Esophagus Flashcards
What is the anatomy of the esophagus
Lines by stratified squamous
Upper 1/3 is skeletal (voluntary)
Lower 1/3 is smooth (involuntary)
What are the sphincters of the esophagus
UES controls food entry into esophagus
LES prevents reflux of gastric contents (contracted while resting, relaxed during swallowing)
What is the physiology of swallowing
Bolus is voluntarily pushed to back of mouth by tongue, and projected into pharynx
Rest is involuntary: UES relaxation, bolus into upper esophagus, peristaltic waves push bolus down, LES opens
How long does deglutition take
Swallowing: 1 second
Bolus reaches LES in 6 seconds
LES relaxes 2 seconds after swallowing and stays relaxed until bolus is in stomach
What is toe root of the problem in heartburn, dysphagia, and odynophagia
Heartburn: LES is relaxed
Dysphagia: UES relaxation and peristaltic waves
Odynophagia: peristaltic waves
What is esophagitis
Infectious d/o
common in immunocompromised (candida) but also immunocompetent (CMV, HSV)
How does esophagitis present
Pain*
fever, LAD is immunodeficient
How do you diagnose esophagitis
Endoscopy first
Definitive diagnosis: cytology or culture from endoscopy brushings
What etiology do certain endoscopic findings point to
CMV: 1 to several large, linear, or longitudinal
HSV: multiple, small, volcano like lesions
Candida: linear yellow-white plaques
How do you treat esophagitis
Candida: Fuconazole or Ketoconazole (x 2-3 weeks)
HSV: Acyclovir
CMV: IV gancyclovir or Foscarnet
If you find CMV caused esophagitis, what must you test for
HIV!
What is corrosive esophagitis
inflammation of esophagus 2/2 ingestion of caustic agents (cleaners, bleach)
If there are strictures, dilate them!
How does corrosive esophagitis present
Ulceration, necrosis, and perforation from oropharynx to stomach
May lead to fibrosis and stricture formation.
*Increased risk of squamous cell carcinoma!
What meds can cause medication induced esophagitis
NSAIDs K+ pills Antiretrovirals Bisphosphanates Doxycycline Clindamycin Bactrim Iron Vitamun C Quinidine (if there is prolonged mucosal contact)
How does med induced esophagitis present
Severe retrosternal CP
Odynophagia
Dysphagia
If chronic, may lead to stricture, hemorrhage, or perforation
What are the common etiologies of esophageal motility disorders
Neurologic dysfunction
Blockage
Failure of peristalsis
MC Sx of esophagela dysmotility is…
DYSPHAGIA!!
Someone with neurogenic dysphagia may experience
Trouble with any swallowing, liquids or solids
it can be caused by brainstem dz, CVA, parkinson’s, MG, botulism, MD, etc.
Someone with Zenker’s diverticulum par present with
Undigested food and liquid; it looks similar to when you ate it! and halitosis
Occurs 2/2 a pouch in posterior hypopharynx just above UES
Someone with esophageal stenosis may present with
Difficulty swallowing solids. but liquids can usually slide through
It can manifest w/ rings, webs, or malignancy
What is Schatzki’s ring
a mechanical disorder with a thin circumferential ring at GE junction
Caused by GERD, or congenital deformity
How does Schatzki’s ring manifest
Episodic solid food dysphagia
Large food bolus becomes impacted
Abrupt onset substernal discomfort
What are esophageal webs
Mucosal folds that protrude into the lumen causing intermittent dysphagia of solid foods
Unknown cause
When are webs symptomatic
in iron deficient, middle aged women
plummer vinson syndrome
What is Plummer Vinson syndrome
Dysphagia + Esophageal webs + Iron deficiency anemia
They are higher risk for squamous cell esophageal cancer
Someone with achalasia may present with
Difficulty with solids and liquids
Caused by ineffective relax of LES, decreased peristalsis
Someone with diffuse esophageal spasm may present with
dysphagia or intermittent CP
Someone with scleroderma may present with
Reflux
caused by decreased sphincter tone and peristalsis
What is Achalasia
Dilated esophagus tapering into a distal obstruction
Shows up as parrot beak on esophagram
How do you diagnose and treat achalasia
Dx: esophageal manometry
Tx: Dilate the esophagus- can likely recur
What causes diffuse esophageal spasm
frequent, intermittent, abnormal, nonpropulsive esophageal contractions equal for solids and liquids
How does esophageal spasm present
CP, radiates to back, chest, arms, and jaw (looks like an MI!)
dysphagia
precipitated by drinking cold liquids
How do you diagnose esophageal spasm
1st, r/o MI!!!
Barium esophagram shows corkscrew esophagus
Difficult to diagnose bc you can only see positive findings on esophagram when the spasm is happening
How do you treat esophageal spasm
Smooth muscle relaxers; NTG: before meals, QHS Isosorbide dinitrate: before meal Nifedipine: before meals *Remind pt that these DROP your BP, use caution!
