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Clin Med II > Disorders of the Esophagus > Flashcards

Disorders of the Esophagus Flashcards

1
Q

What is dysphagia?

A

Difficulty swallowing

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2
Q

What is odynophagia?

A

Pain with swallowing, with or without difficulty swallowing

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3
Q

What are 3 patient complaints when the esophagus is involved?

A

Heartburn
Dysphagia
Odynophagia

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4
Q

What is the most common cause of heartburn?

A

GERD

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5
Q

What is on the differential diagnosis of heartburn?

A

GERD
Zollinger-Ellison Syndrome
Cardiac origin of pain

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6
Q

What is Zollinger- Ellison Syndrome?

A

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

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7
Q

What is GERD?

A

Gastroesophageal reflux disease

The reflux of gastric contents into the esophagus results in symptoms and/or complications

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7
Q

What is GERD?

A

Gastroesophageal reflux disease

The reflux of gastric contents into the esophagus results in symptoms and/or complications

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8
Q

How is GERD objectively defined?

A

The presence of characteristic mucosal injury seen at endoscopy and/or abnormal esophageal acid exposure demonstrate on a reflux monitoring study

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9
Q

What is the pathophysiology of GERD?

A

Incompetent lower esophageal sphincter, impaired esophageal clearance, compromised integrity of the esophageal mucosa

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10
Q

What condition can cause GERD?

A

Hiatal hernia

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11
Q

The heartburn in GERD is mostly…

A

Postprandial or positional

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12
Q

What are the signs and symptoms of GERD?

A 
Heartburn 
Acid taste or refluxate 
Dysphagia 
Atypical presentations 
(Degree of symptoms not related to degree of tissue damage)
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13
Q

What will you find on physical exam in GERD?

A

Normal physical exam

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14
Q

What will the lab tests in GERD show?

A

Normal lab tests

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15
Q

What exams are done in atypical or complicated cases of GERD?

A 
Upper endoscopy 
Barium esophagography (barium swallow) 
Ambulatory esophageal pH monitoring *
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16
Q

What should be done first in the treatment of GERD?

A

Lifestyle changes

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17
Q

What lifestyle changes can be made to treat GERD?

A

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

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18
Q

H pylori testing is/is not recommended in GERD?

A

Is not

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19
Q

What are some pharmacologic therapies for GERD?

A

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)

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20
Q

How are H2 receptor blockers used?

A

As needed with breakthrough nocturnal symptoms on a PPI or with low-level symptoms

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21
Q

What are some examples of a H2 receptor blocker?

A

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

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22
Q

What kind of medication is recommended for empiric treatment as an 8 week trial in uncomplicated GERD? How should it be used?

A

PPI - proton pump inhibitor

QD before a meal

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23
Q

What are some examples of PPIs?

A

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)

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24
Q

What is another med for GERD?

A

Metoclopramide- Reglan (prokinetic)

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25
Q

What are some treatments for GERD in pregnancy?

A

Lifestyle changes
Antacids
Alginate
Sucralfate

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26
Q

If a patient is not responding to medical or surgical treatment of GERD, what should you consider?

A

A different diagnosis- Zollinger-Ellison, pill induced esophagitis, resistance to PPIs, or non-compliance

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27
Q

How should you work up a non-responder?

A

Ambulatory esophageal reflux monitoring

Upper endoscopy only if Alarm symptoms

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28
Q

What are alarm symptoms?

A

?

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29
Q

What is a complication of GERD?

A

Barrett’s esophagus

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30
Q

What is a complication of GERD?

A

Barrett’s esophagus

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31
Q

What is Barrett’s esophagus?

A

Chronic acidic injury

Squamous epithelium replaced by meta plastic columnar epithelium

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32
Q

What percentage of patients with chronic GERD develop Barrett’s esophagus?

A

10%

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33
Q

How is Barrett’s esophagus diagnosed?

A

Endoscopic biopsy

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34
Q

Who should be screened for Barrett’s esophagus?

