Esophageal Cancer, Disorders and GI Motility Disorders Flashcards
What are the 2 principal types of esophageal carcinomas?
Most commonly squamous cell carcinoma followed by adenocarcinoma.
What causes have been tied to these esophageal carcinomas?
Adenocarcinoma - associated with chronic acid reflux
SCC - associated with smoking and EtOH abuse
How do both esophageal carcinomas initially manifest?
Due to chronic irritation and inflammation.
- Clinical Presentation as a mechanical obstruction.
- Dysphagia with solids first then liquids.
- Odynophagia
- Anemia, weight loss, adenopathy
How is each esophageal carcinoma typically diagnosed and staged?
Labs: Barium swallow, EGD with biopsy
Treatment: Esophagectomy &/or Chemotherapy
What are the 2 gastroesophageal (anatomical) barriers to stomach acid?
- Crural diaphragm and LES
Understand the difference between paraesophageal and hiatal hernias – what type can require surgical amendment?
Paraesophageal hernias can require surgical amendment
What is achalasia?
Achalasia is tonically contracted LES that fails to relax appropriately during swallows along with a dilated, aperistaltic esophagus.
How is achalasia diagnosed?
Bird-beak appearance, dilated fluid-filled
What are the basic surgical and pharmacologic treatments for achalasia?
Heller myotomy, Balloon dilation, Nitrates/CCBs
What are the esophageal manifestations of systemic scleroderma?
Dilated, aperistaltic esophagus
How is systemic scleroderma treated?
treated with PPI to reduce reflux/gastritis
What is the composition of a Schatzki’s ring and what is it almost always associated with? How does it manifest and how is it treated?
Schazki’s ring is a circumferential mucosal ring in the setting of a hiatal hernia (“steakhouse syndrome” solids dysphagia); dilation during EGD.
What is Plummer-Vinson syndrome and what are 2 symptoms?
Esophageal webs that form in the proximal esophagus in association with iron deficiency anemia;
Symptoms include the web, fatigue, pica etc.
What is the most common disorder of the esophagus?
GERD
Although GERD can often be diagnosed empirically based on history of symptoms and response to PPI medications, how can it be documented and graded?
GERD can be documented and graded based on severity and classified into four grades according to the Los Angeles Classification
What are the symptoms and complications of GERD?
Heartburn, epigastric pain, dysphagia, odynophagia, water brash etc.
How are mild, moderate and severe GERD treated?
Mild/moderate are treated with H2-antagonists/PPIs, antacids temporarily, lifestyle changes;
Severe can be treated by laparoscopic fundoplication
What is gastroparesis?
Delayed gastric emptying resulting in early satiety, bloating, N/V, anorexia, wt loss
Inflammation of the stomach
What are the symptoms of gastroparesis and what are possible underlying causes?
Mechanical, endocrine/metabolic (DM is the most common), CNS, miscellaneous causes;
What are effective treatments for gastroparesis?
Treated by dietary changes and with medications including erythromycin, Zithromax, domperidone, metaclopramide etc.
How is gastroparesis diagnosed?
x
How is GERD treated?
- Lifestyle modifications
- Antacids (Magnesium or Aluminum based)
- H2 receptor blockers
- Proton pump inhibitors
- Promotility agents
- Surgery
What are the symptoms of achlasia?
Dysphagia, Regurgitation of nonacidic material
What are the radiographic findings of achlasia?
- Dilated, fluid-filled esophagus
- Distal bird-beak stricture
What are the manometric finding for the LES in achlasia?
High resting pressure and an Incomplete or abnormal relaxation with swallow
What are the manometric finding for the body of the esophagus in achlasia?
Low-amplitude, simultaneous contractions after swallowing
What are the symptoms of scleroderma?
- Gastroesophageal reflux disease
- Dysphagia
What are the radiographic findings of scleroderma?
- Aperistaltic esophagus
- Free reflux
- Peptic stricture
What are the manometric finding for the LES in scleroderma?
Low resting pressure
What are the manometric finding for the body of the esophagus in scleroderma?
Low-amplitude peristaltic contractions or no peristalsis
What are the symptoms of diffuse esophageal spasm?
