Esophageal Disorders Flashcards
Esophageal Disorders
Esophagitis
- GERD
- Eosinophilic esophagitis
- Infectious
- Medication
Barrett’s Esophagus
Esophageal Carcinoma
Achalasia
Esophageal Motor Disorders
- Spasm
- Nutcracker
- Jackhammer
- Hypotensive Peristalsis
Oropharyngeal dysphagia
Zenker’s
Boerhaave’s
Types of Esophagitis
Reflux (GERD)
Eosinophilic esophagitis: food allergy
Infectious: candida, CMV, herpes
Medication Induced:
- cycline drugs
- NSAIDs
- K supplements
- Biphosphonates
GERD Pathophysiology
Sustained or transient decreased in LES tone
Incompetence of the diaphragmatic crural muscle
Pressure gradient between LES and stomach is lost (intrathoracic becomes < intraabdominal)
GERD Risk Factors
Central Obesity
Smoking
Alcohol Abuse
Systemic disease (i.e. Neuro)
Medications
Pregnancy
GERD Sxs
- **Regurgitation **
- **Retrosternal burning **
- **Epigastric burning **
- **Dysphagia **
Extraesophageal Sxs (Atypical)
- Hoarseness
- Sore throat
- Throat clearing
- Globus
- Cough
- Inc’d sinus drainage
- Chest pain
- Asthma
- Nausea
Complications of GERD
**Common: **
- Schatzki’s Ring
- **Esophagitis **
Uncommon:
- Hemorrhage/anemia
- Perforation
- Barrett’s esophagus/CA
- Esophageal spasm
GERD Diagnosis
- Esophagitis on EGD
- Barrett’s esophagus
- Hiatal hernia
- Positive pH testing (catheter in esophagus, measure % time acidic)
Treatment for GERD (Lifestyle modifications)
Elevate head of bed
Weight loss to reduce central obesity
Avoid
- lying down after meals
- eating late at night
- cigarettes and alcohol
- NSAIDs
- meds/foods that exacerbate reflux
Surgical treatment options
Nissen Fundoplication
Toupet procedure (modified Nissen if have trouble swallowing)
Torax Magnetic Sphincter
Eosinophilic Esophagitis Presentation and Sxs
Usually presents as solid food dysphagia ongoing for many years. May present as GERD unresponsive to tx
Pt has Hx of environmental allergies (result of a food allergy)
Eosinophilic Esophagitis Diagnosis
Endoscopy with esophageal biopsies for diagnosis
Appears ringed and furrowed
Stiff and rigid
Eosinophilic Esophagitis Treatment
Fluticasone swallowed BID
PPI
Prednisone in severe case
Can try anti-histamines but are minimally effective
Elimination Diet for 8 weeks (gluten, milk, soy, eggs, nuts/tree nuts, fish/shellfish)
Candida Esophagitis
Usually presents as dysphagia or odynophagia
Occurs in immunosupressed pts
Herpes Esophagitis
Presents as odynophagia, occasional dysphagia
Usually in immunocompromised pts
Can lead to herpes encephalitis if not tx’d promptly
CMV Esophagitis
Usually in immunocompromised pts
Activated from a latent phase or acquired from a blood product transfusion
Serpiginous ulcers in otherwise normal mucosa
Present with odynophagia, chest pain, hematemesis, nausea
Barrett’s Esophagus Definition, Risk Factors, Sxs
Metaplastic columnar epithelium (intestinal cells) that is predisposed to CA development replaces squamous epithelium–from ongoing GERD
Often no symptoms
Risk factors:
- Age >50
- Male
- Caucasian
- Central obesity
- Chronic GERD
Surveillance for Barrett’s
3months - 3years depending on level of dysplasia present and if segment is long or short
Long segment more likely to develop malignancy
Barrett’s Treatment
**First line: Radiofrequency ablation **
Endoscopic mucosal resection or Esophagectomy
Esophageal Carcinoma Epidemiology and Presentation
Becoming more and more common
More likely in men and 50-70yrs old
Poor prognosis: 5% alive after 5 years
Can spread to LN, lungs, liver
Symptoms: progressive dysphagia and weight loss
Types of Esophageal CA
Squamous cell carcinoma:
- Increased risk with ETOH and smoking
Adenocarcinoma
- More common type
- From GERD/Barrett’s
- Distal esophagus
Types of Esophageal Motors Disorders
Achalasia
Diffuse Esophageal Spasm
Hypercontractility Disorders
Hypocontractility Disorders
Achalasia
(Path, sxs, dx, type, tx)
Loss of intramural neurons
**Inadequate LES relaxation **
Any age group–Generally idiopathic
Sxs: progressive solid and liquid dysphagia (things are building up), refractory GERD, regurgitation
Diagnosis: Barium esophagram (“Bird’s Beak”); Gold Standard is Esophageal manometry with increased LES pressure
Treatment depends on**Type: **
Type I: aperistaltic, more difficult to tx
Type II: peristaltic, more favorable to tx
Tx: Drugs (CCB), botox, pneumatic dilatation (dilation with large balloon under fluoro), Heller myotomy (Cut LES–best way to resolve sxs).
Important to tx b/c otherwise will progress to type II and won’t be able to eat
Diffuse Esophageal Spasm
Results from uncoordinated contractions
Any age group
Sxs: chest pain or dysphagia
Dx: Esophageal manometry is gold standard
Tx: Only need to tx if symptomatic (won’t progress like achalasia). NTG, CCB, botox, long myotomy
Hypercontractile Motor Disorders
Characterized by high pressure manometric contractions
Peristaltic contractions propagate normally, LES relaxes normally
Nutcracker (constant) or Jackhammer (more spastic)
Hypocontractile Disorders
AKA peristaltic dysfunction
Reduced or absent peristaltic waves; decreased or absent resting LES pressure
Can result from scleroderma, connective tissue diseases, or idiopathic
Sx: solid/liquid dysphagia or refractory GERD
Dx: manometry
No good tx options available
Oropharyngeal (Transfer) Dysphagia
Difficulty transferring a bolus from the mouth to the esophagus
Due to epiglottic dysfunction or poor muscle coordination
Sxs: coughing or choking with swallowing
Causes:
- Brain: CVA, Parkinson’s, MS, head injury
- Muscle/Nerve: myasthenia gravis, polio
- Cricopharyngeal dysfunction: Zenker’s diverticulum, cricopharyngeal bar
Zenker’s Diverticulum
Outpouching in the wall of the esophagus, usually in posterior hypopharyngeal wall
Can cause regurgitation of food particles consumed several days previous
Dx: barium swallow (endoscopy could puncture)
Tx: surgery–sew shut
Esophageal Varices
Dilated, sub-mucosal veins in the lower esophagus from portal hypertension, usually the result of cirrhosis
Can be fatal
Esophageal Webs
Webs are usually congenital or inflammatory
Intermittent dysphagia to solids
Schatzki’s Ring
Thin, weblike constriction near the LES which is benign
Usually smooth and circumferential
Can produce dysphagia when lumen is small enough
Tx: Dilation
Mallory Weiss Tear
Linear mucosa tear near at the GE jtn
Non-penetrating
Alcoholism is a pre-disposing factor
Usually associated with vomiting or retching
Most often self-limiting, may resulting in brisk bleeding
Dx: from Hx or endoscopy
Boerhaave’s Syndrome
From increased intra-esophageal pressure from forceful vomiting/retching or instrumentation
Free air enters mediastinum and causes pain, sub-Q emphysema, and can produce pneumothorax
Pressents as hematemesis and severe, retrosternal pain
Initial dx with CXR, confirm with CT, esophagram
Tx: Surgery
