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Esophageal Disorders Flashcards

1
Q

What is Dyspepsia?

A
  1. Impaired Digestion
  2. Discomfort in upper abdomen or chest described as gas, feeling of fullness, gnawing, or burning
  3. Described as Indigestion, heartburn, & Agida
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2
Q

What are the most common causes of dyspepsia?

A
  1. GERD

2. PUD

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3
Q

Name some less common causes of Dyspepsia?

A
  1. Gastritis
  2. Esophageal/Gastric Ca
  3. Celiac Dz
  4. Food allergy
  5. Gastroparesis
  6. Ischemic bowel Dz
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4
Q

What is Dysphagia?

A 
Difficulty swallowing (generally painless)
A. Pressure sensation or food gets stuck
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5
Q

With Dysphagia what do you want to determine?

A

Do Solids or Solids & Liquids get stuck?
A. Solids (Obstruction)
B. Solids & Liquids (mechanical abnormality)

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6
Q

Causes for Dysphagia

A
  1. Achalasia
  2. Esophageal CA
  3. Zenker’s diverticulum
  4. Schatzki’s ring
  5. Esophageal stenosis/stricture
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7
Q

What is Odynophagia?

A

Painful swallowing

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8
Q

Causes for Odynophagia

A
  1. Esophageal spasm
  2. Esophagitis
  3. Mallory-Weiss tear
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9
Q

What are the alarm symptoms of esophageal cancer

A 
Dysphagia with:
Age > 60 yr
Anemia
Heme (+) stools
Sx’s > 6 mo
Weight loss
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10
Q

Name for Diagnostic Modalities

A
  1. Esophagram (Barium Swallow)
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11
Q

What is GERD?

A

Recurrent reflux of gastric contents into distal esophagus due to mechanical or functional abnormality of Lower Esophageal Sphincter (LES )

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12
Q

Symptoms of GERD

A
  1. Pressure
  2. Heartburn (pyrosis)
  3. Dysphagia
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13
Q

Factors promoting GERD

A
  1. ↑ Gastric volume after meals
  2. ↑ Gastric pressure
    A. Truncal obesity
    B. PP recumbency
    C. Pregnancy
  3. Delayed gastric emptying
    A. Gastroparesis
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14
Q

Contributing Factors of GERD

A
  1. Medications
    A. Anticholinergics (dyspepsia/constipation), TCA’s (ileus)
    B. NSAID’s, ASA, Steroids, Bisphosphanates
  2. Foods
    A. Caffeine, chocolate, spicy foods, citrus, carbonated liquids
    Fats (Slow to digest)
    B. Peppermint, ETOH (Relax LES)
  3. Lifestyle behaviors
    A. Smoking, wt gain, eating late, overeating
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15
Q

Complications of GERD

A
  1. Reflux Esophagitis
    A. Visible mucosal damage
    B. Erosions or ulcers in distal esophagus at squamocolumnar junction (Z-line)
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16
Q

Causes of esophagitis

A
  1. Inflammation of esophagus
  2. Causes in non-immunocompromised pt
    A. Candidiasis (Tx with oral fluconazole (Diflucan))
    B. Pills
    Alendronate (Fosamax), risendronate (Actonel), doxycycline, NSAIDs, iron, Vit C, KCl, quinine
    Tx w/ Sucralfate (Carafate) susp., viscous lidocaine
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17
Q

Complications of esophagitis

A
  1. Esophageal Stricture

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18
Q

Risk factors for esophageal adenocarcinoma

A
  1. Large HH
  2. Duration of GERD
  3. Long segment of BE
  4. Abnormal mucosa
    A. Ulcerations
    B. Stricture
    C. Nodules
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19
Q

What is the gold standard for diagnosing Barrett’s Esophagitis?

