Disorders of the Esophagus - Exam 3 Flashcards
What is the technical term for heartburn?
pyrosis
Describe heartburn. Where does it radiate?
The feeling of substernal burning
often radiates into the neck
What is the process for swallowing?
elevation of the tongue
closure of the nasopharynx
relaxation of the upper esophageal sphincter
closure of the airway
pharyngeal peristalsis
What is Oropharyngeal Dysphagia? What are some s/s? What will the pt complain of/ characterized by?
Problems with the oral phase of swallowing cause
drooling or spillage of food from the mouth, inability to chew or initiate swallowing, or dry mouth
an immediate sense of the bolus catching in the neck, the need to swallow repeatedly to clear food from the pharynx, or coughing / choking during meals
What are the 2 different types of esophageal dysphagias? How can you tell the difference between the 2?
mechanical obstruction: usually just solids
-> recurrent and predictable
motility disorders: BOTH solids and liquids
-> episodic and unpredictable
What is odynophagia? What does it reflect?
Sharp substernal pain on swallowing that may limit oral intake
Usually reflects severe erosive disease
odynophagia is most commonly associated with infectious esophagitis due to _________, _______ or _______. especially in ______pt
Candida, herpes viruses, or CMV
especially in immunocompromised patients
Odynophagia that is not infectious can also be due to _______. What was the example Adkins gave in class? What medication?
corrosive injury due to caustic ingestions and by pill-induced ulcers
button batteries are especially known for causing this!
fosfomax
What are the 2 MC complaints associated with GERD? What is the timing?
heartburn and regurgitation
occurs 30–60 minutes after meals and upon reclining
What are the 3 most common pathophys reasons GERD happens?
- Transient lower esophageal sphincter relaxation
aka increase in relaxation leads to increase in acid that comes into esophagus
- Anatomic disruption if GE Junction
aka the junction does NOT close properly
- Hypotensive lower esophageal sphincter
aka disruption of normal pressure
Which mechanism is responsible for the action of belching?
Transient lower esophageal sphincter relaxation that allows gas to leave
What factors reduce the lower esophageal sphincter pressure?
gastric distention
smoking
certain foods
medications
GERD severity is ______ with the degree of tissue damage
NOT correlated
aka pt can have minor symptoms with SEVERE disease
What are some atypical or extraesophageal manifestations of GERD?
Asthma, chronic cough, chronic laryngitis, sore throat, non-cardiac chest pain, and sleep disturbances
**What are the alarm features that would require additional work-up for GERD?
What is the diagnostic imaging for GERD? When NOT on PPI therapy, what can be seen?
Esophagogastroduodenoscopy or EGD
visible mucosal damage (known as reflux esophagitis
What is the pt education needed before a pt has an EGD?
Need to stop PPI 1 week before EGD
_____ are found in 3/4 of patients with severe erosive esophagitis and over 90% with _______
Hiatal Hernia
barrett esophagus
What are hiatal hernias caused by?
Caused by movement of the lower esophageal sphincter above the diaphragm which results in dysfunction of the gastroesophageal junction reflux barrier
What are the 2 different types of hiatal hernias? briefly describe each. Which one is MC?
**sliding hiatal hernia: Widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane allow a portion of the gastric cardia to herniate upward
aka it slides UP in the same direction of the esophagus
Paraesophageal Hernias: Are associated with abnormal laxity of the gastrosplenic and gastrocolic ligaments, which normally prevent displacement of the stomach
aka it slides up to the SIDE of the esophagus
**sliding hernia is MC of the 2- 95% of the hernia as this kind
Paraesophageal Hernias are associated with abnormal laxity of the ______ and _____ ligaements that hold the stomach in place. What part of the stomach is displaced?
gastrosplenic and gastrocolic ligaments
As the hernia enlarges, the greater curvature of the stomach rolls up into the thorax
What are the risk factors for a hiatal hernia? **What are the 2 major ones?
age 50 and older
obesity
injury to the area
being born with an unusually large hiatus
persistent and intense pressure on the surrounding muscles (coughing, vomiting, straining, pregnancy)
_____ are common and may cause no symptoms and are associated with higher amounts of _____ and delayed ________. What does it lead to?
