Esophageal Disease

Question 0

Differential for dysphagia

Answer 0

Oropharyngeal: liquids > solids
-stroke, Parkinson’s, Zenker’s diverticulum, myasthenia gravis, intubation

Esophageal: solids > liquids or solids = liquids

• Obstruction: webs, Schatzki rings, carcinoma, strictures
• Motility: achalasia, scleroderma, esophageal spasm

Question 1

Oropharyngeal vs esophageal dysphagia

Answer 1

Oropharyngeal dysphagia: difficulty swallowing liquids (2/2 aspiration) leading to coughing and choking
-Neurologic or muscular: Zenkers, stroke, Parkinsons, MG, intubation

Esophageal dysphagia: due to obstruction (solids more than liquids) or motility disorder (liquid and solid dysphagia)

• obstruction: strictures, Schatzki rings, webs, carcinoma
• motility: achalasia, scleroderma, esophageal spasm

Question 2

Diagnostic steps for dysphagia

Answer 2

Oropharyngeal dysphagia (liquids > solids): video fluoroscopy
Esophageal dysphagia: barium swallow (esophagram) followed by endoscopy, mannometry, and/or pH monitoring
-if obstructive is suspected, go straight to endoscopy and biopsy

Oxynophagia: upper endoscopy

Question 3

Plummer-Vinson syndrome

Answer 3

Esophageal webs, glossitis, Fe deficiency anemia

Question 4

Different types of infectious esophagitis

Answer 4

Candida, HSV, CMV

Question 5

Findings of HSV infectious esophagitis

Answer 5

Upper endoscopy: small, deep ulcerations; multinucleated giant cells w/ intranuclear inclusions on biopsy + Tzanck smear

Question 6

Findings of CMV esophagitis

Answer 6

Upper endoscopy: large, superficial ulcerations; intranuclear and intracytoplasmic inclusions on biopsy

Question 7

Definition of diffuse esophageal spasm

Answer 7

Motility disorder where normal peristalsis is periodically interrupted by high-amplitude nonperistaltic contractions aka nutcracker esophagus

Sx: chest pain, dysphagia, odynophagia precipitated by hot or cold liquids
-relieved by NTG

Question 8

Dx of diffuse esophageal spasm

Answer 8

Corkscrew-shaped esophagus on barium swallow

Esophageal manometry reveals high-amplitude, simultaneous contractions

Question 9

Tx for diffuse esophageal spasm

Answer 9

Nitrates and CCB for sx relief

Surgery: esophageal myotomy for severe, incapacitating symptoms

Question 10

Definition of achalasia

Answer 10

Esophageal motility disorder where there is increased LES pressure and decreased peristaltic contractions in the lower 2/3 of the esophagus
-2/2 degeneration of the inhibitory neurons in the myenteric (Auerbach’s) plexus

Question 11

Diagnosis of achalasia

Answer 11

Barium swallow: bird’s beak appearance
Manometry: increased resting LES pressure, incomplete LES relaxation on swallowing, and decreased peristalsis in the esophageal body
Endoscopy to rule out mechanical causes

Question 12

Tx for achalasia

Answer 12

Nitrates, CCBs, or endoscopic injection of botulinum toxin into the LES = symptomatic relief

Pneumatic balloon dilation and surgical (Heller) myotomy are definitive treatments

Question 13

Zenker’s diverticulum location

Answer 13

Cervical outpouching through the cricopharyngeal muscles

Question 14

Dx of Zenker’s diverticulum

Answer 14

Barium swallow which will show outpouching

Question 15

Tx of esophageal diverticulum

Answer 15

Norma: surgical excision of the diverticulum

Zenker’s: myotomy of the cricophyarngus muscles

Question 16

Dx of esophageal carcinoma

Answer 16

Barium study -> narrowing of the esophagus with an irregular border
EGD with biopsy

Question 17

LES

Answer 17

High LES pressures = achalasia
Low LES pressures = GERD
-it’s actually transient LES relaxation

Question 18

Dx of GERD

Answer 18

Barium study to look for hiatal hernia
Esophageal manometry and 24 hour pH monitoring

When to use EGD: patient’s w/ symptoms that are unresponsive to initial emperic therapy, long standing, or associated with blood in the stool, weight loss, and dysphagia/odynophagia

Question 19

Tx of GERD

Answer 19

Pharm: antacids in mild, intermitted symptoms; if patients have frequent or chonic symptoms then give H2 receptor antagonists or PPIs
-note: antacids first, then PPI/H2 receptor blocker

Question 20

Surgery for GERD

Answer 20

Nissen fundoplication

Question 21

Types of hiatal hernia

Answer 21

Sliding: may present w/ GERD
Paraesophageal
Mixed