A

Chronic GERD symptoms and other risk factors- over 50 years old, male, hiatal hernia, elevated BMI, elevated visceral fat

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35
Q

How often should those at risk be screened for Barrett’s esophagus?

A

Every 3-5 years

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36
Q

How does Barrett’s esophagus progress into cancer?

A 
Squamous esophagus
Chronic inflammation 
Barrett's meta plasia 
Low grade dysplasia 
High grade dysplasia 
Adenocarcinoma (needs ablation/esophagectomy)
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37
Q

What complication of GERD causes a gradual and progressive dysphagia with solid foods over months to years?

A

Peptic stricture

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38
Q

How does peptic stricture affect heartburn?

A

Can see a reduction in heartburn due to anatomical barrier to reflux

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39
Q

What should be done to diagnose peptic stricture?

A

Endoscopy with biopsy to exclude malignant causes of stricture

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40
Q

How is peptic stricture treated?

A

Most cases are treated successfully with dilation over one or several sessions
Long term treatment with PPI

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41
Q

What is Achalasia?

A

Poorly relaxing lower esophageal sphincter

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42
Q

What is Achalasia?

A

Poorly relaxing lower esophageal sphincter

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43
Q

What are the sxs of achalasia?

A

Gradual, progressive dysphagia for solids and liquids
Substernal discomfort or postprandial fullness
Regurgitation of undigested food
Weight loss

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44
Q

What will you see on physical exam in achalasia?

A

Physical exam will be negative

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45
Q

What will you see on imaging in achalasia?

A

Bird’s beak esophagus

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46
Q

What is the best initial imaging study in achalasia?

A

Barium esophagography/esophagram

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47
Q

What other imaging can be done in achalasia?

A

Esophageal manometry

Endoscopy

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48
Q

What is the treatment for achalasia?

A

Pneumatic dilation
Surgical myotomy
Botulinum toxin injection
Calcium channel blockers or long-acting nitrates

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49
Q

What is diffuse esophageal spasm? (DES)

A

Simultaneous and repetitive contractions, some normal peristalsis

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50
Q

What is the condition of the LES in diffuse esophageal spasm (DES)?

A

The LES is normal

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51
Q

How do patients with DES present?

A

Chest pain and/or dysphagia

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52
Q

Although not completely effective, what are the treatments for DES?

A

Nitrates

Calcium-channel blockers

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53
Q

What does DES show on imaging?

A

Corkscrew esophagus

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54
Q

What is the normal diameter of the lumen of the esophagus?

A

20mm

55
Q

At what diameter does an esophageal stricture usually cause dysphagia?

A

<15 mm

56
Q

What are the causes of esophageal stricture?

A

Intrinsic and extrinsic

Intrinsic is more common- majority caused by acid/peptic cause

57
Q

What is the treatment for esophageal stricture?

A

Esophageal dilation

58
Q

What causes refractory esophageal strictures?

A

Continued pill-induced irritation
Uncontrolled GERD
Inadequate dilation diameter

59
Q

What medication is superior for prevention of recurrent esophageal strictures?

A

PPIs are superior to H2 blockers

59
Q

What medication is superior for prevention of recurrent esophageal strictures?

A

PPIs are superior to H2 blockers

59
Q

What medication is superior for prevention of recurrent esophageal strictures?

A

PPIs are superior to H2 blockers

60
Q

What are esophageal rings?

A

Circumferential mucosa or muscle in the distal esophagus

60
Q

What are esophageal rings?

A

Circumferential mucosa or muscle in the distal esophagus

60
Q

What are esophageal rings?

A

Circumferential mucosa or muscle in the distal esophagus

61
Q

What are esophageal webs?

A

Occupy only part of the esophageal lumen, always mucosal, usually proximal

62
Q

Rings and webs are common/uncommon endoscopy finds

A

Common

63
Q

Rings and webs are often symptomatic/ asymptomatic

A

Asymptomatic

64
Q

If rings and webs are symptomatic, what symptoms are seen?

