ESOPHAGITIS Flashcards
what is esophagitis?
inflammation and irritation of esophageal mucosa secondary to direct mucosal injury, infection or an inflammatory process
what are the types of esophagitis?
reflux esophagitis/GERD
Eosinohphilic esophagitis
infectious esophagitis
drug-induced esophagitis
what is GERD?
it occurs as a result of incompetent LES allowing reflux of gastric contents into esophagus
what is the sphincter doing in GERD?
- generalized loss of sphincter tone
- recurrent inappropriate transient relaxations of sphincter triggered by gastric distention
does GERD occur frequently in infants?
yes
what are the big 4 RF of GERD?
- cig smoking
- obesity
- hiatal hernia
- food and drink
what food and drink should a GERDer avoid?
alcohol and caffeinated beverages
fried or fatty food
citrus or spicy food
chocolate
red sauce
what meds decrease LES pressure?
nitrates
CCB
what are the 4 complications of GERD?
- peptic esophageal ulceration
- esophageal strictures
- barrett esophagus
- esophageal adenocarcinoma
what happens in barretts esophagus?
there is replacement of normal squamous epithelium of distal esophagus with metaplastic columnar epithelium during healing phase of acute esophagitis
what malignancy arises from barrett esophagitis?
esophageal adenocarcinoma
what is the clinical presentation of GERD in infants?
vomitting
anorexia
irritability
dx of chronic aspiration
what is the typical adult clinical presentation of a patient with GERD?
- RETROSTERNAL HEARTBURN (PYROSIS) 30-60 min after meals or upon reclining
- regurgitation- sour or bitter taste in mouth
what is the atypical adult clinical presentation of a patient with GERD?
dysphagia/odynophagia (esophagitis has developed)
globus sensation
hoarseness
sore throat
chronic cough
weight loss
what is the tx for a pt w/ mild and intermittent sx (fewer than 2 episodes per week) and no evidence of erosive esophagitis?
- lifestyle and dietary modifications and
- PRN, low-dose histamine 2 receptor antagonists (H2RAS)
- famotidine 20 mg BID
- cimetidine 400 mg BID
what is the tx for a patient of regular, typical symptoms of GERD?
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
what do you do for a pt who does not improve with empiric therapy or symptoms of complications?
refer to gi
endoscopy with cytologic washings and/or biopsy of abnormal areas
what is the first line testing for patients with alarm symptoms or refractory symptoms?
EGD
what can you see on EGD?
DIRECT INSPECTION OF ESOPHAGUS AND GASTRIC MUCOSA FOR OBJECTIVE EVIDENCE OF GERD (EROSIVE ESOPHAGITIS OR BARRETT ESOPHAGUS)
what should a patient with a grade C or D on initial endoscopy do?
should undergo F/U endoscopy after 2 month cours of twice daily PPI therapy to assess healing and r/o barretts esophagus
what system is there for grading severity of reflux?
class A-D grading system
what is ambulatory pH monitoring for?
allows for detection of GERD
CONFIRMS DX and checks adequacy of tx
how long is ambulatory pH monitoring measured for?
24-48 hours
what does ambulatory pH monitoring measure?
frequency of pH dropping below <4.0
what does ambulatory pH monitoring reliably detect?
pathologic acid exposure
frequency of reflux episodes
correlation of sx with reflux episodes
ambulatory pH monitoring is for patients with:
extraesophageal sx
GERD refractory to meds
no endoscopic findings
what is the overall general tx for GERD?
lifestyle and dietary changes
- elevate head of bed about 6 in
- encourage weight loss
what should you AVOID in GERD?
- 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
what side should a patient with GERD lie on?
L side to prevent acid from coming up
what does the tx of antacids do?
does not tx disease, but balances pH
useful in intermittent dz ONLY
provides relief within 5 min; duration of 30-60 min
what are examples of antacids?
calcium carbonate
aluminum hydroxide
what does the tx of H-2 blockers do?
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
what are examples of H2 blockers?
famotidine
cimetidine
what does the tx of PPIs do?
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
what are examples of PPIs?
“POLE”
pantoprazole 40
omeprazole 20
lansoprazole 30
esomeprazole 40
what happens if a pt has only partial response to once-daily dosing of PPIs?
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
what does the tx of sucralfate do?
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
what are the 2 surgical procedures that are options for a pt who needs it d/t something like maxing out meds?
- endoscopic dilation
- antireflux surgery
is an esophageal dilation a one time thing? explain
no. it can be repeated as needed for esophageal strictures
what is antireflux surgery?
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
what is Barrett’s esophagus?
precursor to adenocarcinoma of esophagus
what are the RF of barrett’s esophagus?
male > or equal to 50, obesity, sx > or equal to 5 years (unrelated or sub-optimal tx)
when should endoscopic surveillance be done for Barrett’s?
endoscopic surveillance for malignant transformation is recommended every 3-5 year in nondysplastic disease
what dx study should be done for confirmed low-grade dysplasia?
endoscopic ablative therapy
what are the types of endoscopic ablative therapy?
mucosal resection
photodynamic therapy
cryotherapy
laser ablation
what is EoE?
eosinophilic esophagitis
chronic allergic inflammatory dz characterized by presence of eosinophils in esophageal tissue
what does EoE have strong association to?
strong assoc. w/ allergic conditions - food allergies, environmental allergies, asthma, atopic dermatitis
what is the pathogenesis of EoE?
- Type 2 T helper cell-mediated systemic response to food and environmental allergens
- release of cytokines: IL-5, IL-13, and exotaxin
what is the age presentation of EoE?
