Esophageal Disorders Flashcards
1
Q
2 types of dysphagia
A
- oropharyngeal (oropharynx to proximal esophagus)
2. esophageal (through proximal esophagus to stomach)
2
Q
symptoms of dysphagia
A
non cardiac chest pain
weight loss
globus
3
Q
epidemiology of dysphagia
A
7% during lifetime
4
Q
prevalence of dysphagia
A
common compliant in primary care
impaired swallowing common in tertiary facilities
common post CVA
common in elderly
5
Q
risk factors for dysphagia
A
hereditary congenital malformations age >50 CVA GERD COPD smoking/ETOH obestiy infections medications neuro events or disease HIV Trauma radiation Tx anterior cervical extrinsic mechanical lesions iron deficiency
6
Q
prevention of dysphagia
A
denture check educate on proper meal behavior (chewing/fluids/mechanical soft or pureed diets) NO ETOH with meals when concern get a swallow eval - more aggressive with those who have head/neck CA closely observe your pts meds postures LOC oral hygiene airway
7
Q
etiology of dysphagia - mechanical issues
A
carcinomas epiglottis carotid body tumors pharyngitis tonsillitis diverticulum
8
Q
etiology of dysphagia- esophageal mechanic lesions
A
CA esophageal diverticula Webs schatski's ring strictures (peptic, chemical trauma, radiation FB
9
Q
etiology of dysphagia - extrinsic mechanical lesions
A
peritonsillar abscess thyroid disorders tumors enlarged LA mediastinal compression (lung tumors) AA osteoarthritis C spine (eagle syndrome) esophageal cysts
10
Q
dysphagia to both solid/fluids indicates what?
A
motility issue
11
Q
if dysphagia presents with solids and progresses to liquids think what?
A
mechanical obstrcution
12
Q
progressive symptoms of dysphagia indicates what?
A
cancer or strictures
13
Q
intermittent dysphagia most often what?
A
LES issue
14
Q
ROS questions for dysphagia
A
- heartburn?
- weight loss/anemia?
- hematemesis/coffee/ground/emesis/melena?
- undigested food regurg?
- respiratory symptoms?
- FB sensation/drooling/aspiration?
- Where? upper sternum posterior throat vs lower sternum?
odynophagia? inflammation?
globus sensation?
bad taste in mouth? Halitosis?
hx of chronic GERD?
ETOH and tobacco use….the true story
associated symptoms concerning for cardiac cause
meds?
connective tissue disorder?
changes in speech think neuromuscular
15
Q
common imaging for dysphagia
A
- CXR - AP views looking for abn filling of esophagus or absent gastric bubble - foreign body?
- barium esophagography or Barium Swallow
- upper endoscopy
- esophageal manometry
- esophageal pH recording and impedance testing
- capsular endoscopy
16
Q
what is barium esophagography?
A
pt drinks a thick chalky substance and plain films are taken in a timed sequence to eval subtle esophageal narrowings
17
Q
what is upper endoscopy
A
thin lighted tube inserted for direct visulatization and mucosal biopsies
18
Q
what is esophageal manometry
A
measures changes in pressures within the esophagus that are caused by the contraction of the muscles that line the esophagus
19
Q
what is esophageal pH recording and impedance testing
A
measures pH within the lumen
20
Q
2 muscular layers of esophgus
A
- outer longitudinal layer
2. inner circular layer
21
Q
what type of cells line the esophagus
A
stratified squamous epithelium
22
Q
what is the squamo-columnar junction
A
approx 2cm superior to the gastro-esophageal junction recognized as irregular Z line on EGD
23
Q
how is the upper esophageal sphincter closed
A
continuous contraction of crico-pharyngeal mucscles
24
Q
closing of LES
A
has a high resting tone and prevents gastric content reflux
25
what prevents excessive ingested air into esophagus
UES
26
3 types of esophageal contractions
1. primary peristalsis
2. secondary peristalsis
3. tertiary peristalsis
27
s/s of esophageal disorders
```
odynophagia
dysphagia
sub sternal chest pain
heartburn
acid taste in mouth
chronic cough or asthma exacerbation
vomiting/ can occur with leaning forward/regurg undigested food
muscle weakness
neck pain/mass/nodes
abrupt onset sx
hiccups
```
28
how would you focus your physical exam for esophageal disorders?
1. vital signs: hypovolemic? hypotensive? fever?
