Esophagus Flashcards
What TESTING should be done for DYSPHAGIA NOT explained by stenosis or esophagitis, CHEST PAIN not explained by heart disease or other extra-esophageal processes and PRE-OP for patients being considered for ANTI-REFLUX surgery?
ESOPHAGEAL MANOMETRY
INADEQUATE LES RELAXATION is found in what ESOPHAGEAL disorder?
ACHALASIA
UNCOORDINATED esopahgeal contractions are noted in what ESOPHAGEAL condition?
DIFFUSE ESOPHAGEAL SPASM
HYPERcontraction of the ESOPHAGUS is noted in what esophageal disorder?
NUTCRACKER ESOPHAGUS (also in isolated hypertensive LES)
HYPOcontraction of the ESOPHAGUS is found in what esophageal condition?
INEFFECTIVE ESOPHAGEAL MOTILITY
What is considered NORMAL (basal) LES (EGJ) PRESSURE?
10-35 mmHg
In which ACHALASIA TYPE do you see an IRP (EGJ releaxation pressure) >15 mm Hg, and 100% FAILED peristalsis (DCI <100 mmHg/cm/second) - should be >450 and <8,000?
ACHALASIA TYPE-I
What is considered NORMAL EGJ RELAXATION with SWALLOW (Integrated Relaxation Pressure - IRP)
<15 mmHg
Waht is considered NORMAL SPEED of PERILSTALSIS (Contractile Front Velocity - CFV) from UES to LES?
<9 cm/second
What is considered a NORMAL DISTAL WAVE AMPLITUDE (mean Distal Contractile Integral - DCI)?
>450 and <8,000 mmHg/cm/second (the AMPLITUDE of PERISTALSIS)
What is the DISTAL LATENCY in esophageal manometry?
The interval between the START of a SWALLOW and the Contractile Deceleration Point (CDP) - the point of transition from esophageal peristaltic clearance to esophageal emptying
In which ACHALASIA TYPE do you see an IRP (EGJ releaxation pressure) >15 mm Hg, and 100% FAILED peristalsis (DCI <100 mmHg/cm/second) - should be >450 and <8,000 AND PANESOPHAGEAL PRESSURIZATION with ≥20% of SWALLOWS?
ACHALASIA TYPE-II
In which ACHALASIA TYPE do you see an IRP (EGJ releaxation pressure) >15 mm Hg, and NO NORMAL peristalsis, SPASTIC CONTRACTIONS (DL <4.5 seconds) with DCI >450 mmHg/cm/second) - should be >450 and <8,000 with ≥20% of SWALLOWS?
ACHALSIA TYPE-III
NORMAL IRP, 100% FAILED peristalsis (DCI <100 mmHg/cm/second)
ABSENT CONTRACTILITY
NORMAL IRP, ≥20% PREMATURE CONTRACTIONS (DL <4.5 seconds), with DCI >450 mmHg/cm/second (some normal peristalsis mat be seen)
DISTAL ESOPHAGEAL SPASM
NORMAL IRP, ≥20% SWALLOWS with DCI >8,000 mmHg/cm/second
HYPERcontractile (jackhammer esophagus)
NORMAL IRP, ≥50% INEFFECTIVE SWALLOWS (FAILED DCI <100 or WEAK DCI <450 mmHg/cm/second)
INEFFECTIVE ESOPHAGEAL MOTILITY
NORMAL IRP, ≥50% FRAGMENTED contractions (breaks >5 cm in 20 mmHg isobaric contour) with DCI >450 mmHg/cm/second
FRAGMENTED PERISTALSIS
In this TYPE of ACHALASIA, swallowing results in NO CHANGE in the pressurization of the esophagus?
TYPE-I ACHALASIA
In this TYPE of ACHALASIA, swallowing results in SIMULTANEOUS, LOW-AMPLITUDE PRESSURIZATION that spans the ENTIRE LENGTH of the esophagus?
TYPE-II ACHALASIA
In this TYPE of ACHALASIA, swallowing results in PREMATURE SPASTIC CONTRACTIONS of the esophagus with a DCI >450 mmHg/cm/second?
