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
2
Q
Major esophageal symptoms
A
- Heartburn (pyrosis)
- Regurgitation
- Chest pain
- Dysphagia
- Odynophagia
- Globus sensation
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
4
Q
Characteristics of heartburn
A
- after eating
- during exercise
- while lying recumbent
- relieved w/ drinking water or antacid
- interferes normal activities including sleep
5
Q
Effortless return of food or fluid into the pharynx without nausea or retching
A
Regurgitation
6
Q
Preceded by nausea and accompanied by retching
A
Vomiting
7
Q
Behavior in which recently swallowed food is regurgitated and then reswallowed repetitively for up to an hour
A
Rumination
8
Q
Most common cause of esophageal chest pain
A
Gastroesophageal reflux
9
Q
Pain either caused by or exacerbated by swallowing
A
Odynophagia
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
11
Q
Excessive salivation resulting from a vagal reflex triggered by acidification of esophageal mucosa
A
Water brash
12
Q
Most useful test for evaluation of proximal GI tract
A
Endoscopy or EGD (esophagogastroduodenoscopy)
13
Q
Advantages of endoscopy vs barium radiography
A
- Increased sensitivity for detection of mucosal lesions
- vastly increased sensitivity for the detection of abnormalities mainly identifiable by color such as Barrett’s metaplasia or vascular lesions
- ability to obtain biopsy specimens for histologic exam of suspected abnormalities
- Ability to dilate strictures during the exam
14
Q
Main disadvantages of endoscopy
A
- Cost
2. Utilization of sedatives or anesthetics
15
Q
In detecting esophageal strictures, which has greater sensitivity? Endoscopy or Barium radiography
A
Barium radiography
16
Q
T or F: Hypopharyngeal pathology and disorders of cricopharyngeus muscle are better appreciated using radiography than endoscopy.
A
True
17
Q
Major shortcoming of barium radiography
A
Rarely obviates the need for endoscopy
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
19
Q
Major esophageal applications of EUS
A
- Stage esophageal cancer
- Evaluate dysplasia in Barrett’s esophagus
3 Assess submucosal lesions
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
21
Q
Can demonstrate excessive esophageal exposure to refluxed gastric juice, the physiologic abnormality of GERD
A
Reflux testing
24-48h esophageal pH recording
22
Q
Herniation of viscera, most commonly the stomach, into the mediastinum through the esophageal hiatus of the diagphragm
A
Hiatus hernia
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
24
Q
Gastroesophageal junction and gastric cardia translocate cephalad from weakening of the phrenoesophageal ligament
A
Sliding hiatal hernia
25
Main significance of sliding hernias
Propensity of affected individuals to have GERD
26
Thin membranous narrowing at the squamocolumnar mucosal junction; a lower esophageal mucosal ring
B ring
27
Distal rings are usually associated with episodic solid food dysphagia
Schatzki rings
28
One of the most common cause of intermittent food impaction
"steakhouse syndrome"
29
Combination of symptomatic proximal esophageal webs and iron-deficiency anemia in middle aged women
Plummer-Vinson syndrome
30
Categorization of esophageal diverticula by location
1. Epiphrenic (most common)
2. Hypopharngeal (Zenker's)
3. Midesophageal
31
T or F: Epiphrenic and Zenker's diverticula are false diverticula
True
32
Obstruction is a stenotic cricopharyngeus muscle (upper esophageal sphincter)
Zenker's
33
Area of natural weakness proximal to the cricopharyngeus
Killian's triangle
34
Type of esophageal diverticula that produces halitosis and aspiration
Zenker's diverticula
35
The only true diverticula
Midesophageal diverticula usually caused by tuberculosis
36
T or F: Esophageal cancers are rare but lethal.
True
37
Most common congenital esophageal anomaly
Esophageal atresia
38
Esophagus is compressed by an aberrant right subclavian artery arising from the descending aorta and passing behind the esophagus
Dysphagia lusoria
39
Heterotropic gastric mucosa or esophageal inlet patch is a focus of gastric type epithelium in PROXIMAL or DISTAL esophagus?
Proximal cervical esophagus
40
Rare disease caused by loss of ganglion cells within the esophageal myenteric plexus presenting between age 25 and 60.
