Esophageal Disorders Flashcards
- Functions to deliver food and fluid to stomach; no role in direct digestion
- squamous epithelium
- UES: striated muscle valve
- LES: smooth muscle valve
- esophageal muscle: starts as triated and then transitions to smooth muscle
The esophagus
reflux of gastric contents other than air in to the esophagus. Normal post-prandial condition
Physiologic reflux
a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications
Pathologic gastroesophageal reflux
Classic features
- Heartburn (pyrosis): restrosternal burning ascending toward chest and neck
- regurgitation: unpleasant return of sour gastic contents to the pharynx
Atypical symptoms
- chest pain, globus sensation, nausea
- laryngopharyngeal reflux (LPR): cough, hoarse voice, sore throat
- dental enamel erosions
GERD
What is the pathophysiology of GERD?
Imbalance of protective versus offending agents
Offending agents
- Acidic gastric contents (pH 1.5-3.5)
- bile, pepsinogen, pancreatic enzymes, mucus, contents
- overwhelms mucosal resistance and stimulates sensory nerves
Defects
- Impaired barrier to function of the LES (transient relaxtion of LED to hypotensive LES; Hiatal hernia, increased intragastric pressure)
- esophageal motility disorders (impaired esophageal acid clearance; hypo or hypercontractile)
- gastric motility disorders: gastroparesis
- reduced salivation
Diagnosis of GERD
- Pyrosis and regurgitation: can be treated with a PPI trial if no alarm symptoms
- Endoscopy- gold standard for diagnosing esophagitis and investigating possible comoplications
what are considered alarming symptoms?
- dysphagia or odynophagia
- GI bleeding or anemia
- weight loss
- symptoms > 5 years
- don’t respond to PPI trial or relapse after discontinuing therapy
When and who should you screen for Baretts’s eshophagus?
Chronic (> 5 years) and or frequent (weekly or more) symptoms of GERD and two or more risk factors
* age >50
* presence of central obesity
* current or past history of smoking
* confirmed family history or esophageal adenocarcinoma?
when should you refer to gastroenterology?
- Refractory GERD
- atypical GERD manifestations (non cardiac chest pain, extra-esophageal symptoms)
- considering referral for anti-reflux surgery
- alarm symptoms (dysphagia)
- abnormal findings on imaging (esophagram) or endoscopy
- Quantifies reflux
- helpful in patients unresponsive to empiric therapy and may have non-acid reflux
- disadvantages: time consuming, availability, difficult to tolerate
Ambulatory pH-impedence testing
lifestyle modifications that can be done with esophageal disorders
- Weight loss for obese patients
- elevation of the head of the bed
- avoid late meals (3 hours before bed)
- avoid specific foods: coffee, alcohol, chocolate, fatty foods, colas, red wine, orange juice
- rapidly acting (should be taken immediately after eating)
- only temporarily alleviate symptoms of episodic GERD
- should not be used for healing esophageal damage (poor compliance & high dose requirements)
antacids
ranitidine, famotidine
- inhibits histamine stimulation of the parietal cell
- can use sporadically or regularly
not as good for healing severe esophagitis
- compared to PPI
Adverse effects
- changes in bowel habits
- frequent drug interactions (warfarin, phenytoin, propranolol)
H2 receptor blockers
- Irreversibly inhibit the H+-K + ATPase of the parietal cell
- work better when taken regularly (30 minutes prior to a meal)
- provide better symptom control, esophageal healing and maintenence of remission than either H2 receptor blockers or prokinetic agens
- low side effect profile
Proton pump inhibitors
safety concerns of proton pump inhibitors?
- Achlorhydria (calcium malabsorption/risk fracture)
- hypomagnesemia
- infection (increased risk for C.diff infections in people treated with chronic PPIs)
- Metaplastic columnar epithelium replaces normal stratified squamous epithelium
- a consequence of chronic acid exposure
- can predispose to cancer development
Barrett’s esophagus
treatment of barretts esophagus?
- acid suppression with PPI indefinitely
- regular surveillance endoscopy
- if low grade, dysplasia is detected: needs to be verified by and expert pathologist
- high grade dysplasia–> Surgery vs. RFA
Adjunctive therapy for GERD?
Prokinetic agents
- enhances gastric emptying
- no clear benefit demonstrated
Reflux inhibitors
- Baclofen: Reduce TLESRs & reflux events, use is limited by neurological side effects
Surgical options for the treatment of gerd
Fundoplication
- surgical procedure in which gastric fundus is wrapped around lower esophagus and stictched in place (definitive tx for GERD)
- complications: dysphagia, gas bloat syndrome
LINX procedure
- Laparoscopic placement of titanium string of magnets
- not with hiatal hernia
Roux-en-y
- Surgery of choice for anti-reflux surgery if BMI > 35 due to high failure rates with fundoplication
what are complications of reflux?
- esophagitis
- scaring: rings/stricutres
- barretts esophagus
- esophageal cancer (adenocarcinoma)
- two categories: oropharyngeal/esophageal
- evaluation: video swallow evaluation
Dysphagia
Neurogenic and myogenic disorders
- Difficulty initiating a swallow
- couging, choking, nasal regurgitation
- voice changes with or after a meal
Oropharyngeal dysphagia
sensation of food transporting slowly or getting stuck in the esophagus seconds after the swallow
- solids and liquids=motility disorder
- solids only= mechanical obstruction
- progressive dysphagia: cancer or stricture, achalasia
Esophageal dysphagia
Painful swallowing
- pill esophagitis: NSAIDS, iron, beta blockers, calcium channel blockers, potassium chloride
- Bisphosphonates
Infectious
- Candida
- herpes
- cytomegalovirus
Radiation therapy
Odynophagia
chronic allergic inflammatory condition
can affect anyone
- most common in young (mid 30s) caucasian males, with atopic disease
- requires endoscopy with biopsies
- > 15 eosinophils per hpf on biopsy
Eosinophilic esophagitis
treatment of eosinophilic esophagitits?
medication therapy
- proton pump inhibition
- topical corticosteroids
Diet therapy
- empiric elimination, allergy testing directed
indirect inspection for mechanical functional cause of dysphagia?
Barium esophagram
- Diffuse spasm (DES)
- nutcracker esophagus
- Hypertensive LES
hypercontractile peristalsis
- scleroderma
- inefficint motlity disorder
Hypocontractile peristalsis
- Impaired relaxation at the lower esophageal sphincter
- idopathic proximal degeneration of Auerbach’s plexus leads to increased LES pressure & impaired LES relaxation
- dysphagia to both solids and liquids at the same time, regurgitation of undigested food, chest pain and cough
- no normal esophageal peristalsis
- absence of structural explanation
Achalasia
diagnosis of achalasia?
- barium esophagram: Bird’s beak appearance of the LES
- Manometry: most accurate test- increased LES pressure and lack of peristalsis GOLD STANDARD
- endoscopy: usually performed in achalasia prior to initiating treatment
treatment of Achalasia
No cure and has a progressive nature
- smart eating habits
- smooth muscle relaxants- don’t work well (nitroglycerin, Ca channel blocker)
Surgical Myotomy
- Heller myotomy with fundoplication
Large ballon dilation with/controlled tear
Endoscopic injection of Botox into LES
