DSA 1: Atypical CP, Dysphagia, Odynophagia Flashcards
Atypical CP is defined as?
CP that is not due to angina (it is not located L substernal, worse on exertion or does not radiate to L arm/neck).
30% of CP is atypical CP, due to _______.
An esophageal source.
Can we distinguish GI vs CV causes of chest pain, based on H&P?
No, they are clues, but we need diagnostics.
When evaluating chest pain, it is most important to do what?
1. Exclude cardiac (life-threatening; MI, aortic dissection, PE, pneumothorax) causes
- Also, exclude life threatening GI causes.
What are life-threatening GI causes of chest pain?
- Boerhaave Syndrome
- Iatrogenic esophageal perforation
- Peptic ulcer disease (PUD)
What diagnostics do you run for atypical chest pain?
- ECG and cardiac enzyme
- CXR
- CT angio of chest
- Barium swallow
- Manometry
- Video fluoroscopy
- EGD
What finding can help to differentiate between MI and PE?
MI: ST
PE: S1Q3T3
Esophageal perforation can cause atypical CP.
- Presentation:
- Cause(s):
- Pleuritic/retrosternal chest pain causing patients to be in distress and can be life-threatening.
-
Iatrogenic/spontaneous
- Iatrogenic can be caused by trauma in nasogastric tube placement and endoscopy
-
Spontaneous can be caused by
- forceful retching/vomiting
- History of alcohol use
- Boerhaaves
Esophageal perforation can cause atypical CP.
Dx:
TX:
Dx:
- CXR with air in mediastinum/SubQ emphysema
- CT chest w/ contrast (Gastrografin, not barium, because barium will cause inflammation if there is a perforation)
Tx:
- NPO
- Parenteral ABX
- Surgery
- Endoscopic stenting
What 3 symptoms are indicative of pneumomediastinum (air in mediastinum), seen in _______________.
Boerhaave’s perforation.
- SubQ emphysema in the neck or precordial area (30-90% of pts)
- Hammans signs- crunching sound heart w heart beat during systole while pt it L lateral recumbant (12-50%)
- Dyspnea (30-60%)
Peptic ulcer disease is a cause of _____________, most commonly occuring in where?
Atypical CP
- Duodenal bulb => duodenal ulcer (DU)
- Stomach => gastric ulcer (GU)
What important findings are seen on H&P for peptic ulcer disease?
- Epigastric pain that is gnawing, dull or aching that lasts up to several weeks, with months-years of no symptoms.
- GI bleeding, causing coffee ground emesis, melana, hemachezia
- Worsened with anxiety, stress, coffee, alcohol
- In uncomplicated PUD, PE is NL and only mild tenderness is seen with deep epigastric palpation.
What diagnostic testing is ESSENTIAL with PUD?
- EGD + biopsy to rule out cancer.
-
Fecal antigen test to test for H.Pylori
* Stop PPI 14 days before fecal or breath testing, bc can cause a false (-)
Other ways to test for H. pylori:
- IgA AB in serum
- Urea breath test
- Upper endoscopy w/ gastric biopsy
Treatment plan for PUD?
- PPI/H2 blocker to supress acids
- Get rid of H.pylori
- Stop smoking, NSAIDS
- 4. Repeat EGD testing w biopsy to excluse cancer
What complications can occur in PUD?
If ulcer is located on posterior wall of duodenum or stomach, it can perforate into pancreas (pancreatitis), liver or gallbladder.
