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Esophageal Disorders Flashcards

1
Q

define dyspepsia

A
  1. impaired digestion
  2. Discomfort in upper abdomen or chest described as gas, feeling of fullness, gnawing, or burning
    A. “Indigestion”
    B. “Heartburn”
    C. Agida”
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2
Q

What is the etiology of dyspepsia?

A
  1. 50-70% of cases, no definite organic cause determined
  2. Most common: GERD, PUD
  3. Less common: gastritis, esophageal/gastric CA, celiac disease, food allergy, IBD, gastroparesis, ischemic bowel Dz
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3
Q

Define dysphagia

A
  1. Difficulty swallowing (generally painless)
    A. “Pressure” sensation or “food gets stuck”
  2. Determine:
    Solids (obstruction)
    vs
    Solids & liquids (mechanical abnormality)
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4
Q

What are the causes of dysphagia?

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

Define Odynophagia

A

Painful swallowing

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6
Q

What causes odynophagia?

A
  1. Esophageal spasm (can also occur when not swallowing)
  2. Esophagitis
  3. Mallory-Weiss tear
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7
Q

What are the alarm symptoms of esophageal CA?

A 
1. Dysphagia with:
A. Age > 60 yr
B. Anemia
C. Heme (+) stools
D. Sx’s > 6 mo
E. Weight loss
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8
Q

What are the diagnostic modalities for esophageal disorders?

A
  1. Esophagram (Barium Swallow)
    A. esophagus is viewed as a person is swallowing in order to see the peristalsis
  2. Esophagogastroduodenoscopy (EGD/upper endoscopy)
    A. Stops at the duodenum
  3. Esophageal Manometry (Motility testing)
    A. Evaluate neuromuscular functions of esophagus/LES. Checks pressure and motility
  4. 24 Hour Esophageal pH monitoring
    A. Usually order by specialists for refractory cases
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9
Q

Define GERD

A

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

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10
Q

What are the sxs of GERD?

A 
1. Sx’s vary
A. Pressure
B. Heartburn (pyrosis)
-↑ PP & supine
-Relieved w/antacids
C. Dysphagia
D. Regurgitation
E. Dysphagia 
F. Chronic laryngitis
G. Sore throat or “lump in throat” sensation (globus)
H. Halitosis
I. Nausea
J. Odynophagia
K. Atypical CP
L. Asthma
M. Chronic cough
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11
Q

What is the epidemiology of GERD?

A
  1. Most have mild disease
  2. 25% report having heartburn at least 1x/month
  3. 5-10% daily sx’s
  4. M > F
  5. 9 million visits in US yearly
  6. Managing costs > $9 billion
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12
Q

How common is mucosal damage in GERD?

A

Esophageal mucosal damage in 1/3 of cases

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13
Q

What is the normal phys of gerd?

A
  1. LES

A. Normally contracts to maintain pressure ≈ 15 mmHg > intragastric pressure

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14
Q

What is the pathophys of GERD?

A
  1. Incompetent LES
  2. Pressure w/in stomach > LES pressure
  3. Retrograde flow of stomach contents
  4. High acid content in stomach causes pain & irritation in esophagus
  5. Scarring, stricture or ulceration may occur
  6. 1/3 of pts will have endoscopic abnormalities
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15
Q

What factors may promote GERD?

A
  1. ↑ Gastric volume after meals
  2. ↑ Gastric pressure
    A. Truncal obesity
    B. PostPrandial recumbency
    C. Pregnancy
  3. Delayed gastric emptying
    A. Gastroparesis
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16
Q

What factors may contribute to GERD?

A
  1. Medications: cause back up of GI system
    A. Anticholinergics (dyspepsia/constipation)
    B. TCA’s (ileus)
    C. NSAID’s
    D. ASA
    E. Steroids
    F. Bisphosphanates
  2. Foods: irritate lining of esophagus
    A. Caffeine, chocolate, spicy foods, citrus, carbonated liquids
    B. Fats: Slow to digest
    C. Peppermint, ETOH: Relax LES
  3. Lifestyle Behaviors
    A. Smoking, wt gain, eating late, overeating
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17
Q

What dx studies are indicated to uncomplicated GERD?

