Esophagus Flashcards
GERD, BE, H. pylori
How do you manage extraesophageal reflux symptoms?
How do you manage new symptoms of GERD?
How do you manage refractory GERD symptoms?
How do you manage new symptoms of extraesophageal reflux?
How do you manage non-cardiac chest pain?
- Cardiac evaluation
If reflux symptoms present, then PPI BID 8 to 12 weeks
If no reflux symptoms presents, then EGD or pH study
Can GERD be diagnosed off layngoscopy findings alone?
no
How do you manage GERD in pregnancy?
- lifestyle changes
- antacids, sucralfate
- H2 blockers or PPI (any except omeprazole)
How long do you continue PPI?
- stop PPI- GERD w/o erosive esophagitis or BE; patients whos symptoms resolved on PPI
- Indefinite treatment with PPI- LA grade C/D or BE
When should you use BRAVO vs impedence pH testing?
Is this GERD? - use any test OFF therapy to establish a diagnosis
This patient has GERD, why are they still symptomatic?- use impedance pH testing ON therapy because you can learn about non-acid reflux
Does 2CM BE confirm a diagnosis of GERD?
No.
Endoscopic finidings of GERD are LA grade C/ D or BE >3cm
LA grade B only if symtoms of GERD and response to PPI
What is the symptom index (SI)?
reflux-related symptoms / total # of symptom episodes
> 50% is significant
What is the symptom sensitivity index (SSI)
of reflux-related symptoms / total # of reflux events
> 10% is significant
What is the symptom association probability
p value for the test
> 95% is significant
What enzyme metabolizes PPI?
CYP2C19
Rabeprazole is least dependent
Are all PPIs equivalent?
what is superior to PPI?
All are clinically equivalent at healing esophagitis
All are NOT equivalent in lowering acid pH
Rabeprazole > esomeprazole> omeprazole > lansoprazole > pantoprazole
vonoprazan is highly effective for treating LA Grade A and B esophagitis, so is lansoprazole, and healing rates at 8 weeks are 100% versus 99.2%, respectively.
In contrast, vonoprazan healing of LA Grade C and D
What are the possible results of impedance pH study ON PP?
- inadequate acid suppression despite PPI
- non-acid reflux causes symptoms (hypersensitivity)
- normal pH study- functional, other condition (EOE, achalasia, gastroparesis, etc).
What are the types of anti-reflux surgery?
Lap fundoplication
Magnetic sphincter- especially if symptoms are regurgitation
Roux en-y if obese
TIF if regurgitation, not severe GERD
Who gets screened for Barrett’s esophagus?
3 or more RF
-men, caucasion, >50years old, FDR with BE or EAC, smoker, obesity
What should you do if you find salmon colored mucosa on routine EGD? What should the surveillance plan be?
biopsy if >1cm
at least 8 bites
surveillance
*ND BE <3cm - repeat 5 years
*ND BE>3cm- repeat 3 years
*Indefinite for dysplasia- 2nd pathologist review –> PPI BID and repeat EGD w/in 6 months –> if indefinite again the repeat in 1 year otherwise follow algorithm for path result
How do you manage BE w/ LGD?
Surveillance or Ablation
- Surveillance - 6 months after diagnosis, 12 months after diagnosis, then every year
- Local resection + ablation until CEIM, then surveillance at 1 year, 3 years, and every 2 years
How do you manage BE w/ HGD or cacinoma insitu
assuming T1a disease (limited to mucosa, T1b invades submucosa),
resection then ablation until CEIM
Surveillance at 3mo, 6mo, 12mo, then annually
How do you manage Esophageal adenocarcinoma T1b disease?
endoscopic ablation/resection IF low risk features: well differentiated, <2cm, no LVI
otherwise surgical management
Where do you biopsy for surveillance after CEIM for dysplasic BE?
at GEJ and distal 2 to 5cm of esophagus
Esophageal lumen diameters for
1. dysphagia
2. modified diet
3. regular diet
- dysphagia = diam <13
- modified diet in diam 15mm
- regular diet 18mm diam
How do you grade and manage caustic ingestions?
EGD within 48 hours
Zargar’s grading scale
0-normal
1- edema (liquid diet)
2a- friable and superficial erosions (liquid diet)
2b deep ulcers or circumfrential- NPO x 48 hours
3a scattered necrosis -NPO x 48 hours
3b extensive necrosis -NPO x 48 hours
4 perforation
middle aged woman with proximal esophageal stricture refractory to PPI and dilation
Lichen planus
Who needs to be screened for esophageal SCC?
h/o caustic injury (15 to 20 years later) - esp lye
h/o tylosis (start at age 30)
(leukoplakia, hyperkeratosis, and esophageal papillomas)
other associations that DON’T need screening
Plummer-Vinson syndrome (iron deficiency anemia and esophageal web formation)
Fanconi anemia (an inherited bone marrow failure syndrome)
systemic sclerosis.
achalasia
HPV
radiation
How do you treat HIV-related esophageal ulcers
Steroids or thalidomide
What condition is this?
Hiatal Hernia
Barrett’s esophagus
Barrett’s esophagus with dysplasia
EOE
what type of gastric polyps are these?
fundic gland (remove if >1cm)
hyperplastic (remove if >5mm)
adenomatous (remove any size)
What is Plummer-Vinson syndrome?
triad of:
1. dysphagia
2. IDA
3. esophageal web
increased risk of esophageal squamous cell cancer
glycogenic acanthosis
Rumination syndrome
The pull sign
specific for EOE
resolves after successful treatment
Dysphagia after POEM or Lap heller. Esophogram shows this…
pseudodiverticulum at the myotomy site, or a blown out myotomy (BOM)
focal increase in luminal diameter in the distal esophagus on barium esophagram.
These patients typically have an adequate myotomy defined on HRM or do not respond to further LES-targeted therapy
treat with esophagectomy
dysphagia
EGD shows this
Zenker’s diverticulum
severe chest pain after eating
Boerhaave syndrome
if septic needs surgery
if not can consider conservative mgmt or even endoscopic stent
How do you screen for esophageal SCC?
Lugol’s chromoendoscopy-
Esophageal mucosa with squamous dysplasia remains unstained compared to normal squamous epithelium on chromo
