Esophageal Disorders Flashcards
What is the esophagus?
Muscular tube that conveys food from pharynx to stomach
Muscle layers of the esophagus? 2
What is it missing?
Food passes through quickly because of what?
- Inner circular muscle
- Outer longitudinal muscle
No serosa
peristalsis
Which part of the muscle is contracting during swallowing and which is relaxaing?
- Circular muscle contraction after the bolus
- Circular muscle relaxation before the bolus
What are the two types of movement in the esophagus and describe them?
Dysphagia common etiologies
- Originating in the lumen? 1
- Originating in the wall? 3 main ones, 3 more rare
- Originating outside the wall? 1 main, 3 more rare
- Neuromuscular disorders? 1 main, 1 more rare
- ^ In the lumen
- Tumor - ^ In the wall
- Achalasia*
- Tumor of the esophagus*
- GERD*
- Plummer Vinson syndrome- iron deficiency anemia
- Scleroderma- replaced with collagen tissue that has no contractibility
- Chagas’ disease- infectious. - ^ Outside the wall
- Pressure of enlarged lymph nodes*
- Thoracic aortic aneurysm
- Bronchial carcinoma
- Retrosternal Goiter - ^ Neuromuscular disorders
- Myesthenia gravis
- Stroke*
- UES moves how?
- LES moves how?
- Longitudinal and circular muscle moves how?
- UES….closes and relaxes
- LES….base line tone. Mostly stays shut
- Longitudinal and circular muscle…peristalsis
Normal phases of swallowing
- The voluntary part of swallowing consists of what?
- Involuntary swallowing consists of what? 3
Voluntary
- Oropharyngeal phase – bolus is voluntarily moved into the pharynx
Involuntary
- UES relaxation
- peristalsis (aboral movement)
- LES relaxation
Between swallows:
- UES prevents what? 2
- LES prevents what? 1
1.
- prevents air entering the esophagus during inspiration and
- prevents esophagopharyngeal reflux
2. gastroesophageal reflux
Esophageal disorders
6
- Motility
- Anatomic & Structural
- Reflux
- Infectious
- Neoplastic
- Miscellaneous (Perforation, Burns, Bleeding)
What kind of epithethium makes up the esophagus?
squamous
Oropharyngeal dysphagia (transfer dysphagia)
- Patients complain of what?
- What may cause symtpoms?
- patients complain of difficulty swallowing
- tracheal aspiration may cause symptoms
What are some pharyngoesophageal neuromusclar disorders?
8
- stroke
- Parkinson’s
- poliomyelitis
- ALS
- multiple sclerosis
- diabetes
- myasthenia gravis
- dermatomyositis and polymyositis
Upper esophageal sphincter dysfunction/HTN aka?
cricopharyngeal
What is a achalasia?
Incomplete relaxation of lower sphincter during swallowing leading to functional obstruction and proximal dilatation
(failure to relax)
Achalasia:
- PP: 3 contributing factors?
- What structures are usually dimished or absent?
- Histology findings?
- Hypotheses for etiologies? 2
- 5% develop what?
1.
- Aperistalsis,
- incomplete relaxation,
- increased resting tone
2. Ganglion cells of the myenteric plexus are diminished or absent
3. Histology: Inflammation in the area of M. plexus
4. Hypotheses: autoimmune, viral infections
5. 5% develop squamous cell carcinoma
Clincial picture of Achalasia:
History? 5
- Dysphagia (most common)
- Regurgitation
- Chest pain
- Heartburn
- Weight loss
Achalasia:
1. 25-50% report episodes of what?
2. 80-90% experience spontaneous what?
3. some patients may present with signs or symptoms of what?
- retrosternal chest pain
2. regurgitation.
3. pneumonia
Lab studies for Achalasia? 1
Imaging studies? 3 (and what will the findings be?)
The radiologic examination of choice in the diagnosis of achalasia is what?
