11-20 Diseases of the Esophagus and Stomach Flashcards
What are some types of dysphagia?
oropharyngeal dysphagia
esophageal dysphagia
odynophagia
What is oropharyngeal dysphagia?
difficulty swallowing due to problems transferring the food bolus to the upper esophagus
What goes into the oropharyngeal phase of swallowing?
Complex process:
elevation of the tongue,
closure of the nasopharynx,
relaxation of the upper esophageal sphincter,
closure of the airway, and
pharyngeal peristalsis
What are some causes of oropharyngeal dysphagia?
Try to get 8, but up to 13 possible
Often neurological:
- CVA,
- tumors,
- ALS,
- MS,
- pseudobulbar palsy,
- Guillain-Barre,
- Parkinson’s,
- muscular dystrophies
Can also include infectious causes; or muscular, rheumatological, metabolic, structural (Zenker’s diverticulum), or motility disorders
What is the clinical presentation of oropharyngeal dysphagia?
problems with the oral phase of swallowing cause drooling or spillage of food from the mouth,
inability to chew or initiate swallowing, or
dry mouth.
Pharyngeal dysphagia is characterized by an immediate sense of the bolus catching in the neck,
the need to swallow repeatedly to clear food from the pharynx, or
coughing or choking during meals
(Think drunk person attempting saltine challenge)
What is the general theme for causes of esophageal dysphagia?
mechanical obstructions of the esophagus or by motility disorders
What are some specific causes of esophageal dysphagia?
Mechanical:
- Schatzki ring
- Peptic stricture
- Esophageal cancer
- Eosinophilic Esophagitis
Motility disorders:
- Achalasia
- Diffuse esophageal spasm
- Scleroderma
- Ineffective esophageal motility
What is the general presentation for esophageal dysphagia?
mechanical obstruction:
dysphagia, primarily for solids
recurrent, predictable, will worsen as the lumen narrows
motility disorders/obstruction:
dysphagia for both solids and liquids
episodic, unpredictable, and can be progressive
What is odynophagia?
difficulty swallowing due to sharp substernal pain on swallowing that may limit oral intake.
What is odynophagia caused by?
(It usually reflects severe erosive disease)
most commonly associated with infectious esophagitis due to Candida, herpesviruses, or CMV
(especially in immunocompromised patients)
It may also be caused by corrosive injury due to caustic ingestions and by pill-induced ulcers.
What is the clinical presentation of odynophagia?
Immunocompromised patient with c/o severe substernal pain on swallowing
-or-
patient with Hx of pill injury
What is infectious esophagitis?
odynophagia, dysphagia and chest pain d/t infections in immunocompromised patients
Patients are often are/have HIV+/AIDS, transplant recipients, blood cancer, or on immunosuppressive meds
Common pathogens are HSV, CMV, Candida albicans
What is the clinical presentation of infectious esophagitis?
most common Sx: odynophagia and dysphagia, some have substernal chest pain
Oral thrush in ~75% with Candida infection
CMV infection at other sites (colon, retina) in CMV-mediated infection
Herpes labialis associated with HSV-mediated esophagitis
What is the best way to Dx infectious esophagitis?
Endoscopy with biopsy and brushings (for micro and histo studies)
What will the 3 major causes of infectious esophagitis look like under endoscopic examination?
Candida:
diffuse, linear, yellow-white plaques adherent to the mucosa
CMV:
one to several large, shallow, superficial ulcerations
HSV:
multiple small, deep ulcerations
Name 7 benign esophageal lesions.
- Mallory-Weiss Syndrome (Mucosal Laceration of Gastroesophageal Junction)
- Eosinophilic Esophagitis
- Esophageal Webs & Rings
- Zenker Diverticulum
- Esophageal Varices
- Esophageal Diverticula
- Benign Esophageal Neoplasms
What are the ‘essentials’ for dx of Mallory-Weiss Syndrome?
Hematemesis; usually self-limited.
Prior history of vomiting, retching in 50%.
Endoscopy establishes diagnosis.
What is Mallory-Weiss Syndrome?
nonpenetrating mucosal tear at the gastroesophageal junction
from events that suddenly raise transabdominal pressure, such as lifting, retching, or vomiting
Alcoholism is a strong predisposing factor.
What is the clinical presentation for Mallory-Weiss Syndrome?
Patients usually present with hematemesis with or without melena.
A history of retching, vomiting, or straining is obtained in about 50% of cases.
How is Mallory-Weiss Syndrome dx’ed?
upper endoscopy
0.5- to 4-cm linear mucosal tear usually located either at the gastroesophageal junction
or, more commonly,
just below the junction in the gastric mucosa
What is eosinophilic esophagitis?
disorder in which food or environmental antigens are thought to stimulate an inflammatory response
A history of allergies or atopic conditions (asthma, eczema, hay fever) is present in over half of patients
What are the SSXs associated with eosinophilic esophagitis?
Most adults have a long history of dysphagia for solid-foods or an episode of food impaction. Heartburn may be present.