- Substernal chest pain (angina-like)
- Dysphagia with pain
What are the radiographic findings for diffuse esophageal spasm?
Simultaneous non-coordinated contractions
What are the manometric finding for the LES in diffuse esophageal spasm?
Normal Pressure
What are the manometric finding for the body of the esophagus in diffuse esophageal spasm?
- Some peristalsis
- Diffuse and simultaneous non-peristaltic contractions, occasionally high amplitude
What is the etiology of GERD?
Loss or lack of resting LES tone, this allows reflux of gastric contents into the esophagus.
Persistent irritation of squamous epithelium leads to metaplastic columnar epithelium, called Barrett’s esophagus.
What are the clinical features of GERD?
Heartburn, worse with bending over or lying down, belching, regurgitation.
What are the red flags of GERD?
Progressive dysphagia, recurrent pneumonia, persistent cough, bleeding.
What labs are preformed in diagnosing GERD?
pH monitoring, Berstein test, EGD
X-ray: Barium swallow- injury, ulcer, stricture, hernia
What are the common causes of gastritis?
- Stress: from CNS injury, burns, sepsis, surgery
- Helicobacter pylori: gram-negative flagellated rod
- NSAIDS: cause injury by decreasing local prostaglandin production in the stomach or direct injury to the cells by the pill
What is the clinical presentation of gastritis?
- Due to underlying cause
- Dyspepsia and abdominal pain
What labs are preformed in a patient with gastritis?
- EGD with biopsy
- Tests for H. pylori (Urea breath test)
What is the treatment for gastritis?
Treat the underlying cause or remove the causative agent
What are the risk factors for esophageal carcinomas?
SCC: smoking, alcohol, achalasia, RT
Adenocarcinoma: linked to Barrett’s esophagitis which is a complication of GERD
What is Schatzki ring?
Circumferential, lower esophageal ring
What are characteristics of a Schatzki ring?
Intermittent solid dysphagia
Always associated with hiatal hernia
What is the treatment for a Schatzki ring?
Savary Bougies/Maloney dilators
What are types of esophageal strictures?
Schatzki ring, Esophageal Webs and Zenker’s diverticulum
What is Zenker’s diverticulum?
A protrusion of pharyngeal mucosa at proximal esophagus (cricopharyngeus)
What are the symptoms of Zenker’s diverticulum?
Dysphagia, regurgitation, halitosis
What is the treatment for Zenker’s diverticulum?
Surgery, Often secondary to achalasia
What is a Esophageal web?
Non-circumferential, thin, squamous, mucosal, membrane in the mid or upper portion of esophagus.
What are esophageal webs associated with?
Associated with severe iron deficiency, Plummer-Vinson Syndrome
What are Esophageal Varices?
Dilated submucosal veins
What causes Esophageal Varices?
Secondary to portal hypertension
Due to cirrhosis (hepatic vascular congestion)
What are the signs and symptoms of Esophageal Varices?
Signs and symptoms of acute upper GI bleed
How do we treat Esophageal Varices?
Endoscopic banding/sclerotherapy
What is a Mallory Weiss Tear?
Non-penetrating mucosal tear at the GE junction, due to raise in transabdominal pressure
_______ strong predisposing factor for a Mallory Weiss Tear.
Alcoholism, Prior history of vomiting, retching
How is a Mallory Weiss Tear diagnosed?
Endoscopy
How is a Mallory Weiss Tear treated?
Usually self limiting
What are common esophogeal motor disorders?
Three common causes:
- Achalasia
- Diffuse esophageal spasm
- Scleroderma
What is the etiology of Achalasia?
Loss of ganglion cells in Auerbach’s plexus leads to increased tone and impaired relaxation of the LES, absent peristalsis.
What causes Esophagitis?
Infectious esophagitis usually seen in immuno-compromised patients.
Causes: Candida, herpes, CMV
How does a patient present with esophagitis?
Odynophagia, dysphagia
What is the treatment for esophagitis?
Candida: Fluconazole, ketoconazole
Herpes: Acyclovir
CMV: Ganciclovir
