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RRPA Clinical Med II > Disorders of Esophagus_DOBBS (Exam 3) > Flashcards

Disorders of Esophagus_DOBBS (Exam 3) Flashcards

1
Q

What might a pt CC be when esophagus is involved?

A

Heartburn
Dysphagia (trouble swallowing or drooling)
Odynophagia (painful swallowing)
Food gets stuck

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2
Q

Ddx for heartburn?

A 
Cardiac origin
GERD
Zollinger-Ellison Syndrome 
Esophageal stricture/spasm
Barrett's
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3
Q

What is the pathophysiology of GERD?

A

An incompetent lower esophageal sphincter (LES)

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4
Q

What are some red flag symptoms pts may note?

A 
Evidence of GI bleed i.e. melena/hematochezia 
Weight loss
Swallowing changes 
Vomiting 
Fever
Chest pain
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5
Q

What is a hiatal hernia and what causes it?

A

Phreno-esophageal ligament stretches and ruptures allowing the diaphragm to slip down and portion of stomach herniates through and remains above diaphragm.
-Allows retention of gastric fluid in outpouching (hernial sac)

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6
Q

Symptoms that would actually lead you to think GERD?

A

Heartburn mostly after meals or positional
Acid taste (refluxate)
Dysphagia (make sure to r/o this alarm sx)

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7
Q

What are some atypical presentations of GERD?

A

Cough
asthmatic sxs
respiratory sxs

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8
Q

Are the degree of GERD sxs related to the degree of tissue damage?

A

NO

Could be silent GERD or asymptomatic

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9
Q

If a pt notes their GERD sxs are worse at night what do we want to ask?

A

Do they work at night

Want to know if the sxs are worse when lying down

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10
Q

What could you find on exam and labs when testing for GERD?

A

Normal PE

Normal labs

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11
Q

What are some imaging studies and when are they done for GERD?

A

Upper endoscopy aka scope (alarm sxs, high-risk screening, chest pain)

Barium esophagography aka barium swallow (dysphagia)

-Done in atypical or complicated cases

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12
Q

What is the gold standard diagnostic for GERD?

A

Ambulatory esophageal pH monitoring

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13
Q

Does a negative trial of PPI r/o GERD?

A

NO

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14
Q

What are some lifestyle changes for GERD that have evidence to back them up?

A 
Weight loss (improves sxs and pH)
Head of bead elevation (improves sxs and pH)
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15
Q

What are lifestyle changes that have shown no improvement of sxs?

A

Late meal avoidance 2-3 hrs (improves pH not sxs)
tobacco and alcohol cessation
cessation of chocolate, caffeine, spicy foods, citrus, carbonated beverages

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16
Q

How high should a patient elevate their bed?

A

6 inches or use wedge pillow

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17
Q

What are some H2 blockers?

A

Pepcid (famotidine)
Zantac (ranitidine)
Tagamet (cimetidine)
Axid (nizatidine)

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18
Q

what do PPIs end in?

A

prazole

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19
Q

What is a prokinetic drug for GERD?

A

Reglan (metoclopramide)

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20
Q

What would a last effort procedure for GERD be that is not used very much anymore?

A

Fundoplication aka stomach wrap

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21
Q

What does a LINX device do?

A

Ring around location of LES that allows food to enter but helps keep LES closed to retrograde gastric contents

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22
Q

PPI non-responders are a low percentage. What should you ask first regarding these pts?

A

Compliance and incorrect usage?

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23
Q

If they are truly unresponsive to PPIs what else to consider?

A

Functional heartburn
Zollinger-Ellison Syndrome
Pill-induced esophagitis
True PPI resistance