Children may have abdominal pain, vomiting, chest pain, or failure to thrive.
Endoscopy should be performed, with multiple biopsies (at least 2–4) from the proximal and distal esophagus should be obtained to demonstrate multiple eosinophils in the mucosa.
How is eosinophilic esophagitis treated?
Before making a diagnosis of eosinophilic esophagitis, all patients should be given an empiric trial of a PPI b.i.d. for 2 months followed by repeat endoscopy and mucosal biopsy to exclude GERD.
If no response, cut out all food allergens the patient is sensitive to and use topical (PO or inhaler) cortisone therapy if needed (budesonide PO or fluticasone 2 puffs p.c.)
What are some examples of things that cause mucosal webs or rings?
may be congenital but also occur with eosinophilic esophagitis, graft-versus-host disease, pemphigoid, epidermolysis bullosa, pemphigus vulgaris, and, rarely, in association with iron deficiency anemia (Plummer-Vinson syndrome).
Esophageal “Schatzki” rings are smooth, circumferential, thin (less than 4 mm in thickness) mucosal structures located in the distal esophagus at the squamocolumnar junction
What are Schatzki rings associated with?
associated in nearly all cases with a hiatal hernia, and reflux symptoms are common
acid gastroesophageal reflux may be contributory in many cases
(exact pathogenesis unclear)
At what sizes do esophageal webs and rings start to cause trouble?
Rings less than 13 mm in diameter
Solid food dysphagia most often occurs
dysphagia is intermittent and not progressive.
Large poorly chewed food boluses such as beefsteak are most likely to cause symptoms.
Obstructing boluses may pass by drinking extra liquids or after regurgitation
How are esophageal webs and rings dx’ed?
best visualized using a barium esophagogram with full esophageal distention
(Endoscopy is less sensitive than barium esophagography)
What is Zenker diverticulum?
protrusion of pharyngeal mucosa that develops at the pharyngoesophageal junction between the inferior pharyngeal constrictor and the cricopharyngeus
What causes Zenker diverticulum?
loss of elasticity of the upper esophageal sphincter, resulting in restricted opening during swallowing
What are the SSXs of Zenker diverticulum?
dysphagia and regurgitation tend to develop insidiously over years in older, predominantly male patients
Initial symptoms include vague oropharyngeal dysphagia with coughing or throat discomfort.
As the diverticulum enlarges and retains food, patients may note halitosis, spontaneous regurgitation of undigested food, nocturnal choking, gurgling in the throat, or a protrusion in the neck.
How is Zenker diverticulum Dx’ed?
video esophagography
What are the ‘essentials’ of Dx for esophageal varices?
Develop secondary to portal hypertension.
Found in 50% of patients with cirrhosis.
One-third of patients with varices develop upper gastrointestinal bleeding.
Diagnosis established by upper endoscopy.
What are esophageal varices?
dilated submucosal veins that develop in patients with underlying portal hypertension
- may result in serious upper gastrointestinal bleeding, most common cause of important gastrointestinal bleeding
Bleeding most commonly occurs in the distal 5 cm of the esophagus
What are the risk factors that increase the risk of bleeding from esophageal varices?
(1) the size of the varices
(2) the presence at endoscopy of red wale markings (longitudinal dilated venules on the varix surface)
(3) the severity of liver disease (as assessed by Child scoring)
4) active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding
What are the SSXs of bleeding from esophageal varices?
Hematemesis (bright red blood or “coffee grounds”).
Melena in most cases; hematochezia in massive upper gastrointestinal bleeds.
Volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss
Sometimes dyspepsia or dysphagia
What is the treatment for bleeding esophageal varices?
acute resuscitation - normalize volume status, transfuse blood or packed RBCs, add platelets or FFP if INR > 1.8
Emergent endoscopy for every serious upper GI bleed
Meds - give AB therapy, vasopressors, vitamin K and lactulose (avoid encephalopathy)
Tx: - ligation, balloon tamponade, intrahepatic portosystemic shunt
What are esophageal diverticula?
Diverticula may occur anywhere in the esophagus.
- may arise secondary to motility disorders (diffuse esophageal spasm, achalasia)
- or may develop above esophageal strictures.
Diverticula are seldom symptomatic
What are some benign esophageal neoplasms?
Rare - often leiomyomas or leiomyosarcomas
Often asymptomatic, larger ones can cause dysphagia
Diagnosis important - need to make sure tumor isn’t malignant
What are some major esophageal motility disorders?
- Achalasia
- Diffuse esophageal spasm
- Hypertensive peristalsis (nutcracker esophagus)
- Small cell lung cancers causing a paraneoplastic syndrome via secreting ANNA-1, an antineuronal nuclear Ab
- Tumor invasion into gastroesophageal junction
What is achalasia?
idiopathic motility disorder characterized by loss of peristalsis in the distal two-thirds (smooth muscle) of the esophagus and impaired relaxation of the LES.
