Disorders of Esophagus_DOBBS (Exam 3) Flashcards
What might a pt CC be when esophagus is involved?
Heartburn
Dysphagia (trouble swallowing or drooling)
Odynophagia (painful swallowing)
Food gets stuck
Ddx for heartburn?
Cardiac origin GERD Zollinger-Ellison Syndrome Esophageal stricture/spasm Barrett's
What is the pathophysiology of GERD?
An incompetent lower esophageal sphincter (LES)
What are some red flag symptoms pts may note?
Evidence of GI bleed i.e. melena/hematochezia Weight loss Swallowing changes Vomiting Fever Chest pain
What is a hiatal hernia and what causes it?
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)
Symptoms that would actually lead you to think GERD?
Heartburn mostly after meals or positional
Acid taste (refluxate)
Dysphagia (make sure to r/o this alarm sx)
What are some atypical presentations of GERD?
Cough
asthmatic sxs
respiratory sxs
Are the degree of GERD sxs related to the degree of tissue damage?
NO
Could be silent GERD or asymptomatic
If a pt notes their GERD sxs are worse at night what do we want to ask?
Do they work at night
Want to know if the sxs are worse when lying down
What could you find on exam and labs when testing for GERD?
Normal PE
Normal labs
What are some imaging studies and when are they done for GERD?
Upper endoscopy aka scope (alarm sxs, high-risk screening, chest pain)
Barium esophagography aka barium swallow (dysphagia)
-Done in atypical or complicated cases
What is the gold standard diagnostic for GERD?
Ambulatory esophageal pH monitoring
Does a negative trial of PPI r/o GERD?
NO
What are some lifestyle changes for GERD that have evidence to back them up?
Weight loss (improves sxs and pH) Head of bead elevation (improves sxs and pH)
What are lifestyle changes that have shown no improvement of sxs?
Late meal avoidance 2-3 hrs (improves pH not sxs)
tobacco and alcohol cessation
cessation of chocolate, caffeine, spicy foods, citrus, carbonated beverages
How high should a patient elevate their bed?
6 inches or use wedge pillow
What are some H2 blockers?
Pepcid (famotidine)
Zantac (ranitidine)
Tagamet (cimetidine)
Axid (nizatidine)
what do PPIs end in?
prazole
What is a prokinetic drug for GERD?
Reglan (metoclopramide)
What would a last effort procedure for GERD be that is not used very much anymore?
Fundoplication aka stomach wrap
What does a LINX device do?
Ring around location of LES that allows food to enter but helps keep LES closed to retrograde gastric contents
PPI non-responders are a low percentage. What should you ask first regarding these pts?
Compliance and incorrect usage?
If they are truly unresponsive to PPIs what else to consider?
Functional heartburn
Zollinger-Ellison Syndrome
Pill-induced esophagitis
True PPI resistance
How do you work-up a non-responder
Ambulatory esophageal reflux monitoring Scope em (only if alarm sxs)
What is functional heartburn?
Sxs created by CNS in absence of pathological evidence of GERD i.e. no structure/function cause
How can you treat functional heartburn?
TCAs
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
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
What is Barrett’s?
Tissue dysplasia from chronic acid injury (10% w/ chronic GERD) confirmed by scope. Can lead to adenocarcinoma of esophagus
What tissue is changed in Barrett’s?
Squamous epithelium to metaplastic columnar epithelium
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
What is Barrett’s progression in order?
Squamous esophagus > chronic inflammation > Barrett’s metaplasia > low-grade dysplasia > high-grade dysplasia > adenocarcinoma
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
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
What would make you think of possible stricture?
Gradual and progressive dysphagia over mos to yrs
Pt has difficulty initiating swallow should clue you to what?
Oropharyngeal dysphagia (no esophageal involvement)
Pt with “food sticks after swallowing” should clue you to what?
Esophageal dysphagia
Only solids stick should clue you to what?
Mechanical obstruction
Intermittent = esophageal ring
Progressive = stricture/malignancy
Solids and liquids stick should clue you to?
Motility disorder
Intermittent = esophageal spasm
progressive = achalasia/scleroderma
Main sxs pointing to achalasia?
gradual, progressive dysphagia for solids AND liquids
regurgitation of undigested food
PE negative
What happens in achalasia?
Birds beak
Poorly relaxing LES w/ retrograde esophageal dilation
What is the best initial study if achalasia is suspected?
Barium swallow
What other tests are available for achalasia?
Esophageal manometry
Scope
What is the tx for achalasia?
balloon dilation
surgical myotomy (muscle cutting)
Botox
CCBs or long acting nitrates for poor surg candidate
What is the parasitic disease that can also cause achalasia?
Chagas disease
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
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
How do we tx strictures?
Dilation
If refractory ddx pill-induced, uncontrolled GERD, inadequate dilation diameter to relieve sxs
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
What is the triad for Plummer-Vinson syndrome?
- Proximal esophageal webs
- Iron deficiency anemia
- Dysphagia
* Pts at high risk for SCC of esophagus/pharynx
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
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
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
Risk factors for SCC of esophagus?
ETOH Tobacco Prior esoph injury i.e. radiation/caustic HPV association Achalasia association
adenocarcinoma risk factors?
Obesity
GERD and Barrett’s
Scleroderma
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
Types of esophageal diverticula aka sacs?
Zenker’s (hypopharyngeal)
Midesophageal
Epiphrenic
Intramural pseudo diverticulosis
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
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
Infectious esophagitis mostly in which pt pop? MCC? Dx?
Immunosuppressed pts Candida albicans Herpes simplex CMV scope bx and brushings
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)
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
Ddx for hematemesis?
Mallory-Weiss syndrome
Esophageal varices
peptic ulcer exacerbation
gastritis
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
Mallory-Weiss tear or varices tear tx?
Fluid resuscitation
blood transfusion
scope band placement
Epi injection, cautery, tamponade
Risk factors for esophageal bleed?
Size
Red signs (friability) on scope
Liver dz severity
Active alcohol abuse
Varices Rx tx? Procedural tx?
Abx prophylaxis Vasoconstrictive drugs Vitamin K Lactulose Procedure: portal decompression
Prevention of EV re-bleed?
scope banding scope sclerotherapy beta-blockers to lower pressure shunts liver transplant
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
