esophageal disorders Flashcards by Mai Wells

.GERD presentation

heartburn; worse after meals and when lying down;

often relieved by antacids

may have regurgitation or dysphagia

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.GERD workup

endoscopy(1st line diagnostic test) to assess for epithelial damage;

EKG (MI)

esophageal manometry if decreased LES pressure

24 pH monitoring(definitive-gold standard)

CBC is there is a bleed

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.first line tx for GERD and why

*lifestyle modification first

PPI “prazole” for moderate to severe d/s or pts unresponsive to H2 blockers or have erosive gastritis

bring symptomatic relief and promote healing

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.GERD tx

1) mild symptoms
2) significant night time symptoms

1) H2 blockers “tidine”, antacids, and alginic acid
2) combo of H2 blocker at night and PPI in the daytime

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b agonists, a adrenergic antagonists, nitrates, CCB, anticholinergics, theophylline, morphine, merperidine, diazepam, barbituate

all decrease lower esophageal sphincter pressure;

avoid in GERD

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.how common is infectious esophagitis

common cause

rare, except in immunocompromised patients

candida

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.tetracycline, biphosphonates, iron, NSAIDs, anticholinergics, CCB, narcotics, benzos

all worsen GERD

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.what is barrett’s esophagitis

dx test

monitoring/meds

low grade dysplasia

replacement of nml squamous epithelium with precancerous metaplastic columnar cells from stomach.

upper endoscopy with bx

monitored with an endoscopy every 3-5 years, take PPIs

low grade: monitor every 6-12 monts

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.CMV and HSV are common causes of what

infectious esophagitis

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.lab findings of

1) CMV/HIV
2) HSV
3) candida

CMV/HIV reveals large deep ulcers.

CMV has retinitis and colitis.

HSV has multiple small shallow ulcers; +Tzanck smear

candida has whiteyellow plaques that can be removed

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.tx for infectious esophagitis

1) candida
2) HSV
3) CMV
4) last consideration for dx

1) candida: fluconazole
2) HSV: acyclovir
3) CMV: IV ganciclovir
4) last consideration for dx: HIV testing

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HIV, mycobacterium TB, EBV,

mycobacterium avium intracellulare

uncommon causes of infectious esophagitis

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.infectious esophagitis presentation

odynophagia, retrosternal CP, dysphagia in an immunocompromised pt

may have fever, lymphadenopathy, or rash

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.neurologic factors

intrinsic/extrinsic blockage

malfunction of esophageal peristalsis

causes dysmotility of esophagus

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what does neurogenic dysphagia cause

difficulty with both liquids and solids. caused by injury or disease of the brain stem or cranial nerves involved in swallowing (IX and X)

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.what is zenkers diverticulum

symptoms

outpouching of the posterior hypopharynx that can cause regurgitation of theundigested food and liquid into the pharynx several hrs after eating

bad breath, neck pain, odynophagia, dysphagia

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what is esophageal stenosis

dangerous?

causes dysphagia for solid foods. slow dysphagia means benign; fast is malignancy

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.what is achalasia

patho

loss of peristalsis and failure of relaxation of LES

degeneration of auerbach’s plexus leads to increased LES pressure and impaired LES relaxation

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.how to diagnose achalasia

initial test: barium swallow shows “parrot beaked” or “rat tail” appearance

manometry is definitive test: increased resting LES pressure and lack of peristalsis

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tx for diverticula, achalasia, and stenosis

CCB(nifedipine), nitrates, botulinum or surgery

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.what is a diffuse esophageal spasm

2 tests to order

tx (3)

esophageal motility d/o with severe non-peristaltic esophageal contractions (uncoordinated contractions)

barium swallow: corkscrew shaped esophagus

diagnostic manometry is diagnostic: high amplitude and simultaneous or premature contractions greater than 20% of swallows

tx: antispasmodics(CCB, TCA, or nitrates)

