Esophageal Disorders

Question 1

Infectious Esophagitis

Answer 1

• Risks: immunocompromised (HIV, post-transplant, malignancy)
• Etiology: Candida = most common, CMV, HSV
• S/sxs:
  
  • Dysphagia = difficulty swallowing
  • Odynophagia (Hallmark) = painful swallowing
  • Retrosternal chest pain
• Dx:
  
  • endoscopy:
    
    • candida = linear, yellow white plaques
    • CMV: large, superficial ulcers
    • HSV: small, deep ulcers
• Tx:
  
  • Candida: Fluconazole
  • HSV: Acyclovir
  • CMV: ganciclovir (highly testable on PANCE)

Question 2

Eosinophilic Esophagitis

Answer 2

• Definition: allergic, inflammatory eosinophilic problems of the esophageal epithelium
• Epidemiology:
  
  • most commonly in children, associated with ATOPY
• S/sxs:
  
  • significant Dysphagia and food impaction → food can’t move down esophagus due to ulceration/obliteration
  • odynophagia
  • Reflux or feeding difficulties in children
• Dx:
  
  • Endoscopy
    
    • → normal or multiple Corrugated rings
  • Biopsy → >15 eosinophils/hpf
• Tx:
  
  • Remove foods that cause allergic response → Elimination Diet: 5 day elimination of a single common allergen food
  • PPI + Swallowed steroid Solution (fluticasone, budesonide) → puff steroid from inhaler & SWALLOW IT

Question 3

Pill Esophagitis

Answer 3

• Definition: pill sits in one spot for too long & causes erosion of the mucosal lining
• Most commonly seen in NSAIDs & Bisphosphonates (alendronate for osteoporosis)
• Dx:
  
  • Endoscopy
    
    • → Well Defined ulcerations
• Tx:
  
  • Prevent by taking pills with > 4 oz of water, don’t lay flat for 30 minutes following.
  • PPIs will help protect until healing occurs

Question 4

GERD

Answer 4

• Definition:
  
  • lower esophageal sphincter dysfunction → reflux of acid → injury of mucosa
• Etiology:
  
  • excess acid → increased pressure; LES injury; motility disorder; hiatal hernia
• Risks:
  
  • Barrett’s esophagus, adenocarcinoma, or chronic esophagitis
• S/sxs:
  
  • heartburn frequently following food, sour taste
  • -dysphagia
  • night time cough
  • gagging when brushing posterior teeth
• Dx:
  
  • clinical: typical sxs and timeline with relief with antacids and lifestyle mods
  • endoscopy = 1st line for persistent symptoms or new onset > 50 yo (potentially a neoplasm!)
  • 24hr monitoring = gold standard but infrequently used
  • Manometry
• Tx:
  
  • Lifestyle mods:
    
    • elevate bed, avoid lying down 1-3 hours after eating, avoid certain foods (spicy, acidic, caffeine, mint, chocolate, EtOH)
    • eat smaller portions
    • weight loss (less belly weight while supine)
    • STOP SMOKING!!
• PRN Meds once lifestyle mods fail: H2 receptor antagonists → ranitidine, famotidine; Proton Pump Inhibitors (8-12 weeks) → lansoprazole, pantoprazole
• Failure of all of the above may require surgical procedure → Nissen Fundoplication (VERY invasive)

Question 5

Barrett’s Esophagus

Answer 5

complication of chronic GERD

• chronic exposure of esophagus to acid → replacement of the squamous epithelium with columnar epithelium
• Precancerous finding
• Need to MONITOR AGGRESSIVELY with regular endoscopy & biopsy
• Tx:
  
  • this pt will always be on PPIs

Question 6

Esophageal Cancer: Squamous Cell

Answer 6

• Definition: tumor growing in esophagus (stricture)
• 95% worldwide = most common cause of esophageal cancer in the WORLD
• Risks: Smoking, alcohol, low socioeconomic status, achalasia, ingestion of caustic material with lye
• S/sxs:
  
  • Progressive dysphagia
  • bleeding (anemia)
  • anorexia, weight loss
  • *usually have extensive disease by the time they are symptomatic*
• Dx:
  
  • endoscopic US biopsy
    
    • -squamous cell: diffusely distributed
• Tx:
  
