Clinical Approach to the GI Patient: Dysphagia Flashcards
what are the two types of dysphagia?
oral phase and esophageal phase
what could it mean if a patient presents with Hoarseness and dysphagia?
involvement of the larynx in the primary disease process, neoplastic disruption of the recurrent laryngeal nerve, or laryngitis from GERD
what exams should you do for dysphagia?
neck exam and skin exam (to see if there are any changes with association with scleroderma)
how can you diagnose oropharyngeal dysphagia?
video fluoroscopy of swallowing
how can you diagnose esophageal dysphagia?
barium swallow, EGD with biopsy, esophageal motility study (manometry)
what are the characteristics of oropharyngeal dysphagia?
difficulty initiating swallowing; food sticks at level of suprasternal notch; may have nasopharyngeal regurgitation or aspiration
what type of abnormality is Zenker’s diverticulum?
structural abnormality
what occurs in Zenker’s diverticula?
there is a false diverticula involving herniation of the mucosa and submucosa through the muscular layer of the esophagus posteriorly
in zenker’s diverticula, where does the herniation take place?
posteriorly in an area of natural weakness proximal to the cricopharyngeus known as Killian’s triangle
what is the result of Zenker’s diverticula?
there is loss of elasticity of the upper esophageal sphincter
how does zenker’s diverticula oropharyngeal dysphagia present?
progressive, intermittent then constant, solids and liquids
what are the symptoms associated with zenker’s diverticula?
gradual/insidious; vague symptoms at first–> coughing or throat discomfort; as diverticulum enlarges it will retain food leading to halitosis, spontaneous regurgitation, nocturnal choking, gurgling in the throat, protrusion in the neck, voice changes; palpable mass on the side of the patient’s neck?
how do you diagnose zenker’s diverticula?
video esophagography; barium swallow; DO BARIUM SWALLOW BEFORE EGD due to risk of perforation; EGD
what are the complications associated with zenker’s diverticula?
perforation (if EGD is done before barium swallow); weight loss; aspiration–> PNA/ lung abscess
what is an esophageal web?
a structural problem; thin, diaphragm-like membranes of squamous mucosa; congenital or acquired
where do esophageal webs occur?
proximal or mid esophagus (not the entire lumen)
when might you acquire esophageal webs?
eosinophilic esophagitis or plummer vison syndrome
what are the symptoms associated with esophageal webs?
it can cause oropharyngeal or esophageal dysphagia (if proximal–> oropharyngeal)
what are the characteristics of the presentation of esophageal webs?
dysphagia to solids, intermittent symptoms, not progressive
how do you diagnose esophageal web?
barium swallow (esophagram)–> best view; EGD can be done but it is less sensitive
what is the treatment/management for esophageal webs?
dilation (bougie dilator or pneumatic dilation); small endoscopic electrosurgical incision; persistent heartburn or need repeat dilation–> PPI long term
what population is at risk for plummer-vinson syndrome?
middle-aged, female>male
what is plummer-vinson syndrome?
combination of: symptomatic proximal esophageal webs, Koilonychia (spoon nails); angular chelitis; glossitis; iron-deficiency anemia
what is sjogren syndrome?
autoimmune/rheumatologic cause of oropharyngeal dysphagia; motility/propulsion problem; exocrine gland problem
what are the characteristics of the presentation of sjogren’s syndrome?
female> male, mid 50s, post menopausal; constant, not progressive, solids
what are the symptoms in sjogren’s syndrome cause by?
sicca symptoms (DRY)–> dry mouth, parotid or other major salivary gland enlargement; dry eyes
how do you diagnose sjogren syndrome?
minor salivary gland biopsy, salivary and tear production (Schirmer) testing, and serology: polyclonal hypergammaglobulinemia, anti Ro and anti La
what are the complications associated with sjogren’s syndrome?
increased incidence of oral infection (oral and esophageal candida); dental caries; strong association with B-cell non-Hodgkin lymphoma
what are the characteristics of esophageal dysphagia?
food sticks in the mid to lower sternal area; may have regurgitation, aspiration, or odynophagia; both solids and liquids
what is schatzki’s ring?
structural problem; smooth, circumferential, thin mucosal (band) structures, distal; GERD might be a possible etiology
what is schatzki’s ring associated with?
