Disorders of the Esophagus Flashcards
What is dysphagia?
Difficulty swallowing
What is odynophagia?
Pain with swallowing, with or without difficulty swallowing
What are 3 patient complaints when the esophagus is involved?
Heartburn
Dysphagia
Odynophagia
What is the most common cause of heartburn?
GERD
What is on the differential diagnosis of heartburn?
GERD
Zollinger-Ellison Syndrome
Cardiac origin of pain
What is Zollinger- Ellison Syndrome?
Rare, digestive disorder that results in too much gastric acid- causes peptic ulcers in stomach and intestines. Sxs- abdominal pain, nausea, vomiting, weight loss, diarrhea, heartburn
What is GERD?
Gastroesophageal reflux disease
The reflux of gastric contents into the esophagus results in symptoms and/or complications
What is GERD?
Gastroesophageal reflux disease
The reflux of gastric contents into the esophagus results in symptoms and/or complications
How is GERD objectively defined?
The presence of characteristic mucosal injury seen at endoscopy and/or abnormal esophageal acid exposure demonstrate on a reflux monitoring study
What is the pathophysiology of GERD?
Incompetent lower esophageal sphincter, impaired esophageal clearance, compromised integrity of the esophageal mucosa
What condition can cause GERD?
Hiatal hernia
The heartburn in GERD is mostly…
Postprandial or positional
What are the signs and symptoms of GERD?
Heartburn Acid taste or refluxate Dysphagia Atypical presentations (Degree of symptoms not related to degree of tissue damage)
What will you find on physical exam in GERD?
Normal physical exam
What will the lab tests in GERD show?
Normal lab tests
What exams are done in atypical or complicated cases of GERD?
Upper endoscopy Barium esophagography (barium swallow) Ambulatory esophageal pH monitoring *
What should be done first in the treatment of GERD?
Lifestyle changes
What lifestyle changes can be made to treat GERD?
Avoid supine position within 3 hours postprandial
Elevation of the head of bed 6” or use a wedge
Encourage weight loss
Decreased portion size
Eliminate or decrease aggravating foods
H pylori testing is/is not recommended in GERD?
Is not
What are some pharmacologic therapies for GERD?
Antacids
Gaviscon (OTC antacid with alginate)
H2 receptor blockers (Histamine H2-receptor antagonists, also known as H2-blockers, are used to treat duodenal ulcers and prevent their return)
How are H2 receptor blockers used?
As needed with breakthrough nocturnal symptoms on a PPI or with low-level symptoms
What are some examples of a H2 receptor blocker?
Pepcid (famotidine 20-40 mg bid)
Zantac ranitidine (discontinued and rebranded as Zantac 360- famotidine)
Tagamet- cimetidine 800 mg bid or 400 mg qid ***
Axid- nizatidine 150 mg bid
What kind of medication is recommended for empiric treatment as an 8 week trial in uncomplicated GERD? How should it be used?
PPI - proton pump inhibitor
QD before a meal
What are some examples of PPIs?
Pantoprazole- Protonix (20mg-40mg qd-bid)
Lansoprazole- Prevacid (15mg-otc, 30mg rx, qd-bid)
Omeprozole- Prilosec (20mg qd-bid)
Esomeprazole-Nexium (20mg-otc, 40mg tabs-rx, oral suspension multiple doses, and IV qd) Rabeprazole- Aciphex (20mg qd-bid)
Dexlansoprazole- Dexilant- delayed release (30mg-60mg qd)
Omeprazole and sodium bicarbonate (Zegerid OTC)
What is another med for GERD?
Metoclopramide- Reglan (prokinetic)
What are some treatments for GERD in pregnancy?
Lifestyle changes
Antacids
Alginate
Sucralfate
If a patient is not responding to medical or surgical treatment of GERD, what should you consider?
A different diagnosis- Zollinger-Ellison, pill induced esophagitis, resistance to PPIs, or non-compliance
How should you work up a non-responder?
Ambulatory esophageal reflux monitoring
Upper endoscopy only if Alarm symptoms
What are alarm symptoms?
?
What is a complication of GERD?
Barrett’s esophagus
What is a complication of GERD?
Barrett’s esophagus
What is Barrett’s esophagus?
Chronic acidic injury
Squamous epithelium replaced by meta plastic columnar epithelium
What percentage of patients with chronic GERD develop Barrett’s esophagus?
10%
How is Barrett’s esophagus diagnosed?
Endoscopic biopsy
Who should be screened for Barrett’s esophagus?
Chronic GERD symptoms and other risk factors- over 50 years old, male, hiatal hernia, elevated BMI, elevated visceral fat
How often should those at risk be screened for Barrett’s esophagus?
Every 3-5 years
How does Barrett’s esophagus progress into cancer?
Squamous esophagus Chronic inflammation Barrett's meta plasia Low grade dysplasia High grade dysplasia Adenocarcinoma (needs ablation/esophagectomy)
What complication of GERD causes a gradual and progressive dysphagia with solid foods over months to years?
