Diseases of the Esophagus - GI Flashcards
Diseases of the Esophagus
Heartburn (pyrosis): MC esophageal symptom*
-discomfort, burning sensation behind sternum
-arises from epigastrium, +/-radiate to neck
-typically intermittent
-worsens after eating, lying supine
-often interferes w/sleep
-relieved w/drinking water or antacid med
Regurgitation:
-return of fluid or food into pharynx w/o nausea or retching
-exacerbated by bending, belching
Differentiate from:
-Vomiting: preceded by nausea and associated w/retching
-Rumination: recently swallowed food is regurgitated and then reswallowed repetitively
Chest pain:
-may be difficult to distinguish from cardiac pain w/o complete hx, exam, use of diagnostic tools
-often “pressure” sensation in central chest
-+/- radiate to mid back, arms, or jaw
-MC cause of esophageal chest pain=GERD
Dysphagia:
-difficulty swallowing, food “stuck” or “lodged in throat
-must distinguish if solids, liquids, or both
-must distinguish if intermittent or constant
-*must distinguish if stable or progressive
Odynophagia:
-pain caused or worsened with swallowing
-uncommon w/GERD-if present think about deep ulcer or erosion
Diagnostic studies for Esophageal Disease
Endoscopy:
-AKA Esophagogastroduodenoscopy (EGD)
-Best test for evaluating upper GI tract*
Pros vs. Barium Swallow:
-increased sensitivity->detecting mucosal lesions
-increased sensitivity->detecting lesions w/abnormal color (i.e.-Barrett’s metaplasia)
-ability to obtain specimens for biopsy
-ability to dilate strictures during procedure
Cons vs. Barium Swallow:
-typically requires conscious sedation
Radiography:
-can help to evaluate reflux, hiatal hernia, ulcerations, strictures…
-high sensitivity in high grade esophagitis
Pros vs. Endoscopy:
-increased sensitivity->detecting esophageal strictures
-provide assessment of esophageal function
Cons:
-typically followed by endoscopy to clarify
Endoscopic Ultrasound: (EUS)
-combination of endoscopy and ultrasound
-can help to evaluate tumors, dysplasia in Barrett’s esophagus, and to stage esophageal cancer
Pros vs. Radiography:
-greater resolution of images
-able to guide FNA of lymph nodes or tumor
Esophageal Manometry:
-Pressure sensing catheter measures contraction following swallowing
-Helpful to diagnose disorders of motility (achalasia, spasm)
Reflux Testing:
-Typically unnecessary to diagnose GERD
-Helpful for atypical or refractory sxs
-24-48 hour pH recording w/transmitter in esophagus
-Results based on % of day pH is < 4 (> 5% would be indicative of GERD)
Esophagitis
Esophagitis=inflammation of esophagus
Eosinophilic Esophagitis: (EoE)
Epidemiology: > 1/1000, predilection-white males
Etiology:
-allergic disorder in susceptible individuals
-important role of dietary allergens
-infiltration of esophageal squamous epithelium w/eosinophils
RF’s:
-atopic hx (food allergy, asthma, eczema, allergic rhinitis)
Eosinophilic Esophagitis
Clinical sxs: -dysphagia -heartburn (refractory to PPI) -food impactions -atypical chest pain PE findings: -often normal exam Diagnosis: -EGD->esophageal rings, linear furrows -Histology->dense infiltration of esophageal squamous epithelium w/eosinophils Treatment: -Dietary restrictions -PPI’s -Topical or systemic steroids (severe disease) -Montekulast (Singulair) -Immunomodulators -Endoscopic dilation of strictures Complications: -Food impaction, esophageal rupture
Infectious Esophagitis
- MC*-Immunocompromised: Candida, Herpes, CMV
- Non-immunocompromised: Candida, Herpes
Candida Esophagitis:
Etiology: MC*-Candida Albicans RF’s: Immunocompromised (HIV, Chemo etc.) Clinical sxs: -odynophagia -dysphagia PE findings: -may be accompanied by oral thrush Diagnosis: -EGD w/biopsy->friable white plaques Treatment: -Oral fluconazole x 1-2 weeks -If severe disease and unable to swallow can be treated w/IV meds Complications: -bleeding, perforation, stricture, , systemic infxn
Herpetic Esophagitis
Etiology: HSV 1 or 2, Varicella-zoster virus Clinic sxs: -odynophagia -dysphagia PE findings: -vesicles on nose/lips may be present Diagnosis: -clinical, +/-EGD->vesicles, small ulcerations Treatment: -self-limited -consider oral acyclovir/valacyclovir -if severe disease can treat w/IV meds
CMV Esophagitis
Cytomegalovirus (CMV): Etiology: CMV RF’s: immunocompromised, transplant patients Clinical sxs: -odynophagia +/- chest pain -dysphagia +/-hemorrhage PE findings: -may be signs of poor health Diagnosis: -EGD->serpiginous ulcers-distal esophagus -Histology->antibodies to CMV Treatment: -Ganciclover x 3-6 weeks
Mechanical trauma
Pill Esophagitis:
-Epidemiology: rare, >1000 cases since 1970 (reported)
-Etiology: occurs when a swallowed pill lodges w/in lumen of esophagus
-RF’s: inadequate liquid, lying down after taking pill-
MC*-NSAIDS, tetracyclines, bisphosponates
Clinical sxs:
-CP (over hours or awaken from sleep)
-odynophagia
PE findings:
-likely normal
Diagnosis:
-EGD->localized ulceration or inflammation
-Chest CT-> +/- esophageal thickening
Treatment:
-typically resolves w/in days-wks, occ. Months
-antacids to remove reflux (aggravator)
Complication:
-stricture may form, if so->dilation
Mallory Weiss Tear
-transmural tear at gastroesophageal junctionupper GI bleed Etiology: -vomiting, retching, vigorous coughing RF’s: -alcoholism -eating disorders Clinical sxs: -hematemesis following vomiting/retching -+/-melena PE findings: -possible signs of underlying disease -vomiting/retching Diagnosis: -clinical suspicion -EGD (definitive) Treatment: -MC*-spontaneous resolution (+/- hospitalized) -prolonged bleeds->cauterization or epi, embolization and surgery rare
Esophageal Varices
-dilated submucosal veins in the lower part of esophagus
Etiology:
-portal HTN (occurs when blood flow to liver slows down and backs up into smaller vessels)
RF’s:
-viral hepatitis
-alcoholic liver disease (cirrhosis)
-nonalcoholic steatohepatitis (NASH)
Clinical sxs:
-often asymptomatic
-if severe->hemetemasis, melena, +/-shock
PE findings:
-typically normal exam
Diagnosis:
-EGD* (diagnostic tool of choice)
-Others to consider: endoscopic US, CT, MRI, capsule endoscopy
Treatment:
-Spontaneous resolution (approx. 50% of pts)
-Endoscopic band ligation* (tx of choice)
-Sclerotherapy (med injected to shrink veins)
-TIPS (shunt placement for recurrent bleeds)
-Prevention: BB’s, ligation
Complications:
-Re-bleeding
-Mortality
Motility Disorders of Esophagus
Motility Disorders: neuromuscular dysfunction
Major entities include:
-achalasia, diffuse esophageal spasm, GERD
Achalasia:
Epidemiology: rare, 1:100,000, MC-age 25-60 yo
Etiology:
-ganglion cell degeneration
-presumed to be autoimmune secondary to latent HSV 1 infection + genetic susceptibility
Clinical sxs:
-dysphagia (solids & liquids)
-regurgitation
-chest pain (secondary to spasm)
-weight loss
PE findings:
-may be normal, WL
Diagnosis:
-Barium swallow-> dilated esophagus w/poor emptying, tapering of LES ( “beak-like”)
-Esophageal manometry->impaired LES relaxation and absent peristalsis
Treatment: No known tx to reverse achalasia*