A

Upper Endoscopy (EGD) w/ Bx of distal esophagus

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20
Q

Lifestyle modifications for GERD

A
  1. Small meals
  2. Eliminate acidic/caffeinated foods
  3. Eliminate factors that relax LES
  4. Weight reduction
  5. Avoid lying down w/in 3 hr of meals
  6. Elevate HOB 6-8”
  7. Smoking cessation
  8. Chew (non-mint) gum to ↑ saliva
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21
Q

What can someone take for mild intermittent GERD Sx’s

A
  1. Antacids

2. Histamine 2 Receptor Antagonists

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22
Q

What can someone take for persistent GERD Sx’s

A
  1. Proton Pump Inhibitors (PPI)
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23
Q

Long Term Therapy for GERD

A
  1. PPI Therapy
    A. If sx’s relieved, therapy may be d/c’d after 8-12 wk
    B. Pt w/complications of GERD, lifelong PPI qd-bid
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24
Q

If the patient is unresponsive to PPI’s what is indicated?

A
  1. Upper endoscopy

2. Want to r/o Reflux esophagitis, ZE syndrome, Barrett’s esophagus, stricture, PUD, eosinophilic esophagitis, tumor

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25
When to get an upper endoscopy for Barrett's Esophagus A. For no dysplasia B. Low grade dysplasia C. High grade dysplasia
A. q 2-3 yr, after 2 yearly (-) results B. q 6 mo for 1 year, then yearly thereafter C. : q 3 mo in those being followed
26
Indications for Surgery
1. Extra-esophageal manifestations of reflux 2. Severe GERD & noncompliant w/ lifelong medical Tx 3. Large HH & persistent regurgitation despite PPI’s
27
General Characteristics for infectious esophagitis
``` Most common in immunocompromised A. HIV/AIDS B. Organ transplants C. Leukemia D. Lymphoma E. Chronic steroid therapy ```
28
Pathogens involved in infectious esophagitis
``` 1. Candida albicans A. Immunocompromised B. Uncontrolled DM C. Chronic steroid therapy D. Undergoing radiation treatments E. Systemic Abx 2. Herpes simplex virus (HSV) A. Immunocompromised 3. Cytomegalovirus (CMV) A. Immunocompromised ```
29
S&S of infectious esophagitis
``` 1. Odynophagia (most common) 2. Dysphagia (this sx & above are most common in immunocompromised) 3. May also have: A. CP B. Oral thrush (Candida) C. Oral ulcers (HSV) ```
30
When is an endoscopy w/ Bx done for diagnostic certainty?
1. Candida A. EGD not required if (+) oral thrush-Tx B. Diffuse linear yellow-white plaques adhering to mucosa 2. CMV A. Large shallow superficial ulcerations 3. HSV A. Multiple small deep ulcerations
31
Treatment for candida esophagitis
1. Fluconazole (Diflucan) 200 mg PO/IV x 1, then 100 mg PO/IV qd x 14-21 d (2 weeks after sx’s resolve) 2. IV Amphotericin B for life threatening infection 0.3mg/kg/day
32
Treatment for CMV esophagitis
Ganciclovir (Cytovene) 5mg/kg IV q 12 h x 3-6 wk
33
Treatment for Herpes (HSV) esophagitis
1. Acyclovir (Zovirax) 400 mg po 5 X daily x 7-10 d | 2. Acyclovir 5 mg/kg IV q8h x 7-14 d if odynophagia
34
What is Mallory-Weiss Tear?
1. Non-transmural mucosal tear at lower esophagus 2. May arise from events that suddenly increase trans-abdominal pressure A. 2° to severe prolonged vomiting (50% cases)
35
Primary RF for Mallory-Weiss Tear
1. Chronic Alcoholism | 2. Bulimia
36
Signs & Sx’s of Mallory-Weiss Tear
1. Painless hematemesis following severe vomiting 2. +/- melena 3. Abd pain from retching
37
Diagnostic test for Mallory-Weiss Tear