Peptic stricture
How does peptic stricture affect heartburn?
Can see a reduction in heartburn due to anatomical barrier to reflux
What should be done to diagnose peptic stricture?
Endoscopy with biopsy to exclude malignant causes of stricture
How is peptic stricture treated?
Most cases are treated successfully with dilation over one or several sessions
Long term treatment with PPI
What is Achalasia?
Poorly relaxing lower esophageal sphincter
What is Achalasia?
Poorly relaxing lower esophageal sphincter
What are the sxs of achalasia?
Gradual, progressive dysphagia for solids and liquids
Substernal discomfort or postprandial fullness
Regurgitation of undigested food
Weight loss
What will you see on physical exam in achalasia?
Physical exam will be negative
What will you see on imaging in achalasia?
Bird’s beak esophagus
What is the best initial imaging study in achalasia?
Barium esophagography/esophagram
What other imaging can be done in achalasia?
Esophageal manometry
Endoscopy
What is the treatment for achalasia?
Pneumatic dilation
Surgical myotomy
Botulinum toxin injection
Calcium channel blockers or long-acting nitrates
What is diffuse esophageal spasm? (DES)
Simultaneous and repetitive contractions, some normal peristalsis
What is the condition of the LES in diffuse esophageal spasm (DES)?
The LES is normal
How do patients with DES present?
Chest pain and/or dysphagia
Although not completely effective, what are the treatments for DES?
Nitrates
Calcium-channel blockers
What does DES show on imaging?
Corkscrew esophagus
What is the normal diameter of the lumen of the esophagus?
20mm
At what diameter does an esophageal stricture usually cause dysphagia?
<15 mm
What are the causes of esophageal stricture?
Intrinsic and extrinsic
Intrinsic is more common- majority caused by acid/peptic cause
What is the treatment for esophageal stricture?
Esophageal dilation
What causes refractory esophageal strictures?
Continued pill-induced irritation
Uncontrolled GERD
Inadequate dilation diameter
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
What are esophageal webs?
Occupy only part of the esophageal lumen, always mucosal, usually proximal
Rings and webs are common/uncommon endoscopy finds
Common
Rings and webs are often symptomatic/ asymptomatic
Asymptomatic
If rings and webs are symptomatic, what symptoms are seen?
Intermittent solid food dysphagia, aspiration, regurgitation
What is the triad in Plummer-Vinson syndrome?
Proximal esophageal webs
Iron deficiency anemia
Dysphagia
What are patients with Plummer-Vinson syndrome at a higher risk for developing?
Squamous cell cancer of the esophagus and pharynx
What imaging study is the most sensitive for webs?
Barium radiography
Why can’t some webs be seen on endoscopy?
Because some webs are so proximal that the endoscope could fracture the web before its presence is known
What is the treatment for rings and webs?
Mechanical disruption
What is Schatzki’s ring?
A Schatzki’s ring is a ring of tissue that forms inside the esophagus, the tube that carries food and liquid to your stomach. This ring makes the esophagus narrow in one area, close to where it meets the stomach. It can make it hard to swallow. You may feel like food gets stuck in your esophagus.
Where is Schatski’s ring located?
Near the LES
What is the most common cause of intermittent solid food dysphagia and food impaction?
Schatzki’s ring
What is the most common cause of intermittent solid food dysphagia and food impaction?
Schatzki’s ring
What do symptoms in Schatzki’s ring depend on?
Luminal diameter
Usually 13-20 mm symptoms are variable
What is the most sensitive test to diagnose Schatzki’s ring?
Barium swallow
What is the most sensitive test to diagnose Schatzki’s ring?
Barium swallow
What is the treatment for Schatski’s ring?
PPIs
GERD can progress to ___ ____ and ___
Barrett’s esophagus, strictures. Schatzki’s ring
What are the two types of strictures?
Peptic, esophageal
What can Barrett’s esophagus progress to?
Adenocarcinoma
How does esophageal cancer commonly present?
Rapidly progressive solid food dysphagia
What do 75% of cases of esophageal cancer present with?
Weight loss
SCC esophageal cancer is aggressive/ is not aggressive
Is aggressive
SCC esophageal cancer is locally invasive/ is not locally invasive
Is locally invasive
SCC esophageal cancer has distant metastases/ does not have distant metastases
With distant metastases
Adenocarcinoma is locally invasive/ is not locally invasive
Is not as locally invasive
Adenocarcinoma of esophageal cancer has metastases/ does not have metastases
Has metastases
What are the risk factors for developing SCC esophageal cancer?
Alcohol and tobacco use
Prior esophageal injury (caustic, radiation)
HPV
Achalasia
What are the risk factors of Adenocarcinoma esophageal cancer?
Obesity
GERD and Barrett’s esophagus
Scleroderma
What is used to identify metastases in esophageal cancer?
