Disorders of the Esophagus Flashcards
1
Q
What is dysphagia?
A
Difficulty swallowing
2
Q
What is odynophagia?
A
Pain with swallowing, with or without difficulty swallowing
3
Q
What are 3 patient complaints when the esophagus is involved?
A
Heartburn
Dysphagia
Odynophagia
4
Q
What is the most common cause of heartburn?
A
GERD
5
Q
What is on the differential diagnosis of heartburn?
A
GERD
Zollinger-Ellison Syndrome
Cardiac origin of pain
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
7
Q
What is GERD?
A
Gastroesophageal reflux disease
The reflux of gastric contents into the esophagus results in symptoms and/or complications
7
Q
What is GERD?
A
Gastroesophageal reflux disease
The reflux of gastric contents into the esophagus results in symptoms and/or complications
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
9
Q
What is the pathophysiology of GERD?
A
Incompetent lower esophageal sphincter, impaired esophageal clearance, compromised integrity of the esophageal mucosa
10
Q
What condition can cause GERD?
A
Hiatal hernia
11
Q
The heartburn in GERD is mostly…
A
Postprandial or positional
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)
13
Q
What will you find on physical exam in GERD?
A
Normal physical exam
14
Q
What will the lab tests in GERD show?
A
Normal lab tests
15
Q
What exams are done in atypical or complicated cases of GERD?
A
Upper endoscopy Barium esophagography (barium swallow) Ambulatory esophageal pH monitoring *
16
Q
What should be done first in the treatment of GERD?
A
Lifestyle changes
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
18
Q
H pylori testing is/is not recommended in GERD?
A
Is not
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)
20
Q
How are H2 receptor blockers used?
A
As needed with breakthrough nocturnal symptoms on a PPI or with low-level symptoms
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
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
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)
24
What is another med for GERD?
Metoclopramide- Reglan (prokinetic)
25
What are some treatments for GERD in pregnancy?
Lifestyle changes
Antacids
Alginate
Sucralfate
26
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
27
How should you work up a non-responder?
Ambulatory esophageal reflux monitoring
| Upper endoscopy only if Alarm symptoms
28
What are alarm symptoms?
?
29
What is a complication of GERD?
Barrett's esophagus
30
What is a complication of GERD?
Barrett's esophagus
31
What is Barrett's esophagus?
Chronic acidic injury
| Squamous epithelium replaced by meta plastic columnar epithelium
32
What percentage of patients with chronic GERD develop Barrett's esophagus?
10%
33
How is Barrett's esophagus diagnosed?
Endoscopic biopsy
34
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
35
How often should those at risk be screened for Barrett's esophagus?
Every 3-5 years
36
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)
```
37
What complication of GERD causes a gradual and progressive dysphagia with solid foods over months to years?
Peptic stricture
38
How does peptic stricture affect heartburn?
Can see a reduction in heartburn due to anatomical barrier to reflux
39
What should be done to diagnose peptic stricture?
Endoscopy with biopsy to exclude malignant causes of stricture
40
How is peptic stricture treated?
Most cases are treated successfully with dilation over one or several sessions
Long term treatment with PPI
41
What is Achalasia?
Poorly relaxing lower esophageal sphincter
42
What is Achalasia?
Poorly relaxing lower esophageal sphincter
43
What are the sxs of achalasia?
Gradual, progressive dysphagia for solids and liquids
Substernal discomfort or postprandial fullness
Regurgitation of undigested food
Weight loss
44
What will you see on physical exam in achalasia?
Physical exam will be negative
45
What will you see on imaging in achalasia?
Bird's beak esophagus
46
What is the best initial imaging study in achalasia?
Barium esophagography/esophagram
47
What other imaging can be done in achalasia?
Esophageal manometry
| Endoscopy
48
What is the treatment for achalasia?
Pneumatic dilation
Surgical myotomy
Botulinum toxin injection
Calcium channel blockers or long-acting nitrates
49
What is diffuse esophageal spasm? (DES)
Simultaneous and repetitive contractions, some normal peristalsis
50
What is the condition of the LES in diffuse esophageal spasm (DES)?