A

None initially warranted for pts w/ typical uncomplicated GERD sx’s

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18
Q

When is investigation of the esophagus warranted with EGD/upper endoscopy?

A
  1. New-onset asthma in adult
  2. “Alarm” features
    A. Dysphagia w/
    B. Age > 60 yr
    C. Anemia
    D. Heme (+) stools
    E. Sx’s > 6 mo
    F. Weight loss
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19
Q

What complications can result from GERD?

A
  1. Reflux Esophagitis
  2. Esophageal Stricture
  3. Barrett’s Esophagus
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20
Q

What is esophagitis?

A
  1. Inflammation of esophagus
  2. Causes in non-immunocompromised pt
    A. Candidiasis
    B. Pills:
    Alendronate (Fosamax), risendronate (Actonel), doxycycline, NSAIDs, iron, Vit C, KCl, quinine
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21
Q

How is esophagitis caused by candidiasis treated?

A

Tx with oral fluconazole (Diflucan)

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22
Q

How is esophagitis caused by pills treated?

A

Tx w/Sucralfate (Carafate) susp., viscous lidocaine, pt. ed

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23
Q

What is reflux esophagitis?

A

A. Visible mucosal damage

B. Erosions or ulcers in distal esophagus at squamocolumnar junction (Z line)

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24
Q

What is esophgeal stricture? How frequent is it?

A
  1. 5% of GERD cases
  2. Most located at GE junction
  3. Gradual development of solid food dysphagia over mo – yrs
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25
Q

How is esophageal stricture treated?

A
  1. Endoscopy
  2. Tx w/dilatation via “sounds” & PPI
  3. Sounds: hard rubber instrument with increasing diameter to stretch the area of stricture
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26
Q

What is Barrett’s esophagus? What can it lead to?

A
  1. Normal squamous epithelium of distal esophagus replaced by specialized intestinal metaplasia (SIM)
  2. M>F (3:1)
  3. Can lead to AdenoCA
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27
Q

What are the risk factors for esophageal adenocarcinoma?

A
  1. Large Hiatal Hernia
  2. Duration of GERD
  3. Long segment of Barrett’s Esophagus
  4. Abnormal mucosa
    A. Ulcerations
    B. Stricture
    C. Nodules
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28
Q

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

A

Upper Endoscopy (EGD) w/ Bx of distal esophagus

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29
Q

What are the treatment goals for GERD?

A
  1. Relieve symptoms
  2. Heal inflammation
  3. Prevent complications
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30
Q

What lifestyle modifications can be used to treat 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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31
Q

What meds are used for mild intermittent sxs of gerd?

A
  1. Antacids

2. H2 blocker

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32
Q

What are examples of antacids and contraindications?

A
  1. Mg* containing antacids should be avoided by CRF pts

2. Tums, Rolaids, Maalox, Baking Soda, Mylanta, Gaviscon

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33
Q

What is the moa and examples of H2 blockers?

A
  1. Blocks H2 receptors in gastric parietal cells -> reduces gastric acid secretion
    A. cimetidine / Tagamet
    B. ranitidine / Zantac* (can be used in babies/fewest drug interactions)
    C. famotidine / Pepcid
    D. nizatidine/ Axid
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34
Q

What is the treatment for persistent gerd sxs?

A
  1. Proton Pump Inhibitors (PPI)
  2. Sx’s despite conservative treatment or w/known complications
    A. PPI qd x 4-8 weeks (can ↑ to bid after 2-4 weeks if needed)
    B. Add H2-receptor antagonist in those who continue to have symptoms
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35
Q

What is the moa of ppis? What are ex?

A
  1. Blocks H+/K+ ATPase pump on apical surface of parietal cell
A. omeprazole / Prilosec
B. lansoprozole/ Prevacid
C. pantoprozole / Protonix
D. esomeprazole / Nexium
E. Rabeprazole / Aciphex
F. Dexlansoprazole / Dexilant (Kapidex) 
G. Omeprazole + NaHCO3 / Zegerid

Increases in dose can cause diarrhea

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36
Q

What is 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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37
Q

What is indicated if pt unresponsive to PPI?