CT
What is used to evaluate depth of invasion in esophageal cancer?
Endoscopic ultrasound
What is the treatment for early stage of esophageal cancer?
Surgery
What is the treatment of more advanced esophageal cancer?
Chemotherapy/ radiation prior to surgery
What is the treatment in late stage esophageal cancer?
Palliative treatment- dilation, stent placement, gastrostomy tube
What is an esophageal diverticula?
Sac protruding from the esophageal wall
How are esophageal diverticula classified?
By anatomy Zenker's- hypopharyngeal Midesophageal Epiphrenic Intramural psuedodiverticulosis
Zenker’s diverticulum results from incomplete relaxation of the ____
UES- upper esophageal sphincter
What does Zenker’s diverticulum present with?
Oropharyngeal dysphagia Regurgitation of undigested food Halitosis Cough Aspiration pneumonia
How is Zenker’s diverticulum diagnosed?
Barium swallow
How is Zenker’s diverticulum treated?
Open surgical resection
What is the cause of pill-induced dysphagia?
Ingestion of irritant medication - swallowing a pill without water or while supine
What is the presentation of pill-induced dysphagia?
Severe retrosternal chest pain, odynophagia, dysphagia
What is used to visualize the ulcer in pill-induced dysphagia?
Endoscopy
What is the treatment for pill-induced dysphagia?
Rapid healing with removal of the offender
Infectious esophagitis is most commonly seen in what patient population?
Immunocompromised patients such as patients with HIV
What are the most common offending pathogens in infectious esophagitis?
Candida albicans
Herpes simplex
CMV
How do patients with infectious esophagitis present with?
Odynophagia, dysphagia
How is infectious esophagitis diagnosed?
Evaluation with endoscopy with biopsy and brushing s
50% of all patients with eosinophilic esophagitis have a history of…
Allergies or atopy
the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema). Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.
How does eosinophilic esophagitis present?
Episodic dysphagia/ food impaction
What do labs in eosinophilic esophagitis show?
Eosinophilia or elevated IgG
May do allergy testing
What is seen on endoscopy in eosinophilic esophagitis?
White exudates/ papules
Red furrows
Corrugated concentric rings
Strictures
What is the treatment for eosinophilic esophagitis?
PPIs
Avoidance of known allergen
Inhaled corticosteroids
Referral to an allergist
What should be on your differential diagnosis of Hematemesis?
Mallory-Weiss Syndrome
Esophageal Varices
Peptic Ulcer Disease complications
Gastritis
Mallory-Weiss syndrome is sudden/insidious onset?
Sudden onset
What is Mallory-Weiss syndrome?
Mucosal tear from vomiting/retching, occasional lifting
At the junction of the esophagus and the stomach
Esophageal varices are sudden/ insidious onset
Could be sudden or insidious onset
What are esophageal varicies?
Dilated submucosal veins- varicose veins in the esophagus
What causes esophageal varicies?
Portal hypertension
Cirrhosis
How is Mallory-Weiss syndrome evaluated?
By upper endoscopy
What is the treatment for Mallory-Weiss syndrome?
Fluid resuscitation
Blood transfusion
Endoscopic hemostatic therapy in active bleeding
Epinephrine injection, cautery, or mechanical compression
What factors are associated with increased risk of esophageal varices bleeding?
Size.
Red signs on endoscopy
Liver disease severity
Active alcohol abuse
How do esophageal varices present?
Hematemesis and melena or hematochezia
What can be done to manage esophageal varices?
Acute resuscitation Emergent endoscopy Pharmacologic therapy Balloon tube tamponade Portal decompressive procedures
What pharmacologic therapies can be used to manage esophageal varices?
Antibiotic prophylaxis
Vasoactive drugs
Vitamin K
Lactulose
What endoscopic techniques can be used to prevent rebleeding in esophageal varicies?
Band ligation
Sclerotherapy
What can be done to prevent rebleeding in esophageal varices?
Endoscopic techniques Beta blockers Transvenous intraheptatic portosystemic shunt (TIPS) Surgical portosystemic shunts Liver transplant
What can be done to prevent first bleeds in esophageal varices?
Patients with cirrhosis should have diagnostic endoscopy to determine presence of varices. If they have varices, beta blockers or prophylactic band ligation. If none or small varices present- repeat endoscopy in 1-2 years
Which esophageal disorder is characterized by a birds beak esophagus on a barium study? What causes the birds beak?
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What is the “gold standard” for diagnosing GERD?
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What is the first thing you should do for a patient with suspected GERD?
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What are the alarm symptoms in esophageal disorders?
Commonly encountered alarm symptoms include: dysphagia (difficulty swallowing); odynophagia (painful swallowing); gastrointestinal bleeding or anemia; weight loss; and chest pain. Dysphagia in combination with GERD usually signifies a peptic stricture, but can also be present in esophageal malignancies.