Sliding Hiatal Hernia
acid reflux
delayed esophageal acid clearance
leading to more severe esophagitis and Barrett esophagus
Paraesophageal Hernia may be asymptomatic or present with s/s including ????? GERD symptoms (more/less) prevalent when compared to pts with sliding hiatal hernias
epigastric or substernal pain, postprandial fullness, nausea, and retching
paraesophageal have LESS GERD s/s than sliding
In Barrett’s esophagus ,______ of the esophagus is replaced by _______ from the stomach
squamous epithelium
metaplastic columnar epithelium
What will Barrett’s esophagus look like on endoscopy? How do you confirm dx?
presence of salmon-orange colored, gastric type epithelium that extends upward from the stomach into the distal tubular esophagus in a circumferential fashion
bx obtained during endoscopy
In patients known to have Barrett esophagus, but no dysplasia, how often do you need to do an EGD?
surveillance endoscopy every 3–5 years
What is the f/u requirements for patients with low-grade dysplasia?
Resect any areas of dysplasia, then repeat endoscopic surveillance in 6 months to exclude any areas of dysplasia, then endoscopic surveillance should be repeated yearly until non-dysplastic Barrett’s exist
What is the f/u requirements for patients with high-grade dysplasia?
Resect all areas, then repeat EGD as soon as possible to exclude any other areas
Repeat at 3, 6, and 12 months
then yearly for 5 years, then every 3-5 years
What is considered mild, intermittent GERD? What is the tx?
fewer than 2 episodes per week, no esophagitis)
lifestyle modifications
antacids or oral H2 receptor antagonists (cimetidine, nizatidine, famotidine) all found OTC
What are the GERD lifestyle modifications?
eating smaller meals
eliminating acidic foods or trigger foods
weight loss
avoid lying down within 3 hours after meals
**______ MOA decrease gastric acid secretion by reversibly binding to _____ receptors located on gastric parietal cells
oral H2 receptor antagonists
histamine H2
When oral H2 receptors are taken for active heartburn, how long does it take to go into effect? How long do they provide relief for?
these agents have a delay in onset of at least 30 minutes
provide heartburn relief for up to 8 hours.
When is PPI therapy warranted?
when a patients fails BID H2RA therapy/Lifestyle modifications by consistently having 2-3 more episodes per week and symptoms that impair quality of life
**______ MOA inhibit gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump
PPI
What is the pt education for PPIs?
Taken 30 minutes before breakfast for approx 4-8 weeks
needs to be taking once daily
In those who achieve good symptomatic relief with a course of empiric once-daily proton pump inhibitor, therapy may be discontinued ______. More than likely will come back within ______
after 8–12 weeks
within 3 months
How do you tx patients whose GERD symptoms relapse? What about in patients who do NOT have erosive esophagitis?
continuous proton pump inhibitor therapy, in intermittent 8 week courses
twice daily H2-receptor antagonists may be used to control symptoms
When should long-term PPI therapy (QD or BID) be initiated indefinitely?
pts with severe erosive esophagitis
or
pts with Barrett’s esophagus
**What are the potential risks of long-term PPI use?
Increased risk of infectious gastroenteritis (including C difficile)
Iron and vitamin B12 deficiency
Hypomagnesemia
Hip fractures (possibly due to impaired insoluble calcium absorption)
Dementia ??
What is the name of the new GERD drug that was just approved in July 2024?
Vonoprazan
When should surgical treatment be considered an option for pts with GERD?
(1) patients with extraesophageal manifestations of reflux, may be more effectively controlled with antireflux surgery;
(2) those with severe reflux disease unwilling to accept lifelong medical therapy
(3) patients with large hiatal hernias and persistent regurgitation despite PPI therapy
What is a surgical fundoplication?
passage of the gastric fundus behind the esophagus to encircle the distal 6cm of esophagus
helps to restore a physiologic equivalent to the normal LES
Who is the linx system a good option for?
For patients with a hiatal hernia less than 3 cm in size
magnets open with pressure to to act like a lower esophageal sphincter
When do you need to refer a pt with GERD to GI?