2. inspection: overall well being, demeanor, position/color
- mouth/throat/oropharynx by direct laryngoscopy
3. palpate - floor of mouth to look at the base of the tongue and buccal mucosa for lesions
- upper body for lymphadenopathy
4. observe the pt - drink water or eating crackers
5. complete neuro exam - motor function
6. labs may reveal chronic dz, anemia, eosinophilia - LFTs CBC
29
what is heart burn
feeling of sub sternal burning can radiate to anterior neck
caused by reflux of acidic or rarely alkaline material into esophagus
GERD is hb with related dysfunction?
30
what is dysphagia
difficulty swallowing food bolus or impaired transport of bolus thru the esophagus
-oropharyngeal, pharyngeal, esophageal
31
what is odynophagia
sharp sub sternal pain occurring with swallowing limits oral intake
32
what is globus pharyngeus hystericus
sensation of FB in throat
33
definition of dysphagia
difficult progression of food bolus from the mouth to the stomach
34
mechanical obstruction - which is harder to swallow - solids or liquids?
solids are worse
35
motility disorder - which is harder to swallow - solids or liquids?
equal
36
classification of esophageal disorders
1. primary
| 2. secondary - caused by antoehr dz
37
no matter what classificationof motility disorder, they all cause the same things:
1. dysphagia with solids and liquids
2. episodic and unpredictalbe
3. can be progressive
38
3 important causes of motility disorders
1. achalasia
2. diffuse esophageal spasm
3. scleroderma
39
what is achalasia
```
uncommon idiopathic swallowing disorder
1:100,000
esophageal nerve cell degeneration (decr peristalsis distal 2/3; LES relaxation impaired
ages 20-60yo
no cure but can be treated
```
40
s/s of achalsia
- onset months to years
- substernal discomfort is main complaint
- eats slowly and often uses a maneuver to clear food
- regurgitation - nocturnal or with meals
- weight loss
41
imaging for achalasia
CXR - may show air fluid level in distal esophagus
2. barium esophagography - bird's beak
3. EGD - excludes lesions
4. esophageal manometry (DIAGNOSTIC**) absent peristalsis or incomplete LES relaxation
42
ddx of achalasia
1. chagas (endemic areas Central and south american) immigrants are making it more common
2. primary or metastatic tumors
3. small cell lung cancer, paraneoplastic syndrome
4. esophageal spasm5. scleroderma
6. peptic stricture
43
tx of achalasia
1. botox injection with 65-85improvement
- recurrence in 6-9 months 50%
- most appropriate for pts with comorbidities who are candidates for other tx
2. pneumatic dilation with 90% improvement
- normal 103 sessions
- less effective in
44
complication of achalasia
perforations
45
surgery for achalasia
modified heller cardiomyotomy of the LES and cardiac with over 90% in symptom relief
- surgeons usually perform fundoplication at same time
- there is >25% chance for recurrence in 10 years
46
epidemiology of diffuse esophageal spasm
1:100,000/year in US
women>men
white>other
mortality rare morbidity common depending on severity
worldwide data unknown since not all who suffer seek care
47
what is diffuse esophageal spasm
uncoordinated, simultaneous, or rapidly propagated
48
what is hypertensive peristalsis
"nutcracker esophagus"
"jackhammer esophagus"
present more with pain
49
s/s of diffuse esophageal spasm
vague:
dysphagia
regurg
non cardiac chest pain typically post prandial
-under diagnosed and not adequately understood
50
imaging for diffuse esophageal spasm
currently, high-resolution manometry is the best diagnostic modality
51
ddx of diffuse esophageal spasm
```
GERD
esophagitis
MI
any other non cardiac chest pain cause
perforated ulcer
food bolus
```
52
tx for diffuse esophageal spasm
```
CCB
botox
nitrates
tricyclic antidepressants, trazodone, nortiptyline (many dysmotility associated with psychiatric illness)
**Sildenafil - CAUTION*
```
53
surgery for diffuse esophageal spasm
dilatation
myotomy
esophagectomy
research is ongoing to determine the underlying causes to improve diagnostic capabilities and therapeutic
54
what is scleroderma
-secondary esophageal disorder
-esophageal connective tissue disorder related to smooth muscle atrophy and fibrosis
scleroderma involves the esophagus >=75% of pts
55
two forms of scleroderma
1. progressive systemic sclerosis PSS: characterized by diffuse scleroderma, and a more fulminant form with early involvement of internal organs
2. CREST syndrome: characterized by
Calcinosis
Raynaud's phenomenon
Esophageal dysfunction
Sclerodactyly
Telangiectasia
56
imaging for scleroderma
1. barium swallow
| EGD
57
DDX of scleroderma
same as others?
