Erickson: Esophageal Disorders and GERD Flashcards
What is odynophagia?
**Pain on swallowing
What is dysphagia?
**sx resulting from failure to move a food bolus from the mouth to the stomach
What happens during normal swallowing?
Liquids/solids move from mouth to esophagus
Transport along esophagus
Liquids/solids delivered from esophagus to stomach
You see a pt who is having difficulty swallowing. What may be causing this?
- Inadequate preparation of what’s being swallowed. (decreased saliva/mastication, neuromuscular disorder, impaired mental fxn)
- Abnormal muscle strenth/fxn (motility disorder)
- Esophageal passageway narrowed (mechanical obstruction)
Difficulty initiating swallowing…
oropharyngeal dysphagia
Food stops or STICKS after swallowing initiated
esophageal dysphagia
What is a manifestation of oral pharyngeal dysphagia?
Things go down the wrong pipe–>aspiration!
Elderly present w/ recurrent pneumonias
What are the goals of therapy for a pt w/ oropharyngeal dysphagia?
protect airway
maintain nutrition (may put in feeding tube)
relieve dysphagia
How do you treat oropharyngeal dysphagia?
- Speech/swallow therapy
- esophageal dilation (strictures)
- surgical myotomy (zenker’s diverticulum)
- NPO w/ nutrition support (PEG, PEJ, TPN) –Use gut first
What are causes of benign dysphagia in the esophagus?
peptic strictures
rings and webs
caustic scars (not seen often–drinking lye)
What cancers can cause esophageal dysphagia?
primary esophageal
extrinsic compression pushing on the esophagus
What are neuromuscular causes of dysphagia?
Primary esophageal disease (ACHALASIA, CHAGAS, motor disorders)
Secondary (GERD)
What is achalasia?
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
Manometry of a pt w/ achalaasia shows…
non relaxing LES
esophageal aperistalsis
Barium swallow in a pt w/ achalasia shows…
bird’s beak narrowing at LES
dilated esophagus
What can cause a secondary achalasia?
carcinoma at the esophagogastric jxn (mimics achalasia)
What are two treatments for achalasia?
- Nifedipine (Prevents contraction)
- Botulinum Toxin (Prevents release of ACh)
- Balloon dilation–> tear fibers of lower sphincter
- Esophagogastric myotomy–> tear fibers of lower sphincter
A pt presents to you w/ a diffuse esophageal spasm. What do you see on manometry and barium swallow?
Simultaneous contractions of the esophagus (should be nice and orderly)
What do manometry and a barium swallow show you in a pt w/ systemic sclerosis?
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
What is the MCC of GERD?
Transient LES relaxations
*A pt presents who intermittently can’t swallow solids?
Lower esophageal ring
Likely related to reflux
*A pt presents who progressively can’t swallow solids.
Peptic stricture
Cancer (esp if > 50)
*A pt presents who intermittently can’t swallow solids/liquids.
Diffuse spasm
NEMD
Nutcracker
*A pt presents who progressively can’t swallow solids or liquids.
Achalasia
Scleroderma
What can cause painful swallowing?
- Tongue, tonsillar, pharyngeal pathology
- Inflammation of mucosa lining (esophagitis)
- Muscular spasm
- Mediastinal disease (structures around the esophagus that are inflamed)
What external factors can cause GERD?
Diet
high fat foods
smoking
medication
What can cause diminished esophageal clearance affecting GERD?
Peristalsis
Body position
Saliva
What can cause an defective anti-reflux barrier leading to GERD?
LES
crural diaphragm
hiatal hernia
What are gastric factors that can cause GERD?
Acid
bile acid
gastric emptying
gastric distension
What is the classic sx of GERD?
HEARTBURN
If you suspect that a pt has GERD, what do you ask them?
- do you feel substernal burning/regurgitaiton
- postprandial
- aggravated by change in position
- prompt relief by antacids
What are common esophageal sxs of GERD
Heartburn
regurgitation
belching
water brash (increase in salivary secretion w/ heart burn)
A pt presents w/ chest pain, hoarseness/laryngitis, loss of dental enamel, asthma/chronic cough, dyspepsia. You suspect…
Atypical GERD
What sxs are associated w/ complications of GERD?
dysphagia
odynophagia (ulcer related to the bleeding)
bleeding
How can hitatal hernias contribute to reflux?
- No diaphragmatic support of LES
2. HH is reservoir for gastric contents that causes irritation
If a pt presents w/ heartburn/regurge, that is postprandial, postural and decreased w/ antacid. What do you do?
Start empiric tx
NO diagnostic studies needed…but make sure it’s not cardiac disease
Why might we do a barium swallow?
widely available
inexpensive
Good at identifying hiatal hernia, or stricutres
Why might we not do a barium swallow?
operator dependent
esophagitis, Barrett’s epithelium
What is the best initial diagnostic study for pts w/ reflux sxs and dysphagia?
Barium swallow
What is the best diagnostic study for evaluating mucosal injury?
Endoscopy w/ biopsy
Good for:
- esophagitis, barrett’s epithelium
- Hiatal hernia, strictures
What is the best study to confirm GERD?
Ambulatory pH monitorying
What assesses LES pressure peristalsis?
Esophageal manometry
**What is the cornerstone of GERD therapy?
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
What drugs can decrease LES pressure and make GERD worse?
theophylline
anticholinergics
Ca blockers
nitrates
What drugs can injure the mucosa and make GERD worse?
tetracyclines--can directly injure mucosa quinidine aspirin/NSAIDS K tablets Fe salts
Why are cimetidine, ranitidine, famotidine, and nizatidine all good treatments for you pt w/ GERD?
They all SUPPRESS ACID b/c they are H2 receptor ANTAGONISTS
Why might omeprazole and lansoprazole also be good tx for your pt w GERD?
Both are PPIs and suppress ACID!
What are anti-reflex operations?
Wrap part of the stomach around esophagus
Hill repair
Nissen repair
Belsey repair
What is Barrett’s esophagus?
COLUMNAR epithelium replaces the SQUAMOUS epithelium in the DISTAL esophagus
What causes barrett’s esophagus?
GER injures squamous epithelium and promotes repair by columnar metaplasia
What is a major risk factor for esophageal adenocarcinoma?
Barrett’s esophagus
What causes peptic esophageal strictures?
ulceration stimulates fibrosis
Often associated w/ NSAIDs
How do you tx peptic esophageal strictures?
Aggressive acid suppression
dilation
surgery
Mallory Weiss
Longitudinal esophageal tear related to repeated vomitting
