Esophageal disorders Flashcards
1
Q
2 parts of the GI tract that are made up of squamous epithelium? What is rest of bowel made up of?
A
- esophagus and anus: made up of squamous epi
- rest of bowel: columnar and cuboidal
2
Q
Parts of esophagus, fxn?
A
- muscular tube that conveys food from pharynx to stomach
- inner circular muscle
- no serosa (infection and cancer can spread quickly)
- unforgiving organ
- food passes through quickly because of peristalsis
3
Q
2 main types of movement?
A
- peristaltic: moves food forward
- segmental: mixing
4
Q
27 yo male, presents with prog. increasing difficulty in swallowing over one month period
- dysphagia started with solid food, now trouble with liquids
- wt loss, no previous swallowing problem
- PE unremarkable findings
- what is dx? How do we dx?
A
- achalasia
- UGI: birds beak (barium swallow study)
5
Q
Causes of dysphagia?
A
in the lumen: tumor in the wall: - achalasia, tumor, GERD - plummer vinson syndrome - scleroderma (CT disorder) - chagas' disease outside of wall: -pressure of enlarged lymph nodes - Thoracic aortic aneurysm - bronchial carcinoma - retrosternal goiter
neuromuscular disorders:
- stroke
- myesthenia gravis
6
Q
Distance b/t UES and LES?
A
- 18-24 cm
7
Q
Normal phases of swallowing? (voluntary, involuntary, and b/t swallows)
A
voluntary: oropharyngeal phase - bolus is voluntarily moved into pharynx
involuntary:
-UES relaxation
-peristalsis (aboral movement)
-LES relaxation
b/t swallows:
- UES prevents air entering the esophagus during inspiration and prevents esophagopharyneal reflux
- LES prevents gastroesoph reflux
- persistaltic and non-peristaltic contractions in response to stimuli
- capacity for retrograde movement (belch, vomiting) and decompression
8
Q
origin of esophageal disorders?
A
- motility
- anatomic and structural
- reflux
- infectious
- neoplastic
- miscellaneous (perf, burns, bleeding)
9
Q
3 common sxs pt will present with esophageal disorder?
A
- pain
- obstruction (dysphagia)
- bleeding
10
Q
Upper esophageal motility disorders are due to what?
A
oropharyngeal dysphagia (transfer dysphagia):
- pts complain of difficulty swallowing
- tracheal aspiration may cause sxs
pharyngoesophageal neuromuscular disorders:
- stroke
- parkinsons
- poliomyelitis
- ALS
- MS
- diabetes
- myasthenia gravis
- dermatomyositis and polymyositis
upper esophageal sphincter (cricopharyngeal) dysfxn may occur in HTN
11
Q
What is achalasia?
A
- incomplete relaxation of LES during swallowing leading to fxnl obstruction and proximal dilation
- aperistalsis, incomplete relaxation, increased resting tone
- ganglion cells of myenteric plexus are diminished or absent
- histology: inflammation in area of M. plexus
- hypotheses: autoimmune, viral infections
- 5% develop squamous cell carcinoma
12
Q
Clinical picture of achalasia?
A
- hx: dysphagia (MC) regurgitation chest pain heartburn wt loss - details: 25-50% report episodes of retrosternal chest pain 80-90% experience spontaneous regurg - some pts may present with signs or sxs of pneumonia (aspiration)
- Physical exam - noncontributory
- lab studies: noncontibutory
- imaging studies:
UGI: birds beak
EGD: normal or dilated esophagus
manometry
*** radiologic exam of choice in dx of achalasia is barium swallow study with fluoroscopic guidance
13
Q
When is esophagela manometry used?
A
- to assess LES pressure and peristalsis
14
Q
Tx of achalasia?
A
- goal: relieve sxs by eliminating outflow resistance caused by hypertensive and nonrelaxing LES
- medical and surgical management
- low surgical risk: laraposcopic myotomy, if fail - refer to have repeat myotomy done or pneumatic dilation or esophagectomy done
or can try graded pneumatic dilation - if fail try laparoscopic myotomy - if high risk for surgery: botox - if fail - nifedipine (CCB)/ isosorbide dinitrate
15
Q
How does diffuse esophageal spasm (DES) present?
A
- chest pain
- intermittent dysphagia
- segmental non-peristaltic contractions
- corkscrew esophagus
- muscular hypertrophy
- this can be extremely painful (mistaken for MI - rule this out first!!!)
16
Q
What is a nutcracker esophagus?
A
- high pressure peristaltic contractions
17
Q
What is esophageal atresia?