What is the difference between the definition/etiology of
- - nutcracker esophagus
- - diffuse esophageal spasm
- Nutcracker esophagus: Hypertensive peristalsive: contractions are coordinated, but are too strong ( ↑ amplitude & ↑ duration)
- Diffuse esophageal spasms: multiple spontaneous contractions (occur even when not swallowing) that are long and disrupt coordinated peristalsis
What is the difference between the lower esophageal sphincter (LES) of
- nutcracker esophagus
- diffuse esophageal spasm
- nutcracker esophagus:
- LES relaxes normally, but has a higher pressure at baseline
- diffuse esophageal spasm:
- LES is normal
What are the symptoms seen in
- nutcracker esophagus
- diffuse esophageal spasm
Both:
- Intermittant dysphagia to solids & liquids (NOT progressive)
- Atypical chest pain
What are the diagnosis and treatments seen in
- nutcracker esophagus
- diffuse esophageal spasm
-
- nutcracker esophagus:
- Manometry (Tests pressure of LES)
- Video fluoroscopy
-
- diffuse esophageal spasm:
- Manometry
- EGD
- Barium swallow (corkscrew esophageal spasm)
What are the treatments used in
- nutcracker esophagus
- diffuse esophageal spasm
- Nutcracker esophagus
- Nitrates
- Calcium ANT
- Bc assx with depression and anxiety; check mental health
- Diffuse esophageal spasm
- Nitrates
- Calcium ANT
- Mental health
What is GERD?
Motility disorder of the esophagus that causes intermittant esophageal dysphagia (NOT PROGRESSIVE) to solids and liquids, when accompanied by weak peristalsis.
What are complications of GERD?
If thre patient develops Barretts esophagus, it can become adenocarcinoma.
How do we diagnose GERD?
- Usually GERD is diagnosed clinically, and empirical treatment is given.
- If alarm symptoms are present, conduct a EGD
What are the alarm symtpoms associated with GERD? (7)
- Anemia
- Loss of weight that is unexplained
- Adenopathy or palpable mass
- Recurring vomitting, causing dehydration
- Melena/hematemesis
- Constant or severe pain
- Dysphagia/odynophagia
ALARM + constant/severe pain & dysphagia/odynophagia
If a patient with GERD presents with alarm symptoms, what should be done?
- EGD (esophagogastroduodenoscopy)
- Radiographic ABD imaging
- Eval for surgery
What is the treatment and management for GERD?
- Supress acids and lifestyle modification (↓ ETOH/caffeine, small low fat meals, lay at a incline) is FLOT
- PPI
- Get rid of H.pylori, if present
What is a hiatal hernia?
Herniation of the stomach into the mediastunum => through the diaphram (@ esophageal hiatus)
What are the 2 types of hiatal hernias?
1. Sliding hiatal hernia
2. Paraesophageal hernia
What is the difference between sliding hiatal hernias and paraesophageal hernias?
- Sliding hiatal hernias (90%) is due to increased intraabdominal pressure due to obesity, pregnancy, and heriditary propensity to have GERD, causing the junction between the stomach and esopagus to slide up through esophageal hiatus.
-
Paraesophageal hernia: when a structure other than stomach herniates into mediastium (MCC colon), leading to an
- upside down stomach
- gastric volvus
- strangulation
What is the dx and tx of sliding hiatal hernias and paraesophageal hernias?
- DX: Barium XR
-
TX: if asymptomatic, none.
- When sx appear, surgery.
What is food impaction?
Food bolus impaction or obstruction that mostly passes spontaneously, causing the pt not to swallow liquids, even their own saliva (=> hypersalivation, drooling, foaming)
How is food impaction managed and what are symptoms?
- Mostly managed endoscopically, but may require surgery
- Severe chest pain/pressure, retching, vomitting, hypersalivation.
What is dysphagia?
Difficulty swallowing food/liquid through mouth, pharynx, and esophagus. The patient senses food sticking in path.
What is global pharyngeus?
When you feel like there is a lump in the path, but there is nothing there and you can still swallow.
When looking at dysphagia consider the following
- diff swalling in oral phase (oropharyngeal dysphagia) or in esophageal stage (esophageal dysphagia)
- -Mechanical/ structural/ motility problem
2 important things to consider in history and 2 important things to consider in physical when considering dysphagia and odynophagia.
- Hx: Unintentional WL and hoarseness
- PE: Neck exam (any masses that can impinge ESO) and skin exam (scleroderma)
How do we diagnose orophargneal dysphagia?
Esophageal dysphagia (mechanical vs motor cause)?