-Goal: decrease LES pressure->promotes emptying
-Ways to decrease LES pressure:
-meds (temporary-nitrates, CCB, Botox)
-pneumatic dilatation or surgical myotomy
Complications:
-pneumonia or lung abscess (aspiration/regurg)
-esophageal SC carcinoma
Diffuse Esophageal Spasm (DES)
Diffuse Esophageal Spasm:
-abnormal esophageal contractions w/normal LES relaxation
Etiology: unknown
Clinical sxs: occur in episodes
-dysphagia
-chest pain (often mimics angina)
-+/-heartburn, dysphagia, regurgitation
PE findings:
-may be normal
Diagnosis:
-Manometry-(best test to diagnose*)-abnormal contractions
-EGD-used to r/o other GI differentials
-Barium swallow-> “corkscrew esophagus”, may also be present in achalasia
Treatment:
-meds: +/-nitrates, CCB, botox, anxiolytics
-Surgical measures-rare, only if severe WL or untolerable pain
Hiatal Hernia
herniation of stomach through diaphragm
MC*: Type 1-Sliding hiatal hernia (95%)
-Enlarge w/increased intraabdominal pressure
RF’s: age, obesity, pg, hereditary factors
Clinical sxs:
-asymptomatic
-heartburn
Diagnosis:
-x-ray or endoscopy->sac above diaphragm
Treatment:
-GERD tx, rarely surgery for sliding-unless severe
Complications:
-possible slight increased riskBarrett’s esophagus
Tumors
Esophageal Cancer Epidemiology: 4.5: 100,000 in the US Very high MORTALITY* RF’s: -chronic GERD -age > 50 -Barrett’s metaplasia -Caucasian -smoking -males -alcohol -HPV -elevated BMI -caustic injury (corrosion when in contact w/strong acid or base) -adenocarcinoma->white males (distal esophagus) -SCC->black males (proximal esophagus) Clinical sxs: -progressive solid food dysphagia -weight loss -+/-odynophagia, iron def., hoarseness, vomiting PE findings: -possible WL Diagnosis: -EGD w/biopsy, +/- barium swallow -CT and PET for staging Tx: -surgery, chemo, radiation (depending on stage)
Barrett’s Esophagus
-condition in which metaplastic columnar epithelium replaces stratified squamous epithelium
-Precursor->esophageal carcinoma* (adenocardinoma)
Epidemiology:
-middle-aged, older adults (55 yo-avg onset)
-higher incidence in Caucasians, males 2:1
-estimates in gen population widely vary (0.4-20)
Etiology:
-chronic GERD
-genetics ? (no clear evidence to support)
RF’s:
-+/-strictures, age, obesity, chronic GERD
Clinical sxs:
-GERD: heartburn, dysphagia, regurgitation
PE findings:
-often normal exam
Diagnosis:
-EGD-> must reveal 2 findings:
1. columnar epithelium-distal esophagus
2. biopsy specimens->metaplasia
Treatment:
-Treat underlying GERD w/PPI
-EGD surveillance
-6-12 mos w/verified low-gr dysplasia
-1 yr after diagnosis if questionable bx
-3-5 yrs if no dysplasia on initial EGD
-Treat dyplasia
-low grade-consider ablation, cryotherapy
-high grade-endoscopic eradication (resection, photodynamic therapy, ablation)
-esophagectomy (high mortality)
Screening: (guidelines vary)
-Pts w/at least weekly GERD sxs x 5 yrs + risk factors for esophageal adenocarinoma
-Unnecessary in pts <50 yrs old
Esophageal Strictures
-narrowing of the esophagus Etiology: -chronic GERD (acidscarring) -previous surgery on esophagus -radiation therapy -swallowing harmful substance (cleaner, battery) -cancer -eosinophilic esophagitis Clinical sxs: -dysphagia -heartburn -acidic taste in mouth -stomach or chest pain -hoarseness -cough PE findings: -often normal exam Diagnosis: -EGD -+/-Barium swallow Treatment: -esophageal dilatation* (tx of choice) w/EGD -PPI to help area heal and prevent recurrence -refractory cases-consider temporary stent
