Esophageal Disorders Flashcards
Esophagus
Muscular tube that conveys food from pharynx to stomach
Two Layers of Muscle in the Esophagus
Inner circular muscle
Outer longitudinal muscle
How does food pass through the esophagus?
Perstalsis
What are the two types of movement?
Perstaltic
Segmental
What kind of movement is peristaltic?
Moves food forward
What kind of movement is segmental?
Mixing
3 locations where dysphagia can occur?
In the lumen
In the wall
Outside the wall
Dysphagia in the Lumen
Tumor
Dysphagia in the Wall
Achalasia Tumor of the esophagus GERD Plummer Vinson syndrome Scleroderma Chagas' disease
Define Achalasia
Neurological disturbance of the dilation of the LES
What is Plummer Vinson Syndrome?
Iron deficiency anemia
Define Scleroderma
Normal collagen replaced with tissue with no contractility
Dysphagia Outside the Wall
Pressure of enlarged lymph nodes
Thoracic aortic aneurysm
Bronchial carcinoma
Retrosternal goiter
Dysphagia due to Neuromuscular Disorders
Myasthenia gravis
Stroke
What is the responsibility of the circular muscles of the esophagus?
Propulsion down the esophagus
3 Parts of the Esophageal Anatomy
UES
Esophageal body
LES
UES
Closes
Relaxes
LES
Has base line tone
Closed
Semi-closed
Which muscles are used for peristalsis?
Longitudinal muscle
Circular muscle
Electrode Sleeve Catheter
Measures pressure changes in the esophagus
Normal Phases of Swallowing
Voluntary
Involuntary
Between swallows
Voluntary Swallowing
Bolus is voluntarily moved into the pharynx
Involuntary Swallowing
UES relaxation
Peristalsis
LES relaxation
Between Swallowing
UES prevents air entering esophagus
UES prevents esophagopharyngeal reflux
LES prevents gastroesophageal reflux
Peristaltic & non-peristaltic contractions
Capacity for retrograde movement and decompression
Types of Esophageal Disorders
Motility Anatomic & Structural Reflux Infectious Neoplastic Perforation Burns Bleeding
Presentation of Esophageal Reflux
Pain
Obstruction (dysphagia)
Bleeding
Upper Esophageal Motility Disorders
Oropharyngeal dysphagia
Pharyngoesophageal neuromuscular disorders
UES dysfunction/HTN
Pharyngoesophageal Neuromuscular Disorders
Stroke Parkinson's Poliomyelitis ALS MS DM Myasthenia graves Dermatomyositis & polymyositis
Example of UES Dysfunction/HTN
Lou Gehrig’s Disease
Define Achalasia
Incomplete relaxation of lower sphincter during swallowing leading to functional obstruction and proximal dilatation
Which ganglion cells are diminished or absent in achalasia
Myenteric plexus
Histology of Achalasia
Inflammation in the area of myenteric plexus
Hypotheses of Etiology of Achalasia
Autoimmune
Viral infections
Important History of Achalasia
Dysphagia Regurgitation Chest pain Heartburn Weight loss
Workup of Achalasia
Lab studies
Imaging Studies
Lab Studies for Achalasia Workup
Monometry
Imaging Studies for Achalasia Workup
UGI: Bird’s beak
EGD: normal or dilated esophagus
Manometry
What is the radiologic examination of choice for the diagnosis of achalasia?
Barium swallow study under fluoroscopic guidance
What is Esophageal Manometry Used for?
Assess LES pressure & peristalsis
Treatment of Achalasia
Medical management
Surgical management
What is the goal of therapy for achalasia?
Relieve symptoms by eliminating outflow resistance caused by HTN and non relaxing LES
Symptoms of Diffuse Esophageal Spasm (DES)
Chest pain Intermittent dysphagia Segmental non-peristaltic contractions Corkscrew esophagus Muscular hypertrophy
What is diffuse esophageal spasm mistaken for?
MI
Nutcracker Esophagus
High pressure peristaltic contractions
Define Esophageal Atresia
Congenital abnormality in which the mid-portion of the esophagus is absent
Gasless Abdomen
Absence of gas in the abdomen suggests that the patient has either atresia without a fistula or atresia with a proximal fistula only
GERD
Mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
What is the primary barrier to GERD is the lower esophageal sphincter?
LES
What happens when the LES is disrupted?