A
- congenital abnormalitiy in which mid portion of esophagus is absent
- occurence: 1 in 3,570 and 1 in 4,500
- try to introduce NG tube but it just coils back around
18
Q
What is a TE fistula?
A
- most common form of atresia
esophagus fused into trachea - fluid can accumulate and be regurgitated - into trachea
19
Q
What does gasless abdomen suggest?
A
- that pt has either atresia w/o a fistula or atresia with a proximal fistula only
20
Q
What is GERD?
A
- syndrome not a disease
- mucosal damage produced by abnormal reflux of gastric contents into the esophagus
21
Q
PP of GERD?
A
- primary barrier to GER is LES
- LES normally works in conjunction with diaphragm
- if barrier disrupted, acid goes from stomach to esophagus
22
Q
4 major physiologic mechanism that protect against esophageal acid injury?
A
- clearance mechanisms in upper esophagus
- mucosal integrity
- LES competence
- gastric emptying
23
Q
Classic GERD sxs?
A
- heartburn (pyrosis): substernal burning discomfort
- regurg: bitter, acidic fluid in the mouth when lying down or bending over***
24
Q
Extraesophageal manifestations of GERD?
A
- pulm: asthma (esp at noc) aspiration pneumonia chronic bronchitis pulmonary fibrosis - ENT: hoarsenss laryngitis/pharyngitis chronic cough globus sensation dysphonia sinusitis subglottic stenosis laryngeal cancer
25
Potential oral and laryngopharyngeal signs assoc with GERD?
- edema and hyperemia of larynx
- vocal cord erythema, polpys, granulomas, ulcers
- hyperemia and lymphoid hyperplasia of posterior pharynx
- interarytenyoid changes
- dental erosion
- subglottic stenosis
- laryngeal cancer
26
Etiology of GERD?
combo of factors:
- hiatal hernia
- incompetent LES
- decreased esophagus clearance
- decreased gastric emptying
- meds
- anything that results in esophageal irritation and inflammation
27
What is a hiatal hernia? Types?
- herniation of portion of stomach adjacent to esophagus through opening in diaphragm (slipped valve)
- opening in diaphragm which allows this to happen is called hiatus, these are common, most are harmless but they do promote reflux
- types:
sliding and paraesophageal/rolling
28
Why do hiatial hernias occur? Etiologies?
- food lodges in pouch: inflammation of mucosa, reflux of food up to esophagus, dysphagia
- often incompetent gastro-esophageal sphincter
- contributing factors: shortening of esophagus, weakness of diaphragm (phrenic nerve cut), increased abdominal pressure
```
- factors:
structural changes
obesity
pregnancy
heavy lifting
```
29
Complications of hiatal hernia?
- GERD
- hemorrhage (from acid reflux)
- stenosis of esophagus
- ulcerations
- strangulation of hernia
- regurgitation
- increased risk for resp. disease
30
Clinical manifestations of hiatal hernia?
- may be asx
- heartburn
- dysphagia
- reflux with lying down
- pain, burning when bending over
31
Tx goals for GERD?
- eliminate sxs
- manage or prevent complications
- maintain remission
32
Lifestyle goals to prevent GERD?
- avoid large meals
- avoid acidic foods (citrus/tomato), ETOH, caffeine, chocolate, oninon,s garlic, peppermint
- decrease fat intake
- avoid lying down w/in 3-4 hrs after a meal
- elevate head of bed 4-8 inches
- avoid meds that may potentiate GERD (alpha agonists, theophylline, sedatives, NSAIDS)
- avoid clothing that it is tight around the waist
- lose wt
- stop smoking
33
Tx of GERD?
- antacids: OTC suppressants and antacids approp initial therapy (approx 1/3 pts with heartburn sxs use at least twice weekly)
- H2-receptor antagonists (H2RAs): cimetidine (tagamet), Ranitidine (zantac), famotidine (pepcid), nizatidine (axid)
- PPIs: Omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium)
(these are safe during preg)
- surgery:
reduce hiatal hernia
repair diaphragm
strengthen GE jxn
strengthen antireflux barrier via gastric wasp
75-90% effective at alleviating sxs of heartburn and regurgitation
34
Postsurgery studies of hiatal hernias?
- 10% have solid food dysphagia
- 2-3% have perm. sxs
- 7-10% have gas, bloating, diarrhea, nausea, and early satiety
- w/in 3-5 yrs 52% of pts back on antireflux meds
35
Complications of GERD?
