DSA 1: Dysphagia, Odynophagia, Atypical Chest Pain Flashcards
1
Q
What is atypical chest pain?
A
chest pain that is not angina
- not left substernal, worse with exertion, radiation to neck/left arm
2
Q
What must you exclude with a c/c of chest pain?
A
cardiac (or life-threatening causes)
- MI, aortic dissection, pulmonary embolus/pneumothorax
NOTE: hx and physical can NOT distinguish GI from CV cause
3
Q
What are the possible life-threatening GI ddx to consider?
A
- Boerhaave Syndrome (torn esophagus leading to increased pressure/subQ emphysema)
- lactogenic esophageal perforation
- PUD
4
Q
Life threatening non-GI:
- chest pressure
- distressed, diaphoretic
- “impending doom”
- murmur
- ECG, troponins, CXR
A
MI
- tx: stabilize, MONA, PCI
5
Q
Life threatening non-GI:
- sudden onset
- “tearing or ripping” chest pain
- radiation to neck
- syncope
- hemiparesis, paresthesias
- altered mental status
- “impending doom”
- asymmetrical pulses
- CXR with widened mediastinum
A
Aortic dissection
- tx: surgery and BP management
6
Q
Life threatening non-GI:
- recent travel or surgery
- suddent onset
- pleuritic chest pain
- shortness of breath
- hypoxia
- hemodynamic collapse
- ECG showing sinus tachy or S1q3t3 (rare)
- lower extremity venous duplex ultrasound
A
Pulmonary embolism
7
Q
- life threatening
- pt in distress upon presentation
- iatrogenic (caused by trauma or med procedure like NG tube/endoscopy)
- spontaneous (forceful retching/vomiting, hx of alcohol use, Boerhaave’s)
- pleuritic/retrosternal chest pain
- pneumomediastinum or subQ emphysema
A
Esophageal perforation
8
Q
What is the dx and tx of esophageal perforation?
A
- dx: CXR with air in mediastinum/subQ emphysema or chest CT with contrast (Gastrografin** NOT barium)
- tx: NPO, parenteral antibiotics, surgery, endoscope stenting
9
Q
- subQ emphysema (detected in neck/precordial area)
- Hamman’s sign (crunching, rasping sound, synchronus with heartbeat)
- dyspnea (must differentiate lung disease from GI)
A
pneumomediastinum (Boerhaave’s)
10
Q
- duodenal or gastric ulcer
- PE shows signs of gastrointestinal bleeding (coffee ground emesis, hematemesis, melena, hematochezia)
- EGD (esoph/gastro/duodeno endoscopy) with biopsy (exclude malignancy in GU**)
- detection of H.pylori
A
Peptic Ulcer Disease (PUD)
NOTE: must stop PPI 14 days before fecal tests due to risk of false negative
11
Q
- hypertensive peristalsis
- LES relaxes normally, but has elevated baseline pressure
- dysphagia to solids and liquids
- atypical chest pain
A
Nutcracker Esophagus
12
Q
what is the dx and tx for nutcracker esophagus?
A
- dx: manometry, video fluoroscopy
- tx: nitrates and calcium antagonists, also concomitant mental health
13
Q
- multiple spastic contractions of inner circular muscle in the esophagus, disrupting the coordinated components of peristalsis
- “corkscrew” esophagus
- “rosary bead” esophagus on barium x-ray
- LES function is normal
- dysphagia to solids and liquids, atypical chest pain
A
diffuse esophageal spasm
14
Q
what is the dx and tx for diffuse esophageal spasm?
A
- dx: manometry, EGD, barium swallow
- nitrates, calcium antagonists, also concomitant mental health
15
Q
- motility disorder (ineffective esophageal motility of LES)
- esophageal dysphagia when accompanied by weak peristalsis (intermittent, NOT progressive)
A
GERD
16
Q
what is the dx and tx of GERD?
A
- dx: clinically
- tx: trial of acid suppression and lifestyle modification first line
NOTE: EGD if alarm features are found
17
Q
what are the alarm features of GERD?
