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HPIM Gastro > 347 : Diseases of the Esophagus > Flashcards

347 : Diseases of the Esophagus Flashcards

1
Q

Hollow, muscular tube coursing through the posterior mediastinum joining the hypopharynx to the stomach with a sphincter at each end

A

Esophagus

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2
Q

Major esophageal symptoms

A
  1. Heartburn (pyrosis)
  2. Regurgitation
  3. Chest pain
  4. Dysphagia
  5. Odynophagia
  6. Globus sensation
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3
Q

Most common esophageal symptom

A

Heartburn (pyrosis)

Discomfort or burning sensation behind the sterum arising from epigastrium and may radiate toward the neck

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4
Q

Characteristics of heartburn

A
  1. after eating
  2. during exercise
  3. while lying recumbent
  4. relieved w/ drinking water or antacid
  5. interferes normal activities including sleep
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5
Q

Effortless return of food or fluid into the pharynx without nausea or retching

A

Regurgitation

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6
Q

Preceded by nausea and accompanied by retching

A

Vomiting

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7
Q

Behavior in which recently swallowed food is regurgitated and then reswallowed repetitively for up to an hour

A

Rumination

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8
Q

Most common cause of esophageal chest pain

A

Gastroesophageal reflux

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9
Q

Pain either caused by or exacerbated by swallowing

A

Odynophagia

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10
Q

Perception of a lump or fullness in the throat that is felt irrespective of swallowing and is often relieved by the act of swallowing

A

Globus sensation
“globus hystericus”

In the setting of anxiety or OCD

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11
Q

Excessive salivation resulting from a vagal reflex triggered by acidification of esophageal mucosa

A

Water brash

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12
Q

Most useful test for evaluation of proximal GI tract

A

Endoscopy or EGD (esophagogastroduodenoscopy)

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13
Q

Advantages of endoscopy vs barium radiography

A
  1. Increased sensitivity for detection of mucosal lesions
  2. vastly increased sensitivity for the detection of abnormalities mainly identifiable by color such as Barrett’s metaplasia or vascular lesions
  3. ability to obtain biopsy specimens for histologic exam of suspected abnormalities
  4. Ability to dilate strictures during the exam
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14
Q

Main disadvantages of endoscopy

A
  1. Cost

2. Utilization of sedatives or anesthetics

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15
Q

In detecting esophageal strictures, which has greater sensitivity? Endoscopy or Barium radiography

A

Barium radiography

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16
Q

T or F: Hypopharyngeal pathology and disorders of cricopharyngeus muscle are better appreciated using radiography than endoscopy.

A

True

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17
Q

Major shortcoming of barium radiography

A

Rarely obviates the need for endoscopy

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18
Q

Key advantage of endoscopic ultrasound (EUS) over alternative radiologic imaging techniques

A

Much greater resolution attributable to proximity of the ultrasound transducer to the area being examined

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19
Q

Major esophageal applications of EUS

A
  1. Stage esophageal cancer
  2. Evaluate dysplasia in Barrett’s esophagus
    3 Assess submucosal lesions
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20
Q

Motility testing that involves positioning a pressure-sensing catheter within the esophagus and then observing the contractility following test swallows

A

Esophageal manometry

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21
Q

Can demonstrate excessive esophageal exposure to refluxed gastric juice, the physiologic abnormality of GERD

A

Reflux testing

24-48h esophageal pH recording

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22
Q

Herniation of viscera, most commonly the stomach, into the mediastinum through the esophageal hiatus of the diagphragm

A

Hiatus hernia

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23
Q

Types of hiatus hernia

A

Type I - sliding hiatal hernia (95%)
Type II - paraesophageal hernia; GE junction remains fixed at the hiatus
Type III - combined sliding and paraesophageal hernia
Type IV - viscera other than stomach herniate into the mediastiunum, most commonly the colon

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24
Q

Gastroesophageal junction and gastric cardia translocate cephalad from weakening of the phrenoesophageal ligament

A

Sliding hiatal hernia

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25
Q

Main significance of sliding hernias

A

Propensity of affected individuals to have GERD

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26
Q

Thin membranous narrowing at the squamocolumnar mucosal junction; a lower esophageal mucosal ring

A

B ring

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27
Q

Distal rings are usually associated with episodic solid food dysphagia

A

Schatzki rings

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28
Q

One of the most common cause of intermittent food impaction

A

“steakhouse syndrome”

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29
Q

Combination of symptomatic proximal esophageal webs and iron-deficiency anemia in middle aged women

A

Plummer-Vinson syndrome

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30
Q

Categorization of esophageal diverticula by location

A
  1. Epiphrenic (most common)
  2. Hypopharngeal (Zenker’s)
  3. Midesophageal
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31
Q

T or F: Epiphrenic and Zenker’s diverticula are false diverticula

A

True

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32
Q

Obstruction is a stenotic cricopharyngeus muscle (upper esophageal sphincter)

A

Zenker’s

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33
Q

Area of natural weakness proximal to the cricopharyngeus

A

Killian’s triangle

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34
Q

Type of esophageal diverticula that produces halitosis and aspiration

A

Zenker’s diverticula

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35
Q

The only true diverticula

A

Midesophageal diverticula usually caused by tuberculosis

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36
Q

T or F: Esophageal cancers are rare but lethal.

