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Esophagus Flashcards

1
Q

The various causes of dysphagia can be categorized into 3 types:

A

I) Transfer disorders:

2) Anatomic or structural disorders:
3) Motility disorders:

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2
Q

I) Transfer disorders:

A

This is due to neurological deficit, resulting in difficulty transferring food from the mouth to the esophagus and leads to oropharyngeal muscle dysfunction. Symptoms include coughing, gagging, and nasal regurgitating immediately upon swallowing. Causes include CVA, ALS, etc

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3
Q

2) Anatomic or structural disorders:

A

This is due to an actual physical obstruction of the esophageal lumen.

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4
Q

3) Motility disorders:

A

Trouble with transporting food from the upper esophagus to the stomach.This can be a failure of effective peristalsis and/or failure of LES relaxation. It has endogenous or exogenous causes.

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5
Q

the first test usually performed in the workup of dysphagia, unless the etiology is known from past evaluations

A

barium swallow

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6
Q

esophageal manometry in dysphagia

A

usually done only if dysphagia persists after negative barium swallow and EGD studies

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7
Q

workup of dysphagia

A

1=barium swallow
2= endoscopy if needed,
3= manometry studies if needed.

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8
Q

Achalasia characteristic features of the history

A
  • dysphagia for solids and liquids,
  • long-standing symptoms, usually years,
  • regurgitation of food, especially at night,
  • no age or gender predilection.
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9
Q

diagnosis of achalasia

A

1) Barium Swallow: bird-beak
2) EGD: to confirm the Dx and exclude a tumor
3) Esophagealmanometry:Generally done as a last test to confirm the diagnos is before treatment is offered. This will clearly show the lack of normal peristalsis and the tight non-relaxing LES.

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10
Q

pseudoachalasia and secondary achalasia

A

if

1) onset of symptoms is rapid
2) patient is > 60 years
3) symptoms arc progressive
4) include profound weight loss

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11
Q

Complications of achalasia

A

aspiration pneumonia and weight loss

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12
Q

treatment for achalasia

A

pneumatic dilution
myotomy
Botulinum toxin is effective in 65% of cases but requires repeat therapy in 6-12 months
Calcium-channel blockers and nitrates have been used in the past with, at best, temporary partial relief

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13
Q

DES often precipitated by

A

cold or carbonated liquids.

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14
Q

Barium swallow in DES

A

Usually normal but may show corkscrew pattern

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15
Q

Manometry in DES

A

Confirms the diagnosis by revealing intermittent simultaneous contractions

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16
Q

LES pressure in DES

A

May be low, normal or high

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17
Q

What to do if reflux can be considered as the cause of DES

A

Perform 24h esophageal pH recording or give twice daily PPI for 3months

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18
Q

Treatment of DES

A

Think of this as irritable bowel of esophagus
Reassurance is the most important part of therpy
Avoiding certain foods

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19
Q

Anatomical obstructions in younger and older

A

Younger: schatzki ring (lower esophageal ring)
Older: cancer and stricture

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20
Q

Schatzki ring

A

intermittent solid food dysphagia. especially for meal and bread

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21
Q

LE ring is always associated with

A

hiatal hernia

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22
Q

pathogenesis of LE ring

A

reflux may have a role in pathogenesis. However, at endoscopy there is usually no obvious esophagitis

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23
Q

LE ring diameter in barium swallow to cause symptoms

A

13 mm

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24
Q

Esophageal stricture presentation

A

Esophageal stricture presents with a history of’ constant. not intermittent. dysphagia for solid foods.

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25
Q

Usually the stricture is due to

A

a long history of acid reflux

prolonged nasogastric tube placement

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26
Q

Malignant esophageal Obstruction

A

Usually the history is of ‘rapid progression or symptoms: solid food dysphagia to soft food difficulties and finally to problems with liquids.

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27
Q

Plummer-Vinson syndrome

A

dysphagia due to a web in the cervical esophagus
in females who have iron deficiency anemia
a slight increased risk of esophageal cancer.