TYPE-III ACHALASIA
Modalities to treat achalasia work BEST in what TYPE of ACHALASIA (dilation, botox, POEM)?
TYPE-II ACHALASIA (don’t work well at all in type-III)
In WHICH patients should BOTOX injection be used to treat ACHALASIA rather than PNEUMATIC DILATION (30 mm - 40 mm balloon) or HELLER MYOTOMY/POEM?
In those who are HIGH-RISK for more INVASIVE procedures
Does ANY therapy available for ACHALASIA last long-term (>2 years)?
NO, most patients need further treatment thereafter
ELEVATED IRP (>15 mmHg) with NORMAL PERISTALSIS, what is that condition called?
EGJ OUTFLOW OBSTRUCTION (EOE, cancer, stenosis)
What MEDICATIONS can ELEVATE the IRP and cause HYPERcontraction (elevated DCI) and SPASM with SHORTENED DL?
OPIOIDS
Pt presents with esophageal outlet obstruction (elevated IRP) and SPASTIC contractions, what should be ruled out FIRST?
OPIOID use
Episodes of DYSPHAGIA and CHEST PAIN, TERTIARY esophageal contractions on IMAGING and PREMATURE, SPASTIC contractions on MANOMETRY?
Distal Esophgeal Spasm (diffuse esophageal spasm) - DES
The TIME from RELAXATION of the UES to the CDP (contractile deceleration point) which is the point of transition from ESOPHGEAL PERISTALTIC CLEARANCE to ESOPHAGEAL EMPTYING is known as what?
Distal Latency (DL) - NORMAL is >4.5 seconds
A condition associated with GERD, when TWO or MORE SWALLOWS (≥2) have a DCI >8,000 mmHg/cm/second
HYPERcontractile (jackhammer) esophagus (previusly nutcracker esophagus)
What condition is found in >80% of patients with SCLERODERMA (also MCTD, RA, SLE) with PREDISPOSITION to GERD in which ≥50% of SWALLOWS have a CDI <450 mmHg/cm/second?
Esophageal HYPOcontraction and INEFFECTIVE ESOPHAGEAL MOTILITY
What is considered FAILED PERISTALSIS?
100% of SWALLOWS have a DCI <100 mmHg/cm/second
What is considered INEFFECTIVE ESOPHAGEAL MOTILITY?
≥50% SWALLOWS have a DCI <450 mmHg/cm/second (CHICAGO classification)
What causes NON-CARDIAC CP in patients with GERD?
SENSITIZATION of the esophagus to even normal stimuli
If patient with NON-CARDIAC CP and WITHOUT ALARM SYMPTOMS (dysphagia, weight loss, bleeding) does NOT respond to 2 MONTHS of PPI therapy, whats the NEXT STEP?
ESOPHAGEAL MANOMETRY (if POSITIVE, treat with TCAs, Trazodone or SSRI)
What is the PREFERRED treatment for TYPE-III ACHALASIA (episodic chest pain, dysphagia to BOTH liquids and solids, IRP >15 mmHg, no normal peristalsis, PREMATURE CONTRACTIONS ie SPASMS with some HYPERcontractility (DCI >8,000) involving the distal 2/3rds of the esophagus)?
POEM (with longer tunnel)
What should ALWAYS be done BEFORE evaluating for ESOPHAGEAL causes of CP?
CARDIOLOGY EVALUATION
LONG-standing, INTERMITTENT, NON-PROGRESSIVE dysphagia for SOLID foods WITHOUT CP BETWEEN episodes of dysphasia suggests what diagnosis?
SCHATZKI RING
What are the TREATMENT methods for HYPERcontractile ESOPHAGUS (distal esophgeal spasm) with NORMAL IRP, DL <4.5 seconds in ≥20% of swallows?
PEPPERMINT OIL, SILDENAFIL, CA-Channel Blockers, NITRATES
How LONG is a NORMAL EGJ relaxation window (bottom of tracing before pressure increases again)?
~10 SECONDS
IRP >15 mmHg with NO PERISTALSIS is what? What if there is ANY PERISTALSIS?