Lab Studies
- Laboratory studies are noncontributory.
Imaging Studies
- UGI: Bird’s Beak.
- EGD: Normal or dilated esophagus.
- Manometry
Test of Choice: a barium swallow study performed under fluoroscopic guidance.
Normal esophageal mucosa appears what color?
white to tan
What is esophageal manometry used to assess? 2
Used to assess LES pressure & peristalsis
- The goal of therapy for achalasia is to do what?
- What are our two types of treatment?
- relieve symptoms by eliminating the outflow resistance caused by the hypertensive and nonrelaxing LES.
2.
- Medical Management
- Surgical Management
Diffuse Esophageal Spasm (DES) Characteristics
5
- Chest pain
- Intermittent dysphagia
- Segmental non-peristaltic contractions
- Corkscrew esophagus
- Muscular hypertrophy
What is a nutcracker esophagus characterized by?
High pressure peristaltic contractions
(Nutcracker esophagus, or Hypertensive peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration.)
What is esophageal atresia?
congenital abnormality in which the mid-portion of the esophagus is absent
What is a TE fistula?
What are the etiologies depending on age? 2
A tracheoesophageal fistula is an abnormal connection (fistula) between the esophagus and the trachea.
TEF is a common congenital abnormality, but when occurring late in life is usually the sequela of surgical procedures such as a laryngectomy.
What will show that the tube has not reached the abdomen suggesting either atresia or a fistula?
A plain radiograph will confirm the tube has not reached the stomach
Absence of gas in the abdomen suggests that the patient has either what or what?
- atresia without a fistula or
- atresia with a proximal fistula only
Gastroesophageal reflux (GERD) is defined as what?
Mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
PP of GERD?
- Primary barrier to gastroesophageal reflux is the lower esophageal sphincter
- LES normally works in conjunction with the diaphragm
- If barrier disrupted, acid goes from stomach to esophagus**
WHat are the four major physiological mechanisms that protect against esophageal acid injury?
Classic GERD symptoms
2
- Heartburn (pyrosis): substernal burning discomfort
- Regurgitation: bitter, acidic fluid in the mouth when lying down or bending over
Extraesophageal Manifestations of GERD
Pulmonary? 4
ENT? 9
Other? 2
Pulmonary
- Asthma
- Aspiration pneumonia
- Chronic bronchitis
- Pulmonary fibrosis
ENT
- Hoarseness
- Laryngitis
- Pharyngitis
- Chronic cough
- Globus sensation
- Dysphonia
- Sinusitis
- Subglottic stenosis
- Laryngeal cancer
Other
- Chest pain
- Dental erosion
Potential oral and laryngopharyngeal signs associated with GERD?
7
- Edema and hyperemia of larynx
- Vocal cord erythema, polyps, granulomas, ulcers
- Hyperemia and lymphoid hyperplasia of posterior pharynx
- Interarytenyoid changes
- Dental erosion
- Subglottic stenosis
- Laryngeal cancer
GERD etiology?
6
Could be a combination of these
1. Hiatal hernia
2. Incompetent LES
3. Decreased esophagus clearance
4. Decreased gastric emptying
5. Medications
6. Anything that results in esophageal irritation and inflammation
- What is a hiatal hernia?
- Types? 2
- Herniation of portion of stomach adjacent to the esophagus through an opening in the diaphragm
- Types
- Sliding
- Paraesophageal/rolling
- A hiatal hernia is stomach which has slipped above the what?
- The opening in the diaphragm which allows this to happen is called the what?
- Hiatal hernias are common, most are harmless, but they may promote what?
- Diaphragm
- Hiatus
- reflux
Hiatal hernia:
- Food lodges in pouch and causes what? 3
- What structure is often incompetant?
- Other contributing factors? 3
1.
