Esophageal Diseases- Fich Flashcards
What are the normal resting pressures of the esophagus (LES, UES, Pharynx)?
LES = +25mmHg, Pharynx = 0, UES = +60mmHg, Esophageal body = 0
Divisions of dysphagia (flowchart)
- Oropharyngeal
Problems in initiation of swalloing process
More common in neuromuscular
- Esophageal
If both liquids and solids: usually a motor problem
Describe Achalasia
Motor disorder, type of esophageal dysplasia. Rare, etiology unknown. Can be caused by degenration of dorsol motor nucleus, loss of ganglia cells in myenteric plexis, degeneration of vagal fiberes. Can be caused by Chagas.
Increased pressure in lower esophageal sphincter (>60 instead of 25), doesn’t drop to zero during relaxation and doesn’t relax for all of swalloing.
Could be from no motor activity or from contraction of all parts of esophagus at the same time, causing no peristalsis.
Almost all patients have dysphagia of liquids and solids and problems belching. Develop slowly.
In endoscopy: light pressure opens sphincter bc not a mechanical problem.
Treatment of achalasia
Pneumatic dilation: first option.
Second option is myotomy: cut sphincter muscle completely at esophageal-gastric (EG) junction. Causes problem of reflux so also add antireflux procedure. Also: partial myotomy.
Drugs: Low doses of nitrates and Ca channel blockers. Botox injection but not used anymore because only short term relief.
Other spastic esophageal motility/motor disorders of dyskinesia
Some but not all include features of achalasia (liquids and solids), but they are reversible. Include chest pain and dysphagia. Treatment is nitratres and calcium channel blockers.
Hypertensive LES (high pressure but complete relaxation and normal peristalsis with exaggerated postrelaxation contraction).
Diffuse esophageal spasm (diffuse spasm and points of high pressure and relaxation which can be normal or incomplete, spontaneous spasms)
Nutcracker esophagus: Peristalsis of high amplitude and low duration
Nonspecific esophageal motility disorders.
What are the categories of GERD
60% with NERD (non-esophageal reflux disease)
40% with esophagitis: 5% with complications and 35% without complications
What is the incidence of GERD?
60% of the healthy US population has had any episode in life
20% at least weekly episodes
Acid clearance mechanisms that prevent GERD and LES conditions
Salivation (1.5L of saliva is produced/day), peristalsis, esophageal bicarbonate secretion (by mucosa, effective just against a few drops), gravity (not relevant lying down/at night). Also delayed gastric emptying, diaphragmic pinching on inspiration.
Transient relaxation of the LES (75%), transient increase in intraabdominal pressure, very low basal LES (25%-creating poor barrier in esophagus, especially lying down).
Hiatial hernia is a triple problem (low LES, gastric pouch and no diaphragm pinch).
GE Reflux Sequelae (into Barrett’s esophagus and adenocarcinoma)
Barrett’s Esophagus: Description and Symptoms
Intestinal metaplasia of the esophagus
Columnar epithelium replaces squamous epithelium
Can be premalignant (dysplasia) and lead to adenocarcinoma of the esophagus
Need to follow up well.
Symptoms: Heartburn and regurgitation classically. Otherwise: chest pain, dyspepsia (especially if there is stricture), dysphagia/odynophagia rarely. Cough, worsening of asthma, hoarseness from vocal cord involvement.
Diagnosis and Treatment of Barrett’s Esophagus
After EG junction histology:
No dysplasia:
surveillance endoscopy with biopsy every 3 years.
Low-grade dysplasia:
surveillance endoscopy with biopsy every 6 mos-year until no dysplasia.
High-grade dysplasia:
surveillance endoscopy with biopsy every 3 months. Need to treat: low grade resection with readiofrequency ablation or surgery.
Also diagnosis from 24h pH monitoring. Hiustory most important.
Treatment goals: relieve symptoms (give antacids), heal esophagitis, prevent complications and maintain remission. Medical treatment, endoscopic treatment, surgery and behavior changes.
Main medical treatment: H2 blockeres, proton pump inhibitors, gastrokinetics, antacids. Avoid meds that relax the LES.
Surgery: make a valve. Usually won’t help if meds didn’t.
Causes of Odynophagia (pain in swallowing)
Usually inflammation in the esophagus. Often from infections: Herpes Simplex, CMV or candidiasis. Associated with diminished immune system. If it’s bad in the morning with chest pain and even saliva hurts to swallow: main cause is Pill Induced esophageal damage: when pill swallowed late at night with not enough water, pill gets stuck and lodged in esophagus and erodes walls. Most common in doxycycline and birth control pills.