A

True

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37
Q

Most common congenital esophageal anomaly

A

Esophageal atresia

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38
Q

Esophagus is compressed by an aberrant right subclavian artery arising from the descending aorta and passing behind the esophagus

A

Dysphagia lusoria

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39
Q

Heterotropic gastric mucosa or esophageal inlet patch is a focus of gastric type epithelium in PROXIMAL or DISTAL esophagus?

A

Proximal cervical esophagus

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40
Q

Rare disease caused by loss of ganglion cells within the esophageal myenteric plexus presenting between age 25 and 60.

A

Achalasia

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41
Q

Differential diagnoses of achalasia

A

DES
Chagas’ disease
Pseudoachalasia

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42
Q

Vector causing the Chagas’ disease

A

Reduviid (kissing) bug

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43
Q

Protozoan responsible for Chagas’ disease

A

Trypanosoma cruzi

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44
Q

Modalities for diagnosis of achalasia

A
  1. Barium swallow xray AND/OR

2. Esophageal manometry

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45
Q

Role of Endoscopy in diagnosis of achalasia

A

To exlude pseudoachalasia

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46
Q

Barium swallow xray finding in achalasia

A
  1. Dilated esophagus with poor emptying
  2. Air fluid level
  3. Tapering at LES giving it a beak-like appearance
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47
Q

Diagnostic criteria for achalasia with esophageal manometry

A

Impaired LES relaxation

Absent peristalsis

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48
Q

Identifies early disease before esophageal dilatation and food retention making it the most sensitive diagnostic test

A

Manometry

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49
Q

T or F: Currently, there is no known way of preventing or reversing achalasia

50
Q

T or F: Peristalsis rarely recovers in achalasia

51
Q

Treatment for achalasia

A
  1. Pharmacologic therapy
  2. Pneumatic balloon dilatation
  3. Surgical myotomy
52
Q

Medical therapy for achalasia

A
  1. Nitrates or calcium channel blockers before eating
  2. Botulinum toxin improves dysphagia in 66% of cases for atleast 6 months
  3. Sildenafil and alternative phosphodiesterase inhibitors however practicalities limit their clinical use.
53
Q

Endoscopic technique using a noncompliant, cylindrical balloon dilator positioned across the LES and inflated to a diameter of 3-4cm.

A

Pneumatic dilatation

54
Q

Major complication of pneumatic dilatation

A

Perforation (Incidence: 0.5-5%)

55
Q

Most common surgical procedure for achalasia

A

Laparoscopic Heller myotomy usually with partial fundoplication (anti-reflux procedure)

56
Q

Treatment for achalasia for refractory cases and those that failed to respond to pneumatic dilatation or Heller myotomy

A
  1. Esophageal resection with gastric pull-up or interposition of a segment of transverse colon
  2. Gastrostomy feeding
57
Q

Condition in achalasia associated with esophageal squamous cell cancer

A

Prolonged stasis esophagitis

58
Q

Manifested by episodes of dysphagia and chest pain attributable to abnormal esophageal contractions with normal deglutitive LES relaxation

A

Diffuse esophageal spasm (DES)

*Less common than achalasia

59
Q

Characteristic finding of DES radiographically

A

“corkscrew esophagus”

*others: “rosary bead esophagus”, pseudodiverticula, curling = also found in spastic achalasia

60
Q

Diagnosis of DES

61
Q

The only controlled trial showing efficacy in treatment of DES

A

Anxiolytics

62
Q

3 dominant mechanisms of esophagogastric junction incompetence

A
  1. Transient LES relaxations (a vagovagal reflex where LES relaxation is elicited by gastric distention)
  2. LES hypotension
  3. Anatomic distortion of the esophagogastric junction inclusive of hiatus hernia
63
Q

Factors that exacerbate reflux regardless of mechanism

A
  1. Abdominal obesity
  2. Pregnancy
  3. Gastric hypersecretory states
  4. Delayed gastric emptying
  5. Disruption of esophageal peristalsis
  6. Gluttony
64
Q

