Disorders of the Esophagus Flashcards
anatomy of the esophagus
*mucosa: non-keratinized stratified squamous epithelium
*upper 1/3 = skeletal muscle
*middle = combination of smooth & skeletal muscle
*lower 1/3 = smooth muscle
*circular & longitudinal layers of muscle
gastroesophageal reflux disease (GERD) - overview
*key event = reflux of gastroduodenal contents (acid, pepsin, bile) into the esophagus
*mucosal defenses in the esophagus are minimal and are easily overwhelmed by the acid
pathophysiology of GERD
*transient LES (lower esophageal sphincter) relaxation
*hypotensive LES
*hiatal hernia
*decreased esophageal clearance (peristalsis, salivary function)
GERD - symptoms
*heartburn (pyrosis)
*epigastric abdominal pain
*regurgitation
*nausea
*belching
*dysphagia
*chest pain
*hiccups
*respiratory symptoms
complications of GERD
*erosions/ulcers
*stricture
*Barrett’s esophagus
*adenocarcinoma
GERD - treatment
*lifestyle modifications
*antacids
*H2 receptor antagonists
*PROTON PUMP INHIBITORS
*antireflux surgery (fundoplication)
Barrett’s Esophagus - overview
*occurs when the normal epithelium of the esophagus (non-keratinized, stratified squamous) is replaced by INTESTINAL EPITHELIUM containing GOBLET CELLS (aka intestinal metaplasia of the esophagus)
*metaplasia can progress to dysplasia and then to (adeno)carcinoma
maintenance of Barrett’s Esophagus
*proton pump inhibitors
*routine surveillance (EGD with biopsy every 3-5 years) to monitor for potential progression to cancer
*if dysplasia, endoscopic therapy to get rid of the dysplasia
lifestyle modifications for GERD
1) sleep (sleep on left side; raise head of bed)
2) diet (avoid carbonated beverages)
3) habits (stop smoking, reduce alcohol intake)
4) body weight (lose weight)
antacids - overview
*contain ingredients such as aluminum hydroxide, magnesium hydroxide, calcium carbonate
*neutralize stomach acid
*work only on a short-term basis
common causes of infectious esophagitis
- CANDIDA (most common)
- herpes simplex (HSV-1)
- cytomegalovirus
*primarily occurs in immunocompromised individuals
odynophagia
*pain with swallowing
*causes: infectious esophagitis, pill-induced esophagitis, radiation esophagitis
pill esophagitis
*medications causing pill esophagitis include:
-tetracycline, doxycycline
-KCl, quinidine, alendronate
-chemotherapy (5-FU, daunorubicin, bleomycin)
Boerhaave’s Syndrome
*effort rupture of the esophagus (usually distal esophagus)
*typically presents with severe substernal chest pain and upper abdominal pain following forceful vomiting
*often associated with overeating or heavy alcohol use
*physical findings: tachypnea, fever, subcutaneous emphysema, shock
*chest X-ray: pneumomediastinum, free peritoneal air, subQ emphysema
caustic ingestions
*strong alkalis tend to injure esophagus > stomach: ex = drain cleaners
*strong acids tend to injure stomach > esophagus: ex = battery acid or toilet bowl cleaner
oropharyngeal dysphagia
*disorders of the pharynx or upper esophageal sphincter
esophageal dysphagia
*disorders of the esophageal body or lower esophageal sphincter
symptoms of oropharyngeal dysphagia
*difficulty initiating swallowing
*difficulty propelling the food bolus from the mouth through the throat to the esophagus
*repeated attempts to swallow
*pt localizes sx to throat or cervical esophagus
*nasal regurgitation of liquids
*coughing/choking with swallowing
causes of oropharyngeal dysphagia
*neurologic: STROKE, parkinson’s, MS, etc
*skeletal muscle disorders: polymyositis, MD, MG
*mechanical: pharyngeal tumors, Zenker’s diverticulum, etc
Zenker’s diverticulum
*a posterior pharyngeal pouch formed by the herniation of the pharyngeal mucosa through the cricopharyngeal muscle
*commonly seen in elderly population
*presents with dysphagia, regurgitation, aspiration, and bad breath
diagnostic evaluation of oropharyngeal dysphagia
*modified barium swallow
*functional endoscopic evaluation of swallowing
*esophageal manometry
symptoms of esophageal dysphagia
*pt feels that the food bolus stops somewhere in the chest (from suprasternal notch to xyphoid process)
*if food bolus is regurgitated, it consists of bland chewed food or swallowed liquid (does not have a bitter or acidic taste; does not contain yellow or green fluid of gastric or biliary secretions)
diagnostic evaluation of esophageal dysphagia
*barium esophagram
*esophagoscopy (EGD)
*esophageal manometry
esophageal diseases that may present as dysphagia
1) mucosal disease - peptic stricture, Schatzki ring, Zenker’s diverticulum, eosinophilic esophagitis
2) neuromuscular disease - achalasia, scleroderma esophagus, nonspecific esophageal motility disorders
eosinophilic esophagitis - overview
*chronic, immune-mediated, eosinophil predominant; associated with atopic disorders (asthma)
*clinical sx of esophageal dysfunction (usually solid-food dysphagia and food impactions)
*typically a disease of young males
*many w/ PMHx of atopy/allergy
*> 15 eosinophils/high-power field (presence of eosinophils in esophageal mucosa)
*both genetic and environmental factors are important
eosinophilic esophagitis - treatment
*PROTON PUMP INHIBITORS + topical steroids
*elimination diets?
achalasia - overview
*failure of LES to relax due to degeneration of inhibitory neurons in the myentric (Auerbach) plexus of esophageal wall
*a disorder of esophageal emptying characterized by:
-incomplete LES relaxation with swallowing
-aperistalsis of the esophageal body
*pathophysiology related to loss of nitric-oxide producing inhibitory ganglion cells
achalasia - clinical presentation
*liquids and solids dysphagia
*chest pain
*postprandial regurgitation
*weight loss
*highest incidence in older people but can occur at any age
achalasia - differential dx
*malignancy
*Chagas’ disease
achalasia - treatment
*POEM (PerOral Endoscopic Myotomy)
*botulinum toxin injection
*pneumatic dilation
*surgical myotomy
scleroderma of the esophagus - overview
*a disorder of esophageal emptying characterized by:
-decreased amplitude and frequency of peristaltic contractions in the distal esophagus
-reduced LES pressure
*pathophysiology relates to submucosal fibrosis & smooth muscle atrophy involving the distal 2/3 of the esophagus
scleroderma of the esophagus - clinical presentation
*heartburn
*liquids and solids dysphagia (motility disorder; peptic stricture of the esophagus)
*nocturnal aspiration
esophageal scleroderma - treatment
PROTON PUMP INHIBITORS
manometric features of achalsia
*peristalsis = absent distally
*LES pressure = increased or normal; INCOMPLETE RELAXATION with swallowing
manometric features of scleroderma esophagus
*peristalsis = decreased frequency & decreased amplitude
*LES pressure = decreased
