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ESOPHAGITIS Flashcards

1
Q

what is esophagitis?

A

inflammation and irritation of esophageal mucosa secondary to direct mucosal injury, infection or an inflammatory process

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2
Q

what are the types of esophagitis?

A

reflux esophagitis/GERD
Eosinohphilic esophagitis
infectious esophagitis
drug-induced esophagitis

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3
Q

what is GERD?

A

it occurs as a result of incompetent LES allowing reflux of gastric contents into esophagus

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4
Q

what is the sphincter doing in GERD?

A
  1. generalized loss of sphincter tone
  2. recurrent inappropriate transient relaxations of sphincter triggered by gastric distention
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5
Q

does GERD occur frequently in infants?

A

yes

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6
Q

what are the big 4 RF of GERD?

A
  1. cig smoking
  2. obesity
  3. hiatal hernia
  4. food and drink
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7
Q

what food and drink should a GERDer avoid?

A

alcohol and caffeinated beverages
fried or fatty food
citrus or spicy food
chocolate
red sauce

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8
Q

what meds decrease LES pressure?

A

nitrates
CCB

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9
Q

what are the 4 complications of GERD?

A
  1. peptic esophageal ulceration
  2. esophageal strictures
  3. barrett esophagus
  4. esophageal adenocarcinoma
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10
Q

what happens in barretts esophagus?

A

there is replacement of normal squamous epithelium of distal esophagus with metaplastic columnar epithelium during healing phase of acute esophagitis

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11
Q

what malignancy arises from barrett esophagitis?

A

esophageal adenocarcinoma

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12
Q

what is the clinical presentation of GERD in infants?

A

vomitting
anorexia
irritability
dx of chronic aspiration

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13
Q

what is the typical adult clinical presentation of a patient with GERD?

A
  1. RETROSTERNAL HEARTBURN (PYROSIS) 30-60 min after meals or upon reclining
  2. regurgitation- sour or bitter taste in mouth
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14
Q

what is the atypical adult clinical presentation of a patient with GERD?

A

dysphagia/odynophagia (esophagitis has developed)
globus sensation
hoarseness
sore throat
chronic cough
weight loss

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15
Q

what is the tx for a pt w/ mild and intermittent sx (fewer than 2 episodes per week) and no evidence of erosive esophagitis?

A
  1. lifestyle and dietary modifications and
  2. PRN, low-dose histamine 2 receptor antagonists (H2RAS)
    • famotidine 20 mg BID
    • cimetidine 400 mg BID
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16
Q

what is the tx for a patient of regular, typical symptoms of GERD?

A

no initial dx tests
empiric tx: x2 daily H2 blocker or once daily PPI for 8 weeks
persistent/refractory sx: maximize PPI dosing for 8 weeks

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17
Q

what do you do for a pt who does not improve with empiric therapy or symptoms of complications?

A

refer to gi
endoscopy with cytologic washings and/or biopsy of abnormal areas

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18
Q

what is the first line testing for patients with alarm symptoms or refractory symptoms?

A

EGD

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19
Q

what can you see on EGD?

A

DIRECT INSPECTION OF ESOPHAGUS AND GASTRIC MUCOSA FOR OBJECTIVE EVIDENCE OF GERD (EROSIVE ESOPHAGITIS OR BARRETT ESOPHAGUS)

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20
Q

what should a patient with a grade C or D on initial endoscopy do?

A

should undergo F/U endoscopy after 2 month cours of twice daily PPI therapy to assess healing and r/o barretts esophagus

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21
Q

what system is there for grading severity of reflux?

A

class A-D grading system

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22
Q

what is ambulatory pH monitoring for?

A

allows for detection of GERD
CONFIRMS DX and checks adequacy of tx

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23
Q

how long is ambulatory pH monitoring measured for?

A

24-48 hours

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24
Q

what does ambulatory pH monitoring measure?

A

frequency of pH dropping below <4.0

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25
Q

what does ambulatory pH monitoring reliably detect?

A

pathologic acid exposure
frequency of reflux episodes
correlation of sx with reflux episodes

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26
Q

ambulatory pH monitoring is for patients with:

A

extraesophageal sx
GERD refractory to meds
no endoscopic findings

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27
Q

what is the overall general tx for GERD?

A

lifestyle and dietary changes
- elevate head of bed about 6 in
- encourage weight loss

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28
Q

what should you AVOID in GERD?

A
  • eating within 3 hours of bedtime
  • strong stimulants of acid secretion (coffee, alcohol)
  • specific foods (fatty, chocolate, red sauce)
  • smoking
  • meds that decrease LES pressure
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29
Q

what side should a patient with GERD lie on?

A

L side to prevent acid from coming up

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30
Q

what does the tx of antacids do?

A

does not tx disease, but balances pH
useful in intermittent dz ONLY
provides relief within 5 min; duration of 30-60 min

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31
Q

what are examples of antacids?

A

calcium carbonate
aluminum hydroxide

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32
Q

what does the tx of H-2 blockers do?

A

indicated for mild sx GERD
can be added at bedtime for patients on PPIs w/ nocturnal sx
decreases acid secretion by competitively blocking H2 receptors in gastric parietal cells

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33
Q

what are examples of H2 blockers?

