137. Clinical Esophageal Disorders

Question 1

how to tell the difference between a structural abnormality and a propulsive disorder/sensory abnormality?

Answer 1

Structural abnormality: problems with only solid food

Propulsive Disorder/Sensory Abnormality: dysphagia for solids & liquids

Question 2

Hiatal Hernia

• what it is
• types

Answer 2

herniation of viscera/stomach into mediastinum thru esophageal hiatus of diaphragm
Type 1: sliding hiatal hernia (95%) predisposes to reflux
Type 2,3,4: paraesophageal hernia - may include visceral structure other than gastric cardia

Question 3

Esophageal Rings/Webs
Schatzki Ring: what it is, location, sx, age, tx
Cervical Web: what it is, location, sx, tx
Plummer-Vinson Syndrome

Answer 3

Schatzki Ring: lower esophageal mucosal ring, dysphagia, age >40yo (acquired), tx: esophageal dilation

Cervical Web: higher in esophagus, congenital or inflammatory, circumferential webs causing intermittent dysphagia, tx: esophageal dilatation

Plummer-Vinson Syndrome: middle-age female, cervical web & iron deficiency

Question 4

Esophageal Diverticulum

• What is Zenker’s Diverticulum, who does it affect? sx
• What is traction diverticulum
• What is epiphrenic diverticulum (sx, assoc)

Answer 4

Zenkers: sac-like outpouching of mucosa/submucosa thru Killan’s triangle (area of weakness b/w transverse fibers of cricopharyngeus & oblique fibers of lower inferior constrictor), M>F, older age (70-80s)
sx: pulmonary aspiration, halitosis, regurgitation, neck fullness, throat gurgling

Traction: midportion of esophagus

Epiphrenic: above LES, assoc with motility disorders (achalasia), sx: regurgitation, dysphagia

Question 5

GERD

• pathophys
• worsening factors
• complications
• tx

Answer 5

PPhys: 90% have transient LES relaxations! due to LES hypotension, anatomic distortion of EGJ, impaired salivation/peristaltic emptying

Worseners: obesity (high intraabd pressure), pregnancy (high intraabd pressure, hormones relax LES), gastric hypersecretion, delayed gastric emptying, disrupted esophageal peristalsis, overeating (gastric distention)

Complications: 1. Non-erosive GERD (impairs QoL)

2. Extra-esophageal GERD - ENT/asthma/dental problems
3. Esophagitis: Stricture, Bleeding, Barret’s Metaplasia, Adenocarcinoma

Tx: 1. Meds to decrease acid secretion (PPI, H2RA blockers), 2. Lifestyle modification (lose weight, avoid foods, eating modification - less before bed), 3. Surgical mgmt - Nissen

Testing: Reflux with ambulatory 24-48 hr esophagus pH, intraluminal impedence - detects any reflux acidic/nonacidic

Question 6

Barrett’s Esophagus

• what is it
• epidemiology

Answer 6

Metaplastic columnar epithelium replaces stratified squamous epithelium
Epi: 55 yo, M>F
Increased risk of adenocarcinoma (needs SURVEILLANCE)

Question 7

Eosinophilic Esophagitis (EoE)

• what is it
• Epidemiology
• sx
• Endoscopy
• Dx
• causes
• tx

Answer 7

Chronic, immune-mediated food-antigen driven disease
ISOLATED TO ESOPHAGUS
Epidemiology: M>F, 30-40s yo, white ppl, atopic hx, +FamHx EoE/Atopy
sx: dysphagia, food impaction, heartburn, chest pain
Endoscopy: rings (ridges on esophagus), furrows (railroad tracts), exudates (eosinophil aggregates - white plaques), food impaction
Dx: GOLD STD: Esophageal biopsy (Superficial layering, epithelial hyperplasia, eosinophilic microabscesses, degranulation, spongiosis [intracell edema], LP fibrosis)
Causes: interplay with esophageal acid, linked to allergies, genetics
Tx: 3D’s
Drugs - PPIs, swallowed topical steroids
Diet - SFED (6 food - milk, egg, soy, wheat, nut, seafood)
Dilation - endoscopic esophageal dilation (savary/balloon)

Question 8

Infectious Esophagitis

- 3 types, cause, key endoscopic findings, tx

Answer 8

1. Candidal esophagus (most common) - causes odynophagia, dysphagia, white plaques in esophagus
   tx: oral fluconazole x14 days (antifungal)
2. Herpetic esophagitis: HSV1/2, punched out ulcerations in esophagus
   tx: self-limited, acyclovir/valcyclovir if needed
3. CMV esophagitis: immunocompromised pts, serpiginous ulcerations (snake-like), tx: ganciclovir

Question 9

Pill Esophagitis

- what it is, sx, tx

Answer 9

swallowed pill lodges in esophagus (mid esophagus most common due to crossing of aorta/carina of trachea)

Sx: sudden onset chest pain, odynophagia
tx: self-limited, can use PPI/carafate