-
Oropharyngeal dysphagia
- Video fluoroscopy of swallowing
-
Esophageal dysphagia
-
Mechanical
- Barium swallow
- Esophagogastroscopy with biopsy
-
Motor
- Barium swallow
- Esophageal motility study (manometry)
-
Mechanical
How can we distinguish, based on symptoms between orophargngeal dysphagia vs esophageal dysphagia?
-
Orophargngeal dysphagia: difficulty initiatinng swallowing of SOLIDS or LIQUIDS, causing the food to stick at suprasternal notch
- dysphagia localized to neck and pt may have nasal regurg, aspiration and ENT sx.
-
Esophageal dysphagia
- dysphagia localized to chest or neck and food impaction.
Oropharyngeal dysphagia that causes a hard time swallowing solids only, is most likely due to what?
- Structural causes: cancer, congenital/acquired webs
What are the causes of oropharyngeal dysphagia?
- 1. Neurologic disorders
-
2. Muscular and rheumotologic disorders
- Sjrogens
-
3. Metabolic disorders
- Meds (anticholinergics)
- 4. Infectious disease
- 5. Structural disorders
- 6. Motility disorders
SUMMARY: Causes of oropharyngeal dysphagia discussed here
1. Esophageal webs
2. Zenkers diverticulum
3. Sjrogens
Esophageal webs cause what kind of dysphagias & what pattern?
- Mainly esophageal dysphagia, but if proximal, oropharyngeal that is intermittant (NOT PROGRESSIVE).
Esophageal webs are a __________ problem, making it difficult to swallow ______.
- Structural (thin, diaphragm like membranes of squamous mucosa located proximal or mid esophagus)
- Solids
What is associated with acquired esophageal webs?
1. Eosinophillic esophagitis
2. ***Plummer vision syndrome
Dx and tx for esophageal web?
- Dx: Barium swallow (esophagogram)
-
Tx: Dilatation via bougie dilator
- If <3 burn or need repeat dilation => use PPIs to treat long-term.
Plummer vision syndrome is associated with ______________, occurs in _____________ and is associated with the following symptoms (5).
- Acquired esophageal webs
- Middle-aged women
-
Symptoms (THE PLUMBER VINCENT D.I.G.S A HOLE FOR THE IRON PIPE)
- Dysphagia from esophageal webs
- Iron def. anemia
- Glossitis/Angular chelitis (red tongue/red corner of mouth)
-
Symptomatic proximal esophageal webs,
- Other: Koilonychia (spoon nails),
Zenker’s diverticulum cause what kind of dysphagias & what pattern?
Oropharyngeal dysphagia (bc upper esophagus is affected) that is gradual and insideous over the years.
Zenkers diverticulum is a __________ problem (describe)
Structural problem, creating a false diverticuli (does not involve ALL muscular layers) where the mucosa and submucosa herniatete through muscular layer of the esophagus posteriorly between the [cricopharyngeaus muscle and inferior pharyngeal constrictor muscles] => loss of elasticity of upper esophageal sphincter (UES), causing food to get stuck.
What symptoms are seen in Zenker’s diverticulum and who does it MC occur in??
- Symptoms
- Halitosis
- Spontaneous regurg
- Choking at night
- Gurgling in throat
- MC
- Older males
Dx and Tx of Zenkers Diverticulum.
-
Dx: Video esophagography*** or Barium swallow;
- perform these BEFORE EGD so we will not perforate lumen
- Tx: Surgery
What is a rheumotologic cause of oropharyngeal dysphagia?
Sjrogens syndrome
What symptoms does Sjrogens cause?
Sicca syndrome: dry mouth, dry eyes, bad teeth => causing oropharyngeal dysplsia
Sjrogens is strongly associated with __________ and occurs most commonly in whom?
- B-cell non Hodgkins lymphoma
- F in mid-50s that are post-menopausal.
Dx and Tx of Sjrogens.
- Dx: Lip biopsy and seriolgy
- Tx: supportive
In esophageal dysphagia, food sticks ____________ and may be associated with what symptoms?