There appears to be denervation of the esophagus resulting primarily from loss of nitric oxide-producing inhibitory neurons in the myenteric plexus
What are the SSXs of achalasia?
gradual onset of dysphagia for solid foods and liquids Symptoms at presentation may have persisted for months to years.
Substernal discomfort or fullness may be noted after eating
Regurgitation, sometimes post-prandial or nocturnal
How is achalasia Dx’ed?
Ba esography/ Ba swallow
How is achalasia treated?
pneumatic dilation
botox injections
surgery
What is gastritis?
inflammation of the stomach, with 3 categories:
(1) erosive and hemorrhagic “gastritis” (gastropathy)
(2) nonerosive, nonspecific (histologic) gastritis
(3) specific types of gastritis, characterized by distinctive histologic and endoscopic features diagnostic of specific disorders.
What are some causes and types of gastritis?
Nonerosive, Nonspecific Gastritis
- often due to H. pylori infection, pernicious anemia, or eosinophilic gastritis
Specific Types of Gastritis
- infections, eosinophilic gastritis, and Menetrier Disease/Hypertrophic Gastropathy
What is gastropathy?
conditions in which there is epithelial or endothelial damage without inflammation
What are the essentials of Dx for gastropathy?
Most commonly seen in alcoholic or critically ill patients, or patients taking NSAIDs.
Often asymptomatic; may cause epigastric pain, nausea, and vomiting.
May cause hematemesis; usually in significant bleeding
What are the causes of gastropathy?
medications (especially NSAIDs),
alcohol,
stress due to severe medical or surgical illness,
and portal hypertension (“portal gastropathy)
What are the SSXs of gastropathy?
- usually asymptomatic
- anorexia, epigastric pain, nausea, and vomiting
can present as upper gastrointestinal bleeding
hematemesis, “coffee grounds” emesis, or bloody aspirate, or as melena
How is gastropathy Dx’ed?
Upper GI bleed = endoscopy
What are some differentials to consider with gastropathy?
peptic ulcer disease, esophageal varices, Mallory-Weiss tear, and angiodysplasias.
What is the treatment for gastropathy?
PPIs and H2 receptor antagonists
- propranolol to lower portal system HTN if needed
What are some benign tumors of the stomach?
Generally just gastric polyps
- can be congenital (familial polyposis)
- can be due to irritation (H. pylori)
Remove, potentially premalignant
What are some malignant tumors of the stomach?
Gastrinoma
- causes Zoll Ellison Syndrome
What is Zollinger-Ellison syndrome?
caused by gastrin-secreting gut neuroendocrine tumors (gastrinomas), which result in hypergastrinemia and acid hypersecretion.
Less than 1% of peptic ulcer disease is caused by gastrinomas
What are the common locations for gastrinomas?
pancreas (25%), duodenal wall (45%), or lymph nodes (5–15%), and in other locations or of unknown primary (20%).
Approximately 80% arise within the “gastrinoma triangle” bounded by the porta hepatis, the neck of the pancreas, and the third portion of the duodenum
What are the SSXs associated with Zollinger-Ellison syndrome?
- peptic ulcers
Gastroesophageal reflux symptoms
Diarrhea
Gastric acid hypersecretion can cause direct intestinal mucosal injury and pancreatic enzyme inactivation, resulting in diarrhea, steatorrhea, and weight loss; nasogastric aspiration of stomach acid stops the diarrhea
How is Zollinger-Ellison syndrome dx’ed?
gastrin levels
stomach pH testing
somatostatin receptor scintigraphy (SRS) + endoesophageal US
(gastrinomas express somatostatin receptors that bind radiopaque octreotide, picked up on PET scan)
What are some differential Dx for gastrinoma?
Other neuroendocrine gut tumors:
carcinoid, insulinoma, VIPoma, glucagonoma, and somatostatinoma. These tumors usually are differentiated by the gut peptides that they secrete
Atrophic gastritis with decreased acid secretion is detected by gastric secretory analysis. Other conditions associated with hypergastrinemia (eg, gastric outlet obstruction, vagotomy, chronic kidney disease) are associated with a negative secretinstimulation test
What is the treatment for a gastrinoma?
Surgical resection and/or cryoablation usually fairly effective if done before liver invasion
Use PPIs for symptomatic relief
What are some major causes of upper GI bleeding?
peptic ulcer disease
portal system HTN
Mallory Weiss tears
vascular anomalies - angiectasias and telangiectasias
gastric neoplasms
erosive gastritis
erosive esophagitis
What does SAD CREaP stand for?
For Dysphagia: (MEMORIZE!!)
For solids and liquids (motility):
Scleroderma
Achalasia (watch out for “pseudoachalasia”)
Diffuse esophageal spasm – “corkscrew esophagus”
For solids only (Mechanical):
Carcinoma
Ring(Schatski’s)*/webs**
Eosinophilic esophagitis
and
Peptic stricture
What is the exception to the SAD CREaP rule?
pseudo achalasia