- Inflammation of mucosa,
- reflux of food up to esophagus,
- dysphagia
2. Often incompetent gastro-esophageal sphincter
3. Contributing factors - Shortening of esophagus
- Weakness of diaphragm
- Increased abdominal pressure (pregnancy)
Etiology of Hiatial Hernia? 4
- Structural changes
- Obesity
- Pregnancy
- Heavy lifting
Complications of a hiatal hernia? 7
(most common)
- GERD**
- Hemorrhage
- Stenosis of esophagus
4, Ulcerations
- Strangulation of hernia
- Regurgitation
- Increased risk for respiratory disease
Clincial manifestations of hiatial hernia?
5
- May be asymptomatic
- Heartburn
- Dysphagia
- Reflux with lying down
- Pain, burning when bending over
Treatment goals of GERD?
3
- Eliminate symptoms
- Manage or prevent complications
- Maintain remission
GERD lifestyle modifications?
9
- Avoid large meals
- Avoid acidic foods (citrus/tomato), alcohol, caffiene, 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 (alpha agonists, theophylline, sedatives, NSAIDS)
- Avoid clothing that is tight around the waist
- Lose weight
- Stop smoking
GERD: What is appropraite for inital therapy?
Antacids
Over the counter acid suppressants and antacids appropriate initial therapy
Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly
Acid suppression therapy for GERD
2
- H2-Receptor Antagonists (H2RAs)
- Proton Pump Inhibitors (PPIs)
What are the medications available in the following categories:
- H2-Receptor Antagonists (H2RAs) 4
- Proton Pump Inhibitors (PPIs) 5
1.
- Cimetidine (Tagamet®)
- Ranitidine (Zantac®)
- Famotidine (Pepcid®)
- Nizatidine (Axid®)
2.
- Omeprazole (Prilosec®)
- Lansoprazole (Prevacid®)
- Rabeprazole (Aciphex®)
- Pantoprazole (Protonix®)
- Esomeprazole (Nexium)
Antireflux surgery accomplishes what?
5
- Reduce hiatal hernia
- Repair diaphragm
- Strengthen GE junction
- Strengthen antireflux barrier via gastric wrap
- 75-90% effective at alleviating symptoms of heartburn and regurgitation
What are the four principles of Anti-refulx surgery?
Postsurgery (studies)
- 10% have what?
- 2-3% have what?
- 7-10% have what?
- Within 3-5 years 52% of patients are what?
- solid food dysphagia
- permanent symptoms
- gas, bloating, diarrhea, nausea, early satiety
- back on antireflux medications
Complications of GERD
(This is where we come in….don’t let patients get to this stage!)
3
- Erosive esophagitis
- Stricture
- Barrett’s esophagus
GERD Complications: Erosive esophagitis
- Responsible for _____% of GERD symptoms
- Severity of symptoms often ________severity of erosive esophagitis
- 40-60
- fail to match
GERD complications: Esophageal stricture
- Result of healing of what?
- May need what?
- erosive esophagitis
- Dilation
GERD complications: Barrett’s Esophagus
- PP? 2
- This specialized intestinal metaplasia can progress to what? 2
1.
- Acid damages lining of esophagus and causes chronic esophagitis
- Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells
2.
- dysplasia and
- adenocarcinoma
When to perform diagnostic tests?
5
- Uncertain diagnosis
- Atypical symptoms
- Symptoms associated with complications
- Inadequate response to therapy
- Recurrent symptoms
Diagnostic tests for GERD? 4
- Barium swallow
- Endoscopy
- Ambulatory pH monitoring
- Esophageal manometry
What is the most useful first diagnostic test for patients with dysplagia?
Barium swallow
What could a barium swallow show us?
1. Stricture (location, length)
2. Mass (location, length)
3. Bird’s beak
4. Hiatal hernia (size, type)
- What study will help us quantify reflux in the proximal/distal esophagus?
- What does it measure?
- Ambulatory 24 hour pH monitoring
- % time pH less than 4
Esophageal manometry has a limited role in GERD but what may it help you with?
