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DEMS > Esophageal Diseases > Flashcards

Esophageal Diseases Flashcards

1
Q

What is transfer dysphagia?

A

• Same thing as oropharyngeal dysphagia
• Inability to initiate a swallow or transfer food bolus into esophagus
• May occur with obstruction or neuromuscular disease
○ Dysfunction of oropharyngeal musculature

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2
Q

What are the complications of OP?

A

• Oropharyngeal dysphagia, or transfer dyphagia
• Aspiration
○ Into lungs, either food or saliva
• Nasal regurgitation
• Cough after attempted swallows
• Airway obstruction
○ Choking, stridor, wheezing, cyanosis
• Aspiration pneumonitis
○ Lung injury from acidic or lipophilic properties of food
§ Looks like shortness of breath or hypoxia
• Pneumonia if bacterial colonization occurs
○ SOB, fever, white count, consolidation on CXR

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3
Q

What might cause neurological problems with the oropharynx?

A
  • Stroke
    • ALS
    • Parkinson’s Disease
    • Multiple Sclerosis
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4
Q

What might cause muscular problems with the oropharynx?

A

• Myasthenia gravis
• Muscular dystropy
• Muscle injury
○ Surgery, radiation therapy

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5
Q

What benign obstructions could be found in the oropharynx?

A

• Zenker’s diverticulum
○ Outpouching of esophagus leading to food regurgitation or bacterial colonization
§ Sign = halitosis
• Crycopharyngeal bar
• Thyromegaly
• Fibrosis of neck b/c of radiation or trauma?

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6
Q

What malignant obstructions could be found in the oropharynx?

A 
• (head and neck cancers) Squamous cell carcinoma:
		○ Tongue
		○ Oropharynx
		○ Soft palate
		○ Upper larynx
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7
Q

What are the symptoms associated with achalasia?

A
  • Dysphagia to solids AND liquids
    • Weight loss
    • Regurgitation
    • Chest pain
    • Difficulty belching
    • Heartburn
    • hiccups
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8
Q

How many types of achalasia are there?

A

• 3 types
• Type I
○ Swallowing will cause no significant change in esophageal pressurization
• Type II
○ Swallowing leads to simultaneous pressurization spanning the entire esophagus length
○ Botox injections, pneumatic dilation, surgical myotomy work is best
• Type III
○ “spastic”. Swallowing leads to abnormal, lumen obliterating contractions/spasms
○ Treated with botox injections, pneumatic dilation, surgical myotomy have poor outcomes

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9
Q

What is the pathophys of achalasia?

A

• LES pressure and relxation regulated by excitatory and inhibitory NT
• Selective loss of inhibitory neurons in the myenteric plexus resulting in relatively unopposed excitatory neurons
○ Excitatory is cholinergic.
○ Can you use antimuscarinics?
• This leads to hypertensive nonrelaxed esophageal sphincter (LES)

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10
Q

What is meant by PSS?

A

Progressive systemic sclerosis
• Multisystem disorder
○ Obliterative small vessel vasculitis
○ Connective tissue proliferation with fibrosis of multiple organs
• GI manifestations in 90% of patients
*smooth muscle atrophy might look like weak peristalsis or it might look like flaccid LES and reflux
• Path - smooth muscle atrophy and gut wall fibrosis

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11
Q

How can you treat spastic disorders of the esophagus?

A
  • Calcium channel blockers
    • Sildenafil (NO releaser, smooth muscle relaxant)
    • Botox injections to paralyze some muscle (reduce spasticity)
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12
Q

What are the benign structural esophageal Disorders?

A 
• Strictures
	• Schatzki's ring
		○ ASchatzki ringorSchatzki–Garyringis a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by aringof mucosal tissue (which lines the esophagus) or muscular tissue.
	• Eosinophilic esophagitis (EoE)
	• Extrinsic compression (tumor)
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13
Q

What are the malignant disorders that can cause structural problems in the esophagus?

A 
• Esophageal cancer
		○ These can result in strictures
		○ Adenocarcinoma
		○ Squamous cell cancer
	• Mestasis (rare)
		○ Melanoma
		○ Breast cancer
		○ Renal cell carcinoma
		○ Lung cancer
	• Direct invasion of a tumor
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14
Q

What is the cardinal symptom of esophageal strictures?

A
  • Dysphagia to solids
    • Painless
    • Symptoms usually on a regular or daily basis
    • Potentially progressive
    • Weight loss and NOT acute history
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15
Q

What are the causes and treatment of esophageal stricture?

A

• Causes
○ GERD, radiation, caustic ingestion (including medications), congenital strictures, squamous cell carcinoma, adenocarcinoma
• Treatment
○ EGD, biopsy to rule out cancer
○ Endoscopic dilation using balloons or sequential commercial dilators

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16
Q

What is EoE?

A

• Eosinophilic esophagitis
• Chronic immune/antigen mediated esophageal disease
• Diagnosed by symptomology and by exclusion
○ Symptoms of esophageal dysfunction
○ Eosinophilic infiltrate in the esophagus
○ Absence of other potential causes of esophageal eosinophilia

17
Q

What do people with EoE complain of?

A

• Nearly all have dysphagia
• About 50% of cases have acute food impaction
• Food avoidance
• Heartburn MAYBE
• If children have it the symptoms are more non-specific
○ Feeding intolerance, failure to thrive, abdominal pain
*strong association with other chronic inflammatory conditions or reactions:
*Asthma, atopic dermatitis, seasonal allergies, food allergies

18
Q

What are the drug treatments for EoE?

