Erickson: Esophageal Disorders and GERD

Question 1

What is odynophagia?

Answer 1

**Pain on swallowing

Question 2

What is dysphagia?

Answer 2

**sx resulting from failure to move a food bolus from the mouth to the stomach

Question 3

What happens during normal swallowing?

Answer 3

Liquids/solids move from mouth to esophagus

Transport along esophagus

Liquids/solids delivered from esophagus to stomach

Question 4

You see a pt who is having difficulty swallowing. What may be causing this?

Answer 4

1. Inadequate preparation of what’s being swallowed. (decreased saliva/mastication, neuromuscular disorder, impaired mental fxn)
2. Abnormal muscle strenth/fxn (motility disorder)
3. Esophageal passageway narrowed (mechanical obstruction)

Question 5

Difficulty initiating swallowing…

Answer 5

oropharyngeal dysphagia

Question 6

Food stops or STICKS after swallowing initiated

Answer 6

esophageal dysphagia

Question 7

What is a manifestation of oral pharyngeal dysphagia?

Answer 7

Things go down the wrong pipe–>aspiration!

Elderly present w/ recurrent pneumonias

Question 8

What are the goals of therapy for a pt w/ oropharyngeal dysphagia?

Answer 8

protect airway

maintain nutrition (may put in feeding tube)

relieve dysphagia

Question 9

How do you treat oropharyngeal dysphagia?

Answer 9

1. Speech/swallow therapy
2. esophageal dilation (strictures)
3. surgical myotomy (zenker’s diverticulum)
4. NPO w/ nutrition support (PEG, PEJ, TPN) –Use gut first

Question 10

What are causes of benign dysphagia in the esophagus?

Answer 10

peptic strictures
rings and webs
caustic scars (not seen often–drinking lye)

Question 11

What cancers can cause esophageal dysphagia?

Answer 11

primary esophageal

extrinsic compression pushing on the esophagus

Question 12

What are neuromuscular causes of dysphagia?

Answer 12

Primary esophageal disease (ACHALASIA, CHAGAS, motor disorders)

Secondary (GERD)

Question 13

What is achalasia?

Answer 13

Loss of inhibitory innervation to the LES

Loss of VIP/NO so only have pro-contraction forces. Progresses as life long dysphagia over decades. Eat and then drink a lot of water to push food through.

Regurgitate
Chest pain
Weight loss

Question 14

Manometry of a pt w/ achalaasia shows…

Answer 14

non relaxing LES

esophageal aperistalsis

Question 15

Barium swallow in a pt w/ achalasia shows…

Answer 15

bird’s beak narrowing at LES

dilated esophagus

Question 16

What can cause a secondary achalasia?

Answer 16

carcinoma at the esophagogastric jxn (mimics achalasia)

Question 17

What are two treatments for achalasia?

Answer 17

1. Nifedipine (Prevents contraction)
2. Botulinum Toxin (Prevents release of ACh)
3. Balloon dilation–> tear fibers of lower sphincter
4. Esophagogastric myotomy–> tear fibers of lower sphincter

Question 18

A pt presents to you w/ a diffuse esophageal spasm. What do you see on manometry and barium swallow?

Answer 18

Simultaneous contractions of the esophagus (should be nice and orderly)

Question 19

What do manometry and a barium swallow show you in a pt w/ systemic sclerosis?

Answer 19

Sclerosis is a systemic disease that can lead to NO contractions in the esophagus. It becomes a lead pipe. So pt’s have acid reflux all the time

Question 20

What is the MCC of GERD?

Answer 20

Transient LES relaxations

Question 21

*A pt presents who intermittently can’t swallow solids?

Answer 21

Lower esophageal ring

Likely related to reflux

Question 22

*A pt presents who progressively can’t swallow solids.

Answer 22

Peptic stricture

Cancer (esp if > 50)

Question 23

*A pt presents who intermittently can’t swallow solids/liquids.

Answer 23

Diffuse spasm
NEMD
Nutcracker

Question 24

*A pt presents who progressively can’t swallow solids or liquids.

Answer 24

Achalasia

Scleroderma

Question 25

What can cause painful swallowing?

Answer 25

1. Tongue, tonsillar, pharyngeal pathology 2. Inflammation of mucosa lining (esophagitis) 3. Muscular spasm 4. Mediastinal disease (structures around the esophagus that are inflamed)

Question 26

What external factors can cause GERD?

