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A1-G Surg Note Esophagus > Disorders of Esophageal Motility > Flashcards

Disorders of Esophageal Motility Flashcards

1
Q

What symptoms may patients with esophageal motility disorders present with?

A

chest pain, dysphagia, regurgitation, heartburn, globus sensation, upper respiratory complaints, or a combination of these.

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2
Q

Why is it necessary to rule out other conditions in patients with esophageal motility disorder symptoms?

A

These symptoms are nonspecific, and esophageal motility disorders are rare, so ruling out life-threatening conditions like cardiovascular and pulmonary causes is important, Also Psychiatric Hx

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3
Q

What common gastrointestinal condition can cause noncardiac chest pain and should be considered in the workup of esophageal motility disorders?

A

Gastroesophageal reflux disease (GERD)

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4
Q

What initial treatment may be tried in patients with symptoms of esophageal motility disorders, and what should be done if symptoms persist?

A

A trial of proton pump inhibitors (PPIs) may be used, and further diagnostic testing should be done if symptoms persist.

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5
Q

What associated symptoms should raise suspicion for a mechanical or malignant process in patients with esophageal motility disorders?

A

Dysphagia with weight loss should raise concern for a mechanical or malignant process, prompting an expedited evaluation

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6
Q

Diagnostic Testing

A

contrast esophagram
pH study
endoscopy
High-resolution manometry (HRM) with esophageal pressure topography

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7
Q

Chicago Classification

A

See Pic

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8
Q

What are some potential intrinsic and extrinsic causes of Esophagogastric Junction Outflow Obstruction (EGJOO)

A

hiatal hernia
peptic stricture
stiff esophageal body from scarring or radiation
prior surgeries
pseudoachalasia from malignancy
vascular obstruction from a diseased aortic arch.

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9
Q

What diagnostic tools are recommended for EGJOO when manometry findings suggest vascular or malignant causes?

A

Endoscopic ultrasonography (EUS) or computed tomography (CT) is recommended for further evaluation

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10
Q

How is idiopathic EGJOO differentiated from achalasia on high-resolution manometry (HRM)?

A

incomplete relaxation of the esophagogastric junction (EGJ)
elevated integrated relaxation pressure and intrabolus pressure, in the presence of preserved peristalsis

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11
Q

What recent update was made in Chicago Classification v4.0 regarding the diagnosis of EGJOO?

A

Diagnosis of EGJOO should be supported by both manometric findings and clinical symptoms
(e.g., dysphagia or chest pain), along with evidence of obstruction on a timed barium esophagram or real-time impedance using FLIP

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12
Q

How is opiate use related to EGJOO and HRM findings?

A

Opiate medications have been associated with type III achalasia and EGJOO, so patients should stop these medications before undergoing HRM testing

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13
Q

What are the potential treatment options for patients with EGJOO experiencing dysphagia?

A

proton pump inhibitors (PPIs) for GERD symptoms, medications for esophageal smooth muscle relaxation, endoscopic pneumatic dilation (PD), botulinum toxin (Botox) injections, or surgical interventions such as myotomy or fundoplication.

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14
Q

What surgical options are available for severe or refractory EGJOO cases, particularly in patients with dysphagia?

A

Surgical options include laparoscopic Heller myotomy with partial fundoplication or peroral endoscopic myotomy (POEM).

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15
Q

What is the success rate of antireflux surgery without myotomy in EGJOO cases caused by acid-induced spasm and inflammation?

A

Antireflux surgery without myotomy has achieved good long-term results in these cases, but preoperative dysphagia predicts a higher rate of failure

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16
Q

What are some hypercontractile (spastic) motility disorders of the esophagus?

A

Distal esophageal spasm (DES)
jackhammer esophagus
nutcracker esophagus
achalasia type III.

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17
Q

What clinical symptoms are required for the diagnosis of distal esophageal spasm (DES)

A

Symptoms of chest pain
dysphagia
regurgitation caused by spastic contractions are required for the diagnosis of DES

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18
Q

What is the believed cause of distal esophageal spasm (DES)

A

caused by an impaired neurologic inhibitory pathway, allowing premature esophageal smooth muscle contractions

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19
Q

How is DES defined on high-resolution manometry (HRM)?

A

premature contractions in more than 20% of swallows, indicated by a low distal latency (truncated interval between initiation and deceleration of peristalsis)

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20
Q

What classic finding on barium esophagram is associated with DES, though it is uncommon?

A

A corkscrew pattern of simultaneous contractions is associated with DES

but is not required for diagnosis.

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21
Q

What initial treatment options are available for patients with distal esophageal spasm (DES)?

A

Reassurance
dietary and behavioral modifications
and pharmacologic therapy

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22
Q

What interventions may be required for persistent cases of distal esophageal spasm (DES)?

