Dysphagia, Odynophagia, Atypical Chest Pain Flashcards
Close to one third of pts with chest pain have what as the source?
esophagus
Atypical chest pain = not angina
What part of hx and PE can be used to distinguish CV vs. GI chest pain source?
none - they cannot make a distinction
What are potentially life threatening GI causes of chest pain?
a. Boerhaave Syndrome/Iatrogenic esophageal perforation
b. Peptic ulcer disease
What is Boerhaave Syndrome?
- transmural tear of the distal esophagus induced by a sudden increase in pressure
- classic triad*: vomiting, abdominal or chest pain, and subcutaneous emphysema
*absent in many patients
What are iatrogenic causes of esophageal perforation? spontaneous?
a. trauma: nasogastric tube, endoscopy…
b. forceful retching/vomiting, hx of alcohol use, Boerhaave’s
How do you dx an esophageal rupture?
- CXR - air in mediastinum/subQ emphysema
or
- CT chest with contrast (gastrografin contrast - do not use barium bc it can cause inflammation of mediastinum)
How do you treat an esophageal rupture?
a. NPO
b. Parenteral ABs
c. Surgery
d. Endoscopic stenting
What is Hamman’s sign?
- crunching, rasping sound
- synchronous with heartbeat
- heard over precordium mainly during systole
- best heard in left lateral decubitus position
- often associated with muffled heart sounds
PUD ulcers extend through what layer?
muscularis mucosae
What age group typically gets PUD?
most commonly:
30-55 - duodenal ulcer
55-70 - gastric ulcer
What are the key sx of PUD?
- gnawing, dull, aching, hunger like pain
- periodicity (sx for weeks; fine for months)
- signs of GI bleeds
- mild, localized epigastric tenderness to deep palpation may be present on PE
How do you dx PUD?
- EGD with biopsy, CXR, nasogastric lavage, CBC
- Detection of H. Pylori
What is a key step in H. Pylori detection?
- Stop PPIs 14 days before fecal and breath tests
What does it mean if fluid is negative for blood in nasogastric lavage?
you still cannot rule out active bleeding from a DU
What is unique about GU tx?
need to exclude malignancy
*DUs are almost never malignant
For tx of DU/GU, dietary restriction is …?
unnecessary
Compare and Contrast: Nutcracker Esophagus and Diffuse Esophageal Spasm
a. Define/etiology/association
b. LES
c. Sx
d. Dysphagia
e. Dx/Tx
What is a serious complication of GERD?
laryngopharyngeal reflux
esophagitis
stricture
Barrett’s esophagus –> Adenocarcinoma
With GERD, when should you do an EGD?
When alarm features are present
What is a sliding hiatal hernia?
- due to increased intraabdominal pressure
- abdominal obesity, pregnancy, hereditary
- propensity of affected individuals to have GERD
What is a paraesophageal hernia?
- Herniation into the mediastinum includes a visceral structure other than the gastric cardia (most commonly the colon)
- Can lead to: “upside down stomach,” gastric volvulus, strangulation of the stomach
- on PE, can hear bowel sounds in lung fields
How do we dx and tx hiatal hernias?
a. Dx: barium x-ray
b. asx: nothing; sx: surgery
If a pt cannot swallow liquids (including their own saliva), think:
Foreign bodies/food impaction
risk factors: schatzki ring, peptic stricture, webs, esophagitis, achalasia, cancer
The sensation of a lump lodged in the throat, but with swallowing unaffected, is called?
Globus Pharyngeus
Flow chart: Approach to pt with Dysphagia
With oropharyngeal dysphagia, where does food stick?
level of suprasternal notch
When can an esophogeal web cause oropharyngeal dysphagia?
if it is proximal
*typically causes esophageal dysphagia
What is the problem in esophageal dysphagia?
- structural problem: thin, diaphragm like membranes of squamous mucosa
- congenital or acquired
- acquired: eosinophilic esophagitis, Plummer Vision Syndrome
- sx are intermittent (not progressive)
What is Plummer Vinson Syndrome?
- rare disease characterized by:
angular chelitis
glossitis
symptomatic proximal esophageal webs
koilonychia
iron-deficiency anemia (weakness and fatigue)
- consider middle aged women
What are the sx of a Zenker’s Diverticulum?
- Halitosis
- Spontaneous regurgitation
- Nocturnal Choking
- Gurgling in the throat
- Protrusion in the neck
- Voice changes
- Weight loss
- Aspiration (–> pneumonia/lung abscess)
What is the problem in Zenker’s?
- False diverticula involving herniation of the mucosa and submucosa through the muscular layer of the esophagus posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles (at pharyngoesophageal junction)
- Loss of elasticity of UES
- Occurs in Killian’s triangle
How do you dx Zenker’s?
- video esophagography or Barium swallow
*due before EGD due to risk of perforation
What are the sx of Sjogren’s?
- Dry eyes, dry mouth –> oropharyngeal dysphagia
- Vaginal dryness, tracheo-bronchial dryness
- Increased incidence of oral infection (candida)
- Dental caries
- Parotid/major salivary gland enlargement
- Keratoconjunctivitis sicca (foreign body sensation)
*Strong association with B cell non-Hodgkin lymphoma
How do you dx Sjogren’s? tx?
- dx: lip biopsy, serology
- Tx: supportive
* F>M, mid 50s, post-menopausal
Describe Diffuse Scleroderma
- Topoisomerase I antibodies (Scle-70)
- involves proximal extremities and trunk
- early and progressive internal organ involvment
- worse prognosis
Describe Limited Scleroderma
- anti-centromere ABs
- fingers, toes, face, distal extremities
- Raynaud’s commonly precedes other sx
-
CREST Syndrome
- Calcinosis cutis
- Raynaud’s (20)
- Esophageal dysmotility !!!
