Esophagus Flashcards
the essential feature of the majority of esophageal disorders
dysphagia
dysphagia vs odynophagia - dentition (both can lead to ….(another symptom))
dysphagia: difficulty swallowing
odynophagia: pain while swallowing
BOTH CAN LEAD TO WEIGHT LOSS
when severe, some forms of esophageal disroder will give
anemia and heme (+) stool
esophageal disorders - alarm symptoms
- weight loss
- Blood in stool
- Anemia
esophageal disorders with alarm symptoms - next step
indication for endoscopy
Achalasia - definition
it is the inability of the LES to relax due to a loss of nerve plexus (myenteric) within the esophagus. Also there is aperistalsis of the esophageal body
achalasia - age / associations with RFs
young patient (under 50) NO association with alcohol + tobacco use
achalasia - etiology
not clear
2ry to Chagas disease (T. cruzi) or extraesophageal malignancies (mass effect o paraneoplastic)
achalasia - characetiristic presentation
progressive dysphagia to BOTH solds and liquids at the SAME TIME
achalasia - diagnostic tests (only the names of the tests) - which is the most accurate
- Barium esophagram
- Manometry (the most accurate)
- Chest x-ray
- Upper endoscopy
achalasia - Barium esophagram
bird’s beak as the esophagus comes down to a point
achalasia - manometry
the most accurate
failure of the lower esophageal sphincter to relax
achalasia - chest x-ray
abnormal wideningof the esophagus,
NEITHER SENSITIVE NOR SPECIFIC
achalasia - upper endoscopy
normal mucosa in achalasa –> However useful to exclude malignancy
esophagus disorders - best first test
barium studies are acceptable to do first in most patients, ALTHOUGH RADIOLOGIC TESTS ALWAYS LACK THE SPECIFICITY OF ENDOSCOPIC procedures
esophagus - biopsy
in the esophagus, only CANCER and BARRET are diagnosed by biopsy
achalasia - treatment (explain - only names)
it cannot exactly be cured - nothing can resore the normal function of the missig neuroloical control. All the treatment is based on simple mechanical dilation of the esophagus:
- Pneumatic dilation
- Surgucal secioning or myotomy
- Botulinum toxin injection
achalasia treatment - pneumatic dilation - describe
place an endoscope with the ability to inflate a device that will enlarge the esophagus
achalasia treatment - pneumatic dilation - effective?
effective in more than 80-85% of patients
it can lead to perforation in less than 3% of patients
achalasia treatment - surgical sectioning or myotomy
to alleviate symptoms
achalasia treatment - pneumatic dilation vs surgeon
surgeon is more effective and more dangerous
HARD to choose between them
achalasia treatment - Botulinum injection - describe
relax tha LES
achalasia treatment - Botulinum injection - effective?
the effects will wear off in about 3-6 months, requiring reinjection
esophageal cancer - age / RF
- 50 or older
- more than 5-10 years of GERD symptoms
- association with prolonged alcohol and tobacco use
esophageal cancer - characteristic symptoms
dysphagia first for solids, followed (progressing) for dysphagia for liquids
esophageal cancer - most important clue id diagnosis
Progressive dysphagia
esophageal cancer - diagnosis test (only names)
- Endoscopy
- Barium
- CT and MRI
- PET
esophageal cancer - best initial test
Barium –> but no radiologic test can diagnosed cancer
esophageal cancer - endoscopy
indispensible –> only biopsy can diagnose cancer
esophageal cancer - CT and MRI
not enogu to diagnose esoph cancer –> they are used to determine the extent of spread into the surrounding tissues
esophageal cancer - PET
- to determine the contents of anatomic lesions if you are not certain whether they contain cancer.