58
symptoms of scleroderma
dysphagia usually late in dz
chocking due to dysmotility
GERD
non cardiac chest pain
59
tx for scleroderma
PPI
Prokinetic drugs - metoclopramide, erythromycin
diet restrictions - multiple small meals rather than larger heavy meals, avoiding fatty foods, alcohol peppermint, and chocolate
60
surgery for scleroderma
none
61
complications of scleroderma
strictures
barretts esophagus
and adenocarcinoma of esophagus
62
risks for esophagitis
```
ETOH
any smoking
surgery/radiation to chest
poor po fluid intake when taking pills
meds: alendronate, doxy/tetra,ibandronate, risedrontate, vitC
repeated vointing
immunocompromised pts
```
63
complications of esophagitis
repeated offense leads to scarring
strictures
advances to swallowing difficulties
BE if untreated for eyars
64
what is candidal esophagitis
caused by candida albicans
opportunistic
common in immunocompromised/immunosuppressed hosts
oral thrush in 75%
65
tx of candidal esophagitis
systemic meds indicated
empriric trial first without scoping
initial: fluconazole if no response do EGD with brushings and bx (rule out other causes or resistance)
66
alterante txfor oral thrush in 75%
itraconazole susp OR voriconazole if refractory
capsofungin
ampohtericin B (reserved for ID to sue)
67
2 viral causes of esophagitis
cytomegalovirus & herpetic
68
tx of cytomegalovirus esophagitis
if immunocompromised - control CD4 with HAART
- ganciclovir = can cause neutropenia
- once neutropenia resolves: oral valganciclovir
- if not tolerated foscarnet = toxicity can cause renal injury hypocalcemia, hypomagnesemia
69
what does herpetic esophagitis cause
multiple shallow ulcers
70
tx of herpetic esophagitis in immunocompetent hosts
tx symptomatic hosts with standard antivirals
71
tx of herpetic esophagitis in immunosuppressed hosts
oral acyclovir or oral valacyclovir
foscarnet for refractory cases
most respond, relapse possible, may require suppressive treatment
72
meds or pill induced esophagitis caused by which meds
```
NSAIDS
KCl pills
quinidine
zalcitabine
zidovudine
alendronate
risedronate
emepronium bromide
iron
vitC
certain ABX
```
73
s/s of med induced esophigitis
```
retrosternal CP
odynophagia
dysphagia
can occur immediately or several hours after ingestion and persist for days
elderly may show very mild s/s
```
74
risks of med induced esophagitis
not enough water, pt supine when taking meds
| hospitalized or bed bound
75
EGD findings of med induced esophagitsis
will show one to several discrete ulcers that may be shallow or deep
76
complications of med induced esophagitis
strictures
erosion to the point of hemorrhage
erosion to the point of perforation
healing will occur with removal of offending agent
77
prevention of med induced esophagitis
take meds with at least 4oz water
| upright for 30 min post op dosing
78
caution using pills/capsules to avoid induced esophagitis
esophageal dysmotility disorders
known dysphagia being worked up
known strictures
79
what is caustic esophagitis
accidental
intentional
aka crystalline alkali - drain cleaners & acid
80
s/s of caustic esophagitis
```
burning CP
gagging
dysphagia
drooling
aspiration (wheezing,stridor)
```
81
PE for caustic esophagitis
-circulatory status
airway patency
oropharyngeal mucosa
-pts who don't display major sx (SOB, drooling, oral, burns, hematemesis) are less likely to have severe GI injury, OBS warranted
-severe injuries noted: ICU, may require airway preotection
82
dx imaging for caustic esophagitis
CXR
abdominal series
free air
pneumonitis
83
tx for caustic esophagitis
```
supportive
IV fluids
IV PPI bolus and drip
direct laryngoscopy to eval for airway issues if pt is in resp distress
EGD within 12-24hrs
psych referral when appropriate
```
84
complications of caustic esophagitis
- mild sx recover quickly with littler risk of stricture
- severe sx are high risks with deep ulcers and risk of perf, necrosis, mediastinitis, periotonitis, hemorrhage, strictures, esophageal tracheal fistulas
- close ICU monitoring and may require emergent esophagectomy and colonic or jejunal interposition
- nutrition = naso enteric feeding tube until stable
- esophageal cancer risk 2-3% warranting surveillance by EGD
- life long strictures and intralesional steroid injections
85
what is eosinophilic esophagitis
white exudates or papules, red furrows, corrugated concentric rings, strictures
can be grossly normal on EGD
-food or environmental antigens stimulate inflammation
-seen often in children
-hx of allergies/atopic conditions in 50% of pts
86
s/s of eosinophilic esophagitis
adults: long hx dysphagia for solids
hx of food impaction
GERD
children: CP/abd pain, vomiting, FTT
87
labs for eosinophilic esophagtitis
occasional eosinophilia on CBC
| elevated IgE
88
diagnostics for eosinophilic esophagitis
barium swallow may reveal small caliber lumen, strictures, multiple concentric rings
- EGD is pertinent for dx - bx and histo, multiple from proximal to distal end of
- highly recommended testing for food allergies
89
tx for eosinophilic esophagitis
before making DX - empiric trail PPI
repeat EGD to exclude GERD and PPI responsive eosinophilia
35% of pts will improve after PPI trial
-refer to allergist
-foo elimination diet
-topical steroids for symptoms - budesonide suspension, fluticasone
90
complications of eosinophilic esophagitis
strictures
narrow lumens - may need to be dilated, caution due to higher risk of perforation
thin wall?
