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MED: Nutrition/GI > Esophageal Disorders > Flashcards

Esophageal Disorders Flashcards

1
Q

There are how many sphincters on the esophagus?

A

2, they are high pressure areas that remain contracted at rest

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2
Q

how many layers are in the esophagus?

A

4 layers

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3
Q

where is the swallowing control center?

A

medulla

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4
Q

how many cranial nerves are involved with swallowing? what neurotransmitters are involved?

A

Cranial nerves V, VII, IX, X, XII important
Afferent and efferent neurons travel in vagus nerve
Ach is the major excitatory neurotransmitter
Nitric oxide (NO) and Vasoactive intestinal peptide (VIP) are the major inhibitory neurotransmitters

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5
Q

what are the three phases of swallowing?

A
  1. oral
  2. pharyngeal
  3. esphageal
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6
Q

what are the esophageal symptoms?

A 
Dysphagia
Odynophagia
Chest pain
Heartburn
Acid regurgitation
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7
Q

What are the two types of dysphagia?

A
  1. oropharyngeal (high or transfer)

2. esophgeal (low)

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8
Q

What are the two types of esophageal dysphagia?

A
  1. obstructive

2. non-obstructive or “motility”

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9
Q

what are causes of oropharyngeal dysphagia?

A
  1. neurologic disoders
  2. neuromuscular
  3. MSK
  4. obstructive
  5. Cricopharyngeal Achalasia: lack of relaxation of UES
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10
Q

What is Cricopharyngeal Achalasia?

A

lack of relaxation of UES

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11
Q

What are causes of obstructive esophageal dysphagia?

A

Webs and rings

Reflux esophagitis, peptic stricture

Neoplasms

Caustic ingestion

Pill-induced esophagitis
Radiation therapy

Variceal sclerotherapy

Infections

Dermatologic conditions

Extrinsic compresion

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12
Q

how will someone with oropharyngeal dysphagia present?

A

Drooling, spillage of food from mouth, inability to chew or initiate swallowing, or dry mouth. There may be a feeling of food getting caught in the back of the neck, coughing, or trying to repeatedly swallow to get food down. There may also be other neurological symptoms.

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13
Q

How will someone with esophageal dysphagia present?

A

i. Mechanical lesions: usually experience dysphagia of solid foods. It is recurrent and predictable.
ii. Motility disorders: Occurs with solids and liquids. It is not predictable or episoidic, it usually progresses

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14
Q

What is odynophagia? what is it usually associated with?

A

a. Sharp, substernal pain on swallowning that may limit oral intake. It ususally reflects severe erosive disease.
b. Most commonly associated with infections
i. Candida
ii. Herpes
iii. CMV
c. Can also be caused by caustic ingestion and pill induced ulcers

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15
Q

what are different diagnostic studies that can be used?

A 
A. upper endoscopy
B. videoesophgrogrpahy
C. Barium Esophography
D. Esophageal Manomtery
E. Esophogeal pH testing
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16
Q

Describe Barium esophagogram:

A

a. Esophageal dysphagia usually does barium first to determine whether the lesion is mechanical or motility driven.
b. It is better for motility diagnosis
c. inexpensive
d. unable to perform biopsies

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17
Q

Describe Endoscopy:

A

a. Study of choice for hearburn, dysphagia, odynophagia, and structerual abnormalities detected on barium esophgography.
b. Allows for biopsy and dilation of strictures.
c. cannot detect small rings
d. expensive and invasive

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18
Q

What is the gold standard for evaluating esophageal motility?

A

Esophageal manometry

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19
Q

Describe Esophageal manometry

A

Assess:
LES pressure and function
Esophageal peristalsis
UES pressure and function

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20
Q

Describe Ambulatory pH monitoring:

A

Quantify reflux
Monitor during activities of daily living
Allows symptom correlation

not widely available and cumbersome

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21
Q

if someone is having Difficulty initiating swallows,
postprandial coughing, choking
and nasal regurgitation then what dysphagia do they most likely have?

A

oropharyngeal

22
Q

if someone has Food stops or
“sticks” after
swallowed, what dysphagia do they most likely have?

A

esophogeal

23
Q

if someone has problems with solids getting stuck, it is…

A

obstructive

24
Q

if someone has problems with BOTH solids and liquids it is…

A

motility

25
Q

What is achalasia?

A

failure of smooth muscle fibers to relax, which can cause a sphincter to remain closed and fail to open when needed

26
Q

What causes achalsia?

A

unknown, damage to nerves
secondary causes are:
-Chagas disease T. cruzi–> parasite
-Malignancy related

27
Q

what are the symptoms of achalasia?

A 
Backflow (regurgitation) of food
Chest pain, which may increase after eating or may be felt in the back, neck, and arms
Cough
Difficulty swallowing liquids and solids
Heartburn
Unintentional weight loss
28
Q

What three diagnostics should be used for diagnosis of achalasia and what will you expect to find?

A

Manometry:
Aperistalsis
Impaires LES relaxation

Barium Study (Esophagogram):
“Bird Beak”

Endoscopy:
Exclude “pseudoachalasia”

29
Q

A “birds beak” seen on barium study may indicate what?

A

achalasia

30
Q

what is the treatment for achalasia?