A
  1. upper endoscopy indicated to R/O:

A. Reflux esophagitis, ZE syndrome, Barrett’s esophagus, stricture, PUD, eosinophilic esophagitis, tumor

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38
Q

How often is EGD surveillance indicated for Barrett’s esophagitis w/o dysplasia?

A

No dysplasia: q 2-3 yr, after 2 yearly (-) biopsy results

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39
Q

How often is EGD surveillance indicated for Barrett’s esophagitis w/ low grade dysplasia?

A

q 6 mo for 1 year after (+) biopsy, then yearly thereafter

40
Q

How often is EGD surveillance indicated for Barrett’s esophagitis w/ high grade dysplasia?

A

q 3 mo in those being followed

41
Q

What are the tx options for Barrett’s esophagitis w/ high grade dysplasia?

A
  1. Tx option – endoscopic ablation
    A. Elderly
    B. Comorbidities w/ high-grade dysplasia or early CA
42
Q

What and when is surgery indicated for esophageal disorders?

A
  1. Laparoscopic Nissen Fundoplication
  2. Extra-esophageal manifestations of reflux
  3. Severe GERD & refractory or noncompliant w/ lifelong medical Tx
  4. Large HH & persistent regurgitation despite PPI’s
43
Q

Who is infectious esophagitis most common in?

A 
1. Most common in immunocompromised
A. HIV/AIDS
B. Organ transplants
C. Leukemia
D. Lymphoma
E. Chronic steroid therapy
44
Q

What pts are candida albicans infections common in?

A
  1. Immunocompromised
  2. Uncontrolled DM
  3. Chronic steroid therapy
  4. Undergoing radiation treatments
  5. Systemic Abx
45
Q

What pts are HSV infections common in?

A

Immunocompromised

46
Q

What pts are cytomegalovirus (CMV) infections common in?

A

Immunocompromised

47
Q

What are the sxs of infectious esophagitis?

A 
1. Odynophagia 
A. Most common sx
2. Dysphagia 
A. Above 2 sx’s most common in immunocompromised 
3. May also have: 
A. CP
B. Oral thrush (Candida) 
C. Oral ulcers (HSV)
48
Q

What are the endoscopy results for a candida infection?

A
  1. EGD not required if (+) oral thrush-Tx

2. Diffuse linear yellow-white plaques adhering to mucosa

49
Q

What are the endoscopy results for a cmv infection?

A

Large shallow superficial ulcerations

50
Q

What are the endoscopy results for an hsv infection?

A

Multiple small deep ulcerations

51
Q

How is candida infectious esophagitis treated?

A
  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
52
Q

How is cmv esophagitis treated?

A

Ganciclovir (Cytovene) 5mg/kg IV q 12 h x 3-6 wk

53
Q

How is hsv esophagitis treated?

A
  1. Acyclovir (Zovirax) 400 mg po 5 X daily x 7-10 d

2. Acyclovir 5mg/kg IV q8h x 7-14 d if odynophagia

54
Q

What is mallory-weiss tear?

A
  1. Non-transmural mucosal tear at lower esophagus
  2. Accounts for ~5% cases upper GI bleed
  3. Self-limited
55
Q

What can cause a mallory-weiss tear?

A
  1. May arise from events that suddenly increase trans-abdominal pressure
    A. 2° to severe prolonged vomiting (50% cases)
56
Q

What are the primary risk factors for mallory weiss tears?

A

Chronic Alcoholism

Bulimia

57
Q

What are the sxs of mallory-weiss tear?

A
  1. Painless hematemesis following severe vomiting
  2. +/- melena
  3. Abd pain from retching
58
Q

What dx tests are indicated for m-w tears?

A
  1. Upper Endoscopy (EGD)
    A. Only necessary if (-) Hx
    B. Linear tears (0.5 – 4 cm) usually located at GE junction
59
Q

What are the ddx for m-w tears?

A 
1. 35% of pts with MW tears will have co-morbidities
A. PUD
B. Erosive gastritis
C. AV malformations
D. Esophageal varices / Portal HTN
E. ZE syndrome
60
Q

What is the rx for m-w tear?

A
  1. Fluid resuscitation
  2. Blood transfusions
  3. 80-90% of tear stop bleeding spontaneously w/in few days
61
Q

How is a m-w tear with prolonged bleeding managed?