NO PERISTALSIS - ACHALASIA
ANY PERISTALSIS - EGJ OUTFLOW OBSTRUCTION
What are the PREFERRED treatment modalities for the different TYPES of ACHALASIA?
TYPE-I: Pneumatic Dilation or HELLER
TYPE-II: Pneumatic Dilation or HELLER
TYPE-III: POEM
A SHORT Distal Laency (DL <4.5 seconds) indicates what type of esophageal condition?
ESOPHAGEAL SPASM (≥20% of swallows)
What is the esophageal condition in which ≥20% of contractions, the DCI >8,000 mmHg/cm/second?
HYPERcontractile (Jackhammer) ESOPHAGUS
Esophageal motility where ≥50% of swallows are with a DCI <450 mmHg/cm/s (if <100, FAILED motility)?
Ineffective Esophageal Motility
What is the MAJOR mechanism of GERD?
TRANSIENT LES RELAXATION (NOT preceded by a swallow) and lasting >10 seconds - this is also part of the NORMAL BELCH reflex
Which GABAnergic medication has been shown to DECREASE the frequency of the TLESR (transient LES relaxation) which is the predominant mechanism in GERD?
BACLOFEN
Patients with LARGE HIATAL HERNIAS almost ALWAYS also suffer from what condition?
GERD
Does Helicobacter Pylori cause GERD?
NO
This CONDITION presisposes us to GERD, BARRETT’s ESOPHAGUS, ESOPHAGEAL ADENOCARCINOMA and HIATAL HERNIA by increased intra-gastric pressure?
OBESITY (high BMI)
Patients with GERD and LA grades C&D ESOPHAGITIS, how LONG is PPI therapy needed for?
INDEFINITELY
In patients with GERD, when is an EGD indicated?
ALARM SYMPTOMS (dysphagia, bleeding, anemia, wt loss, recurrent vomiting)
AND
If symptoms persist AFTER 4-8 WEEKS of BID PPI therapy
Age ≥50, MALE, WHITE, CHRONIC GERD, HIATAL HERNIA, elevated BMI are all RISK factors for this condition requiring EGD for screening?
BARRETT’s ESOPHAGUS and ESOPHAGEAL ADENOCARCINOMA
What can be IMMEDIATELY diagnosed if on EGD, REFLUX ESOPHAGITIS is found?
GERD
Are LIFESTYLE modifications efficacious for GERD?
WEAK
What TREATMENT is recommended to patients who have MILD and INTERMITTENT GERD symptoms?
H2-blockers (and as an addition to those on PPI therapy who have NIGHTIME breakthrough symptoms
Is there a ROLE for the use of SUCRALFATE in GERD?
NO (little)
Best PROCEDURE to treat GERD in those NOT morbidly OBESE?
Modern FUNDOPLICATION
BEST PROCEDURE to treat GERD in the MORBIDLY OBSESE?
Roux-en-Y Gastric Bypass
Which BARIATRIC surgery should be AVOIDED in patients with GERD who are MORBIDLY OBESE?
SLEEVE GASTRECTOMY
What is the BEST PROCEDURE for GERD, REGURGITATION and a HIATAL HERNIA <3 cm?
LINX procedure
Which is the ONLY ENDOSCOPIC therapy which has shown to TREAT GERD?
TIF
The presence of troublesome, RFLUX-related symptoms in the ABSENCE of endoscopically visible mucosal breakes is called what?
NERD (non-erosive reflux disease)
When a patient undergoes ESOPHAGEAL pH monitoring and is found to indeed have an esophageal pH <4 for <5% of the time in a 24 hour period, they have REFLUX HYPERSENSITIVITY to even small amounts of acid and should be tested how?
Esophageal IMPEDANCE pH MONITORING
Whenever a NON-GERD esopahgeal disorder causes HEARTBURN (EOE, achalasia), what is the best NEXT TEST?
EGD with BIOPSY and esophageal MANOMETRY
When performing an EGD for a patient with HEARTBURN, and they have a NORMAL-appearing esophagus, what should be done and why?
BIOPSY esophagus for EOE (because this can cause HEARTBURN in the absence of GERD)
Would EOE (eosinophilic esophagtitis) be present on biopsies in a patient on PPI therapy?
