DSA 1: Dysphagia, Odynophagia, Atypical Chest Pain Flashcards
What is atypical chest pain?
chest pain that is not angina
- not left substernal, worse with exertion, radiation to neck/left arm
What must you exclude with a c/c of chest pain?
cardiac (or life-threatening causes)
- MI, aortic dissection, pulmonary embolus/pneumothorax
NOTE: hx and physical can NOT distinguish GI from CV cause
What are the possible life-threatening GI ddx to consider?
- Boerhaave Syndrome (torn esophagus leading to increased pressure/subQ emphysema)
- lactogenic esophageal perforation
- PUD
Life threatening non-GI:
- chest pressure
- distressed, diaphoretic
- “impending doom”
- murmur
- ECG, troponins, CXR
MI
- tx: stabilize, MONA, PCI
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
Aortic dissection
- tx: surgery and BP management
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
Pulmonary embolism
- 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
Esophageal perforation
What is the dx and tx of esophageal perforation?
- dx: CXR with air in mediastinum/subQ emphysema or chest CT with contrast (Gastrografin** NOT barium)
- tx: NPO, parenteral antibiotics, surgery, endoscope stenting
- subQ emphysema (detected in neck/precordial area)
- Hamman’s sign (crunching, rasping sound, synchronus with heartbeat)
- dyspnea (must differentiate lung disease from GI)
pneumomediastinum (Boerhaave’s)
- 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
Peptic Ulcer Disease (PUD)
NOTE: must stop PPI 14 days before fecal tests due to risk of false negative
- hypertensive peristalsis
- LES relaxes normally, but has elevated baseline pressure
- dysphagia to solids and liquids
- atypical chest pain
Nutcracker Esophagus
what is the dx and tx for nutcracker esophagus?
- dx: manometry, video fluoroscopy
- tx: nitrates and calcium antagonists, also concomitant mental health
- 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
diffuse esophageal spasm
what is the dx and tx for diffuse esophageal spasm?
- dx: manometry, EGD, barium swallow
- nitrates, calcium antagonists, also concomitant mental health
- motility disorder (ineffective esophageal motility of LES)
- esophageal dysphagia when accompanied by weak peristalsis (intermittent, NOT progressive)
GERD
what is the dx and tx of GERD?
- dx: clinically
- tx: trial of acid suppression and lifestyle modification first line
NOTE: EGD if alarm features are found
what are the alarm features of GERD?
- unexplained weight loss
- persistent vomiting
- constant/severe pain
- dysphagia/odynophagia
- palpable mass or adenopathy
- hematemesis
- melena
- anemia
herniation of the stomach, into the mediastinum through the esophageal hiatus of the diaphragm
hiatal hernia
result of increased intra-abdominal pressure from abdominal obesity, pregnancy or hereditary
- increased likelihood to have GERD
sliding hiatal hernia
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
paraesophageal hernia
what is the dx and tx of hiatal hernia?
- dx: barium Xray
- tx: asymptomatic => none, symptoms => surgical repair
what are the risk factors for foreign bodies/food impaction? (6)
- Schatzki’s ring
- peptic stricture
- webs
- eosinophilic esophagitis
- achalasia
- cancer
- chest pain/pressure, dysphagia/odynophagia, choking sensation
- inability to swallow liquids including own saliva
foreign body/food impaction
the sensation of a lump lodged in the throat, with swallowing unaffected
globus pharyngeus
- 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
- 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
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
- 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
- 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
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)
What is the dx and tx of Zenker’s diverticulum?
- dx: video esophagography or barium swallow
- tx: surgery - upper myotomy or surgical diverticulectomy
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
what is the dx and tx of Sjogrens?
- dx: lip biopsy, serology
- tx: supportive
what are the mechanical obstruction examples that cause esophageal dysphagia?
- schatzi ring
- peptic stricture
- esophageal cancer
- eosinophilic esophagitis
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
what are the motility disorder examples that cause esophageal dysphagia?
- achalasia
- diffuse esophageal spasm
- scleroderma
- ineffective esophageal motility
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
- topoisomerase 1 antibodies (Scl-70)
- diffuse involvement including proximal extremities and trunk
- early progressive internal organ involvement
- worse prognosis
Diffuse scleroderma (dcSSc)
- 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)
- 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
what is the dx and tx of scleroderma?
- dx: serology
- tx: controls symptoms and slows progression to improve quality of life and prolong survival
what is the most common cause of GERD?
reflux esophagitis
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
- 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
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
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
what is the dx and tx of Barrett esophagus
- dx: surveillance endoscopy (monitoring for adenocarcinoma)
- tx: PPI, endoscopic ablation better than surgery
what are the risk factors for adenocarcinoma?
- white male >50
- chronic GERD
- hiatal hernia
- obesity
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
what is the dx and tx of squamous cell carcinoma of esophagus?
- dx: EGD with biopsy
- tx: surgery (esophagectomy)
- caucasians > Af Am
- Males > females
- distal 1/3 of esophagus
- Barrett metaplasia -> dysplaisa -> ?
adenocarcinoma of esophagus
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
- 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
what is the dx and tx of Schatzki’s ring?
- dx: barium swallow (best view)
- tx: dilation or small endoscopic electrosurgical incision, PPI longterm
- 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
what is considered primary achalasia?
loss of ganglion cells within esophageal myenteric plexus
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
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
what are the manometry findings in achalasia?
- incomplete LES relaxation (high pressure)
- decreased esophageal resting pressure, (lumen dilates) -> BIRDS BEAK/funnel shape
- loss of peristalsis
- what are the types of esophagitis?
- pill
- infectious (candida/herpes/CMV)
- eosinophilic
- caustic
- 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
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
what are the risk factors of infectious esophagitis?
- immunosuppressed pt
- uncontrolled diabetes
- systemic corticosteroid use
- radiation therapy
- systemic antibiotic therapy
- 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)
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
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
what is contraindicated in caustic esophageal injury?
nasogastric lavage and oral antidotes are considered dangerous
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
