Chapter 89 Esophagus, Stomach, Duodenum

Question 1

List the types of dysphagia?

Answer 1

1) oropharyngeal dysphagia
2) esophageal dysphagia

Caused by M+M: think mechanical or motility

Question 2

List 4 causes of oropharyngeal dysphagia: “immediate or transfer dysphagia”

Answer 2

1) Neuromuscular – swallowing muscles don’t work
- CVA #1 cause!

2)Degenerative aging:
-Alzheimer’s, ALS,
-Diabetic neuropathy,
-muscular dystrophy,
-Parkinson’s, Brain
tumour

3) Immunologic –
- poly/dermatomyositis / MS / Myasthenia Gravis / scleroderma
4) Infectious – botulism, diphtheria, polioMyelitis, rabies, Sydenham’s chorea, tetanus

5)Metabolic –
thyrotoxicosis, lead poisoning, Mg deficiency

6)Obstructive
Dysphagia lusoria

Question 3

List 6 causes of esophageal dysphagia. “Delayed / gets stuck”

Answer 3

Think M and M

A) Mechanical
1) Intrinsic issue:

• strictures, webs, rings, tumours, EsophagitIs, foreign bodies
  2) Extrinsic compression: osteopHytes, mediastinal masses, aortic aneurysm, thyroid goitre

B) Motility

   1) Intrinsic:  Achalasia, diffuse esophageal spasm, hypertensive LES, scleroderma, CREST syndrome, nutcracker esophagus

  2)Extrinsic:   Gastric volvulus   Alcoholism, diabetes, GERD,

Question 4

What are some key questions in the history of someone with dysphagia?

Answer 4

1) immediate vs. delayed swallowing difficulty (i.e. oropharyngeal vs. esophageal problem)
2) solids, liquids or both?
3) intermittent or progressive symptoms (i.e. growing mass)
4) associated symptoms
5) GI history
6) family history

Question 5

What are some key physical exam tests in someone complaining of dysphagia?

Answer 5

1) HEENT
including thyroid
2) Observed swallowing attempt *

• people with neuromuscular disease can’t swallow while prone - they depend on gravity to do the work
• people with oropharyngeal dysphagia (can’t initiate a swallow) will do repeated swallowing attempts during hte exam

Question 6

What are some key fts on history and exam and management for achalasia?

Answer 6

1) Hx: esophageal type of dysphagia - difficulty 2-4 seconds after initiating swallowing
- patient may have delayed regurgitation
- insidious onset with BOTH solids and liquids
- dysphagia better with raising arms above the head/standing straight
- chest/retrosternal pain

2) PEx:
- dysphagia better with raising arms above the head/standing straight
- On barium swallow test: birds/corkscrew beak sign

3) Mx: 
achalasia can get better with : 
- nitrates
-CCBs
-Botox injection 
-surgical dilation

Question 7

List 5 diagnostic tests that may be utilized for dysphagia?

Answer 7

These are RARELY indicated in the ED

1) video esophagography
2) barium swallow
3) manometry
4) impedance monitoring
4) CT - with or without contrast for vascular/malignancy/external compression

Question 8

What are the criteria for admission of a patient with dysphagia in the ED?

Answer 8

1) cannot swallow safely while in the ED: oral trial

2) cannot maintain hydration at home - i.e. cannot tolerate po fluid intake

Question 9

What are 4 areas of narrowing in the esophagus where foreign bodies get stuck?

Answer 9

1) cricopharyngeus (upper esophageal sphincter)
2) aortic arch
3) left mainstem bronchus
4) lower esophageal sphincter (LES) at diaphragmatic hiatus

Question 10

Describe the clinical presentation of esophageal obstruction based on whether complete or partial obstruction? include 3 examples of complete esophageal obstruction

Answer 10

typically: dysphagia, odynophagia, neck/chest pain or epigastric pain
1) complete obstruction = unable to swallow sexretions (spit basin), choking, cough, stridor

Examples:
A) Cafe’s coronary: sudden cyanosis and collapse after a piece of swallowed food lodges int eh airway leading to hypoxic arrest/syncope

B) steakhouse syndrome:
large piece of food (steak) causes complete obstruction of the distal esophagus
(fish bones rarely obstruct the esophagus)

2) Partial obstruction:
usually the case in children who present atypically:
- fever, wheezing, stridor, rhonchi, poor feeding

Question 11

What are some causes of esophageal obstruction?

Answer 11

Think M and M
1) Mechanical factors

a) internal: FB, Strictures (schatzki’s ring), webs, malignancy
b) external factors: large left atrium /ventricle, goiter, mediastinal tumour

2) motility/motor factors: (remember that the distal 2/3 of the esophagus is innervated by involuntary smooth muscle)
achalasia
infectious (botulism, tetanus etc)

Question 12

List 3 therapies for a food bolus?

Answer 12

1) BZ (GABA agonist)
it’s anxiolytic

2) Nitroglycerin (a vasodilator)
- relaxes lower esophageal sphincter tone

3) CCB (nifedipine)
thought to work to relax lower esophageal sphincter tone

Question 13

What are some of the investigations for first diagnosing/finding a foreign body before considering removal?