NO (must be stopped for SEVERAL WEEKS before EGD)
In patients with NERD, what is found on esophageal BIOPSIES that can clue you in to the REFLUX etiology of their symptoms?
Dilated INTRACELLULAR SPACES, elongated papillae and thickened BASAL ZONE
In esophageal pH monitoring, a Symptom Index (SI) ≥50% indicates what?
It indicates that >50% of symptoms are indeed associated with acid REFLUX episodes (Symptom Associated Probability SAP >95% also signifies the same thing)
When NORMAL, PHYSIOLOGIC episodes of ACID REFLUX cause symptoms of HEARTBURN, what is this called?
REFLUX HYPERSENSITIVITY (functional disorder) - TCAs, SSRIs
In patients in whom symptoms of HEARTBURN DISAPPEAR with PPI therapy, is esophageal pH monitoring necessary to establish the diagnosis of GERD?
NO
In patients with PPI-resistant GERD symptoms and a POSITIVE SI on pH manometry, BESIDES SURGERY (fundoplication, Roux-en-Y) what other medication can be tried?
BACLOFEN (reduces TLESR events)
As PPIs are not well known to treat LaryngoPharyngeal Reflux (LRP), when treating, what is RECOMMENDED?
BID PPI therapy for 8 WEEKS
WHEN should an H2-blocker be used at NIGHT for breakthrough reflux?
When there is BREAKTHROUGH reflux at night while already on BID PPI therapy
What are the EARLY mucosal changes noted in GERD?
T-lymphocyte predominant inflammation of the esophagus and that PROLIFERATIVE CHANGES in the SQUAMOUS epithilium PRECEDE the development of SURFACE CELL EROSIONS (happen last)
What are HISTOLOGIC chnages seen in GERD (NOT EARLY stages)?
DILATED INTRACELLULAR SPACES
In a patient in whom PPI therapy worked well for a while but no longer does, what SHOULD be performed NEXT?
ON PPI pH MONITORING with IMPEDANCE
What is the BEST treatment for REGURGITATION that occurs in spite of BID PPI therapy?
LINX (magnets) - MUST rule out motility disorder first as DYSPHAGIA is an issue with this procedure (rule out with manometry)
Should you ROUTINELY check for H.pylori in patient’s with GERD?
NO (because H.pylori causes LESS GERD by causing gastritis with less acid production)
What are the BEST therapeuric options for Barrett’s Esophagus with DYSPLASIA?
RFA and EMR (if abnormalities are noted in the Barrett’s mucosa)
What should you ALWAYS do if you find a patient to have H.pylori?
TREAT
What MUST be done after Barrett’s Esophagus is ERADICATED by EMR or RFA?
Continue surveillance EGD every 3-6 months
When is ENDOSCOPIC therapy for Barrett’s Esophagus not an option?
When dysplasia involves the SUBMUCOSA
How OFTEN is EGD with BARRETT’s SURVEILLANCE recommended for a patient WITHOUT DYSPLASIA?
Every 3-5 YEARS
How is DYSPLASIA in Barrett’s Esophagus reviewed?
By TWO PATHOLOGISTS, one of which has EXPERTISE in GI
In patients with LOW-GRADE DYSPLASIA in Barrett’s Esophagus, what is the recommendation?
ENDOSCOPIC THERAPY vs YEARLY EGD surveillance
How are patients with Barrett’s Esophagus treated with findigns of INDEFINITE for DYSPLASIA?
With REPEAT EDG and biopsy AFTER MAXIMAL PPI therapy for 3-6 MONTHS and if STILL INDEFINITE for DYSPLASIA, EGD surveillance every YEAR
After COMPLETE ELIMINATION of INTESTINAL METAPLASIA endoscopically in patients with Barrett’s Esophagus who had HIGH-GRADE DYSLASIA or INTRA-MUCOSAL CARCINOMA, what is the recommended EGD SURVEILLANCE period?
Every 3 MONTHS for the 1st YEAR, then every 6 MONTHS for the 2nd YEAR then YEARLY
After COMPLETE ELIMINATION of INTESTINAL METAPLASIA endoscopically in patients with Barrett’s Esophagus who had LOW-GRADE DYSLASIA, what is the recommended EGD SURVEILLANCE period?