A
  • Exclusively steroids: topical&raquo_space;»systemic
    • Asthma preparations that are then swallowed
    • Some evidence for efficacy
19
Q

What is the more common/practical diet change for EoE?

A
  • 6 food elimination diet (SFED)

* Milk, eggs, wheat, soy, seafood, nuts

20
Q

What are the classic symptoms of GERD?

A 
• Heartburn
		○ Burning sensation, substernal or epigastric, rises in chest
		○ Often post prandial (after meals)
		○ Often positional (nocturnal, lying down)
	• Regurgitation
		○ Acidic taste
		○ Often positional
	• Less classic
		○ Water brash, throat clearing, cough
	• RARE
		○ Wheezing, stridor, hoarseness
	• Often find relief with antacids or anti-secretory medications
21
Q

What might cause GERD?

A 
• Inappropriate LES relaxation
	• Hiatal hernia
	• Gastric or esophageal surgery, dysmotility, obstruction
	• RARE
		○ Zollinger-Ellison syndrome
		○ Sjorgren's
		○ Scleroderma
22
Q

What are the risk factors for GERD?

A 
• Males more than femaile
	• Obesity
	• Caffeine?????? Not good evidence for this
	• Alcohol? Minimal evidence
	• Tobacco
	• Medications
	• Pregnancy
	• Other medial illnesses
		○ Scleroderma, ZE, gastroparesis
23
Q

What is the risk for forming adenocarcinoma in the setting of barretts esophagus?

A
  • Not as much as I though
    • 0.1-0.5% per year
    • Follow these patients and get biopsies
24
Q

If you have a patient with worrisome barrett’s esophagus, what treatment modalities do you recommend?

A

• Esophagectomy: previously for HGD or any cancer
○ This isn’t the best care anymore
• Endoscopic treatment
○ Now for HGD and early esophageal adenocarcinomas
○ Ablation of barrett’s tissue
○ resection of visible lesions

25
Q

What are the risk factors for squamous cell carcinoma?

A

• Risk factors
○ older age
○ Alcohol/tobacco use
○ Caustic injuries
• Incidence is declining in US and Europe
this is the cancer more commonly found above the gastroesophageal junction (like mid esophagus)

26
Q

What are the risk factors for adenocarcinoma?

A
  • Older age, smoking obesity, GERD,
    • BARRETT’S ESOPHAGUS
    • Rising incidence in US and Europe
    • Nearly always in distal esophagus or gastric cardia
27
Q

What infectious diseases can cause esophagitis?

A 
• Probably in immunocompromised patients
	• Fungal
		○ candida
	• Viral
		○ Herpes simplex
28
Q

What buzz word for herpetic esophagitis should you know about?

A

• Punched out ulcers
○ Endoscopic findings
• Viral inclusions on biopsy

29
Q

You are given an endoscopic picture of an esophagus with some erythema, and potentially some erosion of the first layer. The esophagus looks RINGED, like a worm. What are you thinking?

A
  • EoE
    • Eosinophilic esophagitis
    • If given a histology slide that shows obvious inflammatory cell infiltrate into the mucosa, and there are quite a few pink eosinophils in there, you have your diagnosis
    • Usually these patients have signs of being allergic to several things and will have chronic esophagus symptoms as well
30
Q

How many different types of esophageal diverticular are there?

A

• Three.
• Zenker’s, which is the most common and most test appropriate
○ Halitosis, regurgitation, aspiration
○ Patients gurgle after they swallow
○ ASSOCIATED with reduced UES compliance, but doesn’t cause it
• Mid esophagus
○ Asymptomatic usually
○ In cases of TB, associated with mediastinal inflammation
• Epiphrenic
○ Symptomatic, but only occurs as a consequence of hiatal hernia

31
Q

Esophageal atresia and tracheoesophageal fistula are examples of what kind of disease?

A

• Congenital - failure of the foregut to divide into trachea and esophagus during the fourth week of embryonic development
• Clinical features
○ Regurgitation, drooling, aspiration
○ H shape, particular formation of fistula, can be missed and diagnosed later with recurrent childhood pneumonia

32
Q

What is nutcracker esophagus?

A
  • Example of a motility disorder in the esophagus, not a structural obstruction but a functional obstruction
    • Peristaltic high amplitude peristalsis
    • “nutcracker esophagus”
    • Extensive hypertrophy of the inner muscular layer
33
Q

You are given a barium swallow study and you see the bird beak sign. What is the problem?

A
  • Achalasia

* The LES will not open properly

34
Q

Severe retching or vomiting, especially in the context of alcohol intoxication makes you think what?

A
  • Mallory-weiss tears
    • OR boerhaave syndrome
    • Tears in the lining of esophagus and the resultant pain, and bloody vomitus
35
Q

How likely is low-grade dysplasia in the context of barrett esophagus going to result in adenocarcinoma?

A
  • 2-15% in low grade dysplasia
    • Up to 60% in high grade dysplasia
    • FOLLOW THESE PATIENTS
36
Q

A tumor that invades into the muscularis layers of the esophagus is AT LEAST what T stage?

A

• T2 if in the muscularis layers
• T3 is through that into the fat on the outside
• TV is local invasion of other tissues
○ Separate from the N and M grades which rely on lymph node involvement and evidence of metastasis to other organs

37
Q

A biopsy specimen from a mass in the esophagus most likely will show what two possible patterns?

A
  • Either a squamous cell pattern or an adenoma pattern
    • Squamous cell - nests of squamous cells, no gland formation
    • Adenoma - Lots of glandular tissue

DEMS (30 decks)

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