3
- Assess LES pressure, location and relaxation
- Assist placement of 24 hr. pH catheter
- Assess peristalsis prior to antireflux surgery
Infection-induced esophagitis:
- More common in pts with what?
- Fungal origins?
- Viral origins? 2
- More common in patients with impaired immunity
- Fungal : Candida
- Viruses: Herpes and Cytomegalovirus
- How do we diagnosis eosinphilic esophagitis?
- What is it associated with?
- Treatment?
- Esophageal biopsies:
Many intraepithelial eosinophils (80/high power field)
- Associated with food allergies
- Treatment:
- Oral steroid (Fluticasone) therapy
- 220 mcg two puffs a day
Etiologies of esophageal bleeding?
2
- Mallory-Weiss Tear
- Esophageal varicies
- What is a mallory-weiss tear caused by?
- Where does the tear occur?
- Caused by severe retching and vomiting
- Tear occurs at the junction of the esophagus and stomach
Esophageal varicies
- Usually secondary to what?
- Anything that increase pressure can cause what? (example)
- cirrhosis of the liver
- can start massive bleed (coughing)
Esophageal lacerations (mallory-weiss syndrome)
- ___________ tears at the gastroesophageal junction
- Clinical setting where this often happens?
- Tear may be how deep? 2
- Clinical picture: symptoms? 3
- _______________is found in 75% of patients
- Most often bleeding stops w/o intervention, but life-threatening____________ may occur.
- Longitudinal
- chronic alcoholics after a bout of severe vomiting
- superficial or deep affecting all layers
4.
- Pain,
- bleeding,
- superimposed infection
5. Hiatal hernia
6. hematemesis
What are esophageal varices?
Tortuous dilated veins in the submucosa of distal esophagus
Esophageal varices
- Etiology?
- Asymptomatic until when?
- What percent subsides spontaeously?
- What percent die during the first episode?
- Rebleeding occurs in what percent within one year?
- Etiology: portal hypertension secondary to liver cirrhosis
- Asymptomatic until they rupture leading to massive hemorrhage
- 50% subsides spontaneously
- 20-30% die during the first episode
- Rebleeding occurs in 70% of cases within one year
What are esophageal diverticula?
What is the most common of the esophageal diverticula?
Saclike outpouching of one or more layers of the esophagus
Zenker’s diverticulum
Zenker’s diverticulum
- Where is it located?
- Sympotms? 5
- Located above the upper esophageal sphincter
- Symptoms
- Dysphagia
- Weight loss
- Regurgitation
- Chronic cough
- Aspiration
- What is an epiphrenic diverticulum?
- Arises from where?
- Pulsion diverticulum (arrow) that probably related to incoordination of esophageal peristalsis and relaxation of the lower esophageal sphincter
- Arises in the distal esophagus, just above diaphragm
Treatment for esophageal diverticulum?
3
- Clients learn to empty esophagus by applying pressure
- Limit foods (blenderize)
- Endoscopic Surgery
Scleroderma
- What is it?
- What is the motility pattern in the esophagus with this?
- What happens to the GE junction?
- GE reflux can cause what?
- Chronic hardening and tightening of the skin and connective tissues.
2.
- Proximal 1/3 striated muscle = normal peristalsis
- Distal 2/3 smooth muscle = impaired motility
3. Patulous GE junction
4. GE reflux can cause distal stricture
Esophoageal perforation
- whats the number one cause?
- Boerhaave syndrome caused by? 2
- Iatrogenic 75%
- endoscopy #1 cause - Boerhaave syndrome 10-15%
- ETOH
- emesis
Esophageal perforation:
- Very lethal: what two things lead to shock?
- What other things will this cause? 2
1.
- Necrotizing mediastinitis and
- polymicrobial infection lead to shock
2.
- Pleural/peritoneal space- rapidly progressive infection/shock
- Empyema
