Chapter 89 Esophagus, Stomach, Duodenum Flashcards
List the types of dysphagia?
1) oropharyngeal dysphagia
2) esophageal dysphagia
Caused by M+M: think mechanical or motility
List 4 causes of oropharyngeal dysphagia: “immediate or transfer dysphagia”
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
List 6 causes of esophageal dysphagia. “Delayed / gets stuck”
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,
What are some key questions in the history of someone with dysphagia?
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
What are some key physical exam tests in someone complaining of dysphagia?
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
What are some key fts on history and exam and management for achalasia?
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
List 5 diagnostic tests that may be utilized for dysphagia?
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
What are the criteria for admission of a patient with dysphagia in the ED?
1) cannot swallow safely while in the ED: oral trial
2) cannot maintain hydration at home - i.e. cannot tolerate po fluid intake
What are 4 areas of narrowing in the esophagus where foreign bodies get stuck?
1) cricopharyngeus (upper esophageal sphincter)
2) aortic arch
3) left mainstem bronchus
4) lower esophageal sphincter (LES) at diaphragmatic hiatus
Describe the clinical presentation of esophageal obstruction based on whether complete or partial obstruction? include 3 examples of complete esophageal obstruction
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
What are some causes of esophageal obstruction?
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)
List 3 therapies for a food bolus?
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
What are some of the investigations for first diagnosing/finding a foreign body before considering removal?
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
What are the indications for removal of an esophageal foreign body?
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
What are the indications for removal of a gastric foreign body?
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
What is the clinical presentation for someone with esophageal perforation?
odynophagia, fever, decreased PO intake, chest pain, dyspnea, hoarseness, subcutaneous air
What are the possible causes for an esophageal perforation?
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
what is the most common location for esophageal spontaneous perforation?
90% of spontaneous perforations happen in the distal esophagus
List 4 CXR findings of esophageal perforation>
CXR finding
1) pneumothorax
2) subc air/emphysema
3) pleural effusion
4) pulmonary infiltrates
5) wide mediastinum
What are some other possible investigations for esophageal perforation?
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)
What is the ED management of patient with esophageal perforation?
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
What are the symptoms and causes of esophagitis?
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
What are the causes/pathophysiology of GERD?
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
What are possible complications of GERD?
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
List 6 lifestyle modifications for patients with GERD and 3 medical therapies?
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.
