Esophageal Disorders Flashcards
Which structure is a muscular tube that connects the pharynx to the stomach?
Esophagus
Where does the esophagus connect to the stomach?
Just below the diaphragm
Which structure keeps food/secretions from entering the trachea?
Upper esophageal sphincter (UES)
Which structure has high resting tone and prevents gastric content reflux into the esophagus?
Lower esophageal sphincter (LES)
How does food pass in the esophagus?
Via peristalsis
What are the four layers of the esophagus?
Adventitia, Muscular, Submucosa, Mucosa
What are the two sublayers of the muscular layer?
Outer longitudinal layer & Inner circular layer
The esophagus is made up of what kind of epithelium?
Stratified squamous
What represents the gastro-esophageal junction where squamous lining of the esophagus meets the columnar lining of the gastric mucosa?
Squamo-columnar junction (Z-line)
What is dysphagia?
Subjective sensation of difficulty or abnormality of swallowing
What is odynophagia?
Pain with swallowing
What is esophagitis?
Inflammation or irritation of the esophagus
What is the functional esophageal disorder which is a non-painful sensation of a lump, tightness, foreign body or retained food bolus in the pharyngeal or cervical area?
Globus sensation
How is it Globus sensation characterized?
Globus sensation but without an underlying structural abnormality, GERD, or major esophageal motility disorder
What is an upper endoscopy (EGD or esophagogastroduodenoscopy)?
A thin scope with a light and camera at its tip used to look inside the upper digestive tract
What is a barium esophagram or “barium swallow”?
Noninvasive imaging test using barium contrast and x-rays to take images of the upper GI tract
What is an esophageal manometry?
A thin, flexible tube containing pressure sensors passed through the nose, into the esophagus and then the stomach
What does an esophageal manometry evaluate?
Motility and muscle contractions
What is an alarm symptom that warrants prompt evaluation to define the exact cause/appropriate therapy?
Dysphagia (difficulty swallowing)
What may dysphagia be due to?
Structural or motility abnormality in the passage of solids or liquids from oral cavity to stomach
Patients’ chief concerns range for dysphagia?
Inability to initiate a swallow to the sensation of solids or liquids being hindered in passage through esophagus to the stomach
Is dysphagia attributed to the normal aging process?
No
Is dysphagia acute or non-acute?
Can be either
What is the approach to non-acute dysphagia?
Distinguish, differentiate, and diagnose
What are characteristic symptoms of non-acute oropharyngeal (transfer) dysphagia?
Difficulty initiating a swallow, possible oral and pharyngeal dysfunction
What may accompany swallowing with oropharyngeal (transfer) dysphagia?
Nasopharyngeal regurg, aspiration, sensation of residual food remaining in the pharynx
What can oral dysfunction with oropharyngeal (transfer) dysphagia lead to?
Drooling, food spillage, sialorrhea (excessive saliva flow), piecemeal swallows (unable to swallow entire bolus at once), dysarthria (difficulty speaking due to muscle weakness)
What can pharyngeal dysfunction with oropharyngeal (transfer) dysphagia lead to?
Coughing or choking during food consumption, dysphonia (abnormal voice, hoarseness)
What are characteristic symptoms of esophageal dysphagia?
Difficulty swallowing several seconds after initiating a swallow, sensation that food and/or liquid is obstructed in passage from upper esophagus to stomach
Where may a patient with esophageal dysphagia point to as the site of their symptoms?
Suprasternal notch or area behind the sternum
Where may a patient with oropharyngeal (transfer) dysphagia point to as the site of their symptoms?
The cervical region
Where does esophageal dysphagia arise?
Within the body of the esophagus, lower esophageal sphincter (LES), or cardia
What are the iatrogenic causes of oropharyngeal (transfer) dysphagia?
Medication side effects (chemo, neuroleptics, etc.), post-surgical muscular or neurogenic, radiation, corrosion (pill injury, intentional)
What are the infectious causes of oropharyngeal (transfer) dysphagia?
