Esophageal disorders

Question 1

Schatzki rings or esophageal rings are

Answer 1

congenital or acquired (From damage from GERD) and accounts for 15-30% of dysphagia

Question 2

dysphagia with solid food and reflux symptoms

Answer 2

think Schatzki or esophageal ring

Question 3

how to diagnose an esophageal ring?

Answer 3

barium esophagram

Question 4

1st line tx for esophageal ring

Answer 4

EGD endoscopic dilation

Question 5

prognosis of esophageal ring?

Answer 5

can redevelop esophageal ring in one year and have recurrent symptoms 70-80% of pts wil have recurrence in 5 yrs

Question 6

To treat those with recurrent esophageal ring symptoms:

Answer 6

repeat dilation and acid suppression (PPI)

Question 7

eosinophilic esophagitis is associated with:

Answer 7

eosphageal rings, allergies, asthma, atopic dermatitis

Question 8

symptoms of eosinophilic esophagitis

Answer 8

dysphagia, food bolus obstruction seen in 20’s and 50’s

Question 9

diagnosis of eosinophilic esopahgitis is via EGD

Answer 9

biopsy mucosal show: 15 eosinophils/hpf or greater

OR

peristent mucosal eosinophilia despite trial of 8 weeks PPI

no signs of perpheral eosinophilia

Question 10

tx of eosinophilic esophagitis

Answer 10

tx 1st line is with aerosolized topical glucocorticoids (fluticasone or budesonide) dietary modification can give PPI

Question 11

EGD shows rings and longitudinal furrows or luminal narrowing and white exudates and plaques

Answer 11

see trachealization of esophagus think: eosinophilic esophagitis

Question 12

what causes eosinophilic esophagitis?

Answer 12

chronic immune mediated esophageal inflammation

Question 13

dysphagia, chest and epigastric pain, reflux and vomiting FOOD impaction associated atophy - asthma, allegies eczema

Answer 13

eosinophilic esophagitis

Question 14

50% of pts with this condition have food impaction

Answer 14

eosinophilic esophagitis.

Question 15

endoscopy with longitudinal furrows and concentric rings

Answer 15

trachealization of esophagus see eosinophilic microabscesses

Question 16

esophageal cancer seen with history of

Answer 16

caustic ingestion

Question 17

dysphagia regurgitation mild weight loss and barium swallow with bird beak appearance in an elderly pt >60 yrs what to do?

Answer 17

get EGD and rule out cancer especially given his age.

pseudoachalasia from tumor at GE junction should be suspected

Question 18

preferred screen for achalasia

Answer 18

barium swallow study can see dilated esophagus with bird beak narrowing at the terminal and aperistalsis during fluoroscopy

this cannot distinguish between a tumor or primary achalasia

Question 19

confirmation test of achalasia

Answer 19

manometry can confirm diagnosis and show elevated lower esophageal sphincter pressure and incomplete relaxation and peristalsis weakness of this test - cannot distinguish between primary achalasia and pseudo achalasia (tumor at the gastroesophageal junction)

also can’t tell if eosinophilic esophagitis

Note an infectious cause of achalasia is Chaga’s dx or Trypanosoma cruzi.

Question 20

achalasia treatment is

Answer 20

these are 2nd and 3rd line nitrates and calcium channel blockers

botulism toxin injection for pts who are poor operative risk

if can tolerate surgery and young, can undergo pneumatic dilation or surgical myometomy

Question 21

pseudoachalasia

Answer 21

differs from classic achalasia - tumor at the gastroesophageal junction and results from obstruction not impairment in lower esophageal sphincter relaxation.

consider this in pts who >60 years old, those who have shorter symptom duration of dyphagia <6 months consider in pts who have acute weight loss.

diagnosis is made by barium swallow followed by endoscopy

Question 22

zenker’s diverticulum presents as:

Answer 22

defect in musculature of posterior hypopharynx

see esophageal motility abnormalities pharyngeal pouch

eventually enlarges enough to entrap food, mucus, pills and sputum

see this in pts who are >60 years and has transient oropharyngeal dysphagia and halitosis, gurgling of throat and food regurgitation and appearance of neck mass and weight loss

Question 23

see this in pts who are >60 years and has transient oropharyngeal dysphagia and halitosis, gurgling of throat and food regurgitation and appearance of neck mass and weight loss has recurrent aspiration pneumonia

Answer 23

Zenker’s diverticulum

Question 24

treatment of Zenker’s diverticulum is:

Answer 24

surgical endoscopy can be used to close the diverticulum

Question 25

diagnosis of zenker’s diverticulum

Answer 25

barium swallow don’t EGD as this can perforate the blind pouch

Question 26

motility disorders of esophagus

Answer 26

Question 27

How to treat this disorder in a 55 y o man with CHF and an EF of 15%?

EGD shows no masses and this is his barium esophagram?

Answer 27

Endoscopic botulism toxin injection.

Pts who have achalasia and are at high surgical risk should be treated with endoscopic bolutinum toxin injection.

Achalasia - there is aperistalsis and inadequate relaxation of the lower esophageal sphincter (LES) and this results from ganglion cell and myenteric plexus degeneration in the esophageal body and LES. Will have dysphagia to both solids and liquids, see regurgitation, chest pain, and heart burn.

Botulism toxin i_nhibits acetylcholine release and causes relaxation of LES and relief in 85% of pts_. Most (50)% will have recurrent symptoms in 6 to 24 months after injection.

CCB and nitrates are 3rd line because effectivenss is limited.

Question 28

What is definitive treatment for achalasia?

Answer 28

Standard treatments are: surgical myotomy and endoscopic pneumatic dilation for younger healthier people. pneumatic dilation is most effective non surgical treatment but is associated with serious complications like esophageal perforation and so people who can’t undergo surgery shouldn’t get pneumatic dilation either (can’t tolerate the repair).

Question 29

esophageal spasm presentation

Answer 29

dysphagia to solid and liquids soon after swallowing due to sudden spasm

see chest pain.