A

Intermittent solid food dysphagia, aspiration, regurgitation

65
Q

What is the triad in Plummer-Vinson syndrome?

A

Proximal esophageal webs
Iron deficiency anemia
Dysphagia

66
Q

What are patients with Plummer-Vinson syndrome at a higher risk for developing?

A

Squamous cell cancer of the esophagus and pharynx

67
Q

What imaging study is the most sensitive for webs?

A

Barium radiography

68
Q

Why can’t some webs be seen on endoscopy?

A

Because some webs are so proximal that the endoscope could fracture the web before its presence is known

69
Q

What is the treatment for rings and webs?

A

Mechanical disruption

70
Q

What is Schatzki’s ring?

A

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.

71
Q

Where is Schatski’s ring located?

A

Near the LES

72
Q

What is the most common cause of intermittent solid food dysphagia and food impaction?

A

Schatzki’s ring

73
Q

What is the most common cause of intermittent solid food dysphagia and food impaction?

A

Schatzki’s ring

74
Q

What do symptoms in Schatzki’s ring depend on?

A

Luminal diameter

Usually 13-20 mm symptoms are variable

75
Q

What is the most sensitive test to diagnose Schatzki’s ring?

A

Barium swallow

75
Q

What is the most sensitive test to diagnose Schatzki’s ring?

A

Barium swallow

76
Q

What is the treatment for Schatski’s ring?

A

PPIs

77
Q

GERD can progress to ___ ____ and ___

A

Barrett’s esophagus, strictures. Schatzki’s ring

78
Q

What are the two types of strictures?

A

Peptic, esophageal

79
Q

What can Barrett’s esophagus progress to?

A

Adenocarcinoma

80
Q

How does esophageal cancer commonly present?

A

Rapidly progressive solid food dysphagia

81
Q

What do 75% of cases of esophageal cancer present with?

A

Weight loss

82
Q

SCC esophageal cancer is aggressive/ is not aggressive

A

Is aggressive

83
Q

SCC esophageal cancer is locally invasive/ is not locally invasive

A

Is locally invasive

84
Q

SCC esophageal cancer has distant metastases/ does not have distant metastases

A

With distant metastases

85
Q

Adenocarcinoma is locally invasive/ is not locally invasive

A

Is not as locally invasive

86
Q

Adenocarcinoma of esophageal cancer has metastases/ does not have metastases

A

Has metastases

87
Q

What are the risk factors for developing SCC esophageal cancer?

A

Alcohol and tobacco use
Prior esophageal injury (caustic, radiation)
HPV
Achalasia

88
Q

What are the risk factors of Adenocarcinoma esophageal cancer?

A

Obesity
GERD and Barrett’s esophagus
Scleroderma

89
Q

What is used to identify metastases in esophageal cancer?

A

CT

90
Q

What is used to evaluate depth of invasion in esophageal cancer?

A

Endoscopic ultrasound

91
Q

What is the treatment for early stage of esophageal cancer?

A

Surgery

92
Q

What is the treatment of more advanced esophageal cancer?

A

Chemotherapy/ radiation prior to surgery

93
Q

What is the treatment in late stage esophageal cancer?

A

Palliative treatment- dilation, stent placement, gastrostomy tube

94
Q

What is an esophageal diverticula?

A

Sac protruding from the esophageal wall

95
Q

How are esophageal diverticula classified?

A 
By anatomy 
Zenker's- hypopharyngeal
Midesophageal 
Epiphrenic 
Intramural psuedodiverticulosis
96
Q

Zenker’s diverticulum results from incomplete relaxation of the ____

A

UES- upper esophageal sphincter

97
Q

What does Zenker’s diverticulum present with?

A 
Oropharyngeal dysphagia 
Regurgitation of undigested food 
Halitosis 
Cough 
Aspiration pneumonia
98
Q

How is Zenker’s diverticulum diagnosed?

A

Barium swallow

99
Q

How is Zenker’s diverticulum treated?

A

Open surgical resection

100
Q

What is the cause of pill-induced dysphagia?

