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Pathophysiology - Gastrointestinal > Clinical Aspects of Esophageal Diseases > Flashcards

Clinical Aspects of Esophageal Diseases Flashcards

1
Q

What forms the upper and lower esophageal sphincters?

A

Upper - primarily the cricopharyngeus muscle, with some contribution from the inferior constrictor muscle

Lower - Specialzed region of circular smooth muscle of distal esophagus

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2
Q

Where does the upper 1/3, middle 1/3, and lower 1/3 of the esophagus drain its lymph?

A

Upper 1/3 - Deep cervical nodes

Middle 1/3 - Mediastinal nodes

Lower 1/3 - Gastric and celiac nodes

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3
Q

Where is the venous drainage from from the upper 1/3, middle 1/3, and lower 1/3 of the esophagus? Where does the portal system connect?

A

Upper 1/3 - Superior vena cava via inferior thyroid veins

Middle 1/3 - azygous system

Lower 1/3 - portal system via left gastric vein (coronary vein), which forms an anastamosis with the azygous system

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4
Q

Why is it so easy for cancer to metastasize from the esophagus?

A

Serosa is absent from the surface

-> no defined layer separating it from the surrounding tissues

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5
Q

What are the two plexuses found in the wall of the GI tract? Where are they located and what is their function?

A

Meissner’s - subMucosal - receive sensory input from esophageal wall layers

Auerbach’s - myenteric - sits between IC and OL layers of muscularis propria -> coordinates perstalsis

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6
Q

What is the usual first procedure done in the workup of dysphagia?

A

Barium esophagogram

X-ray of esophagus after barium swallow
-> excellent and safe evaluation allowing planning before more invasive tests

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7
Q

What is an esophagogastroduodenoscopy (EGD)? What is it good for? Is it invasive?

A

Using an endoscope to directly visualize the esophageal lumen

-> shows mucosal disease but not function of an organ. Also allows biopsy, culturing, and some therapeutic manuevers

Invasive since patient has to be under anesthesia, but is safe.

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8
Q

What is endoscopic ultrasound useful for?

A

Ultrasound which shows all the layers of the esophageal wall and associated structures

Useful for possible biopsy as well as visualization of what layer of the wall a mass is in

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9
Q

What is the definition of “transfer” as it relates to swallowing?

A

Bolus propulsion into posterior pharynx and proximal esophagus, past the UES

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10
Q

What are the three types of peristaltic waves and what initiates them?

A

Primary - propulsive -> initiated by swallow

Secondary - propulsive, initiated by stretch and material in the lumen (from behind the bolus)

Tertiary - nonpropulsive and uncoordinated contractions

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11
Q

What is the definition of “transport” as it relates to swallowing?

A

Peristalsis propels food through esophagus into stomach

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12
Q

How does esophageal manometry work?

A

Evaluates motility and pressure at various points in the esophagus, demonstrating peristalsis and sphincter function.

Lower pressures indicate relaxation, higher pressures indicate peristaltic or tonic contractions

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13
Q

What is impedance testing good for with manometry?

A

Tests actual proper functioning of esophageal transport -> impedance will decrease as food actually travels with peristalsis. Should travel in accordance to the generated high resolution manometry

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14
Q

How is pH monitoring done now with manometry?

A

Can put a telemetric capsule which measures the pH over 24-48 hours

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15
Q

What is dysphagia vs odynophagia?

A

Dysphagia - Swallowing difficulty - food gets stuck due to mechanical or motor lesion in esophagus

Odynophagia - painful swallowing, usually indicates inflammation

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16
Q

What is transfer dysphagia?

A

Also known as oropharyngeal dysphagia, it is difficulty swallowing due to failure of bolus transfer from mouth to esophagus

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17
Q

What are neurologic and striated muscle disorders which can cause transfer dysphagia?

A

Neurologic - strokes, botulism

Striated muscle - Polymyositis, myasthenia gravis -> poor bolus formation and difficulty propelling food

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18
Q

What are disorders of the UES which can cause transfer dysphagia?

A

Cricopharyngeal achalasia - UES won’t open

Zenker’s diverticulum - food entering weakspot in UES, worsened by cricopharyngeal achalasia (high pressures)

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19
Q

What type of dysphagia is achalasia and why does it occur?

A

Transport dysphagia

Occurs because LES fails to fully relax after swallow
-> esophageal contractions are often uncoordinated or absent as well, leading to absent persitalsis

20
Q

What are the clinical features of achalasia? Include the diagnostic finding.

A

Dysphagia for both solids and liquids

Putrid breath - halitosis

“Bird-beak sign” on barium swallow study

High LES pressure on esophageal manometry

21
Q

What is happening pathologically to cause achalasia?

A

Loss of Auerbach’s (myenteric) plexus, with preferential loss of inhibitor neurotransmitters like NO and VIP -> tonically increased sphincter contraction

Vagal fibers also degenerate -> decreased overall peristalsis, with esophageal dilatation

22
Q

What can cause achalasia?

A

Primary - neurological degeneration

Secondary - Chagas disease, viral infection, autoimmune diseases

23
Q

What are two possible complications of achalasia?