hiatal hernia
what are the characteristics of presentation of schatzki’s ring?
esophageal dysphagia, solids, intermittent symptoms and not progressive; reflux symptoms are common; steakhouse syndrome
what is steakhouse syndrome?
large, poorly chewed food bolus (like steak) is a typical instigator
how do you diagnose schatzki’s ring?
barium swallow (esophagram)–> best view; EGD can be done but is less sensitive
how do you treat schatzki’s ring?
dilation (bougie dilator or pneumatic dilation); small endoscopic electrosurgical incision; persistent heartburn or need repeat dilation–> PPI long term
what are the complications associated with schatzki’s ring?
food bolus impaction–> perforation or ulcer
what is an esophageal stricture?
structural problem; most common is peptic secondary to GERD, also can occur because of eosinophilic esophagitis, caustic ingestions, and radiation therapy
where are most of the esophageal strictures located?
at the gastroesophageal junction
how does an esophageal stricture present?
esophageal dysphagia, heartburn and potential weight loss, gradual (months-years); progressive; solids–> solids and liquids
what happens as an esophageal stricture progresses?
reflux/heartburn lessens/improves because the stricture acts as a barrier to reflux
how do you diagnose esophageal stricture?
barium swallow; endoscopy (EGD) with biopsy
what is mandatory in all cases of esophageal stricture?
endoscopy (EGD) with biopsy- to differentiate peptic stricture from stricture by esophageal carcinoma
what is the treatment/management of esophageal strictures?
pneumatic dilation at the time of endoscopy (EGD); long-term therapy with a proton pump inhibitor
What is barrett esophagus?
specialized intestinal (metaplastic) columnar metaplasia that replaces the normal squamous mucosa of the distal esophagus; proximal displacement of the squamocolumnar junction
what are the risk factors for barrett esophagus?
it is a complication of GERD; truncal obesity
what can barrett esophagus progress to?
esophageal adenocarcinoma
who is the group at greatest risk for barrett esophagus?
obese white males older than 50 who smoke
what are the symptoms of barrett esophagus?
BE, in and of itself, does not provoke specific symptoms–> GERD has symptoms; so they patient may have a long history of reflux symptoms
how do you diagnose barrett esophagus?
if a person has the risk factors for it, screening EGD for barrett esophagus should be considered; EGD with biopsy
when is the EGD positive for barrett esophagus?
when there is a presence of orange, gastric type epithelium that extends upward from the stomach into the distal 1/3 tubular esophagus in a tongue-like or circumferential fashion
when will a biopsy of barrett esophagus be positive?
if there are goblet and columnar cells
what is the treatment/management of barrett esophagus?
acid reduction (PPI»H2 receptor antagonist (control reflux symptoms and may reduce the risk of cancer; but does not appear to cause regression of barrett esophagus); endoscopic ablation: high grade dysplasia or intramucosal adenocarcinoma; surgical resection (esophagectomy–> high morbidity and mortality: NOT recommended)
how often should a surveillance endoscopy be performed for barrett esophagus?
every 3-5 years for those who have BE or have a high risk of CA; you are monitoring for adenocarcinoma
what are the risk factors for adenocarcinoma?
chronic GERD, hiatal hernia, obesity, white race, male gender, and age older than 50
what type of abnormality is squamous esophageal cancer?
structural problem
what is the most common type of esophageal cancer in the world?
squamous esophageal cancer
what are the risk factors for squamous esophageal cancer? (environmental/ habbits)
smoking, alcohol use (smoking+ alcohol= synergistic)
what esophageal disorders are a risk factor for squamous esophageal cancer?
achalasia, HPV, plummer-vinson syndrome, tylosis
what caustic esophageal disorders are a risk factor for squamous esophageal cancer?
chemical or thermal injury: caustic ingestion, hot beverages, radiation (5-10 years ago), Betel nuts
how does squamous esophageal cancer present?
progressive dysphagia–> solid food and then solid and liquid food; males»females, african americans»> Caucasians; weight loss and anorexia; pyrosis, bleeding
how do you diagnose squamous esophageal cancer?
