Esophageal diseases Flashcards
Review the following slide on the esophagus
Recall that food in the esophagus moves thru via peristalsis
Define GERD
GERD: esophageal mucosal damage that happens secondary to reflux of normal gastric contents
(review the slide for epidemiology)
GERD can be caused by a variety of factors. Name the factors that can lead to GERD (5)
Defective anti-reflux barrier
Diminished esophageal clearance
Impaired mucosal resistance
Gastric factors - too much acid, slow gastric emptying, gastric distention
External factors - smoking, diet etc
Normally, an anti-reflux barrier is created by which 2 structures? What is it called when the stomach pushes through that barrier if it becomes defective?
Normally, an anti-reflux barrier is created by Crura of the diaphragm and lower esophageal sphincter
When the stomach pushes through that barrier if it becomes defective: hiatal hernia
Normally, GERD is caused by ___, which can lead to which types of hiatal hernias? (2)
Normally, GERD is caused by transiet LES relaxation, which can lead to sliding hiatal hernia (GEJ + Stomach herniate thru esophageal hiatus), and paraesophageal hernia (only the stomach herniates)
A pt presents to your clinic w/ symptoms of heatburn and a feeling of fluid moving up the chest. This worsens when the pt is lying down. You give the pt antacids to try for a few days and they respond well.
What is the diagnosis?
GERD
*heartburn and regurgitation are classic symptoms so you need to know these*
*also symptoms after eating, aggravated by lying down, relieved by antacids*
Review the slide on extraesophageal manifestations of GERD
T/F: You need to do a few diagnostic studies to Dx GERD
(see slide)
Falsehood. If pts have symptoms suggesting GERD and they respond to antacids, they got GERD and you need to start treating them
GERD can still be diagnosed via which 2 studies?
Barium esophagram and endoscopy
*Barium esophagram: pt is given contrast to swallow (also given a pill to swallow) and its followed thru their esophagus
Esophageal dysmotility can also present as GERD*
Describe the barium esophagram procedure
Barium esophagram: pt is given contrast to swallow (also given a pill to swallow) and its followed thru their esophagus
*note that its used for pts w/ dysphagia , and here you’ll see that Bird’s Beak, and can also see hiatal hernias + strictures
When would you use endoscopy in GERD? (4)
Evaluate GERD complications
Assessing integrity of anti-reflux barrier
Rule out other causes
Therapeautic intervention
Some pts may have an atypical pres. How do you evaluate them (2)?
Ambulatory pH monitoring (24 - 96hrs)
24 hr multichannel intraluminal impedance
Describe ambulatory pH monitoring and 24 hr multichannel intraluminal impedance. When would you use each technique?
Functional testing for atypical symptoms:
Ambulatory pH monitoring: see how much acid is hitting lower esophagus; use when pt has atypical symptoms
24 hr multichannel intraluminal impedance pH study – catheter in the stomach is detecting pH and impedance - amount of fluid/air that is refluxing; use when symptoms persist despite proton pump inhibitor therapy
Name 4 ways to manage GERD
Lifestyle modifications
Medications
Endoscopic Rx
Surgical Rx
What measure is the cornerstone of GERD therapy?
Lifestyle modifications!!
The main medications used to treat GERD are __ (-end in tidine), and ___(-end in prazole). Which group of drugs is the most effective?
The main medications used to treat GERD are H2 receptor antagonists - H2RAs (-end in tidine), and Proton Pump Inhibitors (-end in prazole).
*H2 blockers - great for acid suppression*
*PPIs still the most effective, especially for people w/ atypical pres*
Name Endoscopic/3 surgical ways to treat GERD
Surgical fundoplication - 3 types (Nissen, Dor, Toupet)
Linx procedure - use magnet around sphincter
Endoscopic fundoplication
Review the following slide on GERD Dx and Rx strategy
Name some of the complications of GERD (4)
Erosive/ulcerative esophagitis
Esophageal stricture
Barret’s esophagus
Adenocarcinoma
___ is a complication of GERD that results from narrowing of the distal esophagus due to scarring from chronic acid-induced injury
Peptic stricture is a complication of GERD that results from narrowing of the distal esophagus due to scarring from chronic acid-induced injury
**presents w/ progressive dysphagia to solids**
**ass’d w/ poorly controlled GERD + chronic heartburn, regurgitation**
**Rx: aggressive antireflux therapy, endoscopy w/ balloon dilation**
How does Barrett’s esophagus develop?
Acid shoots up esophagus >> non-keratinizing squamous epithelium changes undergoes metaplasia to columnar epithelium
**this is a precursor to esophageal adenocarcinoma**
How can you prevent progression of Barret’s esophagus to adenocarcinoma?
Ablation of dysplastic mucosa (see slide)
Risk factors for esophageal cancer
older age, Causcasian males, central obesity, smoking, family history of Barret’s esophagus or esophageal cancer
Review the slide on the development of adenocarcinoma from Barret’s esophagus
There are two types of esophageal cancer, ___ ,which is more common in african american males, and __ which is more common in white males
There are two types of esophageal cancer, squamous cell ,which is more common in african american males, and adenocarcinoma, which is more common in white males
(see slide for risk factors and ass’ns)
A pt w/ longstanding GERD w/ previous dysphagia for solids now has dysphagia for liquids, has lost 30 lbs, has developed voice hoarseness and hematemesis. What is on your differential?
Esophageal cancer
(see slide on esophageal cancer presentation)
Review the slide below on esophageal cancer Dx
Which imaging is used in esophageal cancer staging?
