Esophageal Diseases Flashcards
What is transfer dysphagia?
• 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
What are the complications of OP?
• 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
What might cause neurological problems with the oropharynx?
- Stroke
- ALS
- Parkinson’s Disease
- Multiple Sclerosis
What might cause muscular problems with the oropharynx?
• Myasthenia gravis
• Muscular dystropy
• Muscle injury
○ Surgery, radiation therapy
What benign obstructions could be found in the oropharynx?
• 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?
What malignant obstructions could be found in the oropharynx?
• (head and neck cancers) Squamous cell carcinoma: ○ Tongue ○ Oropharynx ○ Soft palate ○ Upper larynx
What are the symptoms associated with achalasia?
- Dysphagia to solids AND liquids
- Weight loss
- Regurgitation
- Chest pain
- Difficulty belching
- Heartburn
- hiccups
How many types of achalasia are there?
• 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
What is the pathophys of achalasia?
• 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)
What is meant by PSS?
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
How can you treat spastic disorders of the esophagus?
- Calcium channel blockers
- Sildenafil (NO releaser, smooth muscle relaxant)
- Botox injections to paralyze some muscle (reduce spasticity)
What are the benign structural esophageal Disorders?
• 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)
What are the malignant disorders that can cause structural problems in the esophagus?
• 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
What is the cardinal symptom of esophageal strictures?
- Dysphagia to solids
- Painless
- Symptoms usually on a regular or daily basis
- Potentially progressive
- Weight loss and NOT acute history
What are the causes and treatment of esophageal stricture?
• 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
What is EoE?
• 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
What do people with EoE complain of?
• 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
What are the drug treatments for EoE?
- Exclusively steroids: topical»_space;»systemic
- Asthma preparations that are then swallowed
- Some evidence for efficacy
What is the more common/practical diet change for EoE?
- 6 food elimination diet (SFED)
* Milk, eggs, wheat, soy, seafood, nuts
What are the classic symptoms of GERD?
• 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
What might cause GERD?
• Inappropriate LES relaxation • Hiatal hernia • Gastric or esophageal surgery, dysmotility, obstruction • RARE ○ Zollinger-Ellison syndrome ○ Sjorgren's ○ Scleroderma
What are the risk factors for GERD?
• Males more than femaile • Obesity • Caffeine?????? Not good evidence for this • Alcohol? Minimal evidence • Tobacco • Medications • Pregnancy • Other medial illnesses ○ Scleroderma, ZE, gastroparesis
What is the risk for forming adenocarcinoma in the setting of barretts esophagus?
- Not as much as I though
- 0.1-0.5% per year
- Follow these patients and get biopsies
If you have a patient with worrisome barrett’s esophagus, what treatment modalities do you recommend?
• 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