Mucositis (herpes, cytomegalovirus, candida, etc.), diphtheria, botulism, lyme disease, syphilis
What are the metabolic causes of oropharyngeal (transfer) dysphagia?
Amyloidosis, cushing’s syndrome, thyrotoxicosis, wilson disease
What are the myopathic causes of oropharyngeal (transfer) dysphagia?
Connective tissue disease (overlap syndrome), dermatomyositis, myasthenia gravis, myotonic dystrophy, oculopharyngeal dystrophy, poloymyositis, sarcoidisis paraneoplastic syndromes
What are the neurological causes of oropharyngeal (transfer) dysphagia?
Brainstem tumors, head trauma, stroke, cerebral palsy, guillain-barre syndrome, huntington disease, multiple sclerosis, polio, postpolio syndrome, tardive dyskinesia, metabolic encephalopathies, amyotrophic lateral sclerosis, parkinson disease, dementia
What are the structural causes of oropharyngeal (transfer) dysphagia?
Cricopharyngeal bar, zenker’s diverticulum, cervical webs, oropharyngeal tumors, osteophytes/skeletal abnormalities, congenital (cleft palate, diverticula, pouches, etc.)
What are the intrinsic (mechanical lesions) causes of esophageal dysphagia?
Benign tumors, caustic esophagitis/stricture, diverticula, malignancy, peptic stricture, eosinophilic esophagitis, infectious esophagitis, pill esophagitis, post-surgery (laryngeal, esophageal, gastric), radiation esophagus/stricture, rings and webs, lymphocytic esophagitis
What are the extrinsic (mechanical lesions) causes of esophageal dysphagia?
Aberrant subclavian artery, cervical osteophytes, enlarged aorta, enlarged left atrium, mediastinal mass (lymphadenopathy, lung cancer, etc.), post-surgery (laryngeal, spinal)
What are the motility disorder causes of esophageal dysphagia?
Achalasia, chagas disease, primary motility disorders, secondary motility disorders
What is the functional (mechanical lesions) cause of esophageal dysphagia?
Functional dysphagia
Rome IV criteria for functional dysphagia?
- Sense of solid/liquid food lodging, sticking, or passing abnormally through esophagus
- No evidence of esophageal mucosal or structural abnormality causing symptoms
- No evidence of GERD or eosinophilic esophagitis causing symptoms
- Absence of major esophageal motor disorder (achalasia, esophagogastric junction outflow obstruction, distal esophageal spasms, hypercontractile esophagus, and absent peristalsis)
*all must be present for the past 3 months w/ symptom onset at least 6 months prior to diagnosis and with frequency of at least one week
What does dysphagia to only solids with gradually progressive symptoms suggest?
Esophageal stricture which may be related to acid reflux, radiation therapy, or eosinophilic esophagus
What does dysphagia to only solids with rapidly progressive symptoms suggest?
Cancer (may have additional symptoms such as chest pain, odynophagia, anemia, anorexia, significant weight loss)
What does dysphagia to solids only with intermittent symptoms suggest?
Eosinophilic esophagitis, esophageal ring or web, vascular anomaly
What does dysphagia to solids and/or liquids suggest?
May be related to esophageal motility disorder, distal esophageal spasms, hypercontractile esophagus, functional disorder
Dysphagia and odynophagia are common in both what?
Infectious esophagitis and medication-induced esophagitis
Dysphagia and odynophagia are less commonly present in what conditions?
Reflux esophagitis and Chron’s disease
What are the multiple causes of esophagitis?
GERD **MC, infectious, medication/pill induced, eosinophilic/allergic, corrosive/caustic
What are the two types of esophagitis?
Infectious vs. non-infectious
What is the hallmark sign of infectious esophagitis?
Odynophagia (painful swallowing)
Diagnostics for esophagitis?