A
  1. Endoscopic hemostatic therapy
  2. Local injection w/ epinephrine (1:10,000)
  3. Electrocautery
  4. Mechanical compression of artery
    A. Endo-clip (hemoclip) or endoscopic band ligation
  5. Operative intervention
    A. Pts who fail endoscopic therapy
62
Q

What is Schatzki’s Ring?

A
  1. Circumferential ring of esophageal tissue in lower esophagus causing narrowing
    A. Squamocolumnar junction
    B. Lower esophageal junction
63
Q

What are the sxs of schatzki’s ring?

A
  1. Most asymptomatic until food gets stuck

2. Dysphagia w/ solid foods

64
Q

How is schatzki’s ring diagnosed?

A
  1. Esophagram: in office

2. Endoscopy: surgeon

65
Q

How is Schatzki’s ring treated?

A

Endoscopic dilatation

66
Q

What is Eosinophilic Esophagitis (EoE)?

A
  1. Eosinophilic inflamm. of esophagus leading to clinical esophageal dysfunction
  2. Hallmark is marked tissue eosinophilia of esophagus on Bx obtained via EGD
67
Q

What is the pathology of EoE?

A
  1. Pathogenesis is unknown

2. Often asst. with allergies

68
Q

How is EoE managed?

A
  1. Esophageal dilatation to relieve dysphagia sx’s from strictures
  2. Allergy testing
  3. PPI trial 8-12 wks
  4. Fluticasone MDI & swallowed
  5. Budesonide (steroid slurry) to coat esophagus
69
Q

What are esophageal varices?

A
  1. Dilated esophageal veins 2° to portal HTN

2. Usually located distally

70
Q

What can cause portal HTN?

A 
1. Cirrhosis (50% of pts)
A. Alcoholics
B. Chronic hepatitis
2. Budd Chiari Syndrome
A. Thrombosis of hepatic vein
71
Q

What can esophageal varices lead to?

A
  1. 1/3 of pts w/ varices develop serious UGI bleed

2. ≈ 15% mortality rate

72
Q

What are the sxs of esophageal varices?

A
  1. Acute & severe UGI hemorrhage
  2. +/- preceding vomiting
  3. Results in:
    A. Hypovolemia
    B. Shock
    C. Death
73
Q

Tru/false: esophageal varices are not emergent

A

False: Varices hemorrhage is life threatening emergency !

74
Q

How are esophageal varices initially assessed?

A
  1. Assess hemodynamic status
    A. SBP < 100 mmHg, HR >100 bpm = severe GI bleed
    B. SBP > 100 mmHg, HR >100 bpm = moderate GI bleed
    C. Normal SBP & HR = minor GI bleed
75
Q

Why is hct level not a reliable indicator of severity of bleeding?

A

Hct takes 24-72 hrs to show effect of active bleeding

76
Q

How are hemorrhaging esophageal varices managed?

A
  1. 2 large bore (≥ 18 g) IV lines
    A. Blood & fluid replacement dependent on hemodynamic status & labs
    B. STAT CBC, PT/INR, BUN/Cr, LFT’s, Type & X-match
  2. FFP, PRBCs, Plts, Vitamin K
    A. Correct coagulopathy
    B. INR > 1.8 or platelets < 50,000
  3. Antibiotic prophylaxis
    A. ↑ Risk for 2° peritonitis, pneumonia, UTI
    B. IV antibx (ceftriaxone/Rocephin or quinolone)
    C. 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 25-50µg/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
    C. Cautery, injection of sclerotic agent, endoclip or banding
77
Q

What is the initial management of hemorrhaging esophageal varices?

A
  1. Balloon tube tamponade
    A. Mechanical tamponade w/ gastric & esophageal balloons
    B. Provides temporary control of variceal bleeding
    C. High complication rate (ulcerations, perforation, airway obstruction)
  2. Once initial bleeding controlled, Tx aimed at reducing high risk re-bleeding
    A. Beta Blockers & variceal band ligation
78
Q

When is TIPS procedure indicated for hemorrhaging esophageal varices?

A

Reserved for pt who fails above management or has recurrent bleeding

79
Q

What is the TIPS procedure?

