Esophagus Flashcards
Describe the musculature of the esophagus
- Top half is striated and circular
2. Bottom half is smooth and longitudinal
What provides intrinsic innervation to the esophagus?
The enteric nervous system
How does sensory information travel from the esophagus to the brain?
Through the vagus nerve to the NTS
What are the red flag symptoms of dysphagia?
weight loss, anemia, melena, hematemesis
What is transfer dysphagia? What are the symptoms?
Difficulty initiating a swallow
- -Neuromuscular mechanism
- -food “sticks in throat” with nasal regurgitation and coughing
What is transport dysphagia of the esophagus? what are the symptoms?
Intralumenal obstruction caused by an esophageal ring, or extrinsic compression, or stricture. Could also be spasm/motor failure
–“Food sticks in chest”
What are examples of structural abnormalities of the exophagus?
Aencker’s diverticulum
Cricopharyngeal web
What are available studies for assessing esophageal function?
- Barium swallow
- Upper endoscopy
- Manometry
- pH studies
At what point does the UES/LES relax?
At the beginning of the swallow
What three muscles make up the UES?
Cricopharyngeus
Inferior constrictor
Prox esophagus
What are some causes of a hypercontractile esophagus?
Achalasia
Diffuse esophageal spasm
What are some causes of a hypocontractile state?
Achalasia
Scleroderma/CREST
Transient LES Relaxations
What is the incidence of achalasia?
.5-1/100K
What is the pathophysiology of Achalasia?
Injury to the ganglion cells in the myenteric plexus with inflammation and death. We are not 100% sure. The degeneration of the vagal fibers results in constricture of the LES.
–>Loss of the normal balance between acetylcholine and nitric oxide
What do you see on chest x ray of someone with achalasia?
dilated esophagus
What do you see on barium swallow of someone with achalasia?
bird’s beak
What is the gold standard for diagnosis of achalasia?
Manometry
What would you see on manometry of someone with achalasia?
- incomplete relaxation of the LES
- Elevated resting pressure
- Aperistalsis with simultaneous instead of staggered contractions
- Vigorous achalasia (high amplitude, vigorous achalasia
Why would you perform an upper endoscopy on a suspected achalasia?
To rule out pseudoachalasia (a tumor at the GEJ). Will see a pinpoint opening of the LES
What are available treatments for achalasia?
- drugs
- pneumatic dilation
- myotomy
- POEM (endoscopic surgery)
What are the symptoms of a diffuse esophageal spasm?
chest pain and dysphagia.
How do you diagnose and treat diffuse esophageal spasm?
Diagnose thru esophageal manometry. Treat using medications
What does diffuse esophageal spasm look like on barium swallow?
Corkscrew appearance
What do you see in the esophagus of someone with scleroderma?
- Weak LES
- Poor esophageal contractility
- Delayed gastric emptying
- ->smooth muscle is weakened
What are the complications of the esophagus in scleroderma?
Peptic stricture and ulcer
What are common causes of extrinsic compression of the esophagus?
- vascular compression (aortica, lusoria=subclavian mass)
- mediastinal mass
- Esophageal rings
- Esoinophilic dsophagitis
- malignant tumors
What is the difference between an esophageal web and ring?
Web: protrusion of the mucosa
Ring: Protrusion of the muscular layer of the esophagus
A ring: muscular, above the GEJ
B ring: ring at the GEJ
What does an eosinophilic esophagitis look like?
Ringed esophagus
or “feline esophagus”
If you see a shelf pattern on barium swallow…
Think of a cancer pushing on the esophagus
What’s the prognosis for esophageal cancer?
poor. cure rates are low. Can stent for comfort, also surgery, chemo, and radiation
What are the most common causes of esophageal symptoms in AIDS?
- Candida, HSV, CMV.
- ->Candida shows a spiculated appearance on barium
What is the major complication of GERD?
Barrett’s esophagus leading to adenocarcinoma
What are the atypical manifestations of GERD?
- Asthma
- Cough
- Laryngitis
- Chest pain
- Globus
- Dental erosion
What are the aggravating factors in GERD?
- Obesity
- alcohol
- tobacco
- preggers
- hiatal hernia
- fat, caffeine, chocolate, juices
What additional test might be helpful in diagnosing GERD?
Bravo pH capsule
What are treatment options for GERD?
- Histamine 2 receptor antagonists: cimetidine etc.
- Prokinetics: limited effectiveness
- PPIs
- surgery (Nissen fundiplication, now can also do endoscopic ablation or suction)
- Antacids and life style changes
–>note that acid suppression does not stop reflux…it only reduces the acidity of that reflux
What treatment would you use for TLESRs?
Baclofen: a GABA receptor agonist
What are some concerns surrounding PPIs?
- hospital acquired pneumonia
- Enteric infections like C difficile
- Decreased B12 absorption, Ca, Mg
- Hip fractures more likely…although controversial b/c bone density is stable
What is the defining feature of achalasia?
Lack of motility, aperistalsis. With or without the bird beak phenomenon
