Esophagus Flashcards by Caitlin Dale

why should you do an EGD with refractory GERD or GERD with concerning symptoms?

43% have Barrett’s Esophagitis and/or esophagitis

How well did you know this?

Not at all

Perfectly

what is physiological reflux

degree of reflux that does not induce symptoms or esophageal mucosal abnormalities

How well did you know this?

Not at all

Perfectly

pathophys of GERD

LES transiently relaxes allowing back flow of stomach contents

How well did you know this?

Not at all

Perfectly

Montreal classification of GERD

condition that develops when the reflux of stomach contents cause troublesome symptoms or complications

How well did you know this?

Not at all

Perfectly

what is hallmark symptom in GERD

heartburn (pyrosis)

usually post-prandial

How well did you know this?

Not at all

Perfectly

what do we need to rule out if chest pain is present

cardiac cause

squeezing, substernal, radiates to back, neck, jaws, or arms – this is how chest pain can present

How well did you know this?

Not at all

Perfectly

with what GERD system should you consider laryngoscopy?

hoarseness/laryngitis

How well did you know this?

Not at all

Perfectly

what must we rule out of dysphagia is present

stricture

How well did you know this?

Not at all

Perfectly

odynophagia versus dysphagia

painful swallowing versus difficulty swallowing

How well did you know this?

Not at all

Perfectly

6 things that may worsen GERD

obesity

gravity

preg

tobacco/ETOHz

meds

foods

How well did you know this?

Not at all

Perfectly

what medications decrease LES pressure and may increases GERD sxs

anticholinergics

TCAs

Ca++ channel blockers

nitrates

narcotics

How well did you know this?

Not at all

Perfectly

what medications may injure the mucosa and increase GERD sxs?

bisphosphonates

iron supplements

NSAIDS/Aspirin

Potassium

Tetracycline

How well did you know this?

Not at all

Perfectly

what part of the stomach does hiatal hernia effect

portion of the stomach enters above the diaphragm into the chest

How well did you know this?

Not at all

Perfectly

most common type of hiatal hernia

sliding

How well did you know this?

Not at all

Perfectly

other type of hiatal hernia (not most common)

paraesophageal hernia

How well did you know this?

Not at all

Perfectly

which hernia may require surgical repair

paraesophageal

How well did you know this?

Not at all

Perfectly

clinical presentation of hiatal hernia

usually asymptomatic and incidental finding

can cause GERD - heartburn, cough, hoarseness, CP
** tx similarly to GERD

How well did you know this?

Not at all

Perfectly

hiatal hernia may be seen as a retrocardiac mass with or without what

air fluid level

without air fluid level - it is tough to dx based on xray alone

How well did you know this?

Not at all

Perfectly

what dx test?

hiatal hernia and strictures are seen BUT mucosal inflammation are NOT seen

barium contrast esophagram

How well did you know this?

Not at all

Perfectly

best diagnostic study to evaluate mucosal injruy

EGD - do it for Barrett’s esophagus

How well did you know this?

Not at all

Perfectly

what dx test is used to observe bolus transit (complete or incomplete)

esophageal impedance testing

How well did you know this?

Not at all

Perfectly

what dx test is used to QUANTIFY reflux and allows pt to log sxs

has a high sensitivity for detecting reflux

esophageal pH monitoring

How well did you know this?

Not at all

Perfectly

what dx test?

measures the function of the LES and peristalsis

pressure and pattern of esophageal muscle contractions

esophageal manometry

How well did you know this?

Not at all

Perfectly

can you used barium swallow for GERD

nope

does not show mucosal injury

How well did you know this?

Not at all

Perfectly

does barium contrast show mucosal injury

two options for esophageal pH monitoring

transnasal catheter wireless capsule option

if a pt comes in with typical GERD symptoms, infrequent medication use to tx symptoms, no chest pain, no dysphagia, do you need labs or dx?