Every 6 MONTHS for the 1st YEAR then YEARLY
FOOD-ALLERGEN triggered, LONG histroy of DYSPHAGIA to SOLID foods with hospitalizations for esophageal food IMPACTIONS?
Eosinophilic Esophagitis (EOE) - asthma, atopic dermatitis, eczema, hay fever
What is REQUIRED for the diagnosis of EOE?
>15 EOSINOPHILS/HPF (reflux will cause usually <10 eosinophils/hpf)
What is the MOST COMMON food allergen that triggers EOE?
MILK (then wheat, eggs, soy, seafood, nuts)
What are the ACCPETED TREATMENTS for EOE?
STEROIDS (fluticasone, budesonide); PPIs; Elimination DIETs
Which infectious agents can cause ESOPHAGEAL ULCERS that require treatment of the UNDERLYING infection?
HSV, CMV, HIV (multiple round ulcers)
Whenever there is a NODULAR area in BARRETT’s esophagus, waht MUST be done PRIOR to proceeding with any other invasive therapy?
EGD with EMR to ensure NO SUBMUCOSAL involvement
When RFA has been performed in a patient taking BID PPI therapy and still after several sessions, there is long-segment Barrett’s, what needs to be done NEXT?
Ensure patient is taking the BID PPI therapy CORRECTLY, 30 min before breakfast and 30 min before dinner PRIOR to repeating RFA - only if this too fails, proceed with fundoplication
White exudates, linear furrows, long-standing history of solid-food dysphagia, history of asthma, >15 eosinophils/hpf allindicate EOE, what ELSE needs to be done to ESTABLISH a diagnosis of EOE?
Exclusion of OTHER CAUSES of EOE (vasculitis, eosinophilic gastroenteritis, Crohn’s, connective tissue disease)
By what MECHANISM do PPIs treat EOE?
They INHIBIT Th2 CYTOKINE-STIMULATED SECRETION of EOTAXIN-3 by esophageal epithelial cells due to their ANTI-INFLAMMATORY effects
What is the RECOMMENDED dose of PPI in a patient with Barrett’s esophagus?
ONCE DAILY (increase to twice daily if once daily is insufficient to manage acid reflux or treat GERD esophagitis)
After an ORGAN TRANSPLANT, a patient develops FEVER, NAUSEA, VOMITING, ABDOMINAL PAIN with SEVERE ODYNOPHAGIA, whats the MOST LIKELY CAUSE?
INFECTIOUS ESOPHAGITIS with CMV
Which is the ONLY stage of esophageal carcinoma that is potentially treatable ENDOSCOPICALLY?
T1a (NO SUBMUCOSAL INVOLVEMENT)
Should ENDOSCOPIC ALBLATIVE THERAPY be used in Barrett’s Esophagus when there is NO DYSPLASIA?
NO
What are the DIET therapies that are available and efficacious for EOE?
ELEMENTAL (most successful), DIRECTED ELIMINATION and EMPIRIC ELIMINATION
What is the ONLY SYMPTOM indication for a BARIUM ESOPHAGRAM in GERD?
DYSPHAGIA (if ENDOSCOPY is REFUSED)
In a patient with features of severe GERD with RAYNAUD’s, what is a test that can be done?
ANA
In a patient with FREQUENT CHEST PAIN and GERD SYMPTOMS UNRESPONSIVE to MAXIMAL therapy and negative cardiac work-up, what is the NEXT STEP?
Ambulatory pH-IMPEDANCE testing
In a patient with TYPICAL SYMPTOMS of UNCOMPLICATED GERD (heartburn, regurgitation, etc.) WITHOUT ALARM symptoms, what is the RECOMMENDED TREATMENT?
DAILY PPI (antacids and lifestyle modifications are UNLIKELY to resolve symptoms alone)
If suspecting EOSINOPHILIC ESOPHAGITIS (EOE), where do you perform BIOPSIES from on the EGD?