2 causes of prolonged acid clearance

A
  1. Impaired peristalsis

2. Reduced salivation

65
Q

Extraesophageal syndromes with established association to GERD

A
  1. Chronic cough
  2. Laryngitis
  3. Asthma
  4. Dental erosions
66
Q

Comparison of ulcerations in the ff: Peptic esophagitis, Infectious esophagitis, Eosinophilic esophagitis, Pill esophagitis

A

Peptic: Solitary and distal
Infectious: Punctate and diffuse
Eosinophilic: Multiple esophageal rings, linear furrows, or white punctate exudate
Pill: Singular and deep at points of luminal narrowing near carina with sparing of distal esophagus

67
Q

Most severe histologic consequence of GERD

A

Barrett’s metaplasia

68
Q

On endoscopy, showed tongues of reddish mucosa extending proximally from the GE junction or histopathologically by finding of specialized columnar metaplasia

A

Barrett’s metaplasia

69
Q

Gold standard treatment for high-grade dysplasia in Barrett’s esophagus

A

Esophagectomy

Mortality rate: 3-10%

70
Q

3 categories of lifestyle modifications in GERD therapy

A
  1. Avoidance of foods that reduce LES pressure, making them “refluxogenic”
  2. Avoidance of acidic foods that are inherently irritating
  3. adoption of behaviors to minimize reflux/heartburn
71
Q

The most broadly applicable recommendation for GERD

A

Weight reduction

72
Q

Dominant pharmacologic approach to GERD management

A

Inhibitors of gastric acid secretion

*this does not prevent reflux; it allows esophagitis to heal

73
Q

T or F: PPI and histamine 2 receptor antagonists are both superior to placebo and also have equal efficacy

A

False

PPI are superior to histamine 2 receptor antagonists

74
Q

Side effects of PPI therapy

A
  1. Vitamin B12 and iron absorption may be compromised
  2. Slight increased risk of bone fracture with chronic use
  3. Susceptibility to enteric infections (Clostridium defficile colitis)
75
Q

Surgical alternative to management of chronic GERD

A

Laparoscopic Nissen fundoplication

proximal stomach is wrapped around the distal esophagus to create an antireflux barrier

76
Q

Diagnosed based on combination of typical esophageal symptoms and esophageal mucosal biopsies demonstrating squamous epithelial eosinophil-predominant inflammation

A

Eosinophilic esophagitis (EoE)

An immunologic disorder induced by antigen sensitization in susceptible individuals

77
Q

Alternative etiologies of EoE

A 
GERD
Drug hypersensitivity
Connective tissue disorders
Hypereosinophilic syndrome
Infection
78
Q

Clinical manifestations of EoE

A

In children and adults:

  1. Dysphagia
  2. Esophageal food impactions
  3. Atypical chest pain and heartburn refractory to PPI
  4. Atopic history of food allergy, asthma, eczema, allergic rhinitis
  5. Peripheral blood esosinophilia in 50%
79
Q

Endoscopic findings in EoE

A

Loss of vascular markings (edema)
Multiple esophageal rings
Longitudinally oriented furrows
Punctate exudate

80
Q

Histologic finding in EoE

A

Esophageal mucosal eosinophilia (+/-15 eosinophils per hpf)

81
Q

Complications of EoE

A

Esophageal stricture
Narrow-caliber esophagus
Food impaction
Esophageal perforation

82
Q

Goals of EoE management

A

Symptom control

Prevention of complications

83
Q

Treatment of EoE

A
  1. Trial of PPI (to rule out GERD)
  2. If GERD is ruled out: Elimination diets or swallowed topical glucocorticoids (fluticasone propionate or budesonide)
  3. Systemic glucocorticoids (severe)
  4. Esophageal dilation

e.g. Empiric elimination of common food allergies (milk, wheat, egg, soy, nuts, seafood)

84
Q

Common causes of Infectious Esophagitis in NONimmunocompromised

A
  1. Herpes simplex

2. Candida albicans

85
Q

Common causes of Infectious Esophagitis in IMMUNOcompromised

A
  1. Candida species
  2. Herpesvirus
    3 Cytomegalovirus (CMV)

Common in CD4 <100, rare if >200

86
Q

Characteristic symptom of INFECTIOUS ESOPHAGITIS

A

Odynophagia

Other symptoms: dysphagia, chest pain, hemorrhage

87
Q

T or F: Odynophagia is also common in reflux esophagitis

88
Q

T or F: Candida is normally found in the throat

A

True

Becomes pathogenic in a compromised host

89
Q

When is empirical treatment for Candida esophagitis warranted?

