Esophageal Disorders Flashcards by Meg Dolohanty

atypical symptoms of GERD

noncardiac chest pain
pulmonary problems (asthma, cough)
laryngeal symptoms (hoarseness and aspiration)
loss on dental enamel

How well did you know this?

Not at all

Perfectly

when do you do a barium swallow for GERD?

considering surgery

How well did you know this?

Not at all

Perfectly

only test to give you the length of the esophagus

barium swallow

How well did you know this?

Not at all

Perfectly

is a barium swallow diagnostic of GERD

How well did you know this?

Not at all

Perfectly

what can diagnose GERD

upper endoscopy with
barrett esophagus
stricture
excludes other dz that can mimic GERD (PUD)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

does someone w/ endoscopically confirmed esophagitis, stricture or Barrett’s need pH monitoring

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

pharm tx stepwise for GERD

Histamien H2-receptor antagonists

PPIs

How well did you know this?

Not at all

Perfectly

ADRs w/ long term PPIs

Can interfere with calcium homeostasis and aggravate cardiac conduction defects
Responsible for hip fracture in postmenopausal women

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

who has the best results w/ antireflex surgery

well controlled on PPI and has typical symptoms

How well did you know this?

Not at all

Perfectly

most frequently preformed surgery for GERD

Laparoscopic Nissen fundiplication (360° wrap)

How well did you know this?

Not at all

Perfectly

complications with GERD

Esophagitis
Esophageal ulcer
Esophageal stricture
Barrett’s esophagus

How well did you know this?

Not at all

Perfectly

The esophagus is lined with columnar epithelium
Represents advanced GERD
Salmon-pink mucosa that lines the esophagus

Barret’s Esophagus

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

is there malignant potential w/ barrett’s esophagus

yes

How well did you know this?

Not at all

Perfectly

Do PPIs prevent bile reflex?

How well did you know this?

Not at all

Perfectly

what do prevent bild reflex?

antireflex surgery

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

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 ```