Upper endoscopy, biopsy, barium esophagram
What is the treatment of esophagitis dependent on?
Cause dependent
Infectious esophagitis occurs mainly in those in what state?
Immunocompromised state (HIV, post-transplant, malignancy, chemo)
Primary infectious causes of infectious esophagitis?
Candida albicans **MC, cytomegalovirus (CMV), herpes simplex virus (HSV)
Other infectious causes of esophagitis?
EBV, histoplasmosis, cryptococcosis, mycobacterium tuberculosis, mycobacterium avium intracellular
(Not an all inclusive list)
Signs and symptoms of infectious esophagitis?
Odynophagia, dysphagia, retrosternal chest pain
Diagnostics for infectious esophagitis?
Upper endoscopy
Treatment for infectious esophagitis?
Treat underlying cause
Endoscopy findings for infectious esophagitis?
Linear yellow-white plaques
First line treatment for infectious esophagitis?
Fluconazole
Duration of treatment for esophageal candidiasis (initial and refractory)?
14-21 days for initial treatment extended to 28 days for refractory
Alternative treatment options for initial therapy for esophageal candidiasis?
IV echinocandin or liquid amphotericin B
Initial treatment approach to refractory esophageal candidiasis?
Double dose of fluconazole (max 800mg daily)
If no response to doubling fluconazole after several days, what treatment for esophageal candidiasis would be suggested?
Itracoazole oral solution
or
posaconazole oral susp.
or
voriconazole
or
isavuconazole
or
IV echinocandin
or
Liquid amphotericin B
What are the endoscopy findings for infectious esophagitis caused by CMV?
Large shallow ulcers or erosions
First and second line treatment for infectious esophagitis caused by CMV?
First line: Ganciclovir
Second line: Valganciclovir, Foscarnet
What are the endoscopy findings for infectious esophagitis caused by HSV?
Discrete shallow ulcers
First and second line treatment for infectious esophagitis caused by HSV?
First line: Acyclovir
Second line: Foscarnet
What may be present on a barium swallow in a patient with HSV, CMV, HIV, and medication related esophagitis?
Single aphthous ulcer on distal esophagus
What is eosinophilic esophagitis?
Allergic, inflammatory eosinophilic infiltration of esophageal epithelium
What is eosinophilic esophagitis defined as?
A chronic, immune/antigen-mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant eosinophil-predominant inflammation
Does eosinophilic esophagitis affect children or adults?
Both
Does eosinophilic esophagitis affect male or females more?
Male predominant (3:1)
What is eosinophilic esophagitis associated with?
Atopic disease (asthma, eczema) and other allergies (celiac)
Is the incidence of eosinophilic esophagitis increasing or decreasing?
Increasing
What are the clinical manifestations of eosinophilic esophagitis?
Dysphagia to solids **MC, chest pain, heartburn, food impaction, reflux or feeding difficulties in children, (+/-) longstanding odynophagia
Diagnostics for eosinophilic esophagitis?
Endoscopy w/ biopsy
What would an endoscopy and biopsy show for eosinophilic esophagitis?
Endoscopy: normal or multiple corrugated rings, white exudates
Biopsy: presence or abundance of eosinophils
Management for eosinophilic esophagitis?
Remove foods that illicit allergic response, acid suppression (PPI’s), topical glucocorticoids (fluticasone, budesonide), allergy testing
New therapy for eosinophilic esophagitis?
Dupilumab (monoclonal antibody) recently approved by USFDA
When is dupilumab indicated for treatment of eosinophilic esophagitis?
Adults/children > or = 12 y/o weighing > or = 40 kg who have not responded to PPI therapy
*higher rates of histologic improvement and dysphagia symptoms after 24 weeks
What is medication/pill-induced esophagitis?
Esophagitis due to prolonged pill contact with the esophagus
Which commonly prescribed medications cause medication/pill induced esophagitis?