  • Localized: non-invasive surgery, <15% of patients
  • Advanced: multimodal tx (radiation, chemo, palliative stenting to improve dysphagia),

Question 7

Esophageal Cancer: Adenocarcinoma

Answer 7

• Most common in the US, 5% worldwide
• Risks: smoking, alcohol,GERD, Barrett’s esophagus, obesity (causes more reflux)
• S/sxs:
  
  • Progressive dysphagia
  • Bleeding (anemia) anorexia
  • weight loss
  • *usually have extensive disease by the time they are symptomatic*
• Tx:
  
  • Localized: non-invasive surgery, <15% of patients
  • Advanced: multimodal tx (radiation, chemo, palliative stenting to improve dysphagia), 5 year survival < 15%

Question 8

Mallory Weiss Tear

Answer 8

• Definition:
  
  • superficial mucosal laceration of the gastric mucosa that occur from recurrent retching or vomiting
• Risks:
  
  • Alcohol = Strong predisposing factor (persistent vomiting after EtOH binge), bulimia
• S/sxs:
  
  • hematemesis
  • melena
  • hematochezia
  • abd pain
• Dx:
  
  • upper endoscopy = test of choice
• Tx:
  
  • Stop the bleed → will heal well
  • Epi, band ligation, or balloon tamponade
  • if not actively bleeding → supportive care (acid suppression with PPIs)

Question 9

• Hamman’s sign:

Answer 9

mediastinal crackling accompanying every heartbeat in LLD position, associated with Boerhaave’s Syndrome

Question 10

Boerhaave’s Syndrome

Answer 10

• Definition:
  
  • full thickness perforation of the distal esophagus
• S/sxs:
  
  • retrosternal Chest Pain→worsening with swallowing and deep inspiration
  • gross hematemesis
  • hematochezia
  • melena
• PE:
  
  • pneumomediastinum: crepitus on auscultation & shock
  • Hamman’s sign: mediastinal crackling accompanying every heartbeat in LLD position
• Dx:
  
  • CT chest → Pneumomediastinum
• Tx:
  
  • STAT surgery
  • perf of the esophagus is one of the fastest ways to bleed to death

Question 11

Esophageal Web

Answer 11

“The Itsy bitsy spider crawl UP the water spout”

• Definition:
  
  • noncircumferential thin membrane in the upper esophagus
• Etiology:
  
  • congenital or acquired from inflammation (associated with eosinophilic esophagitis
• S/sxs:
  
  • mainly asymptomatic but can have Dysphagia to solids
• Plummer-Vinson Syndrome:
  
  • esophageal webs
  • iron deficiency anemia
  • glossitis
• Dx:
  
  • Barium esophagram:
    
    • ridge above the diaphragm that narrows the esophagus
• Tx:
  
  • endoscopic dilation

Question 12

Plummer-Vinson Syndrome

Answer 12

• esophageal webs
• iron deficiency anemia
• glossitis

Question 13

Esophageal Ring (Shatzki Ring)

Answer 13

“When you wear a ring, you put it at the base of your finger”

• Definition: circumferential diaphragm of tissue that protrudes into the esophageal lumen. Most common at the lower esophagus, lumen <13mm
• Risks:
  
  • hiatal hernia (usually present), eosinophilic esophagitis, corrosive esophageal injury
  • usually acquired > 40
• S/sxs::
  
  • Mainly asymptomatic
  • Dysphagia to solids (lumen <13mm)
  • Bolus stuck in lower esophagus (“Steakhouse syndrome” →when someone eats a steak too quickly and the bolus gets stuck in your esophagus )
  • relieved by chewing more
• Dx:
  
  • barium esophagram:
    
    • ridge above the diaphragm that narrows the esophagus
  • Upper endoscopy:
    
    • thin, circumferential ring
• Tx:
  
  • endoscopic dilation

Question 14

Achalasia

Answer 14

• Definition: impaired esophageal peristalsis & failure of relaxation o the lower esophageal sphincter → loss of peristalsis into the stomach → food stasis & dilation of the esophagus
• Pathophys:
  