Achalasia
41
Differential diagnoses of achalasia
DES
Chagas' disease
Pseudoachalasia
42
Vector causing the Chagas' disease
Reduviid (kissing) bug
43
Protozoan responsible for Chagas' disease
Trypanosoma cruzi
44
Modalities for diagnosis of achalasia
1. Barium swallow xray AND/OR
| 2. Esophageal manometry
45
Role of Endoscopy in diagnosis of achalasia
To exlude pseudoachalasia
46
Barium swallow xray finding in achalasia
1. Dilated esophagus with poor emptying
2. Air fluid level
3. Tapering at LES giving it a beak-like appearance
47
Diagnostic criteria for achalasia with esophageal manometry
Impaired LES relaxation
| Absent peristalsis
48
Identifies early disease before esophageal dilatation and food retention making it the most sensitive diagnostic test
Manometry
49
T or F: Currently, there is no known way of preventing or reversing achalasia
True
50
T or F: Peristalsis rarely recovers in achalasia
True
51
Treatment for achalasia
1. Pharmacologic therapy
2. Pneumatic balloon dilatation
3. Surgical myotomy
52
Medical therapy for achalasia
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
Endoscopic technique using a noncompliant, cylindrical balloon dilator positioned across the LES and inflated to a diameter of 3-4cm.
Pneumatic dilatation
54
Major complication of pneumatic dilatation
Perforation (Incidence: 0.5-5%)
55
Most common surgical procedure for achalasia
Laparoscopic Heller myotomy usually with partial fundoplication (anti-reflux procedure)
56
Treatment for achalasia for refractory cases and those that failed to respond to pneumatic dilatation or Heller myotomy
1. Esophageal resection with gastric pull-up or interposition of a segment of transverse colon
2. Gastrostomy feeding
57
Condition in achalasia associated with esophageal squamous cell cancer
Prolonged stasis esophagitis
58
Manifested by episodes of dysphagia and chest pain attributable to abnormal esophageal contractions with normal deglutitive LES relaxation
Diffuse esophageal spasm (DES)
*Less common than achalasia
59
Characteristic finding of DES radiographically
"corkscrew esophagus"
*others: "rosary bead esophagus", pseudodiverticula, curling = also found in spastic achalasia
60
Diagnosis of DES
Manometry
61
The only controlled trial showing efficacy in treatment of DES
Anxiolytics
62
3 dominant mechanisms of esophagogastric junction incompetence
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
Factors that exacerbate reflux regardless of mechanism
1. Abdominal obesity
2. Pregnancy
3. Gastric hypersecretory states
4. Delayed gastric emptying
5. Disruption of esophageal peristalsis
6. Gluttony
64
2 causes of prolonged acid clearance
1. Impaired peristalsis
| 2. Reduced salivation
65
Extraesophageal syndromes with established association to GERD
1. Chronic cough
2. Laryngitis
3. Asthma
4. Dental erosions
66
Comparison of ulcerations in the ff: Peptic esophagitis, Infectious esophagitis, Eosinophilic esophagitis, Pill esophagitis
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
Most severe histologic consequence of GERD
Barrett's metaplasia
68
On endoscopy, showed tongues of reddish mucosa extending proximally from the GE junction or histopathologically by finding of specialized columnar metaplasia
Barrett's metaplasia
69
Gold standard treatment for high-grade dysplasia in Barrett's esophagus
Esophagectomy
Mortality rate: 3-10%
70
3 categories of lifestyle modifications in GERD therapy
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
The most broadly applicable recommendation for GERD
Weight reduction
72
Dominant pharmacologic approach to GERD management
Inhibitors of gastric acid secretion
*this does not prevent reflux; it allows esophagitis to heal
73
T or F: PPI and histamine 2 receptor antagonists are both superior to placebo and also have equal efficacy
False
PPI are superior to histamine 2 receptor antagonists
74
Side effects of PPI therapy
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
Surgical alternative to management of chronic GERD
Laparoscopic Nissen fundoplication
| proximal stomach is wrapped around the distal esophagus to create an antireflux barrier
76
Diagnosed based on combination of typical esophageal symptoms and esophageal mucosal biopsies demonstrating squamous epithelial eosinophil-predominant inflammation
Eosinophilic esophagitis (EoE)
An immunologic disorder induced by antigen sensitization in susceptible individuals
77
Alternative etiologies of EoE
```
GERD
Drug hypersensitivity
Connective tissue disorders
Hypereosinophilic syndrome
Infection
```
78
Clinical manifestations of EoE
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
Endoscopic findings in EoE
Loss of vascular markings (edema)
Multiple esophageal rings
Longitudinally oriented furrows
Punctate exudate
80
Histologic finding in EoE
Esophageal mucosal eosinophilia (+/-15 eosinophils per hpf)
81
Complications of EoE
Esophageal stricture
Narrow-caliber esophagus
Food impaction
Esophageal perforation
82
Goals of EoE management
Symptom control
| Prevention of complications
83
Treatment of EoE
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
Common causes of Infectious Esophagitis in NONimmunocompromised
1. Herpes simplex
| 2. Candida albicans
85
Common causes of Infectious Esophagitis in IMMUNOcompromised
1. Candida species
2. Herpesvirus
3 Cytomegalovirus (CMV)
Common in CD4 <100, rare if >200
86
Characteristic symptom of INFECTIOUS ESOPHAGITIS
Odynophagia
Other symptoms: dysphagia, chest pain, hemorrhage
87
T or F: Odynophagia is also common in reflux esophagitis
False
88
T or F: Candida is normally found in the throat
True
Becomes pathogenic in a compromised host
89
When is empirical treatment for Candida esophagitis warranted?