NO try tx first then if those don't work or red flags happen, re-eval

7 (!!!) red flags on physical exam or in history that REQUIRE further workup

dysphagia (could be complication or could just be a symptom of GERD) hematemesis/GI bleed unexplained weight loss, fever, fatigue anemia inadequate response to tx prior anti-reflux surgery personal hx of cancer

3 broad options for GERD tx

lifestyle and dietary modifications meds anti-reflux surgery

what lifestyle mods can help tx GERD

adjustment of bed no food or drink within 3 hours of bedtime weight loss selective elimination of dietary triggers

what 3 broad types of meds used to tx GERD

Antacids (TUMS) H2 blockers (Zantac, Ranitidine) PPI (Prilosex, Prevacid, Nexium)

step down or step up therapy needed?? less than 1-2 episodes/week no evidence of erosive esophagitis

step up therapy: lifestyle meds, H2RAs, +/- antacids

step up or step down therapy needed? 2+ episodes of reflux/week + sxs impair quality of life

step down therapy: PPI daily for 8 weeks + lifestyle mods gradually decrease therapy unless maintenance PPI tx is needed

what meds am i describing do not prevent GERD neutralizes gastric pH short lived

antacids (TUMS)

what med am i describing? block action of histamine at gastric parietal cells decrease secretion of stomach acid

ranitidine (Zantac), Famotidine (Pepcid) H2 blockers/antagonists

what med am i describing? reduce amount of acid produced by glands in stomach MUST take 30 min before 1st meal of the day

PPI - Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole

what medication puts pt at risk for increased risk of infection

PPIs

why do PPIs increase infection risk

acidic environment is protective; decreasing acid can increase risk of C.Diff without antibiotic use + other infections

what GERD med is associated with risk of malabsorption (spec of magnesium)

PPIs

what should you have checked with PPIs

Mg level B12 bone density

how long should this pt stay on medication for GERD? pt does not have severe erosive esophagitis and Barrett's esophagus

lowest possible dose and shortest duration appropiate DC completely in pts without symptoms

how long should this pt stay on meds to tx GERD? severe esophagitis or Barrett's esopagus?

requires maintenance and suppression with PPI; they will have recurrent symptoms and complications if they discharge meds

when do you consider surgical management of GERD

failed optimal medical management GERD complication (esophagitis, Barret's) noncompliance

what is Nissen Fundoplication

surgical tx of GERD passage of gastric fundus behindt he esophagus to encircle to the distal esophagus can be laparoscopic or open

if a pt is on H2 blocker and symptoms aren't gone, what do you do

switch to PPI

if pt is on PPI and still having symptoms, what do you do?

BID dosing with close follow-up OR ENDOSCOPY -- do this first if warning signs have developed

most common cause of esophagitis

GERD

what happens in esophagitis

gastric acid, pepsin, and bile irritate the squamous epithelium which leads to irritation, inflammation, erosion, ulceration

5 kinds of esophagitis

reflux esophagitis (most common) infectious esophagitis pill esophagitis eosinophillic esophagitis radiation esophagitis

signs/sxs of esophagitis

similar to GERD

complicatiosn of esophagitis

bleeding, stricture, Barrett's

Barrett's esophagus; ____ in distal esophagus replaced with ___

squamous epithelium is replaced with columbar epithelium

Barrett's predisposes pt to what

adenocarcinoma of esophagus

what predisposes pt to adenocarcinoma

Barrett's Esophagus

Barrett's: more common in males or females

males

avg age of onset for Barretts

5 steps in progression of Barrett's to adenocarcinoma

GERD --> Barrett's --> Low grade dysplasia --> high grade dysplasia --> adenocarcinoma

tx of Barrett's

indefinite use of PPIs (aggressive to precent cancer) can do QD dosing first before BID

what must be done to monitor progression of Barrett's

EGD - detects evidence of dysplasia

surgical tx of Barrett's esophagus

endoscopic resection or endoscopic ablation

what surgical procedure? remove segment of Barrett mucosa; therapeutic and provides info on depth of involvement

endoscopic resection

what surgical procedure? thermal or photochemical energy to destroy Barrett mucosa

endoscopic ablation

2 types of esophageal cancer

squamous cell adenocarcinoma

more common in African American males incidence is decreasing risk factors of smoking, ETOH abuse what type of cancer

squamous cell carcinoma

more common in Caucasian males incidence is increasing among white males prevention and early detection is key Barrett's esophagus is a risk factor

adenocarcinoma

what if a patient has progressive dysphagia (had problems swallowing meat, the pasta, to fluids), what do you need to do?