The LES is normal
51
How do patients with DES present?
Chest pain and/or dysphagia
52
Although not completely effective, what are the treatments for DES?
Nitrates
| Calcium-channel blockers
53
What does DES show on imaging?
Corkscrew esophagus
54
What is the normal diameter of the lumen of the esophagus?
20mm
55
At what diameter does an esophageal stricture usually cause dysphagia?
<15 mm
56
What are the causes of esophageal stricture?
Intrinsic and extrinsic
| Intrinsic is more common- majority caused by acid/peptic cause
57
What is the treatment for esophageal stricture?
Esophageal dilation
58
What causes refractory esophageal strictures?
Continued pill-induced irritation
Uncontrolled GERD
Inadequate dilation diameter
59
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
59
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
59
What medication is superior for prevention of recurrent esophageal strictures?
PPIs are superior to H2 blockers
60
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
60
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
60
What are esophageal rings?
Circumferential mucosa or muscle in the distal esophagus
61
What are esophageal webs?
Occupy only part of the esophageal lumen, always mucosal, usually proximal
62
Rings and webs are common/uncommon endoscopy finds
Common
63
Rings and webs are often symptomatic/ asymptomatic
Asymptomatic
64
If rings and webs are symptomatic, what symptoms are seen?
Intermittent solid food dysphagia, aspiration, regurgitation
65
What is the triad in Plummer-Vinson syndrome?
Proximal esophageal webs
Iron deficiency anemia
Dysphagia
66
What are patients with Plummer-Vinson syndrome at a higher risk for developing?
Squamous cell cancer of the esophagus and pharynx
67
What imaging study is the most sensitive for webs?
Barium radiography
68
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
69
What is the treatment for rings and webs?
Mechanical disruption
70
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.
71
Where is Schatski's ring located?
Near the LES
72
What is the most common cause of intermittent solid food dysphagia and food impaction?
Schatzki's ring
73
What is the most common cause of intermittent solid food dysphagia and food impaction?
Schatzki's ring
74
What do symptoms in Schatzki's ring depend on?
Luminal diameter
| Usually 13-20 mm symptoms are variable
75
What is the most sensitive test to diagnose Schatzki's ring?
Barium swallow
75
What is the most sensitive test to diagnose Schatzki's ring?
Barium swallow
76
What is the treatment for Schatski's ring?
PPIs
77
GERD can progress to ___ ____ and ___
Barrett's esophagus, strictures. Schatzki's ring
78
What are the two types of strictures?
Peptic, esophageal
79
What can Barrett's esophagus progress to?
Adenocarcinoma
80
How does esophageal cancer commonly present?
Rapidly progressive solid food dysphagia
81
What do 75% of cases of esophageal cancer present with?
Weight loss
82
SCC esophageal cancer is aggressive/ is not aggressive
Is aggressive
83
SCC esophageal cancer is locally invasive/ is not locally invasive
Is locally invasive
84
SCC esophageal cancer has distant metastases/ does not have distant metastases
With distant metastases
85
Adenocarcinoma is locally invasive/ is not locally invasive
Is not as locally invasive
86
Adenocarcinoma of esophageal cancer has metastases/ does not have metastases
Has metastases
87
What are the risk factors for developing SCC esophageal cancer?
Alcohol and tobacco use
Prior esophageal injury (caustic, radiation)
HPV
Achalasia
88
What are the risk factors of Adenocarcinoma esophageal cancer?
Obesity
GERD and Barrett's esophagus
Scleroderma
89
What is used to identify metastases in esophageal cancer?
CT
90
What is used to evaluate depth of invasion in esophageal cancer?
Endoscopic ultrasound
91
What is the treatment for early stage of esophageal cancer?
Surgery
92
What is the treatment of more advanced esophageal cancer?
Chemotherapy/ radiation prior to surgery
93
What is the treatment in late stage esophageal cancer?
Palliative treatment- dilation, stent placement, gastrostomy tube
94
What is an esophageal diverticula?