A
- unexplained weight loss
- persistent vomiting
- constant/severe pain
- dysphagia/odynophagia
- palpable mass or adenopathy
- hematemesis
- melena
- anemia
18
Q
herniation of the stomach, into the mediastinum through the esophageal hiatus of the diaphragm
A
hiatal hernia
19
Q
result of increased intra-abdominal pressure from abdominal obesity, pregnancy or hereditary
- increased likelihood to have GERD
A
sliding hiatal hernia
20
Q
herniation into the mediastinum includes a visceral structure other than the gastric cardia, most commonly the colon
- can lead to an upside down stomach, gastric volvulus, strangulation of the stomach
A
paraesophageal hernia
21
Q
what is the dx and tx of hiatal hernia?
A
- dx: barium Xray
- tx: asymptomatic => none, symptoms => surgical repair
22
Q
what are the risk factors for foreign bodies/food impaction? (6)
A
- Schatzki’s ring
- peptic stricture
- webs
- eosinophilic esophagitis
- achalasia
- cancer
23
Q
- chest pain/pressure, dysphagia/odynophagia, choking sensation
- inability to swallow liquids including own saliva
A
foreign body/food impaction
24
Q
the sensation of a lump lodged in the throat, with swallowing unaffected
A
globus pharyngeus
25
- difficulty initiating swallowing
- food sticks at level of suprasternal notch
- may have nasopharyngeal regurgitation or aspiration
- can be with solids only, or liquids and solids
oropharyngeal dysphagia
26
- mainly *esophageal* dysphagia, but if proximal -> *oropharyngeal*
- can be asymtomatic, or intermittent symptoms that are NOT progressive
- structural problem (**thin diaphragm-like membranes of squamous mucosa**
- proximal or mid esophagus
esophageal web
27
what is the dx and tx of esophageal web?
- dx: barium swallow (esophagogram is best view, EGD can be done but is less sensitive)
- tx: dilation (bougie dilator) or small endoscopic electrosurgical incision, PPI longterm
28
- middle aged women
- combination of angular chelitis (painful inflammed corners of the mouth), glossitis, esophageal webs, koilonychia (spoon nails), iron deficiency anemia
Plummer-Vinson syndrome
29
- oropharyngeal dysphagia due to affected upper esophagus
- vague symptoms at first -> coughing or throat discomfort
- halitosis, spontaneous regurgitation, nocturnal choking, gurgling in the throat, protrusion in the neck
Zenker's diverticulum
30
what is the structural abnormality of Zenker's diverticulum?
FALSE diverticula: herniation of the *mucosa and submucosa* through the muscular layer of the esophagus posteriorly between cricopharyngeus muscle and the inferior pharyngeal constrictor muscles
- loss of elasticity of upper esophageal sphincter (UES)
- occurs in area of natural weakness, proximal to cricopharyngeus (Kilian's triangle)
31
What is the dx and tx of Zenker's diverticulum?
- dx: video esophagography or barium swallow
| - tx: surgery - upper myotomy or surgical diverticulectomy
32
rheumatologic cause of dysphagia
- dry eyes, dry mouth -> oropharyngeal dysphagia
- vaginal dryness, tracheo-bronchial dryness
- increased incidence of oral infection (candida*)
- dental caries
- parotid or other major salivary gland enlargement
- keratoconjunctivitis sicca (foreign body sensation)
- **strong association with B cell non-Hodgkin lymphoma**
Sjogren's syndrome
33
what is the dx and tx of Sjogrens?
- dx: lip biopsy, serology
| - tx: supportive
34
what are the mechanical obstruction examples that cause esophageal dysphagia?
- schatzi ring
- peptic stricture
- esophageal cancer
- eosinophilic esophagitis
35
what are the clues for the following mechanical obstructions?