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28
Q

bulbar palsy

pseudobulbar palsy

A

Bulbar palsy causes dysphagia due to weakness,whereas pseudobulbar palsy causes dysphagia due to disordered contractions

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29
Q

dysphagia and aspiration treatment

A

This aspiration is often well tolerated and does not need treatment, unless pulmonary problems arise.

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30
Q

If aspiration is suspected in dysphagia

A

perform a modified or 3-phase barium swallow to confirm the diagnosis

31
Q

the most common connective tissue disease involving the esophagus

A

Progressive systemic sclerosis (PSS; scleroderma)

32
Q

Scleroderma management

A

Do endoscopy and, if esophagitis is present, begin aggressive PPI therapy.

33
Q

follow-up for Scleroderma

A

Perform a follow-up endoscopy at 2-3 months to confirm healing and to assure effectiveness of the PPI dose

34
Q

Pill-induced esophagitis

A

doxycycline, KCL, ASA, NSAIDs, iron, alendronate, and quinidine.

35
Q

Pill-induced esophagitis diagnosis

A

Diagnosis can be made based solely on history! No need for barium swallow or EGD!

36
Q

Pill-induced esophagitis treatment

A

Stop the offending medicine and reassure the patient that things will get better. Educate your patients to take lots of water with their medications.

37
Q

If you see thrush in the mouth and odynophagia

A

you can assume that the esophagitis is also due to Candida, and treat the patient empirically with fluconazole. If no improvement, or unsure of the diagnosis, then EGD with biopsy is the procedure of choice. Rarely is dilation needed or helpful.

38
Q

LES pressure is increased by

A

LES pressure is increased by motilin, acetylcholine. and possibly gastrin. Therefore, drugs that increase these mediators tend to decrease reflux

39
Q

LES pressure is decreased by

A

progesterone (pregnancy increases GE reflux), chocolate, smoking, and some medications, especially those with anticholinergic properties

40
Q

Suspect GE reflux disease (GERD) in patients with

A

a persistent, nonproductive cough, especially with hoarseness, continual clearing of the throat. and a feeling of fullness in the throat. This cough is usually worse at night when the patient is supine

41
Q

What is the most common cause of non-cardiac chest pain?

A

(GERD)

42
Q

Extraesophageal manifestations of GERD:

A
  • nocturnal cough
  • frequent sore throat
  • hoarseness, laryngitis
  • loss of dental enamel
  • exacerbation of asthma
43
Q

GERD and asthma

A

Some asthma patients, even without symptoms of GERD, have improvement of their asthma symptoms with GERD treatment. When working up GERD, always ask about asthma symptoms especially those occurring at night

44
Q

Diagnosis of GERD

A

If the patient has only the classic symptom of heartburn, the diagnostic workup starts with a therapeutic trial-endoscopy is indicated only if this trial fails.

45
Q

Alarm signals indicating the need to endoscope the GERD patient

A 
1• nausea/emesis
2• dysphagia/odynophagia
3• blood in the stool
4• family hx of PUD
5• weight loss
6• anorexia
7• anemia
8• abnormal physical exam
9• long duration of frequent symptoms, especially in Caucasian males > 45 years old
10• failure to respond to full doses of a PPI
46
Q

(GERD) Conduct the 24-hour esophageal pH monitor for:

A

atypical cases, such as:
I) refractory symptoms and a normal EGD
2) hoarseness, coughing, or atypical chest pain, but no classic symptoms of GERD
3) failure to respond to PPls

47
Q

Treatment of mild-to-moderate GERD:

A

Initial: Raise head of bed, encourage weight loss of > 10 lb if overweight or recent weight gain, small meals, no fatty meals in the evening, eat dinner
at least 3 hours before bedtime, no sweets at bedtime, stop smoking,and antacids
prn. Avoid acidic beverages
(e.g., colas, orange juice,
wine) and excessive alcohol

48
Q

GERD treatment in severe cases

A

H2 blockers may heal mild cases of GERD, but treatment of severe GERD (i.e., grade 2 or worse esophagitis) requires PPls, such as omeprazole, continued indefinitely. unless the patient has corrective surgery.

49
Q

In patients with GERD symptoms who do not respond to PPls

A

check for other medications that may delay gastric emptying and thus promote reflux-especially calcium- calcium channel blockers, antihistamines, tricyclics, and anticholinergics.

