Esophagus

Question 1

Describe the musculature of the esophagus

Answer 1

1. Top half is striated and circular

2. Bottom half is smooth and longitudinal

Question 2

What provides intrinsic innervation to the esophagus?

Answer 2

The enteric nervous system

Question 3

How does sensory information travel from the esophagus to the brain?

Answer 3

Through the vagus nerve to the NTS

Question 4

What are the red flag symptoms of dysphagia?

Answer 4

weight loss, anemia, melena, hematemesis

Question 5

What is transfer dysphagia? What are the symptoms?

Answer 5

Difficulty initiating a swallow

• -Neuromuscular mechanism
• -food “sticks in throat” with nasal regurgitation and coughing

Question 6

What is transport dysphagia of the esophagus? what are the symptoms?

Answer 6

Intralumenal obstruction caused by an esophageal ring, or extrinsic compression, or stricture. Could also be spasm/motor failure
–“Food sticks in chest”

Question 7

What are examples of structural abnormalities of the exophagus?

Answer 7

Aencker’s diverticulum

Cricopharyngeal web

Question 8

What are available studies for assessing esophageal function?

Answer 8

1. Barium swallow
2. Upper endoscopy
3. Manometry
4. pH studies

Question 9

At what point does the UES/LES relax?

Answer 9

At the beginning of the swallow

Question 10

What three muscles make up the UES?

Answer 10

Cricopharyngeus
Inferior constrictor
Prox esophagus

Question 11

What are some causes of a hypercontractile esophagus?

Answer 11

Achalasia

Diffuse esophageal spasm

Question 12

What are some causes of a hypocontractile state?

Answer 12

Achalasia
Scleroderma/CREST
Transient LES Relaxations

Question 13

What is the incidence of achalasia?

Answer 13

.5-1/100K

Question 14

What is the pathophysiology of Achalasia?

Answer 14

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

Question 15

What do you see on chest x ray of someone with achalasia?

Answer 15

dilated esophagus

Question 16

What do you see on barium swallow of someone with achalasia?

Answer 16

bird’s beak

Question 17

What is the gold standard for diagnosis of achalasia?

Answer 17

Manometry

Question 18

What would you see on manometry of someone with achalasia?

Answer 18

1. incomplete relaxation of the LES
2. Elevated resting pressure
3. Aperistalsis with simultaneous instead of staggered contractions
4. Vigorous achalasia (high amplitude, vigorous achalasia

Question 19

Why would you perform an upper endoscopy on a suspected achalasia?

Answer 19

To rule out pseudoachalasia (a tumor at the GEJ). Will see a pinpoint opening of the LES

Question 20

What are available treatments for achalasia?

Answer 20

1. drugs
2. pneumatic dilation
3. myotomy
4. POEM (endoscopic surgery)

Question 21

What are the symptoms of a diffuse esophageal spasm?

Answer 21

chest pain and dysphagia.

Question 22

How do you diagnose and treat diffuse esophageal spasm?

Answer 22

Diagnose thru esophageal manometry. Treat using medications

Question 23

What does diffuse esophageal spasm look like on barium swallow?

Answer 23

Corkscrew appearance

Question 24

What do you see in the esophagus of someone with scleroderma?

Answer 24

1. Weak LES
2. Poor esophageal contractility
3. Delayed gastric emptying
   - ->smooth muscle is weakened

Question 25

What are the complications of the esophagus in scleroderma?

Answer 25

Peptic stricture and ulcer

Question 26

What are common causes of extrinsic compression of the esophagus?

Answer 26

1. vascular compression (aortica, lusoria=subclavian mass) 2. mediastinal mass 3. Esophageal rings 4. Esoinophilic dsophagitis 5. malignant tumors

Question 27

What is the difference between an esophageal web and ring?

Answer 27

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

Question 28

What does an eosinophilic esophagitis look like?

Answer 28

Ringed esophagus | or "feline esophagus"

Question 29

If you see a shelf pattern on barium swallow...

Answer 29

Think of a cancer pushing on the esophagus

Question 30

What's the prognosis for esophageal cancer?

Answer 30

poor. cure rates are low. Can stent for comfort, also surgery, chemo, and radiation

Question 31

What are the most common causes of esophageal symptoms in AIDS?

Answer 31

1. Candida, HSV, CMV. | - ->Candida shows a spiculated appearance on barium

Question 32

What is the major complication of GERD?

Answer 32

Barrett's esophagus leading to adenocarcinoma

Question 33

What are the atypical manifestations of GERD?

Answer 33

1. Asthma 2. Cough 3. Laryngitis 4. Chest pain 5. Globus 6. Dental erosion

Question 34

What are the aggravating factors in GERD?

Answer 34

1. Obesity 2. alcohol 3. tobacco 4. preggers 5. hiatal hernia 6. fat, caffeine, chocolate, juices

Question 35

What additional test might be helpful in diagnosing GERD?

Answer 35

Bravo pH capsule

Question 36

What are treatment options for GERD?

Answer 36

1. Histamine 2 receptor antagonists: cimetidine etc. 2. Prokinetics: limited effectiveness 3. PPIs 4. surgery (Nissen fundiplication, now can also do endoscopic ablation or suction) 5. Antacids and life style changes -->note that acid suppression does not stop reflux...it only reduces the acidity of that reflux

Question 37

What treatment would you use for TLESRs?

Answer 37

Baclofen: a GABA receptor agonist

Question 38

What are some concerns surrounding PPIs?

Answer 38

1. hospital acquired pneumonia 2. Enteric infections like C difficile 3. Decreased B12 absorption, Ca, Mg 4. Hip fractures more likely...although controversial b/c bone density is stable

Question 39

What is the defining feature of achalasia?

Answer 39

Lack of motility, aperistalsis. With or without the bird beak phenomenon