida esophagitis
B. Pill esophagitis
C. Erosive esophagitis
D. Caustic ingestion esophagitis
Treatment?
A. Candida esophagitis
B. Pill esophagitis
C. Erosive esophagitis
D. Caustic ingestion esophagitis
Treatment:
- Avoid offending agent
- If abosolutely necessary, try to obtain liquid form
- NO ROLE for acid suppression, sucralfate
- Heals spontaneously within days
- Prevent recurrence