Typical GERD whose symptoms do not resolve with empiric management with a twice-daily proton pump inhibitor.
Suspected extraesophageal GERD symptoms that do not resolve with 3 months of twice-daily proton pump inhibitor therapy.
Significant dysphagia or other alarm symptoms for upper endoscopy.
Barrett esophagus with dysplasia or early mucosal cancer.
Surgical fundoplication is considered
_____ is the most serious complication of Barrett Esophagus. What type? What part of the esophagus is involved?
Esophageal Carcinoma
adenocarcinoma
distal third of the esophagus
Chronic alcohol and tobacco use more than likely will get _______ carcinoma. In what part of the esophagus?
squamous cell carcinoma
middle esophagus
How does esophageal cancer present?
Over 90% have solid food dysphagia, with some odynophagia,
significant weight loss is common
coughing, chest or back pain
_______ establishes the diagnosis of esophageal carcinoma with a high degree of reliability
Endoscopy with biopsy
What are the 2 general classifications for esophageal cancer?
Therapy for “Curable” Disease
Therapy for Incurable Disease
What is the tx for Therapy for “Curable” Disease esophageal cancer?
Surgery with or without chemoradiation therapy
What is the tx for Therapy for Incurable Disease for esophageal cancer?
Chemotherapy or chemoradiation; Local therapy for esophageal obstruction
What is the overall 5 year survival rate of esophageal carcinoma? What are the 2 most important predictors of poor survival?
less than 20%
adjacent mediastinal spread
lymph node involvement
What is Zenker’s diverticulum?
A sac-like outpouching of the mucosa and submucosa through Killian’s triangle
What is Killian’s triangle?
An area of weakness between the transverse fibers of the cricopharyngeus muscle and the oblique fibers of the lower inferior constrictor muscles
What is the underlying cause of Zenker’s diverticulum?
The cause is believed to be loss of elasticity of the UPPER esophageal sphincter, resulting in restricted opening during swallowing
What are 5 things that generally are present in a pt with Zenker’s diverticulum?
Altered upper esophageal sphincter function
Abnormal esophageal motility
Esophageal shortening
hiatal hernia
reflux
Dysphagia
regurgitation
coughing
throat discomfort
halitosis
spontaneous regurgitation of undigested food
gurgling in the throat
What am I?
What are 6 complications?
Zenker’s diverticulum
-Aspiration pneumonia
-bronchiectasis
-lung abscess
-Ulceration and bleeding due to retained medication
-Fistula between the diverticulum and trachea lumen formation
-Focal cord paralysis due to the pressure from retained food
How do you dx ZD? What is the tx?
barium swallow study
upper esophageal myotomy
What is an upper esophageal myotomy? When is it used?
Surgical procedure to restore the opening of the upper esophageal sphincter
The standard treatment consists of eliminating the functional obstruction at the UES level (myotomy of the cricopharyngeus muscle and the upper 3 cm of the posterior esophageal wall) and excision or suspension of the diverticulum
Zenker’s diverticulum
What is achalasia? What does it result from?
narrowing of the distal esophagus
Results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall
What does the loss of ganglion cells in achalasia lead to? What does that lead to?
This loss of cells leaves inflammatory cells of lymphocytes and eosinophils
leads to failure of relaxation of the LES and loss of peristalsis
**What is the cause of the inflammation seen in achalasia?
**The cause of the inflammation is not known
What does the narrowing of the LES in achalasia lead to ?
narrowing causes dilation of the esophagus above the LES
-gradual onset of dysphagia for solid foods and liquids
-Many patients eat more slowly and adopt specific maneuvers to help emptying
-regurgitation of undigested food is common
-substernal chest pain
-nocturnal regurgitation
-weight loss
What am I?
**What is the diagnostic tool of choice?
achalasia
**Esophageal manometry (#1)
What is an Esophageal manometry?
pressure sensing catheter in esophagus
measures LES sphincter pressure during swallowing
measures esophageal peristaltic contractions
What will a CXR show in a pt with achalasia?
may show an air-fluid level in the enlarged, fluid-filled esophagus
** What is the classic Barium esophagography finding associated with achalasia?
**and a smooth, symmetric “bird’s beak” tapering of the distal esophagus
What is the tx for achalasia? How many treatments does it usually take?
