Esophagus

Question 1

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

Answer 1

I) Transfer disorders:

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

Question 2

I) Transfer disorders:

Answer 2

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

Question 3

2) Anatomic or structural disorders:

Answer 3

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

Question 4

3) Motility disorders:

Answer 4

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.

Question 5

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

Answer 5

barium swallow

Question 6

esophageal manometry in dysphagia

Answer 6

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

Question 7

workup of dysphagia

Answer 7

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

Question 8

Achalasia characteristic features of the history

Answer 8

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

Question 9

diagnosis of achalasia

Answer 9

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.

Question 10

pseudoachalasia and secondary achalasia

Answer 10

if

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

Question 11

Complications of achalasia

Answer 11

aspiration pneumonia and weight loss

Question 12

treatment for achalasia

Answer 12

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

Question 13

DES often precipitated by

Answer 13

cold or carbonated liquids.

Question 14

Barium swallow in DES

Answer 14

Usually normal but may show corkscrew pattern

Question 15

Manometry in DES

Answer 15

Confirms the diagnosis by revealing intermittent simultaneous contractions

Question 16

LES pressure in DES

Answer 16

May be low, normal or high

Question 17

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

Answer 17

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

Question 18

Treatment of DES

Answer 18

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

Question 19

Anatomical obstructions in younger and older

Answer 19

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

Question 20

Schatzki ring

Answer 20

intermittent solid food dysphagia. especially for meal and bread

Question 21

LE ring is always associated with

Answer 21

hiatal hernia

Question 22

pathogenesis of LE ring

Answer 22

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

Question 23

LE ring diameter in barium swallow to cause symptoms

Answer 23

13 mm

Question 24

Esophageal stricture presentation

Answer 24

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

Question 25

Usually the stricture is due to

Answer 25

a long history of acid reflux | prolonged nasogastric tube placement

Question 26

Malignant esophageal Obstruction

Answer 26

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

Question 27

Plummer-Vinson syndrome

Answer 27

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

Question 28

bulbar palsy | pseudobulbar palsy

Answer 28

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

Question 29

dysphagia and aspiration treatment

Answer 29

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

Question 30

If aspiration is suspected in dysphagia

Answer 30

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

Question 31

the most common connective tissue disease involving the esophagus

Answer 31

Progressive systemic sclerosis (PSS; scleroderma)

Question 32

Scleroderma management

Answer 32

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

Question 33

follow-up for Scleroderma

Answer 33

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

Question 34

Pill-induced esophagitis

Answer 34

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

Question 35

Pill-induced esophagitis diagnosis

Answer 35

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

Question 36

Pill-induced esophagitis treatment

Answer 36

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

Question 37

If you see thrush in the mouth and odynophagia

Answer 37

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.

Question 38

LES pressure is increased by

Answer 38

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

Question 39

LES pressure is decreased by

Answer 39

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

Question 40

Suspect GE reflux disease (GERD) in patients with

Answer 40

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

Question 41

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

Answer 41

(GERD)

Question 42

Extraesophageal manifestations of GERD:

Answer 42

* nocturnal cough * frequent sore throat * hoarseness, laryngitis * loss of dental enamel * exacerbation of asthma

Question 43

GERD and asthma

Answer 43

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

Question 44

Diagnosis of GERD

Answer 44

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.

Question 45

Alarm signals indicating the need to endoscope the GERD patient

Answer 45

``` 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 ```

Question 46

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

Answer 46

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

Question 47

Treatment of mild-to-moderate GERD:

Answer 47

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

Question 48

GERD treatment in severe cases

Answer 48

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.

Question 49

In patients with GERD symptoms who do not respond to PPls

Answer 49

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

Question 50

if PPls are stopped abruptly after several months

Answer 50

Be aware of H+ rebound

Question 51

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

Answer 51

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

Question 52

Antireflux surgery is most successful in

Answer 52

in patients responding to PPls

Question 53

Side effects of Nissen fundoplication

Answer 53

bloating, dysphagia, and an inability to belch

Question 54

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

Answer 54

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.

Question 55

to check for evidence of Barrett esophagus

Answer 55

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

Question 56

Barrett esophagus is associated with

Answer 56

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

Question 57

Probability of adenocarcinoma in barrett is related to

Answer 57

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

Question 58

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

Answer 58

No, neither of them

Question 59

management of Barrett

Answer 59

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.

Question 60

Primary eosinophilic esophagitis

Answer 60

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.

Question 61

Primary eosinophilic esophagitis and association with other allergies

Answer 61

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.

Question 62

The leading symptom of Primary eosinophilic esophagitis

Answer 62

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

Question 63

The "classic" EGO finding in Primary eosinophilic esophagitis

Answer 63

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

Question 64

Treatment of Primary eosinophilic esophagitis

Answer 64

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

Question 65

Squamous cell cancer of the esophagus percentage

Answer 65

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

Question 66

Squamous cancer of the esophagus is caused by

Answer 66

smoking and alcohol (especially hard Iiquor).

Question 67

the usual presenting symptom of esophageal cancer

Answer 67

dysphagia

Question 68

to stage the tumor of esophageal cancers

Answer 68

CT scan and endoscopic ultrasound

Question 69

treatment of esophageal cancers

Answer 69

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

Question 70

What is Zenker diverticulum

Answer 70

outpouching of the upper esophagus

Question 71

Symptoms of Zenker diverticulum

Answer 71

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

Question 72

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

Answer 72

Zenker diverticulum

Question 73

treatment of Zenker diverticulum

Answer 73

surgery