- schatzi ring
- peptic stricture
- esophageal cancer
- eosinophilic esophagitis
- schatzi ring: intermittent dysphagia
- peptic stricture: chronic heartburn, progressive dysphagia
- esophageal cancer: progressive dysphagia, age *over 50*
- eosinophilic esophagitis: *young adults*, small caliber lumen, proximal stricture, *corrugated rings*, or white papules
36
what are the motility disorder examples that cause esophageal dysphagia?
- achalasia
- diffuse esophageal spasm
- scleroderma
- ineffective esophageal motility
37
what are the clues for the following mechanical obstructions?
- achalasia
- scleroderma
- ineffective esophageal motility
- achalasia: progressive dysphagia (NO assoc heartburn)
- diffuse esophageal spasm: intermittent, +/- chest pain
- scleroderma: chronic heartburn, Raynaud's, progressive
- ineffective esophageal motility: intermittent (NOT progressive), commonly associated with GERD
38
- topoisomerase 1 antibodies (Scl-70)
- diffuse involvement including proximal extremities and trunk
- early progressive internal organ involvement
- worse prognosis
Diffuse scleroderma (dcSSc)
39
- anti-centromere antibodies
- fingers, toes, face, distal extremities
- Raynaud's commonly precedes other symptoms
- CREST syndrome: calcinosis cutis, Raynauds, esophageal dysmotility, sclerodactyly (tightening of skin on fingers/toes), telangiectasia (tiny red blood vessels on skin)
- indolent course (little/no pain)
- good prognosis
Limited scleroderma (lcSSc)
40
- esophageal dysphagia (mainly solids), propulsion problem
- 30-60 y/o
- W>M, (increase severity in Af Am)
- progressive dysphagia
- **atrophy of the esophageal smooth muscle**
- fibrosis of the skin and visceral organs -> A-peristaltic esophagus
- may present with chronic heartburn (incompetent LES -> reflux esophagitis or stricture)
scleroderma
41
what is the dx and tx of scleroderma?
- dx: serology
| - tx: controls symptoms and slows progression to improve quality of life and prolong survival
42
what is the most common cause of GERD?
reflux esophagitis
43
what are the 4 examples of what can cause esophagitis?
- gastrinoma with gastric acid hypersecretion (ZES)
- pill-induced esophagitis
- resistance to proton pump inhibitors
- medical noncompliance
44
- esophageal dysphagia
- structural problem
- most common is *peptic* secondary to GERD, can also occur because of eosinophilic esophagitis
- as it progresses, *reflux/heartburn lessens/improves*
esophageal stricture
| - heartburn improves as stricture narrows lumen, blocking more acid from flowing up
45
what is the dx and tx of esophageal stricture?
- dx: barium swallow, *EGD with biopsy mandatory in all cases to rule out carcinoma*
- tx: dilation at time of EGD, long term therapy with a proton pump inhibitor, refractory strictures may benefit from endoscopic injection of steroids
46
specialized intestinal (metaplastic) columnar metaplasia that replaces the normal squamous mucosa of distal esophagus
- complications of GERD and truncal obesity
- obese white males older than 50 who smoke most at risk
Barrett esophagus
NOTE: proximal displacement of the squamocolumnar junction progresses to *esophageal adenocarcinoma*
47
what is the dx and tx of Barrett esophagus
- dx: surveillance endoscopy (monitoring for adenocarcinoma)
| - tx: PPI, *endoscopic ablation* better than surgery
48
what are the risk factors for adenocarcinoma?
- white male >50
- *chronic GERD*
- hiatal hernia
- obesity
49
most common type of esophageal cancer in the world
- males > females
- Af Am > caucasians
- risk factors: heavy smoking, alcohol use, esophageal disorders (achalasia, HPV, Plummer-Vinson syndrome, Tylosis)
- *progressive dysphagia, weight loss, anorexia, bleeding, hoarseness, cough*
squamous cell carcinoma
50
what is the dx and tx of squamous cell carcinoma of esophagus?