A

Ingestion of irritant medication - swallowing a pill without water or while supine

101
Q

What is the presentation of pill-induced dysphagia?

A

Severe retrosternal chest pain, odynophagia, dysphagia

102
Q

What is used to visualize the ulcer in pill-induced dysphagia?

A

Endoscopy

103
Q

What is the treatment for pill-induced dysphagia?

A

Rapid healing with removal of the offender

104
Q

Infectious esophagitis is most commonly seen in what patient population?

A

Immunocompromised patients such as patients with HIV

105
Q

What are the most common offending pathogens in infectious esophagitis?

A

Candida albicans
Herpes simplex
CMV

106
Q

How do patients with infectious esophagitis present with?

A

Odynophagia, dysphagia

107
Q

How is infectious esophagitis diagnosed?

A

Evaluation with endoscopy with biopsy and brushing s

108
Q

50% of all patients with eosinophilic esophagitis have a history of…

A

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.

109
Q

How does eosinophilic esophagitis present?

A

Episodic dysphagia/ food impaction

110
Q

What do labs in eosinophilic esophagitis show?

A

Eosinophilia or elevated IgG

May do allergy testing

111
Q

What is seen on endoscopy in eosinophilic esophagitis?

A

White exudates/ papules
Red furrows
Corrugated concentric rings
Strictures

112
Q

What is the treatment for eosinophilic esophagitis?

A

PPIs
Avoidance of known allergen
Inhaled corticosteroids
Referral to an allergist

113
Q

What should be on your differential diagnosis of Hematemesis?

A

Mallory-Weiss Syndrome
Esophageal Varices
Peptic Ulcer Disease complications
Gastritis

114
Q

Mallory-Weiss syndrome is sudden/insidious onset?

A

Sudden onset

115
Q

What is Mallory-Weiss syndrome?

A

Mucosal tear from vomiting/retching, occasional lifting

At the junction of the esophagus and the stomach

116
Q

Esophageal varices are sudden/ insidious onset

A

Could be sudden or insidious onset

117
Q

What are esophageal varicies?

A

Dilated submucosal veins- varicose veins in the esophagus

118
Q

What causes esophageal varicies?

A

Portal hypertension

Cirrhosis

119
Q

How is Mallory-Weiss syndrome evaluated?

A

By upper endoscopy

120
Q

What is the treatment for Mallory-Weiss syndrome?

A

Fluid resuscitation
Blood transfusion
Endoscopic hemostatic therapy in active bleeding
Epinephrine injection, cautery, or mechanical compression

121
Q

What factors are associated with increased risk of esophageal varices bleeding?

A

Size.
Red signs on endoscopy
Liver disease severity
Active alcohol abuse

122
Q

How do esophageal varices present?

A

Hematemesis and melena or hematochezia

123
Q

What can be done to manage esophageal varices?

A 
Acute resuscitation
 Emergent endoscopy
Pharmacologic therapy
 Balloon tube tamponade
 Portal decompressive procedures
124
Q

What pharmacologic therapies can be used to manage esophageal varices?

A

Antibiotic prophylaxis
Vasoactive drugs
Vitamin K
Lactulose

125
Q

What endoscopic techniques can be used to prevent rebleeding in esophageal varicies?

A

Band ligation

Sclerotherapy

126
Q

What can be done to prevent rebleeding in esophageal varices?

A 
Endoscopic techniques 
Beta blockers 
Transvenous intraheptatic portosystemic shunt (TIPS) 
Surgical portosystemic shunts 
Liver transplant
127
Q

What can be done to prevent first bleeds in esophageal varices?

A

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

128
Q

Which esophageal disorder is characterized by a birds beak esophagus on a barium study? What causes the birds beak?

A

??

129
Q

What is the “gold standard” for diagnosing GERD?

A

??

130
Q

What is the first thing you should do for a patient with suspected GERD?

A

??

131
Q

What are the alarm symptoms in esophageal disorders?

A

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.

Clin Med II (7 decks)

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