A

Persistent cases may require endoscopic intervention with pneumatic dilation (PD) or Botox, or surgical myotomy, especially for managing symptomatic dysphagia

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23
Q

Are endoscopic or surgical interventions more effective for managing chest pain or dysphagia in DES?

A

These interventions are generally more successful for managing symptomatic dysphagia
and are less effective if chest pain is the primary symptom

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24
Q

What is the defining feature of jackhammer esophagus on manometry?

A

defined by at least two swallows with significant hypercontractile vigor, measured by a distal contractile integral (DCI) exceeding 8000 mm Hg * s * cm

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25
Q

What is the believed cause of jackhammer esophagus?

A

caused by excessive cholinergic drive, leading to asynchronous contractions of the circular and longitudinal esophageal muscles

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26
Q

How does nutcracker esophagus differ from jackhammer esophagus?

A

Nutcracker esophagus is defined as hypertensive peristalsis with a DCI between 5000 to 8000 mm Hg * s * cm, whereas jackhammer esophagus exceeds 8000 mm Hg * s * cm

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27
Q

What are common symptoms in patients with jackhammer esophagus?

A

Patients typically experience chest pain, dysphagia, or regurgitation

28
Q

What does absent contractility on HRM indicate?

A

Absent contractility is indicated by failed peristalsis in 100% of swallows with a normally relaxing esophagogastric junction (EGJ)

29
Q

What systemic disorder is commonly associated with absent contractility in the esophagus?

A

Systemic sclerosis (scleroderma) is commonly associated with absent contractility, with complete hypocontraction of the esophageal smooth muscle.

30
Q

Why should antireflux surgery be approached with caution in patients with systemic sclerosis?

A

can exacerbate dysphagia, and GERD in these patients may result from overflow reflux due to gastric motility issues.

31
Q

What surgical approach might be considered for patients with systemic sclerosis and refractory GERD?

A

Roux-en-Y gastric bypass (RYGBP) may be considered, as it has shown improvement in controlling reflux and dysphagia compared to fundoplication.

32
Q

What less-invasive options might be considered for treating GERD in patients with systemic sclerosis?

A

Less-invasive options include endoscopic procedures like suture plication or radiofrequency ablation, though they are less effective at reducing reflux

33
Q

What is Ineffective Esophageal Motility (IEM)?

A

minor esophageal motility disorder characterized by a significant number of weak or failed swallows, often associated with heartburn, regurgitation, and sometimes dysphagia

34
Q

What is the role of GERD in IEM?

A

GERD often plays a significant role in the underlying cause of IEM, as many patients with IEM have abnormal esophageal acid exposure.

35
Q

How is IEM defined in CC v4.0 criteria on high-resolution manometry (HRM)?

A

at least 50% failed peristalsis or more than 70% ineffective swallows, where ineffective swallows have a distal contractile integral (DCI) less than 450 mm Hg * s * cm

36
Q

What additional testing may be performed in patients with IEM during manometry?

A

Multiple repetitive swallow (MRS) assessment may be performed to evaluate esophageal contraction vigor and bolus transit

37
Q

What does Multiple Repetitive Swallow (MRS) testing assess in patients with IEM?

A

evaluates deglutitive inhibition of the esophageal body and EGJ, followed by augmented esophageal contraction vigor, which may predict postoperative outcomes

38
Q

Why might MRS testing be important for patients undergoing antireflux surgery?

A

If MRS testing shows augmented contraction, it may be reassuring for performing antireflux surgery like fundoplication, reducing the risk of postoperative dysphagia

39
Q

What therapeutic options are available for patients with IEM

A

Treatment includes reassurance, antacid medications, dietary and behavioral modifications, and management of GERD.

Prokinetic drugs are generally not recommended.

40
Q

How can low-dose antidepressants be used in patients with IEM?

A

Low-dose tricyclic antidepressants or trazodone may help reduce functional chest discomfort, heartburn, and globus sensation, though they are less effective for dysphagia.

41
Q

Why do surgeons sometimes tailor partial fundoplication in patients with IEM?

A

Surgeons may opt for partial fundoplication to reduce the risk of postoperative dysphagia, especially if MRS testing does not show augmented esophageal contraction

42
Q

What dietary and behavioral modifications are recommended for patients with esophageal motility disorders?

A

sit upright during meals
take small bites, chew thoroughly
take sips of liquid between bites
avoid foods like bread, meat, and rice
and opt for soft or liquefied foods during symptom flares

43
Q

What medication class is associated with distal esophageal spasm (DES) and may improve symptoms when discontinued?

A

Chronic opioid use is associated with DES, and opioid cessation can lead to improvement.

44
Q

What pharmacologic therapies can provide symptomatic relief for esophageal spasm and hypercontractile disorders?