EGD with biopsy: middle 1/3 of the esophagus
what is the treatment/management for squamous esophageal cancer?
surgery (esophagectomy)
what is the prognosis like for squamous esophageal cancer?
even when detected as a small lesion, esophageal cancer has poor survival because of the abundant lymphatics leading to regional lymph node metastases
what type of abnormality is adenocarcinoma esophageal cancer?
structural problem
what is the most common type of esophageal cancer in the USA?
adenocarcinoma
what are the risk factors for adenocarcinoma esophageal cancer?
obesity, smoking, achalasia; GERD–> barrett metaplasia–> dysplasia–> adenocarcinoma
what is the typical presentation for adenocarcinoma esophageal cancer?
progressive dysphagia (solid food–> solid and liquid); males> females, caucasians> african americans; >50 years old; weight loss, pyrosis, bleeding
how do you diagnose adenocarcinoma esophageal cancer?
EGD with biopsy: distal 1/3 of esophagus
what would the biopsy look like in a patient with adenocarcinoma esophageal cancer?
squamous–> columnar epithelium
what is the treatment/management for adenocarcinoma esophageal cancer?
endoscopic therapy (ablation) (esophagectomy used to be, but has a high morbidity and mortality rate)
what type of abnormality is achalasia?
motility abnormality–> propulsion problem
what occurs in achalasia?
loss of peristalsis (distal 2/3) and failure of deglutitive lower esophageal sphincter relaxation; denervation of the esophagus resulting primarily from loss of nitric oxide-producing inhibitory neurons (ganglion cells) in the myenteric plexus
what is the relationship between achalasia and age?
incidence increases with age
who is at risk for secondary achalasia?
chagas disease–> patients from endemic regions (mexico, central and south america
how does achalasia present?
gradual onset (months-years); progressive; solids and liquids; regurgitation of undigested foods; nocturnal regurgitation; substernal chest discomfort; they describe adaptive maneuvers (eating slowly and lifting the neck or throwing the shoulders back to enhance esophageal emptying)
what might the physical exam show in a patient with achalasia?
weight loss; for secondary achalasia: swelling, romana sign, arrhythmias, and fever
what is romana sign?
seen in secondary achalasia: unilateral painless swelling around the eye
how do you diagnose achalasia?
labs: peripheral blood smear shows Trypsanosoma cruzi parasite (if it is secondary); barium esophagram; EGD: ALWAYS PERFORMED; biopsy; esophageal manometry: CONFIRMS DIAGNOSIS
what does a barium esophagram show for patients with achalasia?
“bird’s beak” smooth, symmetric tapering of the distal esophagus; characteristic findings: esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying
why is an EGD always performed in cases of achalasia?
to exclude a distal stricture or a submucosal infiltrating carcinoma
what does a biopsy of achalasia show?
loss of ganglion cells within the esophageal myenteric plexus
what confirms diagnosis of achalasia?
esophageal manometry; it shows complete absence of normal peristalsis and incomplete lower esophageal sphincter relaxation with swallowing
what is the treatment/management for achalasia?
reduce LES pressure using nitrates and calcium channel blockers or botulinum toxin injection during endoscopy; pneumatic balloon dilation (risk of perforation or bleeding); surgery; antiparasitic treatment in chagas
what happens if you don’t treat achalasia?
without treatment the esophagus may become markedly dilated
what type of abnormality is scleroderma?
a motility abnormality: propulsion problem
what is scleroderma?
it is an autoimmune disease (smooth muscle fibrosis)
what is the presentation of scleroderma?
30-60 years old, female> male, progressive, esophageal dysphagia (mainly solids but some liquids)
what are the symptoms associated with diffuse scleroderma?
chronic heartburn (incompetent LES–> reflux esophagitis or stricture); malnutrition, xerostomia, dysphagia, gastroparesis, GAVE syndrome, chronic diarrhea
what are the symptoms associated with limited scleroderma?
CREST syndrome: calcinosis cutis, raynaud’s, esophageal dysmotility, sclerodactylt, telangiectasias
how do you diagnose scleroderma?
labs: serology: topisomerase I antibodies (Scl-70) for diffuse scleroderma; anti-centromere antibodies for limited scleroderma; barium esophagram; EGD can be done
what is the treatment/management for scleroderma?
no approved disease modifying therapy; control symptoms (PPI) and slow progression to improve quality of life and prolong survival