- erosive esophagitis
- stricture
- barrett's esophagus
36
What is erosive esophagitis?
- responsible for 40-60% of GERD sxs
| - severity of sxs often fail to match severity of the erosive esophagitis
37
What is an esophageal stricture?
| What may be needed?
- result of healing of erosive esophagitis - collagen is replacing normal lining - narrowing
- may need dilation
38
What is Barrett's esophagus? What is the pt at risk for now?
- acid damages lining of esophagus and causes chronic esophagitis
- damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells
- this specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma
39
When should you perform dx tests on pt with GERD?
- uncertain dx
- atypical sxs
- sxs assoc with complications
- inadequate response to therapy
- recurrent sxs
40
Dx tests for GERD?
- barium swallow
- endoscopy
- ambulatory pH monitoring
- esophageal manometry
41
When is a barium swallow a first dx test?
```
- for pts with dysphagia:
stricture (location, length)
mass (location, length)
birds beak
hiatal hernia (size and type)
```
42
What is ambulatory 24 hr pH monitoring?
- physiologic study
- quantify reflux in proximal/distal esophagus
- % time pH is less than 4
- consecutively lower than 4: chronic reflux
43
When is an esophageal manometry used in GERD?
- limited role in GERD
- assess LES pressure, location and relaxation
- assists placement of 24 hr pH catheter
- assess peristalsis: prior to antireflux surgery
44
What is infection indued esophagitis? Bugs? More common in?
- more common in pts with impaired immunity (HIV)
- fungal: candida
- viruses: herpes and CMV
45
What is eosinophilic esophagitis? Assoc with? Tx?
- esophageal bx: many intraepithelial eosinophils (80/high power field)
- assoc with food allergies
- tx: oral steroid (fluticasone) therapy, 220 mcg 2 puffs/day
46
Cause of mallory-weiss tear? Clinical presentation?
- caused by severe retching and vomiting
- longitudinal tear at gastroesophageal jxn
- clincial setting: chronic alcoholics after a bout of severe vomiting
- tear may be superficial or deep affecting all layers
- clinical picture: pain, bleeding, superimposed infection
- hiatal hernia is found in 75% of pts
- most often bleeding stops w/o intervention but life-threatening hematemesis may occur
47
What are esophageal varices? Secondary to?
- tortuous dilated veins in submucosa of distal esophagus
- etiology: portal HTN secondary to liver cirrhosis, anything that increases pressure: coughing can start massive bleed
- asx until they rupture leading to massive hemorrhage
- 50% subsides spontaneously
- 20-30% die during first episode
- rebleeding occurs in 70% of cases within one year
48
What is esophageal diverticula? diff types? Sx?
- saclike outpouching of one or more layers of the esophagus
- zenker's diverticulum: most common of esophageal diverticulum, located above UES
sxs:
dysphagia
wt loss
regurg
chronic cough
aspiration
- epiphrenic diverticulum: arises in distal esophagus, just above diaphragm, pulsion diverticulum that probably related to incoordination of esophageal peristalsis and relaxation of LES
49
Tx of esophageal diverticula?
- clients learn to empty esophagus by applying pressure
- limit foods (blenderize - yum!)
- endoscopic surgery
50
What is scleroderma?
- chronic CT disease
- motility pattern:
proximal 1/3 striated muscle = normal peristalsis
distal 2/3 smooth muscle: impaired motility
(primarily affects smooth muscle)
- patulous GE jxn: GE reflux can cause distal stricture
51
Causes of esophageal perforation?
- iatrogenic: 75% - endoscopy is #1 cause
| - boerhaave syndrome: 10-15%: due to ETOH or emesis
52
How common is esophageal rupture?
- rare, 300 cases reported per year
- dx is commonly missed/delayed
- mortality is high: most lethal GI perf, mortality falls with early dx/intervention
53
What can an esophageal perforation lead to?
- esophageal contents - leak and may cuase necrotizing mediastinhtis and polymicrobial infection - this can lead to shock
- pleural/peritoneal space: rapidly progressive infection/ shock
- can lead to empyema
54
What pops are we worried about with swallowed FBs?
- peds (80%) of all cases
- prisoners, psych, edentulous adults
- adults = meat and bones
- kids = coins, toys, crayons, pen caps
- pysch and prisoners: unlikey objects, spoons, razors
- most pass spontaneously
- 10-20% require some intervention
- 1% surgical
- most are at anatomic narrowings
55
Common causes of burns in the esophagus?
- lye (goose) vs. acid (stomach)
- risk of perforation
- call someone!!