- dx: EGD with biopsy
| - tx: surgery (esophagectomy)
51
- caucasians > Af Am
- Males > females
- distal 1/3 of esophagus
- Barrett metaplasia -> dysplaisa -> *?*
adenocarcinoma of esophagus
52
what is the dx and tx of adenocarcinoma of the esophagus
- dx: EGD with biopsy
- tx: endoscopic ablation therapy
NOTE: esophagectomy used to be practiced, but has high morbidity and mortality rates
53
- esophageal dysphagia (usually distal, intermittent)
- structural problem (smooth, circumferential, thin mucosal structures)
- **steakhouse syndrome**: food bolus may pass on own with extra liquid, if impacted -> extracted endoscopically
esophageal ring (Schatzki's ring)
**RINGS ARE THICKER THAN WEBS**
54
what is the dx and tx of Schatzki's ring?
- dx: barium swallow (best view)
| - tx: dilation or small endoscopic electrosurgical incision, PPI longterm
55
- esophageal dysphagia
- motility disorder -> PROGRESSIVE dysphagia (solids and liquids)
- **propulsion problem** loss of peristalsis (distal 2/3), failure of LES relaxation
- denervation of esophagus resulting from **loss of nitric oxide-producing inhibitory neurons in the myenteric plexus**
- weight loss is common
Achalasia
56
what is considered primary achalasia?
loss of ganglion cells within esophageal myenteric plexus
57
what is considered secondary achalasia?
Chagas:
- esophageal dysfunction that is indistinguishable from primary idiopathic achalasia
- *should be considered in patients from endemic regions (Mexico, Central, South America)
Other:
- lymphoma, carcinoma, chronic idiopathic intestinal pseudoobstruction
58
what is the dx and tx of achalasia?
- dx: barium esophagram -> "birds beak!", **esophageal manometry** confirms dx
- Secondary: **peripheral blood smear** shows parasite
- tx: nitrates and CCB therapy, PPI, surgery
59
what are the manometry findings in achalasia?
1. incomplete LES relaxation (high pressure)
2. decreased esophageal resting pressure, (lumen dilates) -> BIRDS BEAK/funnel shape
3. loss of peristalsis
60
- what are the types of esophagitis?
- pill
- infectious (candida/herpes/CMV)
- eosinophilic
- caustic
61
- severe retrosternal chest pain, odynophagia, dysphagia
- often begins several hours after taking a pill
- some pt have relatively little pain (especially the elderly), presenting with dysphagia
pill-induced esophagitis
62
what is the dx and tx of pill-induced esophagitis
- dx: endoscopy may reveal one to several discrete ulcers (may be shallow or deep)
- tx: eliminate offending agent (healing occurs rapidly)
- if pill needs to be taken, take with 4oz of water and remain upright for 30 mins after ingestion
63
what are the risk factors of infectious esophagitis?
- immunosuppressed pt
- uncontrolled diabetes
- systemic corticosteroid use
- radiation therapy
- systemic antibiotic therapy
64
- long history of dysphagia
- history of food bolus impaction
- history of **allergies or atopic conditions** (>50% of patients), thought to stimulate inflammation
- complication: esophageal perforation
eosinophilic esophagitis (EOE)
65
what is the dx and tx of EOE?
- dx: EGD shows multiple circular esophageal rings creating a **corrugated** appearance
- "feline" or "tracheal" esophagus
- dx requires biopsy with >15-20 eosinophils per HPF
66
what is the dx and tx of a caustic esophageal injury?
- dx: initial exam should be directed to circulatory status, assessment of airway patency, and oral mucosa, including laryngoscopy
- chest and abdominal radiographs to look for pneumonic or free perforation
- tx: supportive IV fluids, PPI and analgesics, psychiatric referral
67
what is contraindicated in caustic esophageal injury?
**nasogastric lavage** and oral antidotes are considered dangerous
68
what are the complications of caustic esophageal injury?
- risk of esophageal squamous carcinoma is 2-3%, warranting *endoscopic surveillance 15-20 years after* caustic ingestion
- pneumonitis
- perforation
- **esophageal strictures** develop in 70% of patients with serious esophageal injury weeks to months after initial injury