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what disease can predispose a pt to symptoms and complications of reflux esophagitis

scleroderma causes decreased esophageal spincter tone

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.dx tests for esophageal motility

barium swallow to show structural and motor abnormalities
endoscopy(EGD) to direct observation and bx
esophageal manometry to assess strength and coordination of peristalsis

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tx for benign and malignant strictures

benign: dilation
malignant: resection

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what accounts for 5-10% of upper GI bleeds

mallory weiss tear

.common types on esophageal neoplasms and risk factors

squamous (alcohol, tobacco) adenocarcinomas (columnar metaplasia secondary to GERD, smoking, obese)

.location of barretts esophagitis vs squamous cell lesions

barretts is adenocarcinoma in the distal third of the esophagus and squamous is in proximal 2/3

do esophageal neoplasms spread?

yea to the mediastinum b/c esophagus has no serosa

.main clinical feature of esophageal neoplasm

progressive dysphagia for solid food assoc with marked wt loss. then for liquids

.tests to order when you suspect esophageal neoplasm

upper endoscopy with bx: diagnosic study of choice double contrast barium esophagram endoscopic u/s and CT for staging

.tx for esophageal neoplasm prognosis

\*\*surgery and chemoradiation first line tx 4-60% 5 year survival

.what is a mallory weiss tear

longitudinal superficial mucosal tear in the esophagus, generally at the gastroesophageal junction or gastric cardia that occurs with forceful vomiting or retching.

.what is a mallory weiss tear associated with and how to dx. tx

alcohol; upper endoscopy test of choice usually no tx, it is self limiting; supportive

.what is esophageal varices

dilations of the veins of the esophagus, generally at the distal end due to portal HTN

.what is esophageal varices from

portal HTN from cirrhosis or chronic viral hepatitis

what is budd-chiari syndrome

causes a thrombosis of the portal vein, leading to esophageal varices

pt has hematemesis and a history of cirrhosis

think esophageal varices; endoscopy will localize the bleeding

.tx for esophageal varices

hemodynamic support with high volume fluid replacement and vasopressors. do endoscopic therapy(ligation) vasoconstriction(octreotide) 1st line medical mgmt

.treating an active bleed from a mallory weiss tear

PPI endoscopic injection of epi and thermal coagulation may be required if bleeding does not resolve on its own

.esophageal varices presentation dangers of large bleeds

painless upper GI bleed that can be bright red frank bleeding and coffee ground appearance careful of hypovolemic shock ; life threatening

.how to prevent variceal bleeding in cirrhotic pts

b blockers with or without isosorbide mononitrate along with discontinuation of hepatoxic agents endoscopic band ligation may be useful if medical therapy is insufficient

.hemodynamic support for esophageal varices

high volume fluid replacement and vasopressors and immediate control of bleeding are necessary

esophageal varices mortality rate

30% with the first bleed and 50% within 6 weeks

.esophageal varices tx for an acute bleed

endoscopic band ligation

.zenkers dx

barium esophagram initial test of choice upper endoscopy usually perform for surgical evaluation

barium swallow not good for what disorder

GERD; not helpful with diagnosis

avoid endoscopy in what

zenkers

.esophageal web def

noncirferential thin membrane in the mid to upper esophagus dysphagia to solids

difficulty for both liquids and solids

neurogenic dysphagia

regurgitation of undigested food and liquid hours after eating

zenker diverticulum

dysphagia for solid foods can be slow or rapid

esophageal stenosis

.peristalsis is decreased and lower esophageal spincter tone is increased

achalasia

.slowly progressive dysphagia (solids and liquids same time)with episodic regurgitation and chest pain

achalasia

.dysphagia or intermittent chest pain that may or may not be associated with eating

difuse esophageal spasm

.what are protective factors in barretts esophagus?

