esophageal disorders Flashcards
gerd, achalasia
.GERD presentation
heartburn; worse after meals and when lying down;
often relieved by antacids
may have regurgitation or dysphagia
.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
.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
.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
b agonists, a adrenergic antagonists, nitrates, CCB, anticholinergics, theophylline, morphine, merperidine, diazepam, barbituate
all decrease lower esophageal sphincter pressure;
avoid in GERD
.how common is infectious esophagitis
common cause
rare, except in immunocompromised patients
candida
.tetracycline, biphosphonates, iron, NSAIDs, anticholinergics, CCB, narcotics, benzos
all worsen GERD
.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
.CMV and HSV are common causes of what
infectious esophagitis
.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
.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
HIV, mycobacterium TB, EBV,
mycobacterium avium intracellulare
uncommon causes of infectious esophagitis
.infectious esophagitis presentation
odynophagia, retrosternal CP, dysphagia in an immunocompromised pt
may have fever, lymphadenopathy, or rash
.neurologic factors
intrinsic/extrinsic blockage
malfunction of esophageal peristalsis
causes dysmotility of esophagus
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)
.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
what is esophageal stenosis
dangerous?
causes dysphagia for solid foods. slow dysphagia means benign; fast is malignancy
.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
.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
tx for diverticula, achalasia, and stenosis
CCB(nifedipine), nitrates, botulinum or surgery
.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)
what disease can predispose a pt to symptoms and complications of reflux esophagitis
scleroderma causes decreased esophageal spincter tone
.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
tx for benign and malignant strictures
benign: dilation
malignant: resection
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)