PNEUMATIC DILATION #1
1-3 sessions
What is happening in pneumatic dilation? Once the first episode has resolved, when do pts need additional treatment?
Forceful Dilation with pneumatic balloon dilation of the LES weakens the LES by circumferential stretching or tearing of its muscle fibers
Symptoms recur following pneumatic dilation in up to 35% within 10 years but usually respond to repeated dilation
Name 2 additional treatments for achalasia.
BOTULINUM TOXIN INJECTION directly into the LES
surgery: Heller myotomy
When are botox injections used in achalasia tx? How often do they need them?
This therapy is most appropriate for patients with comorbidities who are poor candidates for more invasive procedures
symptom relapse occurs in over 50% of patients within 6–9 months and in all patients within 2 years.
What is a Heller myotomy? What is a common complication? How do you fix it?
cut LES muscle fibers, only the OUTER muscles of the esophagus are cut. Incisions will reduce the force of the contracting muscles and relax the LES, thereby, allowing food to pass easily.
makes it easy for the stomach acid to recede into the esophagus. Hence, a fundoplication is often performed along with myotomy.
**_____ confirms diagnosis of achalasia
esophageal manometry
What does diffuse esophageal spasms present as? ** What is the classic finding on barium swallow?
Episodes of dysphagia and chest pain
**“corkscrew esophagus” with barium swallow #1
What is diffuse esophageal spams defined as on manometry?
uncoordinated (“spastic”) activity in the distal esophagus
spontaneous and repetitive contractions
Or, high-amplitude and prolonged contractions
What is the running theory as to why diffuse esophageal spasms occur?
thought to be a consequence of impaired inhibitory innervation, leading to premature and rapidly propagated contractions
for diffuse esophageal spasm pts, will the dysphagia be present for solids and liquids? The dysphagia will occur in association with: (3 things)
YES! both solids and liquids
retrosternal, noncardiac chest pain
heartburn
regurgitation
What are the top 2 MC treatment options for DES? What are 3 additional options?
CCB: Diltiazem 60-90mg QID for 3 months, then prn
or
TCA
_________
NTG
sildenafil
botulinum toxin
What is scleroderma? What are the 5 limited symptoms?
Autoimmune disorder that can involve skin, lungs, heart, and GI tract
CREST (see picture)
What is scleroderma esophagus? _____ is the often the only identifiable association
Hypotensive LES and absent esophageal peristalsis
Reflux disease
What is the pathogenesis of Scleroderma esophagus? What are these pts at severe risk for?
Infiltration and destruction of the esophageal muscularis with collagen deposits and fibrosis
high risk for severe GERD due to inadequate LES barrier
What is the tx for scleroderma?
PPI for GERD
metoclopramide for dymotility
What is a mallory weis tear? What is it characterized by? What is it caused by?
a tear in the mucosal layer at the junction of the esophagus and stomach
Characterized by a nonpenetrating mucosal tear at the gastroesophageal junction
suddenly raise transabdominal pressure due to lifting, retching and vomiting
______ is a strong predisposing factor for a mallory weis tear
alcoholism
What are s/s of a mallory weis tear?
Acute onset of GI bleeding with hematemesis
may have epigastric or back pain
history of vomiting/retching
How do you dx a mallory weis tear? What will it look like? What are the 2 MC sites?
EGD
0.5- to 4-cm linear mucosal tear
usually located either at the gastroesophageal junction or, more commonly, just below the junction in the gastric mucosa
What is the tx for a mallory weis tear? What happens if the bleeding does NOT stop?
fluid resuscitation and blood transfusions because most pts stop bleeding spontaneously and require no therapy
Endoscopic hemostatic therapy
What are the 3 options for Endoscopic hemostatic therapy in a mallory weis tear?
Injection with epinephrine (1:10,000)
Cautery with a bipolar or heater probe coagulation device
Or mechanical compression of the artery by application of an endoclip or band is effective in 90–95% of cases
_______ or operative intervention is required in patients who fail endoscopic therapy for a mallory weis tear
Angiographic arterial embolization
What are esophageal webs? **Where are they located in the esophagus?