PROXIMAL and DISTAL ESOPHAGUS (>15 eosinophils/hpf)
If a patient with TYPICAL GERD SYMPTOMS and CONFIRMATORY EGD with REFLUX ESOPHAGITIS who does NOT respond to once daily PPI therapy BEFORE BED, what should be RECOMMENDED NEXT?
BID PPI, 30 min before BREAKFAST and 30 min before DINNER
In a patient with GERD, being a WHITE MALE, having CENTRAL OBESITY and CHRONIC REFLUX SYMPTOMS (>5 years), puts him at risk for what?
That BARRETT’S ESOPHAGUS will be found on EGD
What is the RECOMMENDATION for ENDOSCOPIC MANAGEMENT of a patient with LONG-SEGMENT BARRETT’S ESOPHAGUS WITHOUT DYSPLASIA?
EGD with SURVEILLANCE BIOPSIES in 1 YEAR (then, if no dysplasia is found, EGD every 3-5 years)
What is the PPI DOSAGE GOAL in patients with REFLUX and BARRETT’s ESOPHAGUS?
SYMPTOM CONTROL (do NOT increase dosage or frequency if asymptomatic on current regimen)
Is ENDOSCOPIC ABLATIVE THERAPY recommended in patients with BARRETT’s ESOPHAGUS WITHOUT DYSPLASIA (i.e. long-segment)?
NO
What is the RECOMMENDATION for treatment of a patient with BARRETT’s ESOPHAGUS noted to have a NODULAR LESION with DYSPLASIA?
ENDOSCOPIC MUCOSAL RESECTION (superior to biopsy alone)
What should be done when a BIOPSY of a patient with BARRETT’s ESOPHAGUS comes back as LOW-GRADE DYSPLASIA?
CONFIRMED by an EXPERT GI PATHOLOGIST followed by a REPEAT EGD with 4-QUADRANT BIOPSIES every 2 cm within 6 MONTHS
What is the RECOMMENDED TREATMENT of NON-METASTATIC CANCER of the ESOPHAGUS post-staging?
NEOADJUVANT CHEMOTHERAPY followed by SURGERY
In the ABSENCE of HIGH-GRADE DYSPLASIA, what is the RECOMENDED tratment for a patient with LONG-SEGMENT BARRETT’s ESOPAHGUS with GI PATHOLOGIST CONFIRMED LOW-GRADE DYSPLASIA?
REPEAT EGD in 1 YEAR
What is the MAIN INHIBITORY NEUROPEPTIDE for RELAXATION of the LES?
NITRIC OXIDE
What type of NEUROPEPTIDES are SUBSTANCE P and ACETYLCHOLINE?
EXCITATORY
ISOBARIC PRESSURIZATIONS in response to SWALLOWS?
ACHALASIA TYPE-II
NO DISCERNABLE PRESSURIZATIONS in response to SWALLOWS?
ACHALASIA TYPE-I
SPONTANEOUS and REPETATIVE PRESSURIZATIONS in response to SWALLOWS (spastic)?
ACHALASIA TYPE-III
PROLONGED PRESSURIZATIONS in response to SWALLOWS is found where?
DIFFUSE ESOPHAGEAL SPASM, ACHALASIA TYPE-III and NUTCRACKER ESOPHAGUS
For the DIAGNOSIS of ACHALASIA, which MANOMETRIC FINDING is the MOST SENSITIVE?
ELEVATED INTEGRATED RESIDUAL PRESSURE (IRP) - this measures BOTH LES pressure and relaxation
ELEVATED PHARYNGEAL PRESSURES with DEGLUTITION can result in what pathology?
ZENCKER’s DIVERTICULUM
WHAT is the TREATMENT of CHOICE for a SMALL ZENCKER’s DIVERTICULUM?
CRICOPHARYNGEAL MYOTOMY
What effect do ACHALASIA, SCLERODERMA and AMYLOIDOSIS have on the ESOPHAGUS?
COMPLETE SMOOTH MUSCLE DYSFUNCTION
Does DERMATOMYOSITIS cause COMPLETE SMOOTH MUSCLE DYSFUNCTION of the ESOPHAGUS?
NO (only affects striated muscle)