- Mid to lower sternal area.
- Regurg, aspiration and odynophagia
What causes of mechanical obstruction can cause esophageal dysphagia?
What types of food do they affect?
Mechanical obstruction affect solid foods WORSE than liquids
- Schatzki ring
- Peptic stricture
- Esophageal cancer
- Eosinophillic esophagittis
What motility disorders can cause esophageal dysphagia?
Motility obstruction affect both solid and liquid foods.
- Achalasia
- Diffuse esophageal spasm
- Scleroderma
- Ineffective esophageal motility
Describe clues for the following mechanical obstructions, which cause esophageal dysphagia.
- Schatzki ring
- Peptic stricture
- Esophageal cancer
- Eosinophillic esophagitis
-
- Schatzki ring (I, NP)
- Intermittant dysphagia that is NOT progressive
-
- Peptic stricture (P)
- Progressive dysphagia with chronic heartburn that gets BETTER as stricture gets worse
-
- Esophageal cancer (P)
- Progressive dysphagia over 50 YO.
-
- Eosinophillic esophagitis
- Young adults with small-caliber lumen, proximal strictures or white papules
Describe clues for the following motility disorders, which cause esophageal dysphagia.
- Achalasia
- Diffuse esophageal spasms
- Scleroderma
- Ineffective esophageal motility
-
Achalasia (P)
- Progressive dysphagia W/O heartburn
-
Achalasia (P)
-
- Diffuse esophageal spasms (I, NP)
- intermittant dysphagia (NOT progressive) that may be assx with atypical CP
-
Scleroderma (P)
- Progressive dysphagia assx with chronic heartburn and Rayneuds
-
Scleroderma (P)
-
- Ineffective esophageal motility (I, NP)
- Intermittant dysphagia (NOT progressive) commonly assx with GERD
What is scleroderma?
Scleroderma
- Microangiopathy
- Atrophy of smooth muscle of the esophagus
- Fibrosing of skin and visceral organs = aperistaltic esophagus (motility problem)
Causes esophageal dysphagia of MAINLY solid foods
Scleroderma is MC in whom?
Pattern?
- F 30-60YO.
- Progressive dysphagia (↑ severity in AA)
Scleroderma assx symtoms
- Chronic heartburn because LES is incompetent => reflux
- Rayneuds
Dx and Tx of Scleroderma
Dx: Serology
- If diffuse scleroderma (topoisomerase I AB; Scl-70)
- BAD prognosis
- If limited scleroderma (anti-centromere AB)
- GOOD prognosis
Tx: Control sx to slow progression and improve quality of life
Which Scleroderma is considered a CREST syndrome?
Limited scleroderma (good prognosis)
- Calcinosis cutis
- Rayneuds
- Esophageal dysmoltility
- Sclerodactyly
- Telangiectasia
Other causes of esophageal dysphagia:
1. Hiatal hernia
2. GERD
What is the MCC of reflux esophagitis?
GERD
What are causes of truly refractory (unresponsive) esophagitis?
- Zollinger-Ellison syndrome (gastrinoma with gastric acid hypersection)
- Pill-induced esophagitis
- No response to PPIs
- Noncompliance
What are 2 complications of GERD?
1. Esophogeal stricture
2. Barrots esophagus
Esophageal stricture is a ________ problem that can cause ________ dysphagia.
- Structural problem (MC located at GE junction)
- Esophageal
What is the MCC of esophageal stricture?
Peptic ulcers caused by GERD.
Pt with esophogeal stricture will report what on history?
Progressive worsening that is gradual (months-years) that begins with solids => solids & liquids. As it gets worse, reflux/heartburn gets BETTER.
Dx and tx of esophageal stricture
Dx:
- Barium swallow
- EGD is MANDATORY to differentiate peptic stricutre from esophageal cancer.
Tx:
- Dilation at the time of EGD
- Long-term: PPI
What is Barrett’s esophagus?
Metaplastic columnar cells (like in intestine) replace NL stratified squamous cells in distal 1/3 esophagus due to GERD or truncal obesity
- Proximal displacement of [squamocolumnar junction] progresses to esophageal adenocarcinoma.