aspirin and NSAIDs

bright red frank bleeding or coffee ground appearance

esophageal varices

what is an AIDs defining illness

candidal esophagitis

describe musculature of the esophagus

upper third is skeletal the lower 2/3rds is smooth muscle

.most common cause of esophagitis classic 3 symptoms dx

gerd hallmark is odynophagia, dysphagia, retrosternal CP upper endoscopy

.upper endoscopy shows linear yellow white plaques

candida, tx fluconazole

.upper endoscopy shows large, superficial shallow ulcers

CMV. tx: ganciclovir

.upper endoscopy shows small deep ulcers

HSV. tx acyclovir

.endoscopy shows multiple corrugated rings in a child

eosinophilic esophagitis tx remove food that triggered this. PPI maybe. inhaled corticosteroids WITHOUT spacer

.common meds to induce pill esophagitis

NSAIDs, bisphosphonates, bb, ccb, KCL, iron, vit C

.NSAIDs, bisphosphonates, bb, ccb, KCL, iron, vit C

common meds to induce pill esophagitis

.tracheoesophageal fistula commonly associate with what

esophageal atresia

.presents immediately after birth with excessive oral secretions that leads to choking, drooling, inability to feed, resp distress, coughing

esophageal atresia

.gerd is incompetency of what

transient relaxation of LES

.gerd hallmark symptom

heartburn(pyrosis), often retrosternal and postpradial.

.hoarseness, aspiration pneumonia, wheezing, CP

atypical signs of gerd

.Alarm symptoms for GERD

dysphagia, odynophagia, wt loss, bleeding

.dysphagia, odynophagia, wt loss, bleeding

Alarm symptoms for GERD

.adenocarcinoma and squamous esophageal neoplasm age race r/f

adenocarcinoma: young white males barretts. squamous: blacks 50-70s alcohol and smoking

.achalasia s/s

dysphagia to both solids and liquids at the same time, regurgitation, cp, cough

.when to perform an endoscopy on a pt with achalasia

performed in Achalasia prior to initiating tx to r/o esophageal squamous cell carcinoma

.birds beak appearance of LES on barium esophragram

achalasia

.what is Zenker's diverticulum

pharynogoesophageal pouch(false diverticulum)

.dysphagia, regurgitation, halotosis, choking sensation

zenkers

.barium esophagram shows collection of dye behind the esophagus at the pharynesophageal junction

zenkers diverticulum

.esophageal motility d/o with severe non-peristaltic esophageal contractions (uncoordinated contractions)

esophageal spasm

.barium swallow: corkscrew shaped esophagus diagnostic manometry is diagnostic: high amplitude and simultaneous or premature contractions greater than 20% of swallows

esophageal spasm

.dysphagia to both liquids and solids at the same time. sensation of something stuck in the throat

esophageal spasm

.esophageal motility d/s with increased pressure during peristalsis

hypercontractile esophagus aka nutcracker/jackhammer esophagus

.how to differeniate esophageal spasm and hypercontractile esophagus

manometry will show different peristaltic patterns esophageal spasm: premature contractions hypercontractile: increased pressure during peristalsis

.what is boerhaave syndrome mortality

full thickness rupture of left posterolateral wall of lower esophagus 40% mortality

.retrosternal CP worse with deep breathing and swallowing, vomiting, hematemesis

boerhaave syndrome

.crepitus on chest auscultation(subcutaneous emphysema) Hamman's sign: mediastinal crackling with every heart beat/ left lateral decubitus position

boerhaave syndrome

.what is plummer vinson syndrome at risk for what?

triad of dysphagia, cervical esophageal webs, fe def anemia poss atrophic glossitis esophageal squamous cell carcinoma

.what is a shatzki ring? location

circumferential diaphram of tissue that protrudes into the esophageal lumen most common lower esophagus (at squamocolumnar junction

.shatzki ring s/s

most asymptomatic. episodic dysphagia, especially solid bolus of food can get stuck in lower esophagus (steakhouse syndrome)

esophageal disorders Flashcards

gerd, achalasia