- Sclerodactyly
- Telangiectasia
- Good prognosis
What is the hallmark of Scleroderma?
- atrophy of esophageal smooth m.
- fibrosis of skin and visceral organs —> aperistalic esophagus
- microangiopathy
- progressive
What are causes of esophagitis due to truly refractory reflux?
- Gastrinoma with gastric acid hypersecretion (Zollinger-Ellison Syndrome)
- Pill-induced esophagitis
- Resistance to PPIs
- Medical noncompliance
What is the most common cause of reflux esophagitis?
GERD
For esophageal strictures, are sx progressive or intermittent? What is unique about heartburn/reflux?
a. progressive
b. lessens/improves because stricture acts as a barrier
What is mandatory in all cases of esophageal stricture dx? tx?
a. EGD - differentiates b/t peptic stricture from stricture by esophageal carcinoma
*barium swallow might be helpful
b. dilation at time of EGD, long term PPIs, endoscopic steroid injection
*operative management is rarely used
What is the tissue switch in Barrett’s Esophagus?
normal stratified squamous mucosa of distal esophagus —> specialized intestinal (metaplastic) columnar metaplasia
*risk factors: GERD, truncal obesity ==> obese WMs >50 who smoke
pathoma: NKSS –> nonciliated columnar with goblet cells
What are the risk factors for adenocarcinoma?
- chronic GERD
- male
- white
- obese
- hiatal hernia
- age 50+
What do we see on biopsy of Barrett’s Esophagus?
goblet and columnar cells
What are tx options for Barrett’s Esophagus?
- PPI
- Endoscopic ablation
- Surgical resection has high risk of morbidity and mortality —> NOT recommended
What do you know about Squamous Cell Carcinoma of the Esophagus?
What do you know about adenocarcinoma of the esophagus?
What is the problem with an esophageal ring (schatzki)?
- structural problem: smooth, circumferential, thin mucosal structures, distal
- Intermittent sx, not progressive
*associated with hiatal hernia
What is another name for esophageal ring?
“Steakhouse Syndrome”
= typically instigated by large, poorly chewed food bolus
How do we get rid of a food bolus?
- may pass on own with drinking extra liquids after regurgitation
- if impacted —> extracted endoscopically
How do we dx and tx esophageal rings?
- Dx: barium swallow (esophagogram)
- Tx: dilation (bougie dilator) or small endoscopic electrosurgical incision; PPIs for heartburn
What is the problem in Achalasia?
- propulsion problem
- Loss of peristalsis (distal 2/3) and failure of deglutitive LES relaxation
- denervation of the esophagus resulting primarily from loss of nitric oxide-producing inhibitory neurons (ganglion cells) in the myenteric plexus
What are the two types of Achalasia?
- Primary (Idiopathic)
- loss of ganglion cells within the esophageal myenteric plexus
- Secondary causes (Chagas’ disease or other)
- Chagas’ disease (think Mexico, SE US…)
- Other secondary causes: lymphoma, carcinoma, chronic idiopathic intestinal pseudoobstruction, ischemia, neurotropic viruses, drugs, toxins, radiation therapy, postvagotomy
What is Chaga’s Disease?
- esophageal dysfunction that is indistinguishable from primary, idiopathic achalasia
- should be considered in patients from endemic regions
- reduviid bug that transmits the protozoan, Trypanosoma cruzi
- chronic phase of the disease develops years after infection, and results from destruction of autonomic ganglion cells throughout the body including the heart, gut, urinary tract, and respiratory tract
What causes “pseudoachalasia”?
Primary or metastatic tumors that invade the gastroesophageal junction
What is Romana sign and when do we see it? Bird’s peak?
a. painless periorbital swelling; Achalasia
b. narrowing of distal esophagus; Achalasia
Why is esophageal manometry useful in achalasia?
confirms diagnosis - complete absence of normal peristalsis and incomplete LES relaxation with swallowing
Dx?
bird beak esophagus - Achalasia
What are the manometry findings in achalasia?
How do you distinguish between schatzki or web?
schatzki = distal
web = mid to proximal
What pills most commonly cause pill induced esophagitis?
- NSAIDs
- potassium chloride pills
- alendronate, risedronate (both for osteoporosis)
- iron
- antibiotics
*most likely to occur if pills are swallowed without water or while supine
What sx imply pill induced esophagitis?
- severe retrosternal chest pain
- odynophagia
- dysphagia
*begin several hours after taking a pill; can occur suddenly and persist for days
Dx, complications, tx, and prevention of pill induced esophagitis
What organisms most commonly cause infectious esophagitis?
- Candida albicans
- herpes simplex
- CMV
What are the sx of infectious esophagitis?
odynophagia
dysphagia
substernal chest pain
what are the risk factors of infectious esophagitis?
what is the significance of eotaxin 3?
eosinophil chemokine implicated in etiology of eosiniphilic esophagitis
what is a way to distinguish GERD from eosiniphilic esophagitis?
eosiniphilic esophagitis will have more eosinophils
eosiniphilic esophagitis: adults vs. children
Caustic Esophageal Injury: RFs, Sx, Dx, Complications, Tx
what are the risk factors for foreign bodies/food impaction?
- Schatzki ring
- peptic stricture
- webs
- esophagitis (Eosinophilic!)
- achalasia
- cancer
What are sx of a foreign body/food impaction?
severe chest pain
chest pressure
dysphagia
odynophagia
sensation of choking
neck or throat pain
