Achalasia/hiatal herna/gastritis Flashcards
Esophagus
general
Made up of an outer longitudinal muscle layer and an inner circular muscle layer
Circular muscle fibers: allowperistalsis
Upper ⅓ ofesophagus: predominantlyskeletal muscles
Lower ⅔ ofesophagus:smooth muscles become more dominant from the middle to the distalesophagus
Auerbach plexus (Myenteric plexus)
general
Between the circular muscle layer and the longitudinal muscle layer in the loweresophagus, stomach, and intestines
Responsible for the peristaltic movement of the bowels
Can act independently from the central nervous system
achalasia
general
Difference between major and minor
Rare, neurogenic esophageal motility disorder
Age 25-60 years
Male = female
Pathological features:
Failed relaxation in the lower esophageal sphincter (LES) during swallowing (MAJOR)
Impaired peristalsis in the lower 2/3 of the esophagus (minor)
achalasia
causes
Degeneration of myenteric plexus ganglia in the lower esophagus
Viral and autoimmune factors are suspected; appear there is a genetic predisposition (familial cases)
achalaisa
complications
Aspiration pneumonia: from regurgitation
Megaesophagus in 10% of cases
Increase in size affects the transport of food
Increased risk ofesophageal cancer
Food stasis, bacterial overgrowth, and chronic inflammation
achalasia
primary vs secondary
Primary – no known cause
Secondary
Due to diseases that cause esophageal motor abnormalities
Malignancy (esophageal, gastric, or other extraesophageal cancers) by mass effect
Chagas disease
Caused by a protozoan parasite(Trypanosoma cruzi)
Seen in Central and South America
Infiltrative disorders: amyloidosis, sarcoidosis
Eosinophilic esophagitis
MEN type 2B
achalasia
S/Sx
Onset is insidious
Dysphagia (progressive)
Major symptom
Solids → liquids
Nocturnal regurgitation of undigested food
May cause a nocturnal cough or lead to aspiration pneumonia
Heartburn (pyrosis)
Retrosternal pain
Spontaneous or with swallowing
Weight loss (mild to moderate)
Vomiting
achalasia
Upper endoscopy
Upper endoscopy – performed first
Esophageal dilation
Rule out any obstructing lesions or malignancy
Classic “pop” when the endoscope passes into the stomach
achalasia
High-resolution manometry with esophageal pressure topography (EPT)
Gold standard test
Pressure: represented by color (↑ intensity of color = ↑ pressure)
Demonstrates the following:
Incomplete relaxation of the LES after swallowing
High LES resting pressure
Aperistalsis in the lower 2/3 of the esophagus
achalasia
Barium swallow
Barium swallow
Complementary test in equivocal manometric findings
May show the absence of progressive peristaltic contractions during swallowing
Upper esophagus is dilated, but is narrowed and “beak-like” at the LES
Pathognomonic
Delayed emptying of the barium
achalasia
Tx goal
No therapy will restore peristalsis
Goal of treatment is to reduce the pressure at the LES and allow for the passage of ingested material
achalasia Tx options
Pneumatic balloon dilation of the LES
circumferential stretching
achalsia Tx options
Surgical myotomy of the LES
Muscles of the LES are cut to allow food and liquids to pass to the stomach (relieves pressure)
Complication of treatment – esophageal perforation and/or gastroesophageal reflux
Hiatal hernia
general
Protrusion of the stomach through the diaphragmatic hiatus
Common condition
Increased incidence with advancing age
two types:
Sliding
Paraesophageal
Sliding hiatal hernia
Most common (~95%)
Gastroesophageal junction and a portion of the stomach are above the diaphragm
Paraesophageal hiatal hernia
Higher risk condition
Gastroesophageal junction is in the normal location, but a portion of the stomach is adjacent to the esophagus in the diaphragmatic hiatus
hiatal hernia
Pathogenesis
The distal end of the esophagus is anchored to the diaphragm by the phrenoesophageal membrane
hiatal hernia
Causes
Repetitive stress (swallowing, abdominal straining, vomiting) causes wear and tear on the phrenoesophageal membrane
Tonic contraction of the esophageal longitudinal muscle induced by gastroesophageal reflux and mucosal acidification causing stress on the phrenoesophageal membrane
Hiatal hernia
S/Sx
Majority of patients are asymptomatic
Symptoms:
Chest pain
Dysphagia
Reflex symptoms – heartburn, cough, belching
Incidental finding on x-ray in >40% of the population
hiatal hernia
Dx
3 options
Barium swallow
Best study for discovering a small hiatal hernia
Chest x-ray- Incidental finding on x-ray in >40% of the population
Upper endoscopy