Esophagus Flashcards
Clinical manifestations of GERD
(UpToDate)
- heartburn, regurgitation
- dysphagia, chest pain, water brash
- globus sensation, odynophagia
- extraesophageal: cough, hoarseness, wheezing
- infrequent: nausea
Diagnosis of GERD
- clinical sx alone if they are classic → start PPI
- nonclassical sx → exclude other dx
- alarm sx → EGD w/ biopsies
- dyspepsia and >60
- GI bleed, iron def anemia
- sx of ca: anorexia, wt loss, dysphagia, odynophagia
- fhx of GI ca
- persistent sx or failed PPI trial → ambulatory pH