A

If oral thrush is present

90
Q

Indication for prompt endoscopy with biopsy (Candida esophagitis)

A

Persistent symptoms

91
Q

Characteristic appearance of Candida esophagitis

A

White plaques with friability

92
Q

Treatment for Candida esophagitis

A

Oral Fluconazole (200-400mg on 1st day, then 100-200mg daily) for 14-21 days

if refractory: Itraconazole, Voriconazole, Posaconazole
can’t swallow: IV Echinocandin (Caspofungin 50mg daily for 7-21 days)

93
Q

Endoscopic findings in Herpetic esophagitis

A

Vesicles

Small punched-out ulcerations

94
Q

Biopsy of Herpetic esophagitis

A

Ground-glass nuclei
Eosinophilic Cowdry’s type A inclusion bodies
Giant cells

95
Q

Treatment for Herpetic esophagitis

A

Immunocompetent: Acyclovir 200mg orally 5x a day for 7-10 days (although it is self-limited for 1-2 weeks)

Immunocompromised: Acyclovir 400mg orally 5x a day for 14-21 days, Famciclovir 500mg orally 3x a day, Valacyclovir 1g orally 3x a day

Severe odynophagia: IV Acyclovir 5mg/kg q8h for 7-14 days

96
Q

Esophagitis that occurs primarily among organ transpant recipients

A

CMV esophagitis

97
Q

Endoscopy findings in CMV esophagitis

A

Serpiginous ulcers in an otherwise normal mucosa in distal esophagus

98
Q

Pathognomonic finding in biopsy of ulcer bases in CMV esophagitis

A

Large nuclear or cytoplasmic inclusion bodies

99
Q

Treatment for CMV esophagitis

A

Ganciclovir 5mg/kg q12h IV
Foscarnet 90mg/kg q12h IV
Valganciclovir 900mg BID PO

Duration: 3-6 weeks
For relapse: Continue as maintenance therapy

100
Q

Forceful vomiting or retching can lead to spontaneous rupture at the gastroesophageal junction

A

Boerhaave’s syndrome

101
Q

Site of perforation in esophagus from instruments of endoscopy or NGT

A

hypopharynx or gastroesophageal junction

102
Q

Pain of esophageal perforation

A

Pleuritic retrosternal pain

Associated with pneumomediastinum and subcutaneous emphysema

103
Q

Major complication of esophageal perforation

A

Mediastinitis

104
Q

Most sensitive in detecting mediastinal air

A

Chest CT scan

105
Q

Confirmation of esophageal perforation

A

Contrast swallow (Gastrografin) followed by thin barium

106
Q

Treatment of esophageal perforation

A

NGT suction
Parenteral broad-sepectrum antibiotics with prompt surgical drainage WITH
Prompt surgical drainage AND
Repair in noncontained leaks

107
Q

Surgical treatment if nonoperable iatrogenic perforations or nonoperable perforated tumors

A

Endoscopic clipping OR

Stent placement

108
Q

Condition caused by vomiting, retching, or vigorous coughing causing nontransmural tear at the gastroesophageal junction that is a common cause of GI bleeding

A

Mallory-Weiss Tear

109
Q

T or F: Surgery is always a definitive treatment for Mallory-Weiss Tear

A

False

Rarely needed

110
Q

Radiation exposure that increases risk of esophageal stricture

111
Q

Causes of radiation esophagitis

A
  1. Radiation

2. Radiosensitizing drugs: Doxorubicin, bleomycin, cyclophosphamide, cisplatin

112
Q

Treatment of radiation esophagitis

A

Supportive

Chronic: Esophageal dilation

113
Q

Complications of severe corrosive injury

A

Esophageal perforation
Bleeding
Stricture
Death

114
Q

T or F: Glucocorticoids are recommended to improve the clinical outcome of acute corrosive esophagitis

A

False

NOT been shown to improve clinical outcome

115
Q

Occurs when a swallowed pill fails to traverse the entire esophagus and lodges within the lumen

A

Pill-induced esophagitis

116
Q

Most common location for pill to lodge

A

Mid-esophagus near the crossing or aorta or carina

117
Q

Most common medications implied in pill esophagitis

A 
Doxycycline
Tetracycline
Quinidine
Phenytoin
Potassium chloride
Ferrous sulfate
NSAIDs
Biphosphonates
118
Q

Typical symptoms of pill esophagitis

A

Sudden onset chest pain and odynophagia

Pain develops over a period of hours and awaken individual from sleep

119
Q

Endoscopic findings in Pill Esophagitis

A

Localized ulceration or inflammation

120
Q

Can be used if food or foreign bodies lodge on esophagus

A

Glucagon 1mg IV then evaluated for potential causes of impaction

121
Q

Histopathologic findings in scleroderma

A

Infiltration and destruction of esophageal muscularis propria with collagen deposition and fibrosis

122
Q

Dermatologic diseases that affect oropharynx and esophagus

A 
Pemphigus vulgaris
Bullous pemphigoid
Cicatricial pemphigoid
Behcet's syndrome
Epidermolysis bullosa

Treatment: Glucocorticoid

HPIM Gastro (7 decks)

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