  • degeneration of ganglion cells in myenteric (Auerbach’s) Plexus of the esophagus → Failure of the LES to relax and loss of peristalsis in the distal esophagus ⇒ obstruction
• associated with autoimmune response (latent HSV1 infection)
• S/sxs:
  
  • Dysphagia of both liquids & Solids
  • weight loss/malnutrition
  • regurg of undigested food
  • cough or chest pain
• Dx:
  
  • Manometry = gold standard
    
    • aperistalsis in the distal ⅔rds of the esophagus & incomplete LES relaxation
    • BIRD’s beak on esophagram
• Tx:
  
  • Botox, nitrates, CCBs → to relax the esophagus
  • Pneumatic balloon dilation → at the LES to a diameter of 3-4cm, may cause esophageal perforation

Question 15

Distal (diffuse) Esophageal Spasm

Answer 15

• definition: esophageal motility disorder described as severe non-peristaltic (uncoordinated, intermittent) esophageal contractions → incomplete relaxation of LES
• Pathophys:
  
  • impaired inhibitory innervation leads to premature & rapidly propagated contractions
• S/sxs:
  
  • stabbing chest pain, worse with hot or cold liquids or food
  • Dysphagia to solids & liquids
  • sensation of object stuck in throat
• Dx:
  
  • manometry → increased simultaneous or premature contractions in the distal esophagus
  • esophagram: severe, non peristaltic contractions → “corkscrew esophagus”
• Tx:
  
  • 1st line: anti-spasmodic (CCB, nitrates)
  • 2nd line: botulinum toxin, pneumatic dilation
  • Refractory: esophagomyotomy

Question 16

Esophageal Scleroderma

Answer 16

• Definition: smooth muscle begins to atrophy → replacement with fibrous tissue → decreased peristalsis & esophageal sphincter tone → GERD. Autoimmune disease.
• S/sxs:
  
  • dysphagia to solids & liquids
  • heartburn
  • regurgitation
  • sore, swollen fingers
  • joint pain
• PE:
  
  • tight, shiny skin
  • telangiectasis
• Dx:
  
  • endoscopy: muscle atrophy, fibrosis
  • barium swallow = normal
• Tx:
  
  • control acid reflux with PPIs (omeprazole, lansoprazole)

Question 17

Esophageal Stricture

Answer 17

• Definition: scar tissue buildup that eventually prevents passage of food down esophagus
• Pathophys:
  
  • result of longstanding GERD or other recurrent injury to the esophagus → scar tissue
• Risks: GERD
• Dx:
  
  • barium swallow
  • endoscopy
• Tx: esophageal dilation with balloon catheter
  
  • Counseling: antireflux precautions and lifestyle mods
    
    • Chew well!

Question 18

Esophageal Varices

Answer 18

varicose veins of the esophagus

• Pathophys:
  
  • cirrhosis of the liver → portal HTN → esophageal varices
• Risks:
  
  • EtOH abuse/or chronic hepatitis, alcoholic cirrhosis, hepatitis C
• S/sxs:
  
  • asymptomatic until bleeding which can quickly destabilize & lead to shock
  • Bleeding can occur spontaneously or iatrogenically → Be very careful when intubating or endoscoping these pts!!
• Dx:
  
  • upper endoscopy
• Tx:
  
  • Acute tx: 2 large bore IVs for fluid & blood transfusion
  • tx of choice: endoscopy with ligation of varices (less chance of recurrence)
  • Pharm tx of choice: Octreotide for vasoconstriction, or can also use vasopressin (but not preferred due to systemic vasoconstriction which can lead to MI
  • Balloon tamponade is alternative→ comes with high risk of perforation
  • Prevention of rebleed: non-selective beta blockers (propranolol, nadolol)
  • can stent portal vein to decrease pressure (TIPSS)

Question 19

Zenker’s Diverticulum

Answer 19

• out-pouches in the esophagus that food can get stuck in
  
  • Sxs: similar to that of obstruction
    
    • will regurg undigested food and liquid into pharynx
• Dx: barium swallow
• Tx: observe if small and symptomatic
  
  • otherwise: surgery

Question 20

Nutcracker Esophagus

Answer 20

• excessive contractions during peristalsis
• manometry shows increased pressure during peristalsis
• tx is the relax the esophagus like achalasia