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CMT-dos > Esophagitis > Flashcards

Esophagitis Flashcards

1
Q

Esophagitis

General and types

A

Inflammation and irritation of the esophageal mucosa secondary to direct mucosal injury, infection, or an inflammatory process
Types:
Reflux esophagitis/GERD
Eosinophilic esophagitis
Infectious esophagitis
Drug-induced esophagitis

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2
Q

Gastroesophageal Reflux Disease (GERD)

general

A

Occurs at the result of incompetence of the lower esophageal sphincter allowing reflux of gastric contents into the esophagus

Generalized loss of sphincter tone
Recurrent inappropriate transient relaxations of the sphincter triggered by gastric distention

Common condition
10-20% of adults
Occurs frequently in infants

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3
Q
A

Left image (normal): The LES, a structure at the gastroesophageal junction, maintains a high-pressure zone between the esophagus and the stomach. This prevents the reflux of gastric contents. The LES relaxes transiently in response to meals.

Right image (GERD): An incompetent LES (lower baseline pressure) and increased frequency of TLESRs are among the factors causing GERD.

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4
Q
A

The esophageal and gastric fundi should be at an acute angle to each other (about 50 degrees, the so-called angle of His) for optimal barrier function
A: Normal anatomy
B: Widening of the esophagogastric angle

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5
Q

GERD

RF

A

Cigarette smoking
Obesity
Hiatal hernia
Foods & Drinks:
Alcoholic and caffeinated beverages
Fried or fatty foods
Citrus or spicy foods
Chocolate
Red sauce
Medications that decrease LES pressure:
Nitrates
Calcium channel blockers

also people who lay down 2-3 hours after eating.

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6
Q

GERD

complications (4)

A

Peptic esophageal ulceration

Esophageal strictures

Barrett esophagus
Replacement of normal squamous epithelium of the distal esophagus with metaplastic columnar epithelium during the healing phase of acute esophagitis

Esophageal adenocarcinoma
Malignancy that often arises from Barrett esophagus

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7
Q

GERD

infant clin man

A

Vomiting
Irritability
Anorexia
Symptoms of chronic aspiration

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8
Q

GERD

Adults - typical presentation

A

Retrosternal heartburn (pyrosis)
30-60 minutes after meals or upon reclining
Regurgitation
Sour or bitter taste in the mouth

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9
Q

GERD

Adults - atypical presentation

A

Dysphagia/odynophagia (esophagitis has developed)
Globus sensation
Hoarseness
Sore throat
Chronic cough
Weight loss

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10
Q

GERD Tx

Mild and intermittent symptoms (fewer than two episodes per week) and no evidence of erosive esophagitis/atypical sx

A

Lifestyle and dietary modification and
As needed, low-dose histamine 2 receptor antagonists (H2RAs)
Famotidine 20 mg BID
Cimetidine 400 mg BID

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11
Q

GERD

Dx for Atypical Sx

A

ENDOSCOPY first to rule out more serious symptoms

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12
Q

GERD Tx

Regular, typical symptoms
Empiric and persistent/refractory

A

Initial diagnostic studies are not warranted

Empiric treatment:
Twice daily H2-blocker or once-daily proton pump inhibitor (PPI) for 8 weeks

Persistent/refractory symptoms:
Maximize PPI dosing for 8 weeks
No improvement with empiric treatment or symptoms of complications…time to refer to GI

Endoscopy with cytologic washings and/or biopsy of abnormal areas

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13
Q
A
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14
Q

GERD

Esophagogastroduodenoscopy (EGD)

type of visualization

A

First-line endoscopic test for patients with alarm symptoms or refractory symptoms

Allows for direct inspection of the esophagus and gastric mucosa for objective evidence of GERD (erosive esophagitis or Barrett esophagus)

  • Class A-D grading system for the severity of reflux esophagitis
  • Patients with severe erosive esophagitis (Class C and D) on initial endoscopy should undergo a follow-up endoscopy after a two-month course of twice daily PPI therapy to assess healing and rule out Barrett’s esophagus

Class A = mild esophagitis
Class D = severe esophagitis

Evidence of mucosal healing on repeat endoscopy → decrease PPI therapy to once daily

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15
Q

GERD

Ambulatory pH monitoring

A

Allows for detection of gastroesophageal reflux
Used to confirm the diagnosis and check the adequacy of treatment
Performed for 24 or 48 hours
Measures the frequency of thepHdropping below < 4.0

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16
Q

Ambulatory pH monitoring

reliable detects (3)

A

Pathologic acid exposure

Frequency of reflux episodes

Correlationof symptoms with reflux episodes

17
Q

Ambulatory pH monitoring

Indications/Forpatientswith (3)

A

Extraesophageal symptoms

GERDrefractory to medications

No endoscopic findings

18
Q

GERD

Lifestyle and dietary modification

A

Elevation of the head of the bed about 6 inches
Encourage weight loss
lay on LEFT side (not R side)
Avoiding the following:
Eating within 3 hours of bedtime
Strong stimulants of acid secretion (coffee, alcohol)
Specific foods (fatty foods, chocolate, red sauces)
Smoking
Medications that decreased LES pressure

IMPLEMENTED FOR ALL PTS

19
Q

GERD

Antacids

A

Do not treat the disease, but balancespH
Useful in intermittent disease only
Provides relief with five minutes; duration of 30-60 minutes

Examples:calcium carbonate, aluminum hydroxide

20
Q

GERD

H2-blockers

A

Indicated for mild symptomatic GERD
Can be added at bedtime forpatientson proton-pump inhibitors (PPIs) with nocturnal symptoms