Acid goes from the stomach to the esophagus
4 Major Physiologic Mechanisms Protect Against Esophageal Acid Injury
Esophageal clearance mechanisms
Esophageal mucosal integrity
LES competence
Gastric emptying
Classic GERD Symptoms
Heartburn
Regurgitation
Define Heartburn
Sub-sternal burning discomfort
Define Regurgitation
Bitter, acidic fluid in the mouth when lying down or bending over
Pulmonary Manifestations of GERD
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis
ENT Manifestations of GERD
Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Dysphonia Sinusitis Subglottic stenosis Laryngeal CA
Other Manifestations of GERD
Chest pain
Dental erosion
Oral & Laryngopharyngeal Signs with GERD
Edema/hyperemia of larynx Vocal cord erythema Polyps Granulomas Ulcers Hyperemia & lymphoid hyperplasia of posterior pharynx Interarytenoid changes Dental erosion Subglottic stenosis Laryngeal CA
GERD Etiology
Hiatal hernia Incompetent LES Decreased esophagus clearance Decreased gastric emptying Medications Anything that results in esophageal irritation and inflammation
Define Hiatal Hernia
Herniation of portion of stomach adjacent to the esophagus through an opening in the diaphragm
Types of Hiatal Hernias
Sliding
Paraesophageal/rolling
Sliding Hiatal Hernia
Hernia which protrudes through the diaphragm at the opening where the esophagus enters the abdominal cavity
Contributing Factors of a Hiatal Hernia
Shortening of esophagus
Weakness of diaphragm
Increased abdominal pressure
Etiology of Hiatal Hernia
Structural changes
Obesity
Pregnancy
Heavy lifting
Complications of Hiatal Hernia
GERD Hemorrhage Stenosis of esophagus Ulcerations Strangulation of hernia Regurgitation Increased risk for respiratory disease
What happens in a Paraesophageal Hiatal Hernia
Funds of the stomach enters the chest cavity lateral to the esophagus opening
Clinical Manifestations of Hiatal Hernia
Asymptomatic Heartburn Dysphagia Reflux with lying down Pain, burning when bending over
Treatment Goals for GERD
Eliminate symptoms
Manage or prevent complications
Maintain remission
Lifestyle Modifications for GERD
Avoid large meals
Avoid acidic foods, alcohol, caffeine, chocolate, onions, garlic, peppermint
Decrease fat intake
Avoid lying down within 3-4 hours after a meal
Elevate head of bed 4-8 inches
Avoid meds that may potentiate GERD
Avoid clothing that is tight around the waist
Lose weight
Stop smoking
Treatment of GERD
Antacids
Antireflux surgery
Acid Suppression Therapy for GERD
H2-receptor antagonists (H2RAs)
Proton pump inhibitors (PPIs)
Examples of H2-Receptor Antagonists
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)
Examples of Proton Pump Inhibitors
Omeprazole (Prilosec) Lansoprazole (Prevacid) Rabeprazole (Aciphex) Pantoprazole (Protonix) Esomeprazole (Nexium)
What PPI is safer in pregnant women?
Pantoprazole (Protonix)
What is the importance of antireflux surgery?
Reduce hiatal hernia
Repair diaphragm
Strengthen GE junction
Principles of Anti-Reflux Surgery
Restore Intra-abdominal esophagus
Approximate diaphragmatic crurae
Reduce hiatal hernia
Perform fundoplication
Complications of GERD
Erosive esophagitis
Stricture
Barrett’s esophagus
Erosive Esophagitis
Severity of symptoms often fail to match severity of erosive esophagitis
Esophageal Stricture
Result of healing of erosive esophagitis
May need dilation
Barrett’s Esophagus
Acid damages lining of esophagus
Damaged area heals in a metaplastic process
Metaplasia can progress to dysplasia & adenocarcinoma
When to Perform Diagnostic Tests
Uncertain diagnosis Atypical symptoms Symptoms associated with complications Inadequate response to therapy Recurrent symptoms
Diagnostic Tests for GERD
Barium swallow
Endoscopy
Ambulatory pH monitoring
Esophageal manometry
What is the first diagnostic test for patients with dysphagia
Stricture (locations, length)
Mass (locations, length)
Bird’s beak
Hiatal hernia (size, type)
What does esophageal manometry assess?
LES pressure
LES location
LES relaxation
Peristalsis
Infection-induced Esophagitis due to
Candida
Herpes
Cytomegalovirus
Eosinophilic Esophagitis
Associated with food allergies
Treatment of Eosinophilic Esophagitis
Oral fluticasone
Types of Esophageal Bleeding
Mallord-Weiss tear
Esophageal varicies
Cause of Mallory-Weiss tear
Severe retching and vomiting
Where does a Mallory-Weiss tear occur?
Junction of the esophagus and stomach (longitudinal tear)
What are esophageal arise secondary to?
Cirrhosis
Anything that increases pressure
Clinical Picture of Mallory-Weiss Syndrome
Pain
Bleeding
Superimposed infection
Define Esophageal Varices
Tortuous dilated veins in the submucosa of distal esophagus
Etiology of Esophageal Varices
Portal hypertension secondary to liver cirrhosis
Define Esophageal Diverticula
Saclike outputting of one or more layers of the esophagus
Where is a Zenker’s diverticulum located?
UES
Symptoms of Zenker’s Diverticulum
Dysphagia Weight loss Regurgitation Chronic cough Aspiration
Location of Epiphrenic Diverticulum
Distal esophagus
Just above diaphragm
Treatment of Esophageal Diverticula
Clients learn to empty it by applying pressure
Limit foods
Endoscopic surgery
Scleroderma Motility Pattern
Proximal 1/3 striated muscle (normal)
Distal 2/3 smooth muscle (impaired motility)
Etiology of Esophageal Perforation
Iatrogenic
Boerhaave syndrome
Define Boerhaave Syndrome
When the esophagus is ruptured due to over eating frequently
Esophageal Perforation Mortality
High
Most lethal GI perforation
Complications of a Esophageal Perforation
Necrotizing mediastinitis & polymicrobial infection
Rapidly progressive infection/shock in pleural/peritoneal space
Empyema
Define Empyema
Pus in chest between pleural space and lung
Common FB in Adults
Meat
Bones
Common FB in Peds
Coins
Toys
Crayons
Pen caps
Common FB in Pysch Patients & Prisoners
Unlikely objects
Spoons
Razors