- to determine is cancer is resectable (local is, widely metastatic is not)
cancer - radiologic test for diagnosis
never the most accurate
esophageal cancer - treatment
- no resection = no cure
- chemotherapy and radiation are used in addition to surgical removal
- stent placement
esophageal cancer - stent placement
for lesions that cannot be resected surgically just to keep the esophagus open for palliation and ti improve dysphagia
esophageal spasm - types
the 2 forms of spastic disorders, diffuse esophageal spasm (DES) and nutcracker esophagus are clinically indistinguishable
esophageal spasm - presentation
both types present with the sudden onset of chest pain that is not related to exertion. Therefore, at first it is impossible to distinguish them from some form of atypical coronary artery spasm or unstable angina
esophageal spasm - the case will describe
sudden severe chest pain
esophageal spasm - ecg
normal
esophageal spasm - esophagram + endoscopy
both normal
esophageal spasm - DES vs nutcracker
can be distinguished only by the most accurate test: manometry –> different pattern of abnormal contraction in each them
esophageal spasm - most accurate test
manometry
esophageal spastic disorders - treatment
- CCBs and nitrates –> simlar to Printzmental treatment
2. PPIs can improve the number of cases
patient with aids and odynophagea - diagnosis
esophageal candidiasis (90%) other: CMV hepres
Dyshagia with HIV CD4 under 100 - steps
empirically start fluconazole (oral): IMPROVMENT?
YES: continue therapy and HAART
NO: perform upper endoscopy with biopsy –>
- large ulcerations –> CMV –> gangiclovir or foscarnet
- small ulcerations –> HSV –> acyclovir
- if candida –> IV amphoteriicn
Dyshagia with HIV CD4 under 100 - IV amphotericin
if confirmed candida not responding to fluconazole
candida - nystatin
only oral
medications that cause esophagitis in prolonged contact
- Doxycycline
- alendronate
- KCL (Potassium chloride)
esophagus - rings and webs - some diseases (also both can cause)
- Schatzki ring
- Plummer-Vinson
both give dysphagia
Schatzki ring - definition / association etc
- it is a type of scarring or tightenning (aka peptic stricture) of the DISTAL esophagis
- often from acid reflex and associated with hiatal hernia
- intermittent dysphagia
Plummer vinson - it is associated with / complications
iron def anemia
- rarely transform to squamous cell cancer
Plummer vinson - iron def anema
it is not caused by blood lodd –> plummer vinson is more proximal
esophagis - rings and webs - diagnosis
easily detected in barium studies
esophagis - rings and webs - treatment
Schatzki ring –> pneumatic dialiation
Plummer vinson –> treated with iron replacement at firs –> (lead to resolution of the lesion)
zenker Diverticulum - definition
outpocketing of the posterior pharyngeal constrictor muscles
zenker Diverticulum - symptoms
dysphagia, halitosis (Bad breath), regurgitation of food particles
some patients suffer from aspiration pneumonia
zenker Diverticulum - diagnostic tests
barium studies
zenker Diverticulum - nasogastric tube placement
NEVER –> it can cause perforation
zenker Diverticulum - upper endoscopy
NEVER –> it can cause perforation
zenker Diverticulum - treatment
repaired with surgery
- there is no medical therapy
esophageal Scleroderma - these patients present with
symptoms of reflux and have a clear history of scleroderma or progressive systemic sclerosis
esophageal Scleroderma - manometry
decreased LES pressure from an inablity to close
esophageal Scleroderma - treamtnet
PPI (like any person with reflux)
manometry is esophagus - which diseases
- achalasia
- spasm
- scleroderma
Mallory-Weiss tear presents with
upper GI bleeding after prolonged or severe vomiting or retching –> repeated retching is followed by hematemesis or bright red blood, or by black stool
(CAN BE PAINFUL)
esophageal disease without dysphagia / microscopic imafe
Mallory-Weiss tear
nonpenetrating tear of only mucosa
Mallory-Weiss tear - treatment
no specific therapy –> it will resolve spontaneously –> if severe –> injection of epinephrine to stop bleeding or the use of electrocautery
Boerhaave syndrome?
ful penetration of the esophagus (with pneumodiastinum) –> surgical emergency