A

Smooth muscle–relaxing agents (nitrates, calcium channel blockers) and phosphodiesterase-5 inhibitors (e.g., sildenafil) may provide relief when taken 15 minutes before meals

45
Q

What esophageal motility disorders can be treated with pneumatic dilation (PD)?

A

PD has been used to treat spastic motility disorders like esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), and nutcracker esophagus, with variable success

46
Q

How can botulinum toxin (Botox) be used in treating esophageal motility disorders?

A

Botox injections may provide temporary relief of spasm in EGJOO, DES, and jackhammer esophagus, though the technique for administration varies.

47
Q

Where is botulinum toxin typically injected for esophageal motility disorders?

A

Some endoscopists inject the esophagogastric junction (EGJ) alone, while others include the esophageal body, especially in DES and jackhammer esophagus cases.

48
Q

How can prior botulinum toxin injections affect subsequent surgical myotomy?

A

Prior Botox injections can cause submucosal fibrosis, making surgical dissection more difficult, but it is not an absolute contraindication to surgery.

49
Q

What surgical approach is most commonly used for Ineffective Esophageal Motility (IEM) with GERD?

A

A tailored partial fundoplication, such as a 270-degree posterior wrap, is commonly used and well tolerated.

50
Q

What is the reported success rate of surgical myotomy for Distal Esophageal Spasm (DES)?

A

About 70% of cases treated with surgical myotomy have favorable outcomes for relieving symptoms like dysphagia and chest pain.

51
Q

What are the advantages of POEM (Peroral Endoscopic Myotomy) over traditional surgical approaches?

A

POEM is incisionless, provides flexibility in tailoring myotomy length and location, avoids vagus nerve injury, and results in minimal postoperative pain

52
Q

What is the risk of GERD after POEM, and how does it compare to Heller myotomy with partial fundoplication?

A

The risk of GERD after POEM is between 20% to 46%, similar to the 21% to 42% risk following Heller myotomy with partial fundoplication

53
Q

Can POEM be performed in patients who have previously undergone Heller myotomy, Botox injections, or pneumatic dilation?

A

Yes

54
Q

What preoperative precautions are taken to prevent infection and mucosal edema in POEM?

A

Patients receive a Nystatin rinse for Candida esophagitis prophylaxis
a liquid diet for 1 day before the procedure
and preoperative antibiotics and a single dose of intravenous steroids to prevent mucosal edema.

55
Q

What device is used preoperatively in POEM to measure esophageal parameters like diameter and pressure?

A

An endoscopic functional lumen imaging probe (EndoFLIP) is used to measure baseline esophageal diameter, pressure, cross-sectional area, distensibility, and compliance.

56
Q

Where is the gastric wall tattooed during POEM, and why?

A

The gastric wall is tattooed with indigo carmine 2 cm distal to the EGJ in the anterior position along the lesser curvature to mark the target for the distal extent of the myotomy

57
Q

What is the final step in completing the myotomy during POEM?

A

The myotomy is performed by selectively dividing the circular muscle layers, leaving the thin longitudinal muscle intact when possible, extending across the EGJ and onto the proximal gastric wall.

58
Q

What potential complication can arise during POEM due to insufflation, and how is it managed

A

Capnoperitoneum can develop in up to 30% of cases, and if abdominal overdistension or respiratory compromise occurs, it can be evacuated using a Veress needle.

59
Q

What is the patient’s postoperative care protocol on the first day after POEM?

A

the patient is kept NPO (nothing by mouth) overnight,
and a contrast esophagram is obtained on the first postoperative day to check for leaks or obstructions

60
Q

When is the patient allowed to resume oral intake after POEM?

A

If no leaks or obstructions are identified, the patient is allowed clear liquids and crushed medications on postoperative day 1.

61
Q

What dietary recommendations are made for the first week after POEM?

A

The patient should maintain a puree-consistency diet for 1 week to avoid disrupting the mucosal closure clips

62
Q

What are the acute postoperative complications that can occur after POEM?

A

Acute complications include intratunnel bleeding, mucosal leak or dehiscence, and mediastinitis.

63
Q

How is intratumoral bleeding managed after POEM?

A

may require transfusion and repeat endoscopy to achieve hemostasis

64
Q

What are the treatment options for a mucosal leak or dehiscence after POEM?

A

They may seal with conservative management but often require repeat endoscopy and repair with additional clips or suturing

65
Q

How is mediastinitis treated after POEM?

A

Mediastinitis is treated with antibiotics and may require percutaneous or surgical drainage

66
Q

What were the serious complications that required prolonged hospitalization or intervention after POEM?

A

Serious complications included pneumothorax, pulmonary embolism, capnoperitoneum, and bleeding

A1-G Surg Note Esophagus (15 decks)

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