A

famotidine
cimetidine

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34
Q

what does the tx of PPIs do?

A

blocks gastric acid secretion by irreversibly binding to and inhibiting the H+-K+ ATPase pump that resides on luminal surface of parietal cell membrane
heals esophagus if present

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35
Q

what are examples of PPIs?

A

“POLE”
pantoprazole 40
omeprazole 20
lansoprazole 30
esomeprazole 40

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36
Q

what happens if a pt has only partial response to once-daily dosing of PPIs?

A

may increase PPI to twice daily, add H2 blocker or add on-demand antacid therapy

may be given long term at lowest possible dose to prevent sx

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37
Q

what does the tx of sucralfate do?

A

it is a surface agent that adheres to mucosal surface, promotes healing, protects from peptic injury
MOA: ?
TX OPTION DURING PREGNANCY
can be used short term along w/ PPI therapy

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38
Q

what are the 2 surgical procedures that are options for a pt who needs it d/t something like maxing out meds?

A
  1. endoscopic dilation
  2. antireflux surgery
39
Q

is an esophageal dilation a one time thing? explain

A

no. it can be repeated as needed for esophageal strictures

40
Q

what is antireflux surgery?

A

laparoscopic fundoplication (nissen fundoplication)
- gastric fundus is wrapped around LE
- indicated for patients w/ grade C or D esophagitis, large hiatal hernias, and those who cannot tolerate drug therapy

41
Q

what is Barrett’s esophagus?

A

precursor to adenocarcinoma of esophagus

42
Q

what are the RF of barrett’s esophagus?

A

male > or equal to 50, obesity, sx > or equal to 5 years (unrelated or sub-optimal tx)

43
Q

when should endoscopic surveillance be done for Barrett’s?

A

endoscopic surveillance for malignant transformation is recommended every 3-5 year in nondysplastic disease

44
Q

what dx study should be done for confirmed low-grade dysplasia?

A

endoscopic ablative therapy

45
Q

what are the types of endoscopic ablative therapy?

A

mucosal resection
photodynamic therapy
cryotherapy
laser ablation

46
Q

what is EoE?

A

eosinophilic esophagitis
chronic allergic inflammatory dz characterized by presence of eosinophils in esophageal tissue

47
Q

what does EoE have strong association to?

A

strong assoc. w/ allergic conditions - food allergies, environmental allergies, asthma, atopic dermatitis

48
Q

what is the pathogenesis of EoE?

A
  1. Type 2 T helper cell-mediated systemic response to food and environmental allergens
  2. release of cytokines: IL-5, IL-13, and exotaxin
49
Q

what is the age presentation of EoE?

A

20-30

50
Q

what is the clinical presentation of EoE in infants and children?

A

failure to thrive
vomiting
abd pain
reflux
heartburn

51
Q

what is the clinical presentation of EoE in adolescents and adults?

A

solid food dysphagia -> 15% pts being evacuated for dysphagia w/ endoscopy are found to have eosinophilic esophagitis
heartburn
chest pain -> often centrally located and may not respond to antacids
food bolus impaction-> hx of food impaction is present in up to 54% patients

52
Q

what needs to happen to dx EoE?

A
  1. sx are related to esophageal dysfxn
  2. eosinophil-predominant inflammation on esophageal biopsy (proximal and distal), characteristically consisting of > or equal to 15 eosinophils per HPF
  3. exclusion of other causes that may be responsible for or contributing to sx
53
Q

what confirms the diagnosis of EoE?

A

persistence of esophageal eosinophilia on repeat biopsy after an adequate trial (8 weeks) of x2 daily PPI therapy confirms dx

54
Q

what level will be elevated in 50-60% of EoE patients?

A

serum IgE

55
Q

what will you see on endoscopy of EoE?

A

mucosal fragility
whitish papules (representing eosinophil microabscesses)
linear furrows
STACKED CIRCULAR RINGS -> TRACHEALIZATION
strictures

56
Q

is a barium swallow sufficient to dx EoE?

A

no it only helps to characterize anatomic abnormalities and provide information on the length and diameter of strictures

57
Q

what is the goal of EoE tx?

A

reduce inflammatory response

58
Q

what is entailed in elimination diets of EoE tx?

A
  • do allergy testing to identify foods that cause allergy and therefore should be avoided
  • 6 food elimination: cereals, milk, eggs, fish/seafood, peanuts, soy
59
Q

what pharm therapy is the initial tx of EoE for 8 weeks for acid suppression therapy?

A

PPIs -> acid suppression

60
Q

what are the 3 treatment methods for EoE?

A
  1. elimination diet
  2. inhaled or oral suspension of a corticosteroid for 8 weeks
  3. acid suppression
61
Q

what is the drugs of choice for inhaled or oral suspension of a corticosteroid for 8 weeks?

A

fluticasone
budesonide

no formulation of topical glucocorticoids has been approved specifically for EoE in the USA

62
Q

what is the dosing of PPI for EoE?