50
Q

if PPls are stopped abruptly after several months

A

Be aware of H+ rebound

51
Q

Consider antireflux surgery (fundoplication; now by laparoscope) in patients with

A

severe GERD
Indications are: patients refractory to medical treatment,
young patient” with severe disease.
and as an alternative to long-term PPJ

52
Q

Antireflux surgery is most successful in

A

in patients responding to PPls

53
Q

Side effects of Nissen fundoplication

A

bloating, dysphagia, and an inability to belch

54
Q

In patients with GERD, what study must be done before antireflux surgery?

A

You must do a motility study prior to antireflux surgery-because the results may influence the performance of the fundoplication. Patients with very poor peristalsis are at risk for post-operative dysphagia.

55
Q

to check for evidence of Barrett esophagus

A

perform endoscopy on patients -. 40 years old with a > 10 year history of reflux symptoms (duration is more important than severity)

56
Q

Barrett esophagus is associated with

A

Barrett esophagus is associated only with adenocarcinoma (not squamous). Incidence of adenocarcinoma in patients with Barrett esophagus is 30x the normal rate

57
Q

Probability of adenocarcinoma in barrett is related to

A
  1. length of Barrett esophagus,
  2. presence of a hiatal hernia,
  3. degree of dysplasia,
  4. and concurrent smoking
58
Q

Does antireflux medication
or surgery reverses the epithelial changes of Barrett
esophagus or eliminates the cancer risk?

A

No, neither of them

59
Q

management of Barrett

A

Endoscopy with biopsy is done every 2-3 years for Barrett esophagus without dysplasia,
and every 3-6 months for low grade dysplasia. Esophageal resection surgery is indicated for high-grade dysplasia.

60
Q

Primary eosinophilic esophagitis

A

chronic inflammatory disorder of the esophagus. It has become increasingly recognized, and its pathogenesis involves interleukin-5 (IL-5) in a central role in concert with eotaxin.

61
Q

Primary eosinophilic esophagitis and association with other allergies

A

Over 50% of patients will have a prior history of respiratory allergies, with a smaller number having food or skin allergies. IgE is elevated in 2/3rds of patients.

62
Q

The leading symptom of Primary eosinophilic esophagitis

A

The leading symptom is recurrent attacks of dysphagia with food impaction. On average, patients will have symptoms for 4-5 years before diagnosis. Symptoms are more pronounced in those with a peripheral eosinophilia

63
Q

The “classic” EGO finding in Primary eosinophilic esophagitis

A

scalloped appearance or ridges in the esophagus.
Diagnosis is confirmed by esophageal biopsies showing a dense eosinoph ilic infiltration of the esophagealepithelium (> 24eos/HPF).

64
Q

Treatment of Primary eosinophilic esophagitis

A

Treatment is difficult. Most recommend referral for allergy testing and avoidance of potential allergens. Fluticasone (bid) usually results in a response within a week. Long-term therapy is usually required, and relapses are common off of the steroid. PPI therapy may be helpful in those with concomitant reflux

65
Q

Squamous cell cancer of the esophagus percentage

A

-50’% of esophageal cancer, and it usually occurs in the proximal 2/3 of the esophagus’

66
Q

Squamous cancer of the esophagus is caused by

A

smoking and alcohol (especially hard Iiquor).

67
Q

the usual presenting symptom of esophageal cancer

A

dysphagia

68
Q

to stage the tumor of esophageal cancers

A

CT scan and endoscopic ultrasound

69
Q

treatment of esophageal cancers

A

If small and localized, do surgical resection.
If large or metastasized, treat ‘with combination chemotherapy (cisplatin + 5FU) plus radiation prior to surgery. This combination results in a 2-year survival of38% vs. 10% with radiation alone

70
Q

What is Zenker diverticulum

A

outpouching of the upper esophagus

71
Q

Symptoms of Zenker diverticulum

A

Patients have foul-smelling breath and may regurgitate food eaten several days earlier

72
Q

most common cause of transfer dysphagia (trouble initiating swallowing) for solid foods

A

Zenker diverticulum

73
Q

treatment of Zenker diverticulum

A

surgery

GI (17 decks)

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