20-30
what is the clinical presentation of EoE in infants and children?
failure to thrive
vomiting
abd pain
reflux
heartburn
what is the clinical presentation of EoE in adolescents and adults?
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
what needs to happen to dx EoE?
- sx are related to esophageal dysfxn
- eosinophil-predominant inflammation on esophageal biopsy (proximal and distal), characteristically consisting of > or equal to 15 eosinophils per HPF
- exclusion of other causes that may be responsible for or contributing to sx
what confirms the diagnosis of EoE?
persistence of esophageal eosinophilia on repeat biopsy after an adequate trial (8 weeks) of x2 daily PPI therapy confirms dx
what level will be elevated in 50-60% of EoE patients?
serum IgE
what will you see on endoscopy of EoE?
mucosal fragility
whitish papules (representing eosinophil microabscesses)
linear furrows
STACKED CIRCULAR RINGS -> TRACHEALIZATION
strictures
is a barium swallow sufficient to dx EoE?
no it only helps to characterize anatomic abnormalities and provide information on the length and diameter of strictures
what is the goal of EoE tx?
reduce inflammatory response
what is entailed in elimination diets of EoE tx?
- do allergy testing to identify foods that cause allergy and therefore should be avoided
- 6 food elimination: cereals, milk, eggs, fish/seafood, peanuts, soy
what pharm therapy is the initial tx of EoE for 8 weeks for acid suppression therapy?
PPIs -> acid suppression
what are the 3 treatment methods for EoE?
- elimination diet
- inhaled or oral suspension of a corticosteroid for 8 weeks
- acid suppression
what is the drugs of choice for inhaled or oral suspension of a corticosteroid for 8 weeks?
fluticasone
budesonide
no formulation of topical glucocorticoids has been approved specifically for EoE in the USA
what is the dosing of PPI for EoE?
- 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
what is esophageal dilation effective for in EoE?
effective for relieving dysphagia
what is esophageal dilation reserved for in cases of EoE?
reserved for pts who have failed more conservative therapy or who have high-grade strictures
what is dilation limited to per session of esophageal dilation in case of EoE?
3mm or less per session
what are potential complications of esophageal dilation in case of EoE?
deep mucosal tears
esophageal perforation
what is the dilation goal of esophageal dilation therapy in cases of EoE?
goal: 15-18 mm
what mab is used for EoE tx for 1 y and older weighing 15 lbs?
dupilumab (dupixent)
where is EoE located vs GERD?
EoE: entire esophagus
GERD: distal esophagus
what is the main complaint of EoE vs GERD?
EoE: dysphagia
GERD: burning sensation
whats the difference between EoE and GERD in terms of acid reducing agents?
EoE: refractory
GERD: responds to agents
what does infectious esophagitis mainly occur in?
primarily in pts w. impaired host defenses
what impaired host defenses do patients with infectious esophagitis have?
aids
solid organ transplant
alcohol use
diabetes
cancer
poor nutrition
esophageal motility disorders
what are the 3 primary agents of infxn for infectious esophagitis?
- CANDIDA ALBICANS
- herpes simplex virus
- CMV
what is candida albicans common in?
patients with uncontrolled diabetes, those on swallowed or inhaled steroids or on systemic abx, HIV patient w CD4 <100
what are s/sx of candida albicans?
odynophagia
dysphagia
substernal chest pain
signs of oral thrush (2/3 of patients)
what is the dx study of choice for candida albicans?
endoscopy for direct visualization and culture
when would endoscopy be performed in cases of candida albicans?
performed if theres no improvement w/ empiric tx for 5-7 days
what is the tx of candida albicans?
FLUCONAZOLE 200-400 PO DAILY 14-21 DAYS
FLUCONAZOLE 200-400 IV DAILY 14-21 DAYS
what are the RF for herpes simplex virus esophagitis and CMV?
aids
pt on immunosuppressive therapy of chemo
transplant patients
what are the s/sx of herpes simplex virus esophagitis and CMV?
odynophagia (More severe w/ CMV)
dysphagia
retrosternal chest pain
+/_ fever
what is the dx of choice for herpes simplex virus esophagitis and CMV and what will you see on both?
dx study : endoscopy w/ cytology or biopsy
HSV: vesicular lesions (early) ; punched- out ulcerations
CMV: linear or longitudinal deep ulcerations
what is the treatment for herpes simplex virus esophagitis and CMV?
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
where are the locations of ulcers in HSV vs CMV?
HSV: throughout entire esophagus length
CMV: middle to distal third of esophagus
does HSV or CMV have more severe odynophagia?
CMV
what is the mechanism of drug-induced esophagitis?
- direct, prolonged mucosal contact
- disruption of mucosal integrity (irritation, erosions, and ulcerations)
what are the most common meds that cause drug-induced esophagitis?
NSAIDS, ASA
tetracyclines, doxy, clinda
bisphosphonates
potassium chloride
iron supplements
ascorbic acid
what are the RF of drug-induced esophagitis?
elderly
position of patient (supine>upright)
size of meds (delayed transit w/ large tablets)
amount of fluid ingested with medication
what are the sx of drug-induced esophagitis?
heartburn
retrosternal chest pain
odynophagia
dysphagia
what is the dx study for drug-induced esophagitis?
ENDOSCOPY
what will you see on endoscopy in acute vs chronic drug-induced esophagitis?
discrete punched out ulcers w/ normal bordering mucosa- acute
esophagitis with strictures, hemorrhage, or perforation- chronic or recurrent
what is the tx for acute presentation drug-induced esophagitis?
remove offending agent and use H2 blocker or PPI to promote healing
what should the prevention be in drug-induced esophagitis?
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