A
  1. Epiphrenic diverticulum - just above LES, due to increased pressures
  2. Squamous cell esophageal cancer - due to chronic irritation
24
Q

What is pseudoachalasia?

A

Achalasia caused by carcinomas of the proximal stomach
-> may infiltrate Auerbach plexus by mass effect or cause ganglionic destruction by paraneoplastic secretion

-> EGD is needed to make this diagnosis in the presence of achalasia

25
Q

What is diffuse esophageal spasm (DES) and how does it differ from achalasia?

A

Disorder of esophageal motility where peristalsis is replaced by a series of repetitive, non-propulsive, high amplitude contractions

Major difference from achalasia: Peristalsis and LES function are preserved. They are really opposite ends of the spectrum.

26
Q

What is the clinical presentation of DES and what precipitates it?

A

Dysphagia and chest pain

Made worse with emotional stress and by drinking very hot or cold liquids.

Symptoms are intermittent, and the underlying cause is unknown

27
Q

How is diagnosis of DES made?

A

Corkscrew appearance of barium esophagogram, or peaked waves on manometry

-> often very difficult to catch though because the spasm is intermittent

28
Q

What is nutcracker esophagus and what will manometry show?

A

Esophagus with extremely high pressure peristaltic contractions

Causes chest pain for patients - manometry shows high amplitude peristalsis

29
Q

What characterizes sclerodermal esophageal dysmotility (the E in CREST)?

A

Smooth muscle (distal 1/2) infiltration and atrophy from collagen deposition

  • > Decreased LES pressure (always open)
  • > minimal or aperistalsis (dysmotility)
30
Q

What are the early and late manifestations of sclerodermal esophageal dysmotility?

A

Early - passage of solids / liquids is stopped due to aperistalsis. GERD symptoms worse when supine

Late - Esophagitis with benign stricture causes late dysphagia for solids

31
Q

How will the symptoms progress in mechanical obstruction of the esophagus?

A

Symptoms are due to progressive narrowing of the lumen -> solid food will be harder to swallow than liquids

32
Q

What type of esophagitis is often seen in children and young adults which can lead to food impaction and dysphagia (mechanical obstruction)? What type of inflammation is associated?

A

Eosinophilic esophagitis

-> allergic inflammation associated with many eosinophils, likely a reaction to some food

33
Q

What gross pathology is seen in eosinophilic esophagitis?

A

Mucosal ring and small eosinophilic abscesses, usually biopsied at mid-esophageal level

34
Q

Give several general etiologies of mechanical obstruction of the esophagus.

A

Strictures

Webs/rings

Neoplasms

Diverticula

35
Q

What modalities are used in the treatment of tumors causing dysphagia and their success rate?

A

Surgery, chemo and radiation

Poor success, but often used in palliation

36
Q

How do the palliative techniques of dilation, laser ablation, photodynamic therapy, and stenting work?

A

Dilation - mechanical stretching by balloon

Laser ablation - tissue obstruction

Photodynamic therapy - sensitize tumor to a light wavelength using drug, then expose to light

Stenting - use a semirigid tube to prevent obstruction

37
Q

How is eosinophilic esophagitis treated?

A

Swallowing of inhaled corticosteroids, PPI’s, elimination of triggering food

38
Q

How is transfer dysphagia treated?

A

Depending on the cause. I.e. treatment of neuromyopathies like dermatomyositis or MG (immunosuppressants or anti-Ach-E)

Treatment of UES dysfunction via myotomy (incision of sphincter muscle) or Botulinum toxin (botox) for cricopharyngeal achalasia

Altering food consistency if post-stroke / postsurgical

39
Q

How can speech therapists play a role in the treatment of dysphagia?

A

Speech therapists also help with “swallowing training” -> help correct lack of initial peristalsis

40
Q

What are the treatments for achalasia?

A

Forceful “pneumatic dilation” to split muscles of LES via a balloon for more permanent relief, but risk perforation.

May also do a surgical myotomy as a permanent procedure, but risk development of GERD. Always done if there is a perforation which occurs.

41
Q

What is the treatment for odynophagia?

A

Topical anesthetics, and treatment of underlying cause of inflammation

Often, start taking the locally toxic drugs causing the inflammation with LOTS of fluids

42
Q

What are the mechanical / lifestyle treatments of GERD?

A

Mechanical - elevate head of bed

Lifestyle - eat smaller meals, lose weight, stop smoking / alcohol, avoid fatty foods which decrease gastric emptying, reduce excess caffeine which lowers LES pressure

43
Q

You know most of the antacids, H2 blockers, and PPIs used in the treatment of GERD. Give one prokinetic agent which can be used to improve LES tone in GERD?

A

Metoclopramide - D2 receptor antagonist, promotes gastric emptying

44
Q

What is the surgical treatment for persistent GERD when all other measures fail?

A

Fundoplication - take the fundus of the stomach and wrap it around the distal esophagus

45
Q

What do you use to treat spastic conditions of the esophagus and what must be ruled out first?

A

Nitrates, calcium channel blockers, tricyclics

r/o cardiac disease first before starting all these cardiac-active drugs

46
Q

What is pyrosis?

A

Heartburn - burning sensation in lower esophagus spread into the upper chest after heavy meals or when lying down

Pathophysiology - Gastrointestinal (24 decks)

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