Esophageal Disorders Flashcards
atypical symptoms of GERD
noncardiac chest pain
pulmonary problems (asthma, cough)
laryngeal symptoms (hoarseness and aspiration)
loss on dental enamel
when do you do a barium swallow for GERD?
considering surgery
only test to give you the length of the esophagus
barium swallow
is a barium swallow diagnostic of GERD
no
what can diagnose GERD
upper endoscopy with
barrett esophagus
stricture
excludes other dz that can mimic GERD (PUD)
Defines the function of the LES and the esophageal body (peristalsis)
Rules out esophageal motility disorder
Essential for correctly positioning the probe for the 24-hour pH monitoring
Esophageal manometry
Quantifies the gastroesophageal reflux and allows a correlation between the symptoms of reflux and the episodes of reflux
they push a button everytime they have a symptom
ambulatory 24-hour pH monitoring
does someone w/ endoscopically confirmed esophagitis, stricture or Barrett’s need pH monitoring
No
Indications for esophageal manometry and prolonged pH monitoring
peristance of symptoms while taking adequate PPI or other pharms
recurernce of sx after discontinuation of drugs
atypical symptoms
confirmation in prep for antireflex surgery
lifestyle modication for GERD
Weight lose if overweight Avoid foods that worsen symptoms Avoiding large meals Waiting 3 hours after a meal before lying down Elevating the head of the bed 8 inches
pharm tx stepwise for GERD
Histamien H2-receptor antagonists
PPIs
ADRs w/ long term PPIs
Can interfere with calcium homeostasis and aggravate cardiac conduction defects
Responsible for hip fracture in postmenopausal women
surgical indications for GERD
symptoms not completely controlled by PPI symptoms that are controlled by PPI but dont' want to take forever Barrett esophagus extraesophageal manifestations young patients poor patient compliance postmenopausal w/ osteoporosis pts. w/ cardiac conduct defects
who has the best results w/ antireflex surgery
well controlled on PPI and has typical symptoms
most frequently preformed surgery for GERD
Laparoscopic Nissen fundiplication (360° wrap)
complications with GERD
Esophagitis
Esophageal ulcer
Esophageal stricture
Barrett’s esophagus
The esophagus is lined with columnar epithelium
Represents advanced GERD
Salmon-pink mucosa that lines the esophagus
Barret’s Esophagus
what type cells are found in Barrett’s Esophagus
Specialized intestinal metaplasia of the esophageal mucosa due to replacement of squamaous epithelium by columnar epithelium
goblet cells
is there malignant potential w/ barrett’s esophagus
yes
Do PPIs prevent bile reflex?
No
what do prevent bild reflex?
antireflex surgery
patient’s with long-standing GERD (>5 years) espeically those >50 should have what to screen for Barett esophagus?
upper endoscopy and biopsy in 4 quadrants
Patients with persistent low-grade dysplasia on repeat endoscopy should undergo surveillance how often
every 6 months for 2 cycles (can then be yearly if no progression)
2 ways to manage high-grade syplasia w/ Barett’s esophagus
Surveillance endoscopy, with intensive biopsy at 3-month intervals until cancer is detected
Surgical resection
what type is a sliding hiatal hernia (GE junction is intrathoracic)
Type 1
what type hiatal hernia is rolling where only the fundus is intrathoracic
Type II
what is the only hiatal hernia where the GE junction is intraperitoneal
Type II
Fundus and body and other abdominal organs
are intrathoracic
Type IV hiatal hernia
type of hiatal hernia that can be associated w/ life-threatening complications. should be repaired if symptomatic
paraesophageal hernia (II, III, IV)
symptoms of paraesophageal hernias
only 50% are symptomatic epigastric abdominal pain postprandial fullness chest discomfort heart burn dyphagia vomiting weight loss dyspnea
complications from paraesophageal hernias
Anemia from Cameron ulcers from erosions of the gastric mucosa
incarceration w/ obstruction, strangulation, perf
what is Borchardt’s triad indicative of?
an incarcerated intrathoracic stomach – Surgical emergency
what are the three aspects of Borchardt’s triad?
chest pain
retching w/ inability to vomit
inability to pass an NGT
diagnosis for non-ermegency hiatal hernia
CXR (retrocardiac air bubble)
barium swallow
upper endoscopy
often found incidentaly on CT
before hiatal hernia what needs to be done?