Sac protruding from the esophageal wall
95
How are esophageal diverticula classified?
```
By anatomy
Zenker's- hypopharyngeal
Midesophageal
Epiphrenic
Intramural psuedodiverticulosis
```
96
Zenker's diverticulum results from incomplete relaxation of the ____
UES- upper esophageal sphincter
97
What does Zenker's diverticulum present with?
```
Oropharyngeal dysphagia
Regurgitation of undigested food
Halitosis
Cough
Aspiration pneumonia
```
98
How is Zenker's diverticulum diagnosed?
Barium swallow
99
How is Zenker's diverticulum treated?
Open surgical resection
100
What is the cause of pill-induced dysphagia?
Ingestion of irritant medication - swallowing a pill without water or while supine
101
What is the presentation of pill-induced dysphagia?
Severe retrosternal chest pain, odynophagia, dysphagia
102
What is used to visualize the ulcer in pill-induced dysphagia?
Endoscopy
103
What is the treatment for pill-induced dysphagia?
Rapid healing with removal of the offender
104
Infectious esophagitis is most commonly seen in what patient population?
Immunocompromised patients such as patients with HIV
105
What are the most common offending pathogens in infectious esophagitis?
Candida albicans
Herpes simplex
CMV
106
How do patients with infectious esophagitis present with?
Odynophagia, dysphagia
107
How is infectious esophagitis diagnosed?
Evaluation with endoscopy with biopsy and brushing s
108
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.
109
How does eosinophilic esophagitis present?
Episodic dysphagia/ food impaction
110
What do labs in eosinophilic esophagitis show?
Eosinophilia or elevated IgG
| May do allergy testing
111
What is seen on endoscopy in eosinophilic esophagitis?
White exudates/ papules
Red furrows
Corrugated concentric rings
Strictures
112
What is the treatment for eosinophilic esophagitis?
PPIs
Avoidance of known allergen
Inhaled corticosteroids
Referral to an allergist
113
What should be on your differential diagnosis of Hematemesis?
Mallory-Weiss Syndrome
Esophageal Varices
Peptic Ulcer Disease complications
Gastritis
114
Mallory-Weiss syndrome is sudden/insidious onset?
Sudden onset
115
What is Mallory-Weiss syndrome?
Mucosal tear from vomiting/retching, occasional lifting
| At the junction of the esophagus and the stomach
116
Esophageal varices are sudden/ insidious onset
Could be sudden or insidious onset
117
What are esophageal varicies?
Dilated submucosal veins- varicose veins in the esophagus
118
What causes esophageal varicies?
Portal hypertension
| Cirrhosis
119
How is Mallory-Weiss syndrome evaluated?
By upper endoscopy
120
What is the treatment for Mallory-Weiss syndrome?
Fluid resuscitation
Blood transfusion
Endoscopic hemostatic therapy in active bleeding
Epinephrine injection, cautery, or mechanical compression
121
What factors are associated with increased risk of esophageal varices bleeding?
Size.
Red signs on endoscopy
Liver disease severity
Active alcohol abuse
122
How do esophageal varices present?
Hematemesis and melena or hematochezia
123
What can be done to manage esophageal varices?
```
Acute resuscitation
Emergent endoscopy
Pharmacologic therapy
Balloon tube tamponade
Portal decompressive procedures
```
124
What pharmacologic therapies can be used to manage esophageal varices?
Antibiotic prophylaxis
Vasoactive drugs
Vitamin K
Lactulose
125
What endoscopic techniques can be used to prevent rebleeding in esophageal varicies?
Band ligation
| Sclerotherapy
126
What can be done to prevent rebleeding in esophageal varices?
```
Endoscopic techniques
Beta blockers
Transvenous intraheptatic portosystemic shunt (TIPS)
Surgical portosystemic shunts
Liver transplant
```
127
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
128
Which esophageal disorder is characterized by a birds beak esophagus on a barium study? What causes the birds beak?
??
129
What is the "gold standard" for diagnosing GERD?
??
130
What is the first thing you should do for a patient with suspected GERD?
??
131
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.