91
what is mallory weiss tear
non penetrating tear at the GEJ that is most likely d/t a rise in trans abdominal pressures
ETOH is a risk
makes up 5% of UGI bleeds
92
s/s of mallory weiss tear
hematemesis
| hx of retching, straining, vomiting, in 50% cases
93
ddx of mallory weiss tear
PUD
erosive gastritis
AV malformations
Varices
94
tx of mallory weiss tear
1. EGD once pt stable
2. aggressive fluid resusc
3. blood transfusions
4. endoscopic hemostasis used for pts that don't resolve
5. direct epinephrine injection, cautery with a bipolar or hearter probe device
6. mechanical compression with clipping or bnding
7. OR for arterial embolization or operative intervention for those who fail endoscopic measures
95
what are esophageal webs
thin membranes of squamous mucosa that typically occur in the mid to proximal and may be multiple
congenital but can bbbe related to secondary causes
96
what are schatzki rings
smooth, circumferential in the distal esophagus at the squamo-columnar junction
- cause is controversial
- seen in nearly all HH*?
- most webs and rings are over 20mm
- bolus obstructions occur mostly due to poorly chewd food
- intermittent not progressive
97
at what diameter does dysphagia begin in schatzki rings
dysphagia begins when rings are less than 13mm diameter
98
tx of webs and rings in esophagus
barium swallow better than EGD
| dilation PPI if recurrent
99
what are esophageal varices
dilated submucosal veins seen in pts with portal HTN with pressures over 10mmHg
- normal pressure bw portal vein and inferior vena cava is 2-6 mmHg
- varicose veins of esophagus
- most common cause of emergent UGI bleeding
- occurs in the distal 5cm
100
cuase of esophageal varices
most common cause = cirrhosis
- rebleed is common
- hospital mortality is 15%
101
risks of esophageal varices
size of varices
dilated venules on the varux surface on EGD
severity of liver dz
active ETOH abuse
102
s/s of esophageal varices
acute UGI bleeding
can see proceeding retching, vomiting, dyspepsia, hypovolumemia,
shock
103
what % of chronic liver dz pts with UGI will have non variceal source?
20%
104
tx of esophageal varices
1. acute resuscitation
2. over transfusion and fluids should be avoided, increases venous pressures
3. correct the coagulopathy - FFP, plts if less than 50K
4. ABX prophylaxis - fluoro's, ceftriaxone
5. vasoactive drugs can reduce portal pressure and help prevent re bleed
6. vitK if abnormal Prothrombin time
7. advanced liver dz is a poor prognostic indicator -->ICU-->most of the time palliative care
105
invasive tx of esophageal varices
1. endotracheal intubation
2. balloon tamponade - control bleeding
3. emergent EGD - exclude other causes
- acute endoscopic banding or sclerotherapy can be performed to gain hemostasis
- sclerotherapy is used when visualization is an issue. injections of sclerosing agent into variceal trunks
106
complications of balloon tamponade
ulcers, perforations, aspiration, airway obstruction
107
esophageal varices tx - TIPS
portal decompression procedures
- catheter fed into the jugular vein to the liver parenchyma creating a portosystemic shunt
- can control bleeding in 90% of pts
- mortality is 40% if actively bleeding
- reserved mainly for those who have failed all other measures
108
what can be used by GI specialists to initiate for esophageal varices
non selective beta blockers
| band ligation and BB proved to be superior
109
what can be considered for all chronic liver dz pts but is strict and most pts do not adhere to guidelines
liver transplatation
