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Summer FDTN Exam 5 > Esophagus > Flashcards

Esophagus Flashcards

1
Q

What is the anatomy of the esophagus

A

Lines by stratified squamous
Upper 1/3 is skeletal (voluntary)
Lower 1/3 is smooth (involuntary)

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2
Q

What are the sphincters of the esophagus

A

UES controls food entry into esophagus

LES prevents reflux of gastric contents (contracted while resting, relaxed during swallowing)

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3
Q

What is the physiology of swallowing

A

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

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4
Q

How long does deglutition take

A

Swallowing: 1 second
Bolus reaches LES in 6 seconds
LES relaxes 2 seconds after swallowing and stays relaxed until bolus is in stomach

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5
Q

What is toe root of the problem in heartburn, dysphagia, and odynophagia

A

Heartburn: LES is relaxed
Dysphagia: UES relaxation and peristaltic waves
Odynophagia: peristaltic waves

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6
Q

What is esophagitis

A

Infectious d/o

common in immunocompromised (candida) but also immunocompetent (CMV, HSV)

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7
Q

How does esophagitis present

A

Pain*

fever, LAD is immunodeficient

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8
Q

How do you diagnose esophagitis

A

Endoscopy first

Definitive diagnosis: cytology or culture from endoscopy brushings

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9
Q

What etiology do certain endoscopic findings point to

A

CMV: 1 to several large, linear, or longitudinal
HSV: multiple, small, volcano like lesions
Candida: linear yellow-white plaques

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10
Q

How do you treat esophagitis

A

Candida: Fuconazole or Ketoconazole (x 2-3 weeks)
HSV: Acyclovir
CMV: IV gancyclovir or Foscarnet

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11
Q

If you find CMV caused esophagitis, what must you test for

A

HIV!

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12
Q

What is corrosive esophagitis

A

inflammation of esophagus 2/2 ingestion of caustic agents (cleaners, bleach)
If there are strictures, dilate them!

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13
Q

How does corrosive esophagitis present

A

Ulceration, necrosis, and perforation from oropharynx to stomach
May lead to fibrosis and stricture formation.
*Increased risk of squamous cell carcinoma!

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14
Q

What meds can cause medication induced esophagitis

A 
NSAIDs 
K+ pills 
Antiretrovirals 
Bisphosphanates 
Doxycycline
Clindamycin 
Bactrim 
Iron
Vitamun C
Quinidine 
(if there is prolonged mucosal contact)
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15
Q

How does med induced esophagitis present

A

Severe retrosternal CP
Odynophagia
Dysphagia
If chronic, may lead to stricture, hemorrhage, or perforation

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16
Q

What are the common etiologies of esophageal motility disorders

A

Neurologic dysfunction
Blockage
Failure of peristalsis

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17
Q

MC Sx of esophagela dysmotility is…

A

DYSPHAGIA!!

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18
Q

Someone with neurogenic dysphagia may experience

A

Trouble with any swallowing, liquids or solids

it can be caused by brainstem dz, CVA, parkinson’s, MG, botulism, MD, etc.

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19
Q

Someone with Zenker’s diverticulum par present with

A

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

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20
Q

Someone with esophageal stenosis may present with

A

Difficulty swallowing solids. but liquids can usually slide through
It can manifest w/ rings, webs, or malignancy

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21
Q

What is Schatzki’s ring

A

a mechanical disorder with a thin circumferential ring at GE junction
Caused by GERD, or congenital deformity

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22
Q

How does Schatzki’s ring manifest

A

Episodic solid food dysphagia
Large food bolus becomes impacted
Abrupt onset substernal discomfort

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23
Q

What are esophageal webs

A

Mucosal folds that protrude into the lumen causing intermittent dysphagia of solid foods
Unknown cause

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24
Q

When are webs symptomatic

A

in iron deficient, middle aged women

plummer vinson syndrome

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25
Q

What is Plummer Vinson syndrome

A

Dysphagia + Esophageal webs + Iron deficiency anemia

They are higher risk for squamous cell esophageal cancer

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26
Q

Someone with achalasia may present with

A

Difficulty with solids and liquids

Caused by ineffective relax of LES, decreased peristalsis

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27
Q

Someone with diffuse esophageal spasm may present with

A

dysphagia or intermittent CP

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28
Q

Someone with scleroderma may present with

A

Reflux

caused by decreased sphincter tone and peristalsis

29
Q

What is Achalasia

A

Dilated esophagus tapering into a distal obstruction

Shows up as parrot beak on esophagram

30
Q

How do you diagnose and treat achalasia

A

Dx: esophageal manometry
Tx: Dilate the esophagus- can likely recur

31
Q

What causes diffuse esophageal spasm

A

frequent, intermittent, abnormal, nonpropulsive esophageal contractions equal for solids and liquids

32
Q

How does esophageal spasm present

A

CP, radiates to back, chest, arms, and jaw (looks like an MI!)
dysphagia
precipitated by drinking cold liquids