A
  • one tablet PO daily
    if sx fail to improve after 4 weeks of tx, increase dose to one tablet PO twice daily
  • one tablet PO BID
63
Q

what is esophageal dilation effective for in EoE?

A

effective for relieving dysphagia

64
Q

what is esophageal dilation reserved for in cases of EoE?

A

reserved for pts who have failed more conservative therapy or who have high-grade strictures

65
Q

what is dilation limited to per session of esophageal dilation in case of EoE?

A

3mm or less per session

66
Q

what are potential complications of esophageal dilation in case of EoE?

A

deep mucosal tears
esophageal perforation

66
Q

what is the dilation goal of esophageal dilation therapy in cases of EoE?

A

goal: 15-18 mm

67
Q

what mab is used for EoE tx for 1 y and older weighing 15 lbs?

A

dupilumab (dupixent)

68
Q

where is EoE located vs GERD?

A

EoE: entire esophagus
GERD: distal esophagus

69
Q

what is the main complaint of EoE vs GERD?

A

EoE: dysphagia
GERD: burning sensation

70
Q

whats the difference between EoE and GERD in terms of acid reducing agents?

A

EoE: refractory
GERD: responds to agents

71
Q

what does infectious esophagitis mainly occur in?

A

primarily in pts w. impaired host defenses

72
Q

what impaired host defenses do patients with infectious esophagitis have?

A

aids
solid organ transplant
alcohol use
diabetes
cancer
poor nutrition
esophageal motility disorders

73
Q

what are the 3 primary agents of infxn for infectious esophagitis?

A
  1. CANDIDA ALBICANS
  2. herpes simplex virus
  3. CMV
74
Q

what is candida albicans common in?

A

patients with uncontrolled diabetes, those on swallowed or inhaled steroids or on systemic abx, HIV patient w CD4 <100

75
Q

what are s/sx of candida albicans?

A

odynophagia
dysphagia
substernal chest pain
signs of oral thrush (2/3 of patients)

76
Q

what is the dx study of choice for candida albicans?

A

endoscopy for direct visualization and culture

77
Q

when would endoscopy be performed in cases of candida albicans?

A

performed if theres no improvement w/ empiric tx for 5-7 days

78
Q

what is the tx of candida albicans?

A

FLUCONAZOLE 200-400 PO DAILY 14-21 DAYS
FLUCONAZOLE 200-400 IV DAILY 14-21 DAYS

79
Q

what are the RF for herpes simplex virus esophagitis and CMV?

A

aids
pt on immunosuppressive therapy of chemo
transplant patients

80
Q

what are the s/sx of herpes simplex virus esophagitis and CMV?

A

odynophagia (More severe w/ CMV)
dysphagia
retrosternal chest pain
+/_ fever

81
Q

what is the dx of choice for herpes simplex virus esophagitis and CMV and what will you see on both?

A

dx study : endoscopy w/ cytology or biopsy
HSV: vesicular lesions (early) ; punched- out ulcerations
CMV: linear or longitudinal deep ulcerations

82
Q

what is the treatment for herpes simplex virus esophagitis and CMV?

A

HSV:
1ST LINE ACYCLOVIr 5 mg/kg IV every 8 hrs for 7-14 days
acyclovir 400 mg PO 5 times daily for 7-14 days
valacyclovir 1 g PO x3 daily for 7-14 days

CMV:
GANCICLOVIR 5 mg/kg IV every 12 hours for 14-21 days w/ maintenance at 5 mg/kg IV once daily for immunosuppression
if positive for HIV/AIDS-> antiretroviral therapy

83
Q

where are the locations of ulcers in HSV vs CMV?

A

HSV: throughout entire esophagus length
CMV: middle to distal third of esophagus

84
Q

does HSV or CMV have more severe odynophagia?

A

CMV

85
Q

what is the mechanism of drug-induced esophagitis?

A
  1. direct, prolonged mucosal contact
  2. disruption of mucosal integrity (irritation, erosions, and ulcerations)
86
Q

what are the most common meds that cause drug-induced esophagitis?

A

NSAIDS, ASA
tetracyclines, doxy, clinda
bisphosphonates
potassium chloride
iron supplements
ascorbic acid

87
Q

what are the RF of drug-induced esophagitis?

A

elderly
position of patient (supine>upright)
size of meds (delayed transit w/ large tablets)
amount of fluid ingested with medication

88
Q

what are the sx of drug-induced esophagitis?

A

heartburn
retrosternal chest pain
odynophagia
dysphagia

89
Q

what is the dx study for drug-induced esophagitis?

A

ENDOSCOPY

90
Q

what will you see on endoscopy in acute vs chronic drug-induced esophagitis?

A

discrete punched out ulcers w/ normal bordering mucosa- acute
esophagitis with strictures, hemorrhage, or perforation- chronic or recurrent

91
Q

what is the tx for acute presentation drug-induced esophagitis?

A

remove offending agent and use H2 blocker or PPI to promote healing

92
Q

what should the prevention be in drug-induced esophagitis?

A

take pills with minimum of 4 oz of water
remain upright for 30 min after ingestion
avoid known offending agents in patients with esophageal dysmotility, dysphagia, and/or strictures

GI (22 decks)

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