Esophageal webs are thin, diaphragm-like membranes of squamous mucosa that cause narrowing in the esophagus
**mid or upper esophagus
What are 4 causes of esophageal webs?
Congenital
Esophagitis
Pemphigoid: (autoimmune disorder)
Iron deficiency anemia ( called Plummer-Vinson syndrome)
What are “Schatzki” rings? **Where are they located within the esophagus? ______ is suggestive that might contribute to the cause of schatzki rings
smooth, circumferential, thin (less than 4 mm in thickness) mucosal structures located in the distal esophagus at the squamocolumnar junction
GERD
Most webs and rings are over _____ in diameter and are asymptomatic. Solid food dysphagia most often occurs with rings less than _____ in diameter
20 mm
13 mm
What is the tx for esophageal webs and rings?
passage of dilators to disrupt the lesion
or
endoscopic electrosurgical incision of the ring
often repeat dilations are required
should be on PPI therapy
What are esophageal varices caused by? Is it considered an emergency? Why or why not?
portal hypertension due to cirrhosis
YES!! because it may result in serious upper gastrointestinal bleeding - life threatening
Where is bleeding from an esophageal
varices more likely to occur? What is the pathogenesis?
most commonly occurs in the distal 5 cm of the esophagus
When the portal vein and IVC gradient exceeds 10–12 mm Hg, significant portal hypertension exists
What is the normal portal vein to IVC pressure gradient?
Under normal circumstances, there is a 2–6 mm Hg pressure gradient between the portal vein and the inferior vena cava
What is the MC cause of esophageal varices? Why do varices develop?
Cirrhosis
due to increased portal pressure that results from increased resistance to outflow through obstruction of hepative portal vein
Varices develop in order to decompress the hypertensive portal vein and return blood to the systemic circulation
What is the MC cause of portal hypertension? _____ will stop bleeding spontaneously. What is likely to happen in the future?
cirrhosis
roughly 50%
60% chance of recurrent variceal bleeding, usually within the first 6 weeks
What are the bleeding risk factors for esophageal varices?
(1) the size of the varices (>5 cm)
(2) the presence at endoscopy of red wale markings (longitudinal dilated venules on the varix surface)
(3) the severity of liver disease (as assessed by Child scoring)
(4) active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding
What is the scoring system that evaluates liver disease?
Child scoring
What are red wale markings?
longitudinal dilated venules on the varix surface)
aka red marking on top of esophageal varices
How will esophageal varices usually present?
hematemesis (bright red vomiting of blood)
coffee ground emesis: brown/red blood
melena (dark stools)
retching
dyspepsia
hypovolemic shock
USUALLY VERY SEVERE!!
What is this? What disease? what does it increase your risk for?
Red Whale Markings
esophageal varices
increased risk of bleeding
What is the INITIAL management of esophageal varices?
ACUTE resuscitation!!!
fluids and blood products (fresh frozen plasma or platelets) as necessary
supplemental O2 or intubation as necessary
pts with liver disease need to go to ICU
When do fresh frozen plasma or platelets need to be given in esophageal varices?
fresh frozen plasma or platelets should be administered to patients with INRs greater than 1.8–2.0 or with platelet counts less than 50,000/mcL in the presence of active bleeding
For esophageal varices, once the pt is stable, what do you do next?
- abx: IV Ceftriaxone for 5-7 days
or fluoroquinolones if allergy - Octreotide (Sandostatin)
- vitamin K
- lactulose
Why do you give esophageal varices pts Octreotide (Sandostatin)?
nfusions reduce splanchnic and hepatic blood flow, therefore reducing portal pressure
Inhibits release of vasodilator hormones such as glucagon, indirectly causing splanchnic vasoconstriction and decreased portal blood inflow
Why do you give esophageal varices pts Vitamin K?