Done w/barium swallow + endoscopy
*notice bird’s beak and esophageal strictures*
To stage: do CT, PET or endoscopic ultrasound (shows you depth of tumor invasion + local cancer stages)
Describe the different stages of esophageal cancer (5)
Stage 1: lamina propria or submucosa, no nodes
Stage 2: muscularis propria/adventitia, no nodes
Stage 2b: up to muscularis propria, + regional lymph nodes
Stage 3: adventitia or adjacent structures, + nodes
stage IV: distant metastasis
How is esophageal cancer treated? (2)
Rx is mostly palliative for most pts, curative depends on where the cancer is (superficial = endoscopic resection and following, localized = surgical resection)
What is the difference between mechanical and motor/motility esophageal dysphagia?
Mechanical dysphagia - strutural problem, like a block that’s preventing movement of food
Motor/motility dysphagia - literally movement problem
___ is when the LES fails to relax and there is also abnormal peristalsis
Other motility disorders include which categories? (3)
Achalasia is when the LES fails to relax and there is also abnormal peristalsis
Other motility disorders include:
Spastic/uncoordinated disorders: DES
Hypercontractile disorders: Jackhammer esophagus
Hypocontractile disorders: Scleroderma
Achalasia results from loss of ___
Achalasia results from loss of myenteric/Auerbach plexus due to loss of postganglionic inhibitory neurons
(increased basal LES pressure, incomplete relaxation, absence of peristalsis)
**etiology unknown; secondary achalasia aka pseudoachalasia - arises from Chagas disease or extraesophageal malignancy**
**diagnosed w/ esophageal manometry >> refer to slides 37-39
A characteristic finding in esophageal achalasia is the presence of a __ on barium swallow
A characteristic finding in esophageal achalasia is the presence of a bird’s beak on barium swallow
What are the 3 types of achalasia?
Type 1: no pressurization on manometry; no peristalsis
Type 2: panesophageal pressurization
Type 3: spastic contraction
**note that all involve elevated relaxation pressure**
What are the treatments for achalasia? (4)
Botox injection relaxes sphincter muscles of LES
Pneumatic dilation
POEM - Perioral endoscopy myotomy
Surgery - Heller myotomy
Review this slide on motility disorder epidemiology
A pt presents w/ chest pain, dysphagia and heartburn. What is on your differential?
Spastic esophageal disorder (all 3 are common presentations)
Review the slide below on the diagnosis of spastic disorders
A characteristic feature of distal esophageal spasm is the presence of a ___ esophagus on imaging
A characteristic feature of distal esophageal spasm is the presence of a corkscrew esophagus on imaging
What is the pathology below and what is the ass’d condition?
Corkscrew esophagus on esophagram; characteristic of distal esophageal spasm
What would you expect to see on manometry of a hypercontractile esophagus?
Expect to see lots of red colors, i.e. aggressive contractions
Review this slide
Most important thing to know is that 20% or more of your pts swallows have to be abnormal on manometry to Dx
What are the treatments for DES? (spastic ones) (3 categories)
Drugs: muscle relaxants for the dysmotility, or psych drugs for the visceral hypersensitivity
Endoscopic: botox, pneumatic dilation
Surgical: long myotomy
Describe scleroderma
Scleroderma is a (autoimmune?) connective tissue disease ass’d w/ esophageal dysmotility (remember, CREST)
Another cause of esophageal dysmotility is Plummer-Vinson syndrome, charaterized by esophageal ___ (spiders make these) in the upper esophagus and commonly presents w/ intermittent solid food dysphagia
Another cause of esophageal dysmotility is Plummer-Vinson syndrome, charaterized by esophageal webs in the upper esophagus and commonly presents w/ intermittent solid food dysphagia
**upper esophageal web, iron deficiency anemia, increased risk of oropharyngeal/esophageal squamous cell carcinoma**
Describe an esophageal Schatzki ring
Ring formed at GEJ (or just above), thin and made of symmetric membranes of mucosa/submucosa
**accompanied by hiatal hernia; intermittent solid food dysphagia, for steaks only**
Name 3 types of diverticuli
How do you treat them (2)? What is the most common presenting symptom?
Zenker’s diverticuli: basically have this pouch above the UES that forms from mucosal herniation; where food is collecting in there and will cause obstruction *this is not a real diverticulum! read FA page*
Traction diverticula: near tracheal bifurcation; from TB or inflammation
Epiphrenic diverticula: lower esophagus, ass’d w/ achalasia, spastic dysmotility
Rx: myotomy, diverticulotomy
Review the following on candida esophagitis
Review the following on viral esophagitis
**HSV - biopsied from periphery; CMV biopsied from center**
Review the following on ingestion induced esophagitis
___ is esophagitis w/ an eosinophilic infiltrate that presents in kids and adults, and is linked to allergic conditions
Eosinophilic esophagitis is esophagitis w/ an eosinophilic infiltrate that presents in kids and adults, and is linked to allergic conditions
Review the following slide on eosinophilic esophagitis Dx and Rx
**need to remember the white spots and linear furrows on endoscopy; also note >15-20 eosinophils per high power field to Dx**
Describe Mallory-Weiss syndrome
- Mallory-Weiss syndrome: longitudinal laceration of mucosa at GE junction
- Caused by severe vomiting from alcoholism or bulimia
- Painful hematemesis
- Risk of Boerhaave syndrome: ruptured esophagus >> air in mediastinum >> subcutaneous emphysema
Describe Boorhaave syndrome
**know that this has to be surgically repaired, also its a full thickness tear down the stomach**
Risk of Boerhaave syndrome: ruptured esophagus >> air in mediastinum >> subcutaneous emphysema