What is scleroderma associated with
CREST syndrome (fibrosis of skin and vsicera) Calcinosis Raynaud's syndrome Esophageal dysmotility* Sclerodactyly Telangectasias
What is scleroderma
Fibrosis of skin and viscera
Causes atrophy and fibrous replacement of smooth muscle in distal esophagus
Weakness of contraction in lower esophagus
How do you diagnose dysphagia in general
Barium swallow (esophagram): structure and motor problems Endoscopy (EGD): see directly the abnormality and Bx Esophageal manometry: strength and coordination of peristalsis (always do if w/ dysphagia and no obstruction)*
How do you treat esophageal dysmotility
Neurogenic: treat underlying cause to prevent aspiration PNA
Stricture: dilate if benign, resect if malignant
Diverticula, achalasia, stenosis: endoscopic dilation (bougies), resection if needed. Myotomy
What Tx are not effective for esophageal dysmotility
CCB, nitrates, botox
Pearl for esophageal dysmotility diagnosis is
Initial investigation: barium esophagram, UGI swallow, or barium swallow
Treatment: Endoscopy (EGD)
What is a mallory weiss tear
Linear tear in esophagus, MC at GE junction
causes upper GI bleed (painless hematemesis)
Caused by forceful vomiting
RF for mallory weiss tear are
Alcohol use
hyperemesis gravidarum
How do you diagnose Mallory weiss tear
Endoscopy
-If hemodynamically stable or hematemesis has a cause, dont need EGD
How do you treat mallory weiss tear
Possible spontaneous (no blood, no intervention)
Epinephrine to stop bleeding (vasoconstrict)
Thermal coagulation
Surgery if arterial bleed is severe
What is an esophageal varices
Dilated veins of the esophagus 2/2 *portal HTN (from liver cirrhosis due to alcohol abuse or chronic viral hepatitis) or Budd chiari syndrome (thrombosis of portal vein)
RF for esophageal varices are
NSAIDs, they can exacerbate bleeding
How do esophageal varices present
Painless upper GI bleeding, brisk, bright red or coffee grounds
Can also have melena or hematochezia
If large, Hypovolemic shock
ASx until they bleed! and it is LIFE threatening
How do you diagnose esophageal varices
Endoscopy
How do you treat esophageal varices
Hemodynamic support (IVF, endoscopic vasopressors (Octreotide drip) Emergent EGD for band ligation**
How can you prevent esophageal varices
If with cirrhosis, give beta blockers (propranolol)
NO alcohol
Endoscopic band ligation
What are normal physiologic barriers to acid reflux
LES tone
Resistance of esophageal mucosa to acid
Normal gastric motility
GERD RF are
Smoking
Alcohol
Obesity
What is the etiology of GERD
Stomach contents reflux into esophagus 2/2 LES abnormality
Sx are produced from prolonged exposure to gastric acid
What meds can cause GERD
Antibiotics Bisphosphonates Iron NSAIDs Anticholinergics CCB Narcotics Benzos (they irritate/decrease the LES tone- RF for GERD!)
How does GERD present
*Heartburn (worse after meals, lying down, bending over, regurgitation, dysphagia- mild relief w/ antacids)
Hoarseness, halitosis,cough, hiccuping, sore throat, laryngitis, nausea, atypical CP
Severe: nighttime Sx
Alarm GERD symptoms are
Anemia
Loss of weight
Anorexia
Recent onset progressive Sx
Melena or hematemesis
Swallowing difficulties (dysphagia, odynophagia)
-this means: look for other causes of Sx!!
How do you diagnose GERD
MC clinically (uncomplicated)- but do endoscopy to confirm diagnosis and assess epithelial damage (complicated) Uncomplicated: heartburn + regurg + relief w/ antacids
How do you treat an uncomplicated patient
trial PPI x 4-8 weeks
When would you need an endoscopy instead of just trial PPI
Fail PPI trial or alarm Sx More severe dz >45 w/ new Sx Long standing or recurrent Sx No response to therapy
Other tests for GERD are
Barium swallow
Esophageal manometry
24 hr pH monitoring* (GOLD for surgical planning!!)
What lifestyle modification can you do for GERD
Smoking cessation Avoid eating at bedtime Raise head of bed Avoid large meals Avoid alcohol Avoid irritating foods (tomatoes, fried food, caffeine)
Why PPI’s to treat GERD?
Offer Sx relief and Heal mucosa*
Take prior to eating
(H2 blockers treat Sx but you don’t get mucosal protection. can use these for those w/ 1-2 weeks of Sx)
What are PPI’s
Omeprazole (prilosec) Esomeprazole (nexium) Lansoprzole (prevacid) Pantoprazole (protonix) Rabeprozole (aciphex)
How else can you treat GERD
Surgery if refractive to PPI Nissen fundoplication (wrap gastric fundus around esophagus for sphincter competence)- reduce reflux, restore LES, heal peptic esophagitis, and reverse stricture
Complications of GERD are
Aspiration PNA Acid laryngitis Trigger asthma Stricture formation Barret esophagus and adenocarcinoma
What is Barrett esophagus
Chronic damage to lower esophagus replaces squamous epithelium with metaplastic columnar
Leads to dysplasia and associated with adenocarcinoma
M>W
How do you treat Barrett esophagus
Normalize acid, decrease cell proliferation
Radiofrequency ablation or surveillance endoscopy
Current guidelines say that you should screen who for barrett esophagus
those with high RF, not just those with GERD
if they have dysplasia, continue screening q6-12 months