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24
Q

How do you work-up a non-responder

A 
Ambulatory esophageal reflux monitoring 
Scope em (only if alarm sxs)
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25
What is functional heartburn?
Sxs created by CNS in absence of pathological evidence of GERD i.e. no structure/function cause
26
How can you treat functional heartburn?
TCAs
27
What are the Rome IV Criteria for functional heartburn?
Burning retrosternal pain or discomfort No sx relief despite OPTIMAL PPI/H2 blockers Absence of evidence reflux or EOE is the cause of sxs Absence of major esophageal motor disorders *All criteria must be fulfilled 3 mos prior w/ sx onset >=6 mos ago w/ frequency of >= 2X wk
28
Rome IV criteria for dyspepsia?
``` >= 1 of following for 3 mos w/ sx onset >= 6 mos Bothersome postprandial fullness Bothersome early satiation Bothersome epigastric pain Bothersome epigastric burning ``` *Must also have all the following Basically no structure/function relationship to sxs Must be scoped No alarm sxs No sx onset 50y or greater w/o colonoscopy No fam hx of colon CA No sudden/acute onset change in bowel habit
29
What is Barrett's?
Tissue dysplasia from chronic acid injury (10% w/ chronic GERD) confirmed by scope. Can lead to adenocarcinoma of esophagus
30
What tissue is changed in Barrett's?
Squamous epithelium to metaplastic columnar epithelium
31
What are the Barrett's screening indicators?
``` Screening Q3-5 yrs pts w/ chronic GERD and... 50y or older Male hiatal hernia elevated BMI elevated visceral fat ```
32
What is Barrett's progression in order?
Squamous esophagus > chronic inflammation > Barrett's metaplasia > low-grade dysplasia > high-grade dysplasia > adenocarcinoma
33
Of the Barrett's progressive phases, which get an ablation and what gets esophagectomy?
low/high-grade dysplasia get ablation Adenocarcinoma gets ablation/esophagectomy based on involvement
34
Which complication of GERD can actually lead to reduction in GERD sxs?
Peptic stricture due to creation of physical barrier to reflux Scope to r/o malignancy stricture cause Tx: mechanical dilation, long-term PPI therapy
35
What would make you think of possible stricture?
Gradual and progressive dysphagia over mos to yrs
36
Pt has difficulty initiating swallow should clue you to what?
Oropharyngeal dysphagia (no esophageal involvement)
37
Pt with "food sticks after swallowing" should clue you to what?
Esophageal dysphagia
38
Only solids stick should clue you to what?
Mechanical obstruction Intermittent = esophageal ring Progressive = stricture/malignancy
39
Solids and liquids stick should clue you to?
Motility disorder Intermittent = esophageal spasm progressive = achalasia/scleroderma
40
Main sxs pointing to achalasia?
gradual, progressive dysphagia for solids AND liquids regurgitation of undigested food PE negative
41
What happens in achalasia?
Birds beak | Poorly relaxing LES w/ retrograde esophageal dilation
42
What is the best initial study if achalasia is suspected?
Barium swallow
43
What other tests are available for achalasia?
Esophageal manometry | Scope
44
What is the tx for achalasia?
balloon dilation surgical myotomy (muscle cutting) Botox CCBs or long acting nitrates for poor surg candidate
45
What is the parasitic disease that can also cause achalasia?
Chagas disease
46
What is jackhammer esophagus and how do we tx it?
Diffuse esophageal spasms look like symmetric waves on barium swallow imaging. Has normal LES Present w/ chest pain and/or dysphagia Tx: Nothing great, nitrates and CCBs
47
Concerning strictures, what is the normal lumen diameter of the esophagus and what diameter causes dysphagia?
NML = 20 mm < 15 mm usually causes dysphagia less severe can cause intermittent sxs w/ large food pieces Intrinsic causes i.e. reflux/peptic ulcer MCC
48
How do we tx strictures?
Dilation | If refractory ddx pill-induced, uncontrolled GERD, inadequate dilation diameter to relieve sxs
49
Difference b/w rings and webs?
Rings = circumferential mucosa OR muscle, distal Webs = always mucosa that occupies part of lumen, usually proximal *Common scope finding w/ many asymptomatic *symptomatic = intermittent solid food dysphagia, aspiration, regurgitation
50
What is the triad for Plummer-Vinson syndrome?
1. Proximal esophageal webs 2. Iron deficiency anemia 3. Dysphagia * Pts at high risk for SCC of esophagus/pharynx
51
Imaging and tx for rings/webs?
Barium swallow most sensitive some webs so proximal can be pierced by scope and not even known Tx: mechanical disruption aka slice and dice
52
What is Schatzki's Ring? Imaging? Tx?
Stricture located near LES MCC intermittent solid food dysphagia/food impaction Sxs vary based on luminal diameter usually 13-20mm Imaging: Most sensitive barium swallow Tx: PPIs
53
What would make you think of malignant cause of dysphagia vs stricture or others?
Rapid progression of solid food dysphagia 75% w/ weight loss SCC is agressive, locally invasive w/ distant mets Adenocarcinoma not as locally invasive but still mets
54
Risk factors for SCC of esophagus?
``` ETOH Tobacco Prior esoph injury i.e. radiation/caustic HPV association Achalasia association ```
55
adenocarcinoma risk factors?
Obesity GERD and Barrett's Scleroderma
56
Imaging and tx for esophageal CA dx?
CT to identify mets Scope u/s to determine depth Tx: Early = surg, advanced = chemo/radiation b4 surg late stage = palliative i.e. dilation, stent, g tube
57
Types of esophageal diverticula aka sacs?
Zenker's (hypopharyngeal) Midesophageal Epiphrenic Intramural pseudo diverticulosis
58
What causes Zenker's diverticulum? Sxs? Dx? Tx?
Incomplete relaxation of UES Sxs: oropharyngeal dysphagia, regurg undigested food, halitosis, cough, aspiration pneumonia Imaging: barium swallow Tx: surg resection
59
Cause and dx of pill-induced dysphagia?
swallowing medication w/o water or lying down scope will show ulceration rapidly heals once you stop being an idiot
60
Infectious esophagitis mostly in which pt pop? MCC? Dx?
``` Immunosuppressed pts Candida albicans Herpes simplex CMV scope bx and brushings ```
61
A pt w/ the following on scope should make you think of what? White exudates or papules, red furrows, corrugated concentric rings, strictures
Eosinophilic esophagitis (EOE)
62
EOE dx? sxs? tx?
scope labs may show eosinophilia or elevated IgG Sxs = episodic dysphagia / food impaction tx = PPIs, avoidance of known allergens, inhaled corticosteroids, allergist referral
63
Ddx for hematemesis?
Mallory-Weiss syndrome Esophageal varices peptic ulcer exacerbation gastritis
64
What is a Mallory-Weiss tear and how does it present?
Tear of mucosa at esophagus/stomach junction | Sxs = sudden onset from vomiting, occasionally lifting, usually alcoholism
65
Mallory-Weiss tear or varices tear tx?
Fluid resuscitation blood transfusion scope band placement Epi injection, cautery, tamponade
66
Risk factors for esophageal bleed?
Size Red signs (friability) on scope Liver dz severity Active alcohol abuse
67
Varices Rx tx? Procedural tx?
``` Abx prophylaxis Vasoconstrictive drugs Vitamin K Lactulose Procedure: portal decompression ```
68
Prevention of EV re-bleed?
``` scope banding scope sclerotherapy beta-blockers to lower pressure shunts liver transplant ```
69
Prevention of first EV bleed?
Pts w/ cirrhosis should be scoped for EVs If EVs present = beta-blockers, +/- banding No EVs or small = repeat scope 1-2 yrs

RRPA Clinical Med II (45 decks)

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