Who is at greatest risk for Barrett’s esophagus?
Obese white M >50 who smoke
Hx and Diagnostics for Barretts esophagus.
- Hx: Most pts are asymptomatic, however other pts will have long hx of GERD (heart burn and regurg).
-
Diagnostics:
-
EGD + biopsy
- Orange, gastric epithelium that goes up from stomach => distal 1/3 of the esophagus cirfumferentially
- Biopsy: goblet + columnar cells
-
EGD + biopsy
Tx and management of Barrets ESO.
Tx:
-
PPI for reflux sx
- maaaaay reduce risk of cancer.
-
Endoscopic ablation to remove dysplastic eptihelium ***
- Surgery (esophagectomy) is not recommended bc causes death.
Management
- Survellience endoscopy every 3-5Y to monitor for adenocarcinoma if have [BE or risk factors for cancer]
what are risk factors for adenocarcinoma of esophagus?
Obese, white M older than 50 who is [obsese, has chronic GERD or hiatal hernia].
What is the most common cancer of the esophagus and who is more likely in?
Squamous cell carcinoma of the esopahgus
AA M > 50
Sx, Dx and Tx of squamous cell carcinoma of esophagus.
- Sx: progressive dysphage, WL, anorexia, bleeding, hoarsness and cough
- Dx: EGD with biopsy (50% occur in middle 1/3 of esophagus)
- Tx: Surgery (esophagectomy.
Who is adenocarcinoma of the esophagus MC in?
White Males
What part of esophagus adenocarcinoma is MC in and why?
Distal 1/3 of the esophagus due to Baretts metasplasia => dysplasia => adenocarcinoma.
Dx and Tx of adenocarcinoma of esophagus.
- Dx: EGD with biopsy
- Tx: Endoscopic therapy (ablation)
Esophageal ring (schatzki) is a ________ problem that causes _______ dysphagia
structural (smooth, think, circumferential mucosal structures located distally)
esophageal
Esophageal ring (schatzki) is associated with ___________.
Hiatal hernias
Esophageal ring sx pattern and affects what?
Intermittant (N.P), making it hard to swallow solids.
Reflux/GERD is common.
Dx and Tx of esophageal ring (schatzki)
- Dx: Barium swallow (esophagram)
- Tx: Dilation (bougie dilator)
_______ is also called steakhouse syndrome. Large, poorly chewed food bolus causes it. Tx: drinking extra liquids and if impacted, endoscopic.
Esophageal ring (schatzki)
Achalasia is a _________ problem that causes _________ dysphagia
motility
esophageal
What is achalasia?
[Distal 2/3 of esophagus loses peristalsis] and [LES is tight (fails to relax)] due to denervation of esophagus when NO-producing inhibitor neurons in the myenteric plexus are lost, causing progressive dysphage of solids and liquids
What are the causes of Achalasia?
- Primary (idiopathic) is due to loss of NO-producing inhibitory neurons in mytenteric plexus
-
Secondary: Chagas disease (reduviid bug that transmits trypanaoma cruzi)
* pt may from from/traveling from endemic area
-
Secondary: Chagas disease (reduviid bug that transmits trypanaoma cruzi)
Hx of achalasia?
Gradual, progressive onset of dyspagia of solids and liquids, causing regurigitation of undigested food (diff from Zenkers).
Nocturnal regurg can provoke coughing or aspiration.
PE and diagnostics of achalasia
PE: Painless swelling around eye (romana sign)
Diagnostics:
- Labs: peripheral blood smear shows parasite if Chagas
- Barium esophagogram (birds beaks distal esophagus)
- EGD
-
Esophageal manometry confirms diagnosis
- compelte absence of NL peristalsis and failure of LES to relax when swallowing ***
What 3 findings do you see on manometry in achalasia?
- LES does not relax
- Increase LES tone (high esophageal resting pressure)
- Aperistalsis
What is odynophagia?
Pain when swallowing