If oral thrush is present
90
Indication for prompt endoscopy with biopsy (Candida esophagitis)
Persistent symptoms
91
Characteristic appearance of Candida esophagitis
White plaques with friability
92
Treatment for Candida esophagitis
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
Endoscopic findings in Herpetic esophagitis
Vesicles
| Small punched-out ulcerations
94
Biopsy of Herpetic esophagitis
Ground-glass nuclei
Eosinophilic Cowdry's type A inclusion bodies
Giant cells
95
Treatment for Herpetic esophagitis
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
Esophagitis that occurs primarily among organ transpant recipients
CMV esophagitis
97
Endoscopy findings in CMV esophagitis
Serpiginous ulcers in an otherwise normal mucosa in distal esophagus
98
Pathognomonic finding in biopsy of ulcer bases in CMV esophagitis
Large nuclear or cytoplasmic inclusion bodies
99
Treatment for CMV esophagitis
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
Forceful vomiting or retching can lead to spontaneous rupture at the gastroesophageal junction
Boerhaave's syndrome
101
Site of perforation in esophagus from instruments of endoscopy or NGT
hypopharynx or gastroesophageal junction
102
Pain of esophageal perforation
Pleuritic retrosternal pain
Associated with pneumomediastinum and subcutaneous emphysema
103
Major complication of esophageal perforation
Mediastinitis
104
Most sensitive in detecting mediastinal air
Chest CT scan
105
Confirmation of esophageal perforation
Contrast swallow (Gastrografin) followed by thin barium
106
Treatment of esophageal perforation
NGT suction
Parenteral broad-sepectrum antibiotics with prompt surgical drainage WITH
Prompt surgical drainage AND
Repair in noncontained leaks
107
Surgical treatment if nonoperable iatrogenic perforations or nonoperable perforated tumors
Endoscopic clipping OR
| Stent placement
108
Condition caused by vomiting, retching, or vigorous coughing causing nontransmural tear at the gastroesophageal junction that is a common cause of GI bleeding
Mallory-Weiss Tear
109
T or F: Surgery is always a definitive treatment for Mallory-Weiss Tear
False
Rarely needed
110
Radiation exposure that increases risk of esophageal stricture
5000 cGy
111
Causes of radiation esophagitis
1. Radiation
| 2. Radiosensitizing drugs: Doxorubicin, bleomycin, cyclophosphamide, cisplatin
112
Treatment of radiation esophagitis
Supportive
Chronic: Esophageal dilation
113
Complications of severe corrosive injury
Esophageal perforation
Bleeding
Stricture
Death
114
T or F: Glucocorticoids are recommended to improve the clinical outcome of acute corrosive esophagitis
False
NOT been shown to improve clinical outcome
115
Occurs when a swallowed pill fails to traverse the entire esophagus and lodges within the lumen
Pill-induced esophagitis
116
Most common location for pill to lodge
Mid-esophagus near the crossing or aorta or carina
117
Most common medications implied in pill esophagitis
```
Doxycycline
Tetracycline
Quinidine
Phenytoin
Potassium chloride
Ferrous sulfate
NSAIDs
Biphosphonates
```
118
Typical symptoms of pill esophagitis
Sudden onset chest pain and odynophagia
| Pain develops over a period of hours and awaken individual from sleep
119
Endoscopic findings in Pill Esophagitis
Localized ulceration or inflammation
120
Can be used if food or foreign bodies lodge on esophagus
Glucagon 1mg IV then evaluated for potential causes of impaction
121
Histopathologic findings in scleroderma
Infiltration and destruction of esophageal muscularis propria with collagen deposition and fibrosis
122
Dermatologic diseases that affect oropharynx and esophagus
```
Pemphigus vulgaris
Bullous pemphigoid
Cicatricial pemphigoid
Behcet's syndrome
Epidermolysis bullosa
```
Treatment: Glucocorticoid