A
  1. Transjugular intrahepatic portosystemic shunts (TIPS)
  2. “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
  3. Indicated in pt who fails endoscopic modalities
80
Q

What is esophageal dysmotilty?What are examples?

A

Caused by neurologic factors, intrinsic or external blockage or malfunction of esophageal peristalsis

Neurogenic dysphagia
Zenker’s diverticulum
Achalasia
Esophageal stenosis
Esophageal spasm
81
Q

What is neurogenic dysphagia? What is it caused by?

A
  1. Dysphagia of liquids & solids

A. Caused by injury/disease to brainstem or CN IX, X, XI & XII

82
Q

What is zenker’s diverticulum?

A
  1. Posterior outpouching of esophagus thru pharyngeal constrictor muscles
  2. Impaired relaxation and spasm o cricopharyngeal muscle
    A. “Esophageal herniation”
  3. seen in older pts
83
Q

what are the sxs of zenker’s divertulum?Pouch collects food → regurg & extreme halitosis
Dysphagia (high)
Globus
Older pt

A
  1. Pouch collects food → regurg & extreme halitosis
  2. Dysphagia (high)
  3. Globus
84
Q

What dx studies are used for zenker’s diverticulum?

A

Esophagram

85
Q

What is the rx for zenker’s diverticulum?

A
  1. Surgical Cricopharyngotomy
    A. Cut stronger muscle to equalize pressure, allowing hernia to retract
  2. Botox injection to cricopharyngeal muscle
    A. Relaxes
86
Q

What is achalasia?

A
  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, common in diabetics
87
Q

What is the pathophys of achalasia?

A
  1. Idiopathic
  2. Electroconduction abnormality
  3. Loss of inhibitory neurons w/in the wall of esophagus
    A. Aperistalsis
  4. LES sphincter muscle unable to relax
88
Q

What are the dx studies for achalasia?

A
  1. Esophagram (affirms suspicion)
    A. 1st step in Dx
  2. EGD 1st line if achalasia w/alarm sx’s
  3. Manometry (confirms diagnosis) by gastroenterologist
    A. Final & most accurate test
89
Q

What will be seen on an esophagram in a pt with achalasia?

A
  1. Dilated esophagus
  2. Loss of esophageal peristalsis
  3. Poor esophageal emptying of barium
  4. Narrow esophago-gastric junction w/ “bird-beak” appearance
    A. Caused by persistently contracted LES
90
Q

What is the rx for achalasia?

A
  1. Pneumatic dilatation-1st line: different from esophageal dilatation
  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
91
Q

What are the general characteristics of esophageal stenosis/stricture/

A
  1. Dysphagia for solid foods
  2. Slow progression indicates more benign process
  3. Rapid process suggests malignancy
92
Q

What is the general rx for esophageal stenosis/stricture? What is the tx for benign vs malignant strictures?

A
  1. Long term (lifetime) PPI
  2. Benign strictures
    A. Esophageal dilation x 1-3 sessions
    B. Laproscopic myotomy
  3. Malignant strictures
    A. Surgical resection
93
Q

What are the general characteristics of esophageal spasm?

A
  1. Neural conduction disorder causing intermittent substernal pain
  2. May not be related to swallowing
    A. Triggered by cold drink
94
Q

What are the sxs of esophageal spasm?

A
  1. Substernal crushing CP, often radiates to back, possible dysphagia/regurg
    A. EKG & Cardiac enzymes to R/O CAD
95
Q

What dx studies are used for esophageal spasm?

A
  1. Manometry-confirms Dx

2. +/- Esophagram

96
Q

What is the tx for esophageal spasm?

A
  1. CCB – nifedipine (Cardizem) 10 mg po 30-45 mins ac
    A. esp good for preventative tx right before meals, or use XR if also have HTN
  2. Oral nitrates –SL NTG prn or isosorbide (long acting nitro) 10-20 mg po qid
97
Q

What is symptomatic treatment for esophageal spasm (and any dysphagia issues?

A
  1. Eat slowly & take smaller bites of food
  2. Warm liquids may facilitate swallowing
  3. Trial PPI’s since GERD may cause dysphagia

Gen Med: GI (16 decks)

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