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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
What is Plummer Vinson syndrome
Dysphagia + Esophageal webs + Iron deficiency anemia | They are higher risk for squamous cell esophageal cancer
26
Someone with achalasia may present with
Difficulty with solids and liquids | Caused by ineffective relax of LES, decreased peristalsis
27
Someone with diffuse esophageal spasm may present with
dysphagia or intermittent CP
28
Someone with scleroderma may present with
Reflux | caused by decreased sphincter tone and peristalsis
29
What is Achalasia
Dilated esophagus tapering into a distal obstruction | Shows up as *parrot beak* on esophagram
30
How do you diagnose and treat achalasia
Dx: esophageal manometry Tx: Dilate the esophagus- can likely recur
31
What causes diffuse esophageal spasm
frequent, intermittent, abnormal, nonpropulsive esophageal contractions equal for solids and liquids
32
How does esophageal spasm present
CP, radiates to back, chest, arms, and jaw (looks like an MI!) dysphagia precipitated by drinking cold liquids
33
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
34
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! ```
35
What is scleroderma associated with
``` CREST syndrome (fibrosis of skin and vsicera) Calcinosis Raynaud's syndrome Esophageal dysmotility* Sclerodactyly Telangectasias ```
36
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
37
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)* ```
38
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
39
What Tx are not effective for esophageal dysmotility
CCB, nitrates, botox
40
Pearl for esophageal dysmotility diagnosis is
Initial investigation: barium esophagram, UGI swallow, or barium swallow Treatment: Endoscopy (EGD)
41
What is a mallory weiss tear
Linear tear in esophagus, MC at GE junction causes upper GI bleed (painless hematemesis) Caused by forceful vomiting
42
RF for mallory weiss tear are
Alcohol use | hyperemesis gravidarum
43
How do you diagnose Mallory weiss tear
Endoscopy | -If hemodynamically stable or hematemesis has a cause, dont need EGD
44
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
45
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)
46
RF for esophageal varices are
NSAIDs, they can exacerbate bleeding
47
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
48
How do you diagnose esophageal varices
Endoscopy
49
How do you treat esophageal varices
``` Hemodynamic support (IVF, endoscopic vasopressors (Octreotide drip) Emergent EGD for band ligation** ```
50
How can you prevent esophageal varices
If with cirrhosis, give beta blockers (propranolol) NO alcohol Endoscopic band ligation
51
What are normal physiologic barriers to acid reflux
LES tone Resistance of esophageal mucosa to acid Normal gastric motility
52
GERD RF are
Smoking Alcohol Obesity
53
What is the etiology of GERD
Stomach contents reflux into esophagus 2/2 LES abnormality | Sx are produced from prolonged exposure to gastric acid
54
What meds can cause GERD
``` Antibiotics Bisphosphonates Iron NSAIDs Anticholinergics CCB Narcotics Benzos (they irritate/decrease the LES tone- RF for GERD!) ```
55
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
56
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!!
57
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 ```
58
How do you treat an uncomplicated patient
trial PPI x 4-8 weeks
59
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 ```
60
Other tests for GERD are
Barium swallow Esophageal manometry 24 hr pH monitoring* (GOLD for surgical planning!!)
61
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) ```
62
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)
63
What are PPI's
``` Omeprazole (prilosec) Esomeprazole (nexium) Lansoprzole (prevacid) Pantoprazole (protonix) Rabeprozole (aciphex) ```
64
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 ```
65
Complications of GERD are
``` Aspiration PNA Acid laryngitis Trigger asthma Stricture formation Barret esophagus and adenocarcinoma ```
66
What is Barrett esophagus
Chronic damage to lower esophagus replaces squamous epithelium with metaplastic columnar Leads to dysplasia and associated with adenocarcinoma M>W
67
How do you treat Barrett esophagus
Normalize acid, decrease cell proliferation | Radiofrequency ablation or surveillance endoscopy
68
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

Summer FDTN Exam 5 (12 decks)

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