Decreases acidsecretion by competitively blockingH2 receptorsin gastricparietal cells

Examples:famotidine,cimetidine

21
Q

Proton pump inhibitor (PPI)

A

Block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane
Heals esophagitis, if present

Only partial response to once-daily dosing → may ↑ to the PPI to twice daily, add a H2-blockers, or add on-demand antacid therapy

May be given long-term at the lowest possible dose to prevent symptoms

22
Q

GERD

Sucralfate

A

(aluminum sucrose sulfate)

Surface agent
Adheres to the mucosal surface, promotes healing, and protects from peptic injury
Mechanisms of action is not completely understood
Treatment option during pregnancy

Can be used short term along with PPI therapy

22
Q

PPI examples and doses

A

All are equally effective
Omeprazole 20 mg daily
Pantoprazole 40 mg daily
Esomeprazole 40 mg daily
Lansoprazole 30 mg daily

23
Q

GERD

Surgery options

A

Endoscopic dilation
Repeated as needed for esophageal strictures

Antireflux surgery
Laparoscopic fundoplication
Gastric fundusis wrapped around the loweresophagus
Indicated for patients with grade C or D esophagitis, large hiatal hernias, and those who cannot tolerate drug therapy

24
Q

Barrett esophagus

general

A

Precancer
Precursor to adenocarcinoma of the esophagus
Seen in ~15% of patients with GERD

Risk factors:
Male
Age ≥ 50 years
Obesity
Symptoms ≥ 5 years (untreated or sub-optimal treatment)

Endoscopic surveillance for malignant transformation is recommended every 3-5 years in nondysplastic disease

25
Q

Barrett esophagus

Endoscopic ablative therapy
Indicaron and options (4)

A

For confirmed low-grade dysplasia
Mucosal resection
Photodynamic therapy
Cryotherapy
Laser ablation

26
Q
A
27
Q

Eosinophilic Esophagitis (EoE)

general

A

Chronic allergic inflammatory disease characterized by the presence of eosinophils in the esophageal tissue

Strong association with allergic conditions - food allergies, environmental allergies, asthma, and atopic dermatitis

Common age of presentation: 20-30 years
Prevalence is increasing
Change in epidemiology
Increased awareness and detection

28
Q

EOE

Patho

A

Type 2 T-helper cell-mediated systemic response to food and environmental allergens

Release of cytokines: IL-5, IL-13, IL-4, and exotaxin

29
Q

EOE

Infants & children Clin man

A

Failure the thrive
Vomiting
Abdominal pain
Reflux
Heartburn

30
Q

EOE

Adolescents & Adults
Clin man

A

Solid food dysphagia
15% of patients being evaluated for dysphagia with endoscopy are found to have eosinophilic esophagitis
Heartburn
Chest pain
Often centrally located and may not respond to antacids
Food bolus impaction
History of food impaction is present in up to 54% of patients

31
Q

EOE

Dx

A

Clinicopathologic diagnosis requiring specific symptoms and pathologic changes in the esophageal mucosa:

Symptoms related to esophageal dysfunction
Eosinophil-predominant inflammation on esophageal biopsy (proximal and distal), characteristically consisting of ≥ 15 eosinophils per high power field (HPF)
Exclusion of other causes that may be responsible for or contributing to symptoms

Persistence of esophageal eosinophilia on repeat biopsy after an adequate trial (8 weeks) of twice-daily PPI therapy confirms the diagnosis

Elevated serum IgE level in 50-60% of patients

eosinophils should NOT be in esophagus

32
Q

EOE

endoscopy

A

Variety of morphologic features in the esophagus associated with eosinophilic esophagitis
Mucosal fragility
Whitish papules (representing eosinophil microabscesses)
Linear furrows
Stacked circular rings - “trachealization”
Strictures

do biopsy here.

33
Q

EOE

Barium swallow

A

Not sufficient for the diagnosis of EoE
Helps characterize anatomic abnormalities and provide information on the length and diameter of strictures

34
Q
A
35
Q

EOE

Tx

A

Chronic condition, so the goal of treatment is to reduce the inflammatory response

Inhaled or oral suspension of a corticosteroid for 8 weeks
No formulation of topical glucocorticoids has been approved specifically for eosinophilic esophagitis in the United States
fluticasone (Flovent)
budesonide (Pulmicort)

Acid suppression
Proton pump inhibitors (PPIs)
Initial treatment for eight weeks
One tablet PO daily (if symptoms fail to improve after four weeks of therapy, increase the dose to one tablet PO twice daily)
One tablet PO twice daily

allergy testing is also a good move

36
Q

EOE

Dupilumab (Dupixent)

A

BEST for EOE
May 2022 - Only monoclonal antibody FDA approved for patients 12 years and older, weighing at least 40 kg
January 2024 – FDA approval to treat patients with EoE aged 1 year and older, weighing at least 15 kg

37
Q

EOE

Esophageal dilation
Dilation goal

A

Effective for relieving dysphagia
No effect on underlying inflammation
Often reserved for patients who have failed more conservative therapy or who have high-grade strictures
Dilation is limited to 3 mm or less per session
Dilation goal of 15-18 mm

Potential complications:
Deep mucosal tears
Esophageal perforation

38
Q

EOE

Elimination diets

A

Allergy testing to identify foods that cause allergy and therefore should be avoided
6-food elimination: Cereals, milk, eggs, fish/seafood, peanuts, and soy

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