Answer 26

Diet high fat foods smoking medication

Question 27

What can cause diminished esophageal clearance affecting GERD?

Answer 27

Peristalsis Body position Saliva

Question 28

What can cause an defective anti-reflux barrier leading to GERD?

Answer 28

LES crural diaphragm hiatal hernia

Question 29

What are gastric factors that can cause GERD?

Answer 29

Acid bile acid gastric emptying gastric distension

Question 30

What is the classic sx of GERD?

Answer 30

HEARTBURN

Question 31

If you suspect that a pt has GERD, what do you ask them?

Answer 31

1. do you feel substernal burning/regurgitaiton 2. postprandial 3. aggravated by change in position 4. prompt relief by antacids

Question 32

What are common esophageal sxs of GERD

Answer 32

Heartburn regurgitation belching water brash (increase in salivary secretion w/ heart burn)

Question 33

A pt presents w/ chest pain, hoarseness/laryngitis, loss of dental enamel, asthma/chronic cough, dyspepsia. You suspect...

Answer 33

Atypical GERD

Question 34

What sxs are associated w/ complications of GERD?

Answer 34

dysphagia odynophagia (ulcer related to the bleeding) bleeding

Question 35

How can hitatal hernias contribute to reflux?

Answer 35

1. No diaphragmatic support of LES | 2. HH is reservoir for gastric contents that causes irritation

Question 36

If a pt presents w/ heartburn/regurge, that is postprandial, postural and decreased w/ antacid. What do you do?

Answer 36

Start empiric tx NO diagnostic studies needed...but make sure it's not cardiac disease

Question 37

Why might we do a barium swallow?

Answer 37

widely available inexpensive Good at identifying hiatal hernia, or stricutres

Question 38

Why might we not do a barium swallow?

Answer 38

operator dependent | esophagitis, Barrett's epithelium

Question 39

What is the best initial diagnostic study for pts w/ reflux sxs and dysphagia?

Answer 39

Barium swallow

Question 40

What is the best diagnostic study for evaluating mucosal injury?

Answer 40

Endoscopy w/ biopsy Good for: * esophagitis, barrett's epithelium * Hiatal hernia, strictures

Question 41

What is the best study to confirm GERD?

Answer 41

Ambulatory pH monitorying

Question 42

What assesses LES pressure peristalsis?

Answer 42

Esophageal manometry

Question 43

**What is the cornerstone of GERD therapy?

Answer 43

Life style modifications - elevate head of bed - no food 3 hrs before bed time - stop smoking - less fat/volume - avoid peppermint, onions, citrus juice, coffee, tomatoes - avoid harmful meds - OTS meds

Question 44

What drugs can decrease LES pressure and make GERD worse?

Answer 44

theophylline anticholinergics Ca blockers nitrates

Question 45

What drugs can injure the mucosa and make GERD worse?

Answer 45

``` tetracyclines--can directly injure mucosa quinidine aspirin/NSAIDS K tablets Fe salts ```

Question 46

Why are cimetidine, ranitidine, famotidine, and nizatidine all good treatments for you pt w/ GERD?

Answer 46

They all SUPPRESS ACID b/c they are H2 receptor ANTAGONISTS

Question 47

Why might omeprazole and lansoprazole also be good tx for your pt w GERD?

Answer 47

Both are PPIs and suppress ACID!

Question 48

What are anti-reflex operations?

Answer 48

Wrap part of the stomach around esophagus Hill repair Nissen repair Belsey repair

Question 49

What is Barrett's esophagus?

Answer 49

COLUMNAR epithelium replaces the SQUAMOUS epithelium in the DISTAL esophagus

Question 50

What causes barrett's esophagus?

Answer 50

GER injures squamous epithelium and promotes repair by columnar metaplasia

Question 51

What is a major risk factor for esophageal adenocarcinoma?

Answer 51

Barrett's esophagus

Question 52

What causes peptic esophageal strictures?

Answer 52

ulceration stimulates fibrosis Often associated w/ NSAIDs

Question 53

How do you tx peptic esophageal strictures?

Answer 53

Aggressive acid suppression dilation surgery

Question 54

Mallory Weiss

Answer 54

Longitudinal esophageal tear related to repeated vomitting