-Antibiotics: Tetracyclines MC**, PCNs, macrolides account for 50% of cases
-NSAIDS
-Bisphosphonates
(also BBs, CCBs, Potassium chloride, iron pills, Vitamin C)
Clinical manifestations of medication/pill induced esophagitis?
Odynophagia, retrosternal pain, heartburn, dysphagia
Diagnostics for medication/pill induced esophagitis?
Endoscopy and possible biopsy to establish diagnosis/rule out other causes
What would be seen on an endoscopy for medication/pill induced esophagitis?
Endoscopy: discrete, well defined ulcers of varying depth, “kissing ulcers”
Management of medication/pill induced esophagitis?
D/c offending agent (most will resolve in a few days of d/c), acid suppression (PPIs)
Precautions to reduce risk of developing medication/pill induced esophagitis?
-Take pills in upright position & remain upright 10 min (30 min if med has strong association w/ esophagitis)
-Take pills w/ at least 4 oz of water (8 oz if med has strong association w/ esophagitis)
What causes corrosive/caustic esophagitis?
Accidental or intentional ingestion of acids or corrosive substances
Prognosis of corrosive/caustic esophagitis depends on what?
Substance potency and exposure duration
How do alkaline agents cause corrosive/caustic esophagitis?
Via liquefaction necrosis - disintegrates mucosa early allowing deep penetration *perforation more common
How do acidic agents cause corrosive/caustic esophagitis?
Via coagulation necrosis - esophageal injury reduced & perforation less common d/t coagulum formed on mucosal surface (limits deep penetration) *airway injuries more common
What anatomical region is most commonly effected by alkaline agents?
Esophagus
What anatomical region is most commonly effected by acidic agents?
Stomach
Examples of alkaline agents that cause corrosive/caustic esophagitis?
Drain cleaning, ammonia-containing, oven-cleaning, and swimming pool products, automatic dishwasher detergent, hair relaxers, clinitest tabs, bleaches, cement
Examples of acidic agents that cause corrosive/caustic esophagitis?
Toilet-bowl cleaning products, automotive battery liquid, rust-removal, metal-cleaning, cement-cleaning, and drain-cleaning products, soldering flux containing zinc chloride
Clinical manifestations of corrosive/caustic esophagitis?
Odynophagia, dysphagia, hematemesis, dyspnea (presentation varies)
What symptoms does caustic injury to the oropharynx cause?
Oropharyngeal pain, inability to clear pharyngeal secretions, persistent drooling, possible retrosternal or epigastric pain
Hoarseness, stridor, dyspnea (from caustic burns of the epiglottis and larynx)
Diagnostics of corrosive/caustic esophagitis?
HPI (determine agent), physical exam, CT of abdomen & chest (to evaluate for extensive injury), early upper endoscopy
Physical exam for corrosive/caustic esophagitis?
Check airway, oropharynx may reveal edema, erosions, deep necrosis w/ gray pseudomembrane, may have rebound tenderness on abdominal exam
What patients receive an early upper endoscopy for corrosive/caustic esophagitis?
Patients who do not require surgery (to determine risk of stricture formation)
Management of corrosive/caustic esophagitis?
Admit, supportive care, pain control, IV fluids, respiratory support, (+/-) abx
*emergent surgery if perforation suspected
What is contraindicated in the management of corrosive/caustic esophagitis?
Induction of vomiting, may lead to additional esophageal injury if gastric contents come in contact w/ esophageal mucosa
Complications of corrosive/caustic esophagitis?
Esophageal perforation, esophageal stricture, fistula, pyloric stenosis, esophageal cancer
What % of patients with a history of caustic injuries (corrosive/caustic esophagitis) develop esophageal cancer?
30%
What is indicated for the monitoring of development of esophageal cancer from caustic injury?
Endoscopic surveillance q2-3 yrs beginning 10-20 yrs after caustic ingestion
(Low threshold for upper endoscopy in pts w/ dysphagia and hx of caustic ingestion)