1. Upper Endoscopy (EGD) A. Only necessary if (-) Hx B. Linear tears (0.5 – 4 cm) usually located at GE junction
38
Differential Dx for Mallory-Weiss Tear
1. PUD 2. Erosive gastritis 3. AV malformations 4. Esophageal varices/Portal HTN 5. ZE syndrome
39
Treatment for Mallory-Weiss Tear
1. Fluid resuscitation 2. Blood transfusions 3. 80-90% of tear stop bleeding spontaneously w/in few days
40
Treatment for Pt with continued bleeding in Mallory-Weiss Tear
1. Endoscopic hemostatic therapy A. Local injection w/ epinephrine (1:10,000) B. Electrocautery C. Mechanical compression of artery - Endo-clip (hemoclip) or endoscopic band ligation D. Operative intervention (Pts who fail endoscopic therapy)
41
What is a Schatzki’s Ring?
``` 1. Circumferential ring of esophageal tissue in lower esophagus causing narrowing A. Squamocolumnar junction B. Lower esophageal junction 2. Most asymptomatic 3. Dysphagia w/ solid foods ```
42
Diagnostic studies for Schatzki’s Ring
Esophagram
43
Treatment for Schatzki’s Ring
Endoscopic dilatation
44
What is Eosinophilic Esophagitis ?
1. Eosinophilic inflamm. of esophagus leading to clinical esophageal dysfunction 2. Hallmark is marked tissue eosinophilia of esophagus on Bx obtained via EGD 3. Esophageal dilatation to relieve dysphagia sx’s from strictures 4. Pathogenesis is unknown 5. Allergy testing 6. PPI trial 8-12 wks 7. Fluticasone MDI & swallowed 8. Budesonide (steroid slurry) to coat esophagus
45
What are Esophageal Varices?
``` 1. Dilated esophageal veins 2° to portal HTN A. Cirrhosis (50% of pts) (Alcoholics, Chronic hepatitis) B. Budd Chiari Syndrome (Thrombosis of hepatic vein) ```
46
1/3 of pts w/ varies develop?
Serious UGI bleed
47
Signs & Sx’s of Esophageal Varices
1. Acute & severe UGI hemorrhage 2. +/- preceding vomiting 3. Results in: A. Hypovolemia B. Shock C. Death
48
Esophageal Varices: How do you assess hemodynamic status
1. SBP < 100 mmHg, HR >100 bpm = severe GI bleed 2. SBP > 100 mmHg, HR >100 bpm = moderate GI bleed 3. Normal SBP & HR = minor GI bleed
49
Hct take how long to show effect of active bleeding? (esophageal varices)
24-72 hrs
50
Management of esophageal varices
1. 2 large bore (≥ 18 g) IV lines A. Blood & fluid replacement dependent on hemodynamic status & labs (STAT CBC, PT/INR, BUN/Cr, LFT’s, Type & X-match) 2. FFP, Plts, Vitamin K A. Correct coagulopathy (INR > 1.8 or platelets < 50,000) 3. Antibiotic prophylaxis A. ↑ Risk for 2° peritonitis, pneumonia, UTI B. IV antibx (ceftriaxone/Rocephin or quinolone) - Covers gram (-) as well as resistant gram (+) organisms 4. Nasogastric tube (NGT) A. Use for all suspected UGI bleeds B. (+) blood, coffee ground emesis, (+) guaiac = UGI bleed 5. Vasoactive drugs, Terlipressin & octreotide 50-µg bolus IV, then 25-50 µg/h IVF for 1-5 d A. Reduces splanchnic blood flow and portal HTN B. Effective in initial control of bleeding 6. Lactulose A. Treats hepatic encephalopathy assoc w/ cirrhosis 7. Emergent Upper Endoscopy A. Identify source of bleeding - Varices, PUD, Mallory Weiss tear B. Renders endoscopic therapy - Cautery, injection of sclerotic agent, endoclip or banding
51
Initial management for esophageal varices?
1. Balloon tube tamponade A. Mechanical tamponade w/ gastric & esophageal balloons - Provides temporary control of variceal bleeding - High complication rate (ulcerations, perforation, airway obstruction)
52
Once initial bleeding controlled, Tx aimed at reducing high risk re-bleeding. How is this done?
Beta Blockers & variceal band ligation TIPS procedure - Reserved for pt who fails above management or has recurrent bleeding