esophageal motility study
pH probe not needed
Present with dysphagia, regurgitation, chest pain and heartburn
esophageal motility disorders
what must be done w/ eosphageal motility disorder
esophageal manometry
Failure of esophageal body peristalsis and incomplete relaxation of the LES
All have dysphagia
Most have regurgitation
Late in disease – weight loss
Achalasia
what is a tumor at cardia, tight NIssen or angelchik
pseudoachalasia
what too look for on barium esophagram w/ achalasia
barium esophgram will show a bird beak (later)
late signs- toruous, sigmoid esophagus, epiphrenic diverticulum
on endoscopy w/ achalsia what will you seen
Residual liquid or food in esophagus
Scope can pass the narrowing at distal esophagus with popping sensation
Tx for achalasia
CCB
endoscopic botulinum toxic
balloon dilation of LES (high risk of perf)
surgery
what surgery is done for achalsia
Heller myotomy w/ partial fundoplication
Substernal chest pain or dysphagia
Barium swallow shows tertiary contractions (corkscrew esophagus) An epiphrenic diverticulum is sometimes present
diffuse esophageal spasm
what will manometry show with diffuse esophageal spasm
simultaneous contractions of normal or low amplitude
tx for diffuse esophageal spasm
Meds- CCB and nitreates
sx- myotomy (not as effective as it is for achalasia)
central crushign chest pain is dominant symptoms
dysphagia and heartburn may also be present
barium swallow is normal
nutrcrack esophagus
what will manometry show w/ nutcracker esophagus
Manometric abnormality where the amplitude of esophageal body > 2 standard deviations above normal
Tx for nutcracker esophagus
muscle relaxants such as CCB and nitrates
2 types of esophageal diverticuale
traction (true)
pulsion (false)
diverticula contain only the submucosa and mucosa
pulsion (false)
diverticula contain all layers of the esophageal wall
traction (true) esophageal diverticulae
what causes a true esophageal diverticulaue
Result from an adjacent inflammatory process, like a lymph node, that pulls the entire esophageal wall
cause of pulsion diverticula
Most are due to elevated intraluminal pressure that causes the mucosa and submucosa to herniate through the muscle layer
most common esophageal diverticulae
Pharyngoesophageal – Zencker’s
location of Pharyngoesophageal – Zencker’s
Killian’s triangle - the point of transition between the thyropharyngeus muscle and the cricopharyngeus muscle represents an area of potential weakness
symptoms of pharyngoesophageal -zencker’s diverticulae
Cervical dysphagia, effortless regurgitaiton of undigested food, halitosis, choking and aspiration
main diagnostic for Pharyngoesophageal – Zencker’s
barium esophagram
Tx for Pharyngoesophageal – Zencker’s
surgical- exicision of diverticulum and mytomy of the circopharyngeus muscle and upper 3 cm of teh esopahgeal wall
what usually causes a traction midesophageal diverticula
granulomatous disease such as TB
tx of traction midesophageal diverticulae
tx underlying inflammation
what causes a pulsion midesophageal diverticula
motility disoders
tx for pulsion midesophgeal diverticula
tx underlying motility disorder
Surgery if symptomatic or > 5cm – diverticulectomy and myotomy
what esophageal diverticulae has a high association w/ GERD
Epiphrenic diverticula
tx for symptomatic or enlarging esophageal diverticuale
Diverticulectomy, esophagomyotomy, +/- partial fundiplication
what are benign tumors of the esophagus usually
leiomyomas
where are leiomyomas usually
smooth muscle layer
lower 2/3
narrow the lumen
smooth muscles surronded by a capsule of fibrous tissue
symptoms of esophageal leiomyoas
dysphagia, retrosternal presure and pain
what will a leiomyoa look like on barium swallow
Characteristic smooth, concave submucosal defect with sharp borders on barium swallow
do you need to biopsy a leiomyoma
no
when do you treat a leiomyos
Excise if symptomatic or > 5cm
by Enucleation
squamous cell carcinoma of esophagus risk factors
smoking tobacco Chronic ingestion of hot liquids or foods Poor oral hygiene Nutritional deficiencies Achalasia Caustic injury
adenocarcinoma of the esophagus risk factor
GERD
where does esophageal CA start?
mucosa and invades adjacent structure
number one symptom of carcinoma of espohagus
dysphagia
also heartburn, weight loss
hoarseness
respiratory symptoms
dx for carcinoma of esophagus
barium esophagram then endoscopy w/ biopsy
used for carcinoma of esophagus and shows Depth of mural penetration and invasion to periesophageal tissue and adjacent lymph nodes
endoscopic US (EUS)
if you suspect trachel or bronchial invasion with carcinoma of the esophagus what should be done?
bronchoscopy
paliative tx for carcinoma of esophagus
CT, RT
laser
endoscopic stent placement
what is theonly cure for carcionma of the sophagus
surgery
causes of esophageal bleeding
Esophageal ulcers Esophageal varices Esophagitis Mallory-Weiss tear? Esophageal tumors
presentation of esophageal bleeding
Hematemesis
Coffee-ground emesis
Melena
Shock
tx for esophageal bleeding
2 large bored IVs volume resuscitation possible pRBC (start if 2 L didn't help) draw blood for testing NGT EGD (only imaging needed) hemodynamic monitoring
if you can order one blood test on an upper GI bleeding patient what would you order?
type and cross
Tx for esophageal varices
sclerotherapy somatostatin or vasopressin balloon tamponade TIPS emergency esophagectomy portosystemic shunts
causes of esophageal perf
iatrogenic- endoscopy bougienage dilation NGT intraop- mediastinoscopy, fundoplication
syndrome caused by retching that causes perforation of esophagus at GE junction
Boerhaave’s syndrome
when does moratlity increase w/ esophageal perf
if diagnosed after 24 hours
symptoms of esophageal perf
fever, tachy, leukocytosis subQ emphysema dyspnea on x-ray mediastinal emphysema, pleural effusion peritonitis
what will you see on plain filem w/ esophageal perf
Plain X-ray Mediastinal emphysema Pleural effusion Mediastinal widening PTX hydropneumothorax
how do you do esophagography w/ esophageal perf
water soluble first if no leak then use barium
what may worsen a performation
upper endoscopy
non operative management of esophageal perf
broad spectrum and NPO
must have no signs of sepsis, minimal pleural soilage into esophagus
minimal symptoms and diagnosed days after injury
operative tx for esophageal perf
broad spectrum abx drainage primary repair esophageal exclusion esophageal resection consult surgeon early
