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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
Q

What is functional heartburn?

A

Sxs created by CNS in absence of pathological evidence of GERD i.e. no structure/function cause

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26
Q

How can you treat functional heartburn?

A

TCAs

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27
Q

What are the Rome IV Criteria for functional heartburn?

A

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

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28
Q

Rome IV criteria for dyspepsia?

A 
>= 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
Q

What is Barrett’s?

A

Tissue dysplasia from chronic acid injury (10% w/ chronic GERD) confirmed by scope. Can lead to adenocarcinoma of esophagus

30
Q

What tissue is changed in Barrett’s?

A

Squamous epithelium to metaplastic columnar epithelium

31
Q

What are the Barrett’s screening indicators?

A 
Screening Q3-5 yrs pts w/ chronic GERD and...
50y or older
Male
hiatal hernia
elevated BMI
elevated visceral fat
32
Q

What is Barrett’s progression in order?

A

Squamous esophagus > chronic inflammation > Barrett’s metaplasia > low-grade dysplasia > high-grade dysplasia > adenocarcinoma

33
Q

Of the Barrett’s progressive phases, which get an ablation and what gets esophagectomy?

A

low/high-grade dysplasia get ablation

Adenocarcinoma gets ablation/esophagectomy based on involvement

34
Q

Which complication of GERD can actually lead to reduction in GERD sxs?

A

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
Q

What would make you think of possible stricture?

A

Gradual and progressive dysphagia over mos to yrs

36
Q

Pt has difficulty initiating swallow should clue you to what?

A

Oropharyngeal dysphagia (no esophageal involvement)

37
Q

Pt with “food sticks after swallowing” should clue you to what?

A

Esophageal dysphagia

38
Q

Only solids stick should clue you to what?

A

Mechanical obstruction
Intermittent = esophageal ring
Progressive = stricture/malignancy

39
Q

Solids and liquids stick should clue you to?

A

Motility disorder
Intermittent = esophageal spasm
progressive = achalasia/scleroderma

40
Q

Main sxs pointing to achalasia?

A

gradual, progressive dysphagia for solids AND liquids
regurgitation of undigested food
PE negative

41
Q

What happens in achalasia?

A

Birds beak

Poorly relaxing LES w/ retrograde esophageal dilation

42
Q

What is the best initial study if achalasia is suspected?

A

Barium swallow

43
Q

What other tests are available for achalasia?

A

Esophageal manometry

Scope

44
Q

What is the tx for achalasia?

A

balloon dilation
surgical myotomy (muscle cutting)
Botox
CCBs or long acting nitrates for poor surg candidate

45
Q

What is the parasitic disease that can also cause achalasia?

A

Chagas disease

46
Q

What is jackhammer esophagus and how do we tx it?

A

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
Q

Concerning strictures, what is the normal lumen diameter of the esophagus and what diameter causes dysphagia?

A

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
Q

How do we tx strictures?

A

Dilation

If refractory ddx pill-induced, uncontrolled GERD, inadequate dilation diameter to relieve sxs

49
Q

Difference b/w rings and webs?

A

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
Q

What is the triad for Plummer-Vinson syndrome?

A
  1. Proximal esophageal webs
  2. Iron deficiency anemia
  3. Dysphagia
    * Pts at high risk for SCC of esophagus/pharynx
51
Q

Imaging and tx for rings/webs?

A

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
Q

What is Schatzki’s Ring? Imaging? Tx?

A

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
Q

What would make you think of malignant cause of dysphagia vs stricture or others?

A

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
Q

Risk factors for SCC of esophagus?

A 
ETOH
Tobacco
Prior esoph injury i.e. radiation/caustic 
HPV association 
Achalasia association
55
Q

adenocarcinoma risk factors?

A

Obesity
GERD and Barrett’s
Scleroderma

56
Q

Imaging and tx for esophageal CA dx?

A

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
Q

Types of esophageal diverticula aka sacs?

A

Zenker’s (hypopharyngeal)
Midesophageal
Epiphrenic
Intramural pseudo diverticulosis

58
Q

What causes Zenker’s diverticulum? Sxs? Dx? Tx?

A

Incomplete relaxation of UES
Sxs: oropharyngeal dysphagia, regurg undigested food, halitosis, cough, aspiration pneumonia
Imaging: barium swallow
Tx: surg resection

59
Q

Cause and dx of pill-induced dysphagia?

A

swallowing medication w/o water or lying down
scope will show ulceration
rapidly heals once you stop being an idiot

60
Q

Infectious esophagitis mostly in which pt pop? MCC? Dx?

A 
Immunosuppressed pts
Candida albicans
Herpes simplex 
CMV
scope bx and brushings
61
Q

A pt w/ the following on scope should make you think of what? White exudates or papules, red furrows, corrugated concentric rings, strictures

A

Eosinophilic esophagitis (EOE)

62
Q

EOE dx? sxs? tx?

A

scope
labs may show eosinophilia or elevated IgG
Sxs = episodic dysphagia / food impaction
tx = PPIs, avoidance of known allergens, inhaled corticosteroids, allergist referral

63
Q

Ddx for hematemesis?

A

Mallory-Weiss syndrome
Esophageal varices
peptic ulcer exacerbation
gastritis

64
Q

What is a Mallory-Weiss tear and how does it present?

A

Tear of mucosa at esophagus/stomach junction

Sxs = sudden onset from vomiting, occasionally lifting, usually alcoholism

65
Q

Mallory-Weiss tear or varices tear tx?

A

Fluid resuscitation
blood transfusion
scope band placement
Epi injection, cautery, tamponade

66
Q

Risk factors for esophageal bleed?

A

Size
Red signs (friability) on scope
Liver dz severity
Active alcohol abuse

67
Q

Varices Rx tx? Procedural tx?

A 
Abx prophylaxis 
Vasoconstrictive drugs
Vitamin K
Lactulose 
Procedure: portal decompression
68
Q

Prevention of EV re-bleed?

A 
scope banding
scope sclerotherapy 
beta-blockers to lower pressure
shunts
liver transplant
69
Q

Prevention of first EV bleed?

A

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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