53
What is the TIPS Procedure?
Transjugular intrahepatic portosystemic shunts (TIPS) 1. “Creation of low-resistance channel between hepatic vein & intrahepatic portion of portal vein using angiographic techniques” A. Placement of wire stent from hepatic vein thru liver to portal vein --> decompresses portal venous system & controls acute varices bleeding
54
What is Esophageal Dysmotility?
Caused by neurologic factors, intrinsic or external blockage or malfunction of esophageal peristalsis ``` Includes: Neurogenic dysphagia Zenker’s diverticulum Achalasia Esophageal stenosis Esophageal spasm ```
55
What is Neurogenic Dysphagia?
1. Dysphagia of liquids & solids | A. Caused by injury/disease to brainstem or CN IX, X, XI & XII
56
What is Zenker’s Diverticulum?
1. Posterior outpouching of esophagus thru pharyngeal constrictor muscles A. Impaired relaxation and spasm o cricopharyngeal muscle B. “Esophageal herniation” 2. Pouch collects food → regurg & extreme halitosis 3. Dysphagia (high) 4. Globus 5. Older pt
57
Diagnostic studies for Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?
Esophagram
58
Treatment of Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?
1. Surgical Cricopharyngotomy A. Cut stronger muscle to equalize pressure, allowing hernia to retract 2. Botox injection to cricopharyngeal muscle A. Relaxes
59
What is Achalasia?
1. Loss of peristalsis in distal 2/3 of esophagus & impaired relaxation of LES 2. Causes gradual dysphagia w/ episodic regurg & chest pain A. Solids & liquids B. No alarm sx’s 3. M=F
60
Pathophysiology of Achalasia?
1. Idiopathic 2. Electroconduction abnormality 3. Loss of inhibitory neurons w/in the wall of esophagus Aperistalsis 4. LES sphincter muscle unable to relax
61
Diagnostic Studies for Achalasia
``` 1. Esophagram (affirms suspicion) A. 1st step in Dx B. Dilated esophagus C. Loss of esophageal peristalsis D. Poor esophageal emptying of barium E. Narrow esophago-gastric junction w/ “bird-beak” appearance - Caused by persistently contracted LES ``` 2. EGD 1st line if achalasia w/alarm sx’s 3. Manometry (confirms diagnosis) Final and most accurate test
62
Achalasia Treatment
1. Pneumatic dilatation-1st line 2. Botox injection into LES A. Blocks acetylcholine & relaxes LES 3. Heller Myotomy A. Last resort due to risk of GERD B. Used if refractive to above Tx’s
63
Esophageal Stenosis/Stricture characteristics
1. Dysphagia for solid foods 2. Slow progression indicates more benign process 3. Rapid process suggests malignancy
64
What is an Esophageal Spasm?
1. Neural conduction disorder causing intermittent substernal pain 2. May not related to swallowing A. Triggered by cold drink
65
Sx's of Esophageal Spasm
1. Substernal crushing CP, often radiates to back, possible dysphagia/regurg A. EKG & Cardiac enzymes to R/O CAD
66
Diagnostic Studies for esophageal spasm
1. Manometry-confirms Dx | 2. +/- Esophagram
67
Treatment for esophageal spasm
1. CCB & Nitrates 2. Symptomatic A. Eat slowly & take smaller bites of food B. Warm liquids may facilitate swallowing C. Trial PPI’s since GERD may cause dysphagia 3. Neurogenic dysphagia A. Treat underlying Dz 4. Esophageal spasm A. CCB – nifedipine 10 mg po 30-45 mins ac B. Oral nitrates –SL NTG prn or isosorbide 10-20 mg qid 5. Benign strictures A. Esophageal dilation x 1-3 sessions B. Laproscopic myotomy 6. Malignant strictures A. Surgical resection

Gen Med: GI (9 decks)

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