Esophageal diseases

Question 1

GERD

Answer 1

• Anatomical factors contributing to GERD
• LES: intrinsic sphincter tone/length, transient relaxations
• Esophagus: gravity, peristalsis (primary and secondary), saliva, squamous epithelium
• Stomach: gastric/duodenal secretions, gastric emptying, hiatal hernia

Question 2

Symptoms of GERD

Answer 2

• Esophagus: heartburn (regurg), dysphagia/odynophagia, chest pain
• Extra-esophageal: waterbrash (regurg of tasteless saliva), asthma, cough, laryngitis, pharyngitis, hiccups, dental erosive

Question 3

Complications of GERD

Answer 3

• Esophageal ulverations/bleeding
• Esophageal stricture
• Barrett’s esophagus: metaplastic change of esophageal mucosa from squamous to intestinal epithelium w/ goblet cells
• Barrett’s is pre-malignant, may transform into esophageal adenoCA

Question 4

Work up for GERD

Answer 4

• H&P
• Esophagoscopy: only for older pts, pts w/ persistent or recurring Sx, pts w/ unusual Sx
• 24hr pH: pts w/ unusual Sx, pts w/ typical Sx and a negative endoscopy and/or not responding to Rx
• Esophageal manometry: pts w/ severe dysphagia and negative endoscopy, and prior to surgical interventions

Question 5

Rx for GERD

Answer 5

• Lifestyle changes: elevating head @ night, weight loss, small frequent meals, no late night meals, avoiding food w/ high fat content, avoiding food w/ chocolate, spiciness, tomato paste
• Meds: antacids, mucosal protective agents, H2 blockers, PPI, prokinetic agents
• Surgery: fundoplication (hot-dogging of the esophagus using the stomach)

Question 6

Eosinophilic esophagitis 1

Answer 6

• Seen in children and adults, manifest by dysphagia, food bolus obstruction, chest pain and heart burn
• Esophagus may appear normal under endoscopy, but often shows white patches and concentric rings or linear furrows
• Micro: esophagus as large number of eos (>15) scattered throughout (not normal)

Question 7

Eosinophilic esophagitis 2

Answer 7

• Unknown etiology but most pts have Hx of allergies or asthma
• Most pts have remission when placed on elemental/elimination diet: no soy, wheat, peanuts, milk, shell fish, nuts
• Rx: for adults initiate high dose PPIs to exclude GERD, then if no remission start w/ systemic steroids (short term), PO steroids, LT inhibitors, and IL5 inhibitors

Question 8

Caustic injuries to esophagus

Answer 8

• Alkali injuries more common than acidic injuries
• Alkali: cause liquefactive necrosis
• Acids: cause coagulative necrosis
• Pts w/o complaints and nl physical should undergo endoscopy, and abnormal endoscopies should be hospitalized
• Sx: pain, dysphagia, odynophagia, drooling, dyspnea, hoarsness, chest/back/ab pain, vomiting
• Complications: strictures of esophagus/stomach (wks-mos), squamous cell CA (after many yrs)

Question 9

Pill esophagitis

Answer 9

• Secondary to direct and prolonged contact of meds w/ esophageal mucosa
• Usually see ulceration on endoscopy, most likely at level of aortic arch
• Pts present w/ sudden severe chest pain and dysphagia, usually at night
• Complications: hemorrhage perforation, strictures
• Usually situation: pt takes pill w/o water and immediately lies down
• Most common meds: antibios (doxy), KCL, quinidine

Question 10

Achalasia 1

Answer 10

• An abnormally elevated LES pressure and partial or complete failure of LES relaxation
• Leads to total loss of peristalsis of esophageal smooth muscle
• Idiopathic, usually due to damage to myenteric nervous system: loss of ganglion cells, vagus degeneration, damage to dorsal motor nucleus of X in brainstem, decreased amounts of NO/VIP in LES
• 2/3rds of cases are seen btwn 20-40 yo
• Sxs: dysphagia (starting w/ solid foods and progressing to liquids), regurg, chest pain, heartburn

Question 11

Achalasia 2

Answer 11

• W/U: barium swallow shows dilated esophagus w/ smooth narrowing at LES (bird beak deformity), esophagoscopy (to rule out stricture/malignancy), manometry (reveals poorly relaxing LES w/ elevated pressure, no peristalsis)
• Secondary achalasia: chagas disease, infiltrative disease like CA, lymphomas, amyloid
• Rx: botulinum toxin injected into LES, balloon dilation, surgical myotomy

Question 12

Spastic motor d/os 1

Answer 12

• Major manifestation is chest pain and dysphagia, must use manometry to Dx
• Categories: diffuse esophageal spasm, nut cracker esophagus, hypertensive LES, nonspecific esphageal motor d/o
• Etiology is unknown, dysphagia due to abnormal motility
• W/U: manometry, if pt has chest pain and cardiac eval is nl then they have non-cardiac chest pain
• These pts should undergo a 24hr pH study, about 50% of them will have GERD and respond to PPI, the rest will have spastic motor d/o Dx via manometry

Question 13

Spastic motor d/os 2

Answer 13

• Diffuse esophageal spasm manometry: simultaneous and/or repetitive esophageal contractions seen >10% but 180 mmHg)
• Ineffective esophageal motility: 30% of contractions are non-peristaltic or of low amplitude
• Rx: smooth muscle relaxants (nitrates, anticholinergics, Ca channel blockers), psychotropic drugs, balloon dilations, surgical myotomy

Question 14

UES d/os

Answer 14

• Neurologic (stroke, tumor, dementias), muscle (myesthenia gravis, polymyositis), local
• Clinical: dysphagia, nasopharyngeal regurg, aspiration
• Dx: neuro exam, video esophagram, circopharyngeal manometry
• Rx: speech Rx, nutritional support, Rx underlying disease, crico-haryngeal myotomy

Question 15

Systemic diseases effecting esophagus

Answer 15

• Sclerodema, mixed CT disease, dermatomyositis and polymyositis, SLE/RA
• Scleroderma: majority have esophageal Sx, some have CREST syndrome
• CREST: calcinosis, raynauds phenomena, esophageal involvement, sclerodactyl, telangectasia
• Pathology: arteriolar sclerosis and collagen deposition throughout esophagus wall, leading to atrophy of smooth muscle (usually distal 2/3rds)
• Manometry: LES low, decreased amplitude of contractions (distal 2/3rds)
• Clinical: GERD, strictures, dysphagia
• Rx: aggressive anti-GERD Rx