A
  1. Injection with botulinum toxin (Botox). This may help relax the sphincter muscles, but any benefit wears off within a matter of weeks or months.
  2. Medications, such as long-acting nitrates or calcium channel blockers, which can be used to relax the lower esophagus sphincter
  3. Surgery (called an esophagomyotomy), which may be needed to decrease the pressure in the lower sphincter
  4. Widening (dilation) of the esophagus at the location of the narrowing (done during esophagogastroduodenoscopy)
31
Q

What are some external factors that contribute to GERD?

A 
Diet
High fat foods
Smoking
Medications
spicy foods
32
Q

what is the major mechanism for GERD?

A

Transient LES relaxation: Inappropriate non-swallow-related LES relaxation

33
Q

how does hiatal hernia cause GERD?

A
  • Impairs esophageal emptying
  • Acts as reservoir of acid
  • Lose of diaphragmatic “pinch”
  • Augments LES tone
  • Susceptibility to reflux correlates with hiatal hernia size
34
Q

What are some complications of GERD?

A
  1. esophagitis
  2. bleeding : rare
  3. peptic stricture: dilation may be needed
  4. Barrett’s esophagus
35
Q

what is Barrett’s esophagus?

A 
Specialized columnar epithelium (goblet cells=intestinal metaplasia)
Seen in 10-20% of GERD patients
Strong male and caucasian predominance
Results from severe, long-standing reflux
Single most important risk factor for esophageal adenocarcinoma
36
Q

What can barrett’s turn into?

A

esophageal adenocarcinoma

37
Q

how should Barrett’s be managed?

A

with PPIs but it doesn’t eliminate the lesions, just prevents them from getting worse

-screen patient ever 3-5 years

38
Q

what are some Extraesophageal manifestations of GERD?

A

Pulmonary:
Asthma, chronic cough,recurrent aspiration, subglottic stenosis

Ears, nose & throat:
Hoarseness, laryngitis, chronic sinusitis, laryngeal cancer, globus sensation

Other:
Dental erosion

39
Q

What are the diff GERD therapies available?

A

Lifestyle modification
Pharmacologic agents
Anti-reflux surgery
Endoluminal Therapies

40
Q

Can you treat empirically if history and PE align?

A

yes

41
Q

How should you do treatment for mild, intermittent symptoms?

A

i. Lifestyle modifications
ii. Medication interventions PRN
iii. Weight loss and smoking cessation
iv. Elevation of bed, avoid laying down for 3 hours after eating
v. Antacids (immediate) are good for initial treatment, <2 hours
vi. H2 receptor antagonist → 8 hour protection
1. Cimetidine 200 mg
2. Ranitidine and Nizatidine 75 mg
3. Famotidine 10mg

42
Q

How should you do treatment for complicated symptoms?

A

e. Troublesome Symptoms
i. Intitial therapy:
1. Treat with PPI
a. Omeprazole, rabeprazole 20 mg
b. Lansoprazole
c. Esomeprazole
d. TAKE 30 min before breakfast for 4-8 weeks
e. If patient does not get adequate relief after taking a PPI twice daily, then upper GI study is indicated
ii. Long-Term Therapy
1. In those who achieve relief, it is okay to discontinue after 8-12 weeks.
a. Some have withdrawal heartburn, and those can continue to use a PPI intermittently for 2-4 weeks until symptoms resolve.
2. Side effects are mainly related to decreased calcium absorption, so they should take dairy products at different time if calcium is an issue.

43
Q

What is anti-reflux surgery and what are the indications for it?

A

wrap the top part of the stomach around the esophagus to help tighten the LES

Indications: need for continous drug treatment and…
Young otherwise healthy
Financial burden
Noncompliant with drug therapy
Patient preference
Refractory patient (rare)

10% relapse in 10 years

44
Q

what are some endoluminal treatments for GERD

A

Endoscopic suturing/plication system

Delivery of radiofrequency energy to the GE junction

Injection/implantation of materials into the GE junction

45
Q

What are the two types of tumors of the esophagus?

A

Benign:
Leiomyoma
Lipoma

Malignant:
Squamous cell cancer
Adenocarcinoma
Lymphoma

46
Q

what is the prognosis for malignant esophageal tumors?

A
  • very low, 5%
  • often present after the disease is far gone
  • Symptoms gradual in onset including dysphagia, weight loss, odynophagia
47
Q

Describe Squamous cell esophageal cancer:

A
  • More common in men
  • Blacks > whites (6:1)
  • Uncommon before age 25
  • Most common in mid-esophagus
  • Risk Factors:
  • Tobacco
  • Alcohol
  • Head and neck cancer
48
Q

Describe esophogeal adenocarcinoma

A 
Increasing incidence
More common in men
Whites > Blacks (4:1)
Uncommon before age 25
Most common in distal esophagus
Risk factors:
Barrett´s esophagus
GERD
49
Q

What is a Mallory-Weiss Tear?

A

Occur at the GE junction
Account for 5-10% of all UGI Bleeds
Usually stop bleeding spontaneously
Mechanism unclear (usually emesis)

50
Q

what are the three main causes of esophageal bleeding?

A
  1. mallory-weiss tear
  2. varices
  3. ulcers
51
Q

What is esophageal varices?

A

Due to portal hypertension
Mortality: 40% each episode
>50% have another bleeding episode in the first year

52
Q

what is the most feared complication of an esophageal foreign body?

A

perforation

MED: Nutrition/GI (8 decks)

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