In cirrhotic patients with an abnormal prothrombin time, vitamin K (10 mg) should be administered intravenously
Why do you give esophageal varices pts lactulose? What is the dosing?
decreasing the intestinal production and absorption of AMMONIA to reduce the risk of Encephalopathy (increased ammonia leads to encephalopathy)
30 mL orally every 1–2 hours until evacuation occurs then reduced to 15–45 mL/h every 8–12 hours as needed to promote two or three bowel movements daily
_____ needs to be performed in esophageal varices once the pt is stable and usually within ____ hours of admission. What happens next?
EMERGENT ENDOSCOPY
usually within 12 hours of admission
Immediate endoscopic treatment of the varices generally is performed with BANDING
How many treatments are needed? How often do you need to repeat banding in EV? How long does it take for the varices to slough off? What medication is given to prevent rebleeding?
usually 2-6 treatments
Repeat every 2–4 weeks, until the varices are obliterated or reduced in size
a few days
BB: propranolol, nadolol
What is the prevention of rebleeding?
COMBINATION BETA-BLOCKERS AND VARICEAL BAND LIGATION
**patients with cirrhosis should undergo _______ to look for ______
diagnostic endoscopy
varices are present
All patients with acute upper gastrointestinal bleeding and ______ should be admitted to _____
suspected cirrhosis
an ICU
EV are found on EGD, give _______ to reduce the risk of first variceal hemorrhage
Beta- blockers
________ only used when EV bleeding cannot be stopped by pharmacologic/endoscopic procedures. How does it work? How long is it kept in for?
Balloon Tamponade
A balloon is inflated within the esophagus or stomach to apply pressure on bleeding blood vessels, compress the vessels, and stop the bleeding
24 hours
_______ is used in EV when pharmacologic/endoscopic procedures fail and is not a balloon. How does it work?
Transvenous Intrahepatic Portosystemic Shunts (TIPS)
Wire that is passed through a catheter inserted in the jugular vein
an expandable wire mesh stent (8-12 mm in diameter) is passed through the liver parenchyma
Transvenous Intrahepatic Portosystemic Shunts (TIPS) creates a shunt from the _____ vein in the ____ vein
portal vein in the hepatic vein
When does infectious esophagitis most often occur in ______ patients. What are the 3 MC pathogens?
immunosuppressed
Candida albicans, herpes simplex, and CMV
______ may occur also in patients who have uncontrolled diabetes and those being treated with systemic corticosteroids, radiation therapy, or systemic antibiotic therapy. ______ can affect normal hosts, in which case the infection is generally self-limited
Candida infection
Herpes simplex
How will infectious esophagitis present?
Odynophagia and dysphagia
Substernal chest pain occurs in some patients
may have CMV infection at other sites such as colon and retina
oral ulcers might also be present with herpes simplex esophagitis
How do you dx infectious esophagitis?
endoscopy with biopsy and brushings (for microbiologic and histopathologic analysis)
What is the tx for CANDIDAL ESOPHAGITIS? CYTOMEGALOVIRUS ESOPHAGITIS? HERPETIC ESOPHAGITIS?
CANDIDAL ESOPHAGITIS: systemic fluconazole
CYTOMEGALOVIRUS ESOPHAGITIS: In patients with HIV infection, immune restoration with antiretroviral therapy
HERPETIC ESOPHAGITIS: oral acyclovir
What kind of sedation is given during an EGD? What organs are being assessed?
Intravenous conscious sedation
through the mouth into the esophagus, stomach, and duodenum
Barium swallow evaluates ______ and ______. What is the liquid called?
pharynx and the esophagus
barium sulfate (barium)
What does Esophageal Manometry
measure? When is it commonly used?
Motility testing- examines the coordinated muscle movement (motility) of the esophagus. A pressure-sensing catheter placed within the esophagus and then observe the contractility following test swallows
achalasia and diffuse esophageal spasms
The upper and lower esophageal sphincters appear as zones of high ______ that relax on ______, while the intersphincteric esophagus exhibits _______. All are assessed during ______
pressure
swallowing
peristaltic contractions
Esophageal Manometry
What is Ambulatory Esophageal pH Monitoring do? When is it commonly used?
The recording provides information about the amount of esophageal acid reflux and the correlations between symptoms and reflux
aka info about acid reflux