ENDOSCOPY MUST BE DONE +/- barium contrast esophagram

what other worrisome symptoms may occur with progressive dysphagia?

weight loss, odynophagia, malnutrition, anorexia

esophageal cancer prognosis

not good - regardless of histology, 50-80% of pts present with incurable, unresectable, or metastatic disease THIS IS WHY WE NEED EARLIER DETECTION WITH ENDOSCOPY

Goal for majority of esophageal cancer pts?

palliative tx - chemo, radiation, surgery dep on disease stage

what type of esophagitis? immunocompromised (like with DM) and has asthma which require inhaled steroids for tx + 2 rounds of antibiotics for pneumonia

infectious esophagitis caused by candida - fungal overgrowth

if pt has +PPD, night sweats, and cough - what type of esophagitis should we suspect

tuberculosis esophagitis

if pt has a hard time swallowing pills, what type of esophagitis?

pill esophagitis

if pt has systemic sclerosis, what kind of esophagitis

esophagitis with systemic illness due to poor acid cleaning that leads to epithelial damage

if pt has asthma, rhinitis, food allergy, and chronic eczema, what kind of esophagitis

eosinophilic esophagitis

what kind of inflammation with eosinophilic esophagitis

eosinophil-predominant inflammation

other symptoms assoc with eosinophilic esophagitis

dysphagia food impaction CP refractory heartburn upper abdominal pain

strong connection with other allergic disease - food allergy, rhinitis, asthma, atopic dermatitis

eosinophilic esophagitis

tx of eosinophilic esophagitis

DIET - avoid allergens, acid suppression through PPIs, topical corticosteroids that are SWALLOWED, not inhaled may or may not due esophageal dilation but risky

what kind of disorders should you consider if pt presents with dysphagia, noncardiac chest pain, and refractory GERD sys

esophageal motility disorders

2 disorders of esophageal peristalsis

hypercontractile (Jackhammer) achalasia

what dx test is needed to dx hypercontractile (jackhammer) esophagus

manometry

if pt says they have angina but typically occurs with meals... what are you looking at

esophageal motility disorders

tx of hypercontractile (jackhammer) esopagus

calcium channel blockers (diltiazem) or TCA (imipramine) +/- botox

IF on manometry, aperistalsis occurs - NO esophageal contraction in the distal two-thirds of the esophagus and incomplete LES relaxation, what kind of dx are you thinking

achalasia

birds beak is seen on what dx test with achalasia

barium esophagram

what will barium esophagram show with achalasia

birds beak aperistalsis poor emptying of barium esophageal dilation

progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis what dx?

achalasia

symptoms: dyspagia, regurgitation, difficulty belching, chest pain, heart brun gradual onset

achalasia

what tests must be done if you suspect achalasia?

EGD - rule out malignancy Manometry - required for dx (looking for defect in LES relaxation and aperistalsis in distal 2/3 esophagus) Barium swallow - dilation of esophagus and BIRD'S BEAK

what should you consider when pt is unresponsive to trial PPIs (4 weeks) with dysphagia to solids and liquids + regurg

achalasia

tx of achalasia (WHAT not MEDS or HOW)

disruption of LES muscle fibers biochemical reduction in LES pressure

How do you disrupt the LES muscle fibers in achalasia tx?

pneumatic dilation heller myotomy (incision into muscles of the LES)

What do you use to reduce biochemicals in LES pressure in tx of achalasia?

botox, nitrates, Ca2+ channel blockers

mucosal laceration in distal esophagus and proximal stomach

mallory weiss tear

usually assoc with repetitive vomtiing, retching, excessive alcohol consumption, hiatal hernia (which increases abdominal pressure) what dx

mallory weiss tear

dx of mallory weiss tear

endoscopy (or clinical exam IF problem has already resolved)

tx of mallory weiss tear

stabilize pt control bleeding (if it hasn't stopped) tx with PPI

how do you control bleeding in mallory weiss tear

epi or electrocauterization