Answer 13

1) First diagnose the FB:
A) Imaging: AP and lateral radiographs of: neck soft tissues/chest/abdomen (as applicable)
- CT – more sensitive for that elusive fish bone/chicken bone or to look for signs of inflammation/free air.

B) Nasopharyngoscopy → laryngoscopy → endoscopy
c) Contrast swallow studies – are high risk for aspiration / perforation

Question 14

What are the indications for removal of an esophageal foreign body?

Answer 14

1) Large objects: dentures, tooth brush
2) sharp objects
3) button batteries (can cause severe tissue damage in 2 hours)
4) coins lodged in the proximal esophagus
5) complete esophageal obstruction - preventing liquids to pass
6) incomplete obstructions must be removed in 24 hours

Question 15

What are the indications for removal of a gastric foreign body?

Answer 15

Most can be observed conservatively unless:

1) longer >5cm
2) wider > 2.5 cm (cannot leave duodenum)
3) sharp and pointed objects
4) FB remain in stomach for > 3-4 weeks
5) FB remain in same intestinal location > 1 week

Question 16

What is the clinical presentation for someone with esophageal perforation?

Answer 16

odynophagia, 
fever, 
decreased PO intake, chest pain, 
dyspnea, 
hoarseness, 
subcutaneous air

Question 17

What are the possible causes for an esophageal perforation?

Answer 17

1) food (bones, large pieces steak)
2) button batteries
3) coins
4) forceful valsave (i..e vomitting, coughing, heavy lifting, childbirth)
5) Iatrogenic: post EGD, post NG placement, post ETT
6) severe blunt trauma
7) severe esophagitis

Question 18

what is the most common location for esophageal spontaneous perforation?

Answer 18

90% of spontaneous perforations happen in the distal esophagus

Question 19

List 4 CXR findings of esophageal perforation>

Answer 19

CXR finding

1) pneumothorax
2) subc air/emphysema
3) pleural effusion
4) pulmonary infiltrates
5) wide mediastinum

Question 20

What are some other possible investigations for esophageal perforation?

Answer 20

1) Abdominal radiography
2) Gastrograffin swallow (water soluble agent)
3) CT chest
4) Flexible EGD – 100% sensitivity (although has a risk of enlarging a minimal transmural opening due to insufflation of air)

Question 21

What is the ED management of patient with esophageal perforation?

Answer 21

1) Diagnosis: Mackler’s triad: subcutaneous emphysema, chest pain, vomiting = esophageal perf

Misdiagnosis also happen due to presence of both chest and abdo pain

2) Management:
Broad spectrum antibiotics
admission
NPO

Question 22

What are the symptoms and causes of esophagitis?

Answer 22

1)Symptoms:
dysphagia, odynophagia, chest pain, bleeding → hemorrhage → perforation!

2) Causes
1) GERD
2) eosinophilic esophagitiis ( in non-responders to PPI)
3) infection candida (typically int he immunocompromised, HIV
4) FB
5) Toxic ingestion / pill esophagitis from lasrge pill sticking tot eh esophageal wall and can lead to erosions, ulcers strictures
6) post-radiation

Question 23

What are the causes/pathophysiology of GERD?

Answer 23

1) Decreased LES pressure:
a) meds: CCB, nitrates, anticholinergics, BZ
b) fatty meals/chocolate/caffeine/ ethanol/nicotine
c) pregnancy
d) estrogen/progesterone

2) Increased gastric emptying time / Increased intra-abd. Pressure
a) Anticholinergic drugs
b) Pregnancy
c) Obesity
d) Coughing / bending /
e) Supine position
f) Gastroparesis / neuromuscular disease leading to gastric outlet obstruction

3) Decreased esophageal motility

a) Achalasia
b) DM
c) Scleroderma

Question 24

What are possible complications of GERD?

Answer 24

1) Esophagitis
- Progressing to Barrett’s metaplasia, erosion, ulcerations, scarring
- Stricture formation due to persistent scarring and inflammation

2) Reflux induced asthma
- Microaspiration of

3) Adenocarcinoma of the esophagus
4) Esophageal perforation → mediastinitis

Question 25

List 6 lifestyle modifications for patients with GERD and 3 medical therapies?

Answer 25

A) Lifestyle mods:

1) Avoidance of high risk foods (caffeine, chocolate, alcohol, fatty, spicy foods)
2) Weight loss*
3) Smoking cessation
4) Elevation of the head of bed, and avoidance of lying down after meals*
5) Exercise
6) Alcohol cessation

B) medications :

1) Acid neutralization
Milk of magnesia
TUMS
Pepto Bismol – bismuth salts

2) Decrease acid production (most effective)

PPIs
Pantoprazole 20 – 40 mg PO – daily or BID before meals for 4-8 wks.

H2 blockers
Ranitidine 150 mg PO

3) Strengthening LES / motility amplification
Maxeran 10 mg

4) Mucosal protection
Sucralfate 1 g – q 6 hrs (safe in pregnancy!)
Ideally given 30-60 mins before meals.