33
Q

How do you diagnose esophageal spasm

A

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

34
Q

How do you treat esophageal spasm

A 
Smooth muscle relaxers; 
NTG: before meals, QHS
Isosorbide dinitrate: before meal 
Nifedipine: before meals 
*Remind pt that these DROP your BP, use caution!
35
Q

What is scleroderma associated with

A 
CREST syndrome (fibrosis of skin and vsicera) 
Calcinosis 
Raynaud's syndrome 
Esophageal dysmotility* 
Sclerodactyly 
Telangectasias
36
Q

What is scleroderma

A

Fibrosis of skin and viscera
Causes atrophy and fibrous replacement of smooth muscle in distal esophagus
Weakness of contraction in lower esophagus

37
Q

How do you diagnose dysphagia in general

A 
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)*
38
Q

How do you treat esophageal dysmotility

A

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

39
Q

What Tx are not effective for esophageal dysmotility

A

CCB, nitrates, botox

40
Q

Pearl for esophageal dysmotility diagnosis is

A

Initial investigation: barium esophagram, UGI swallow, or barium swallow
Treatment: Endoscopy (EGD)

41
Q

What is a mallory weiss tear

A

Linear tear in esophagus, MC at GE junction
causes upper GI bleed (painless hematemesis)
Caused by forceful vomiting

42
Q

RF for mallory weiss tear are

A

Alcohol use

hyperemesis gravidarum

43
Q

How do you diagnose Mallory weiss tear

A

Endoscopy

-If hemodynamically stable or hematemesis has a cause, dont need EGD

44
Q

How do you treat mallory weiss tear

A

Possible spontaneous (no blood, no intervention)
Epinephrine to stop bleeding (vasoconstrict)
Thermal coagulation
Surgery if arterial bleed is severe

45
Q

What is an esophageal varices

A

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)

46
Q

RF for esophageal varices are

A

NSAIDs, they can exacerbate bleeding

47
Q

How do esophageal varices present

A

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

48
Q

How do you diagnose esophageal varices

A

Endoscopy

49
Q

How do you treat esophageal varices

A 
Hemodynamic support  (IVF, endoscopic vasopressors (Octreotide drip) 
Emergent EGD for band ligation**
50
Q

How can you prevent esophageal varices

A

If with cirrhosis, give beta blockers (propranolol)
NO alcohol
Endoscopic band ligation

51
Q

What are normal physiologic barriers to acid reflux

A

LES tone
Resistance of esophageal mucosa to acid
Normal gastric motility

52
Q

GERD RF are

A

Smoking
Alcohol
Obesity

53
Q

What is the etiology of GERD

A

Stomach contents reflux into esophagus 2/2 LES abnormality

Sx are produced from prolonged exposure to gastric acid

54
Q

What meds can cause GERD

A 
Antibiotics 
Bisphosphonates 
Iron 
NSAIDs 
Anticholinergics 
CCB 
Narcotics 
Benzos 
(they irritate/decrease the LES tone- RF for GERD!)
55
Q

How does GERD present

A

*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

56
Q

Alarm GERD symptoms are

A

Anemia
Loss of weight
Anorexia
Recent onset progressive Sx
Melena or hematemesis
Swallowing difficulties (dysphagia, odynophagia)
-this means: look for other causes of Sx!!

57
Q

How do you diagnose GERD

A 
MC clinically (uncomplicated)- but do endoscopy to confirm diagnosis and assess epithelial damage (complicated) 
Uncomplicated: heartburn + regurg + relief w/ antacids
58
Q

How do you treat an uncomplicated patient

A

trial PPI x 4-8 weeks

59
Q

When would you need an endoscopy instead of just trial PPI

A 
Fail PPI trial or alarm Sx 
More severe dz 
>45 w/ new Sx 
Long standing or recurrent Sx 
No response to therapy
60
Q

Other tests for GERD are

A

Barium swallow
Esophageal manometry
24 hr pH monitoring* (GOLD for surgical planning!!)

61
Q

What lifestyle modification can you do for GERD

A 
Smoking cessation 
Avoid eating at bedtime 
Raise head of bed 
Avoid large meals 
Avoid alcohol 
Avoid irritating foods (tomatoes, fried food, caffeine)
62
Q

Why PPI’s to treat GERD?

A

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)

63
Q

What are PPI’s

A 
Omeprazole (prilosec) 
Esomeprazole (nexium) 
Lansoprzole (prevacid) 
Pantoprazole (protonix) 
Rabeprozole (aciphex)
64
Q

How else can you treat GERD

A 
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
65
Q

Complications of GERD are

A 
Aspiration PNA 
Acid laryngitis 
Trigger asthma 
Stricture formation 
Barret esophagus and adenocarcinoma
66
Q

What is Barrett esophagus

A

Chronic damage to lower esophagus replaces squamous epithelium with metaplastic columnar
Leads to dysplasia and associated with adenocarcinoma
M>W

67
Q

How do you treat Barrett esophagus

A

Normalize acid, decrease cell proliferation

Radiofrequency ablation or surveillance endoscopy

68
Q

Current guidelines say that you should screen who for barrett esophagus

A

those with high RF, not just those with GERD

if they have dysplasia, continue screening q6-12 months

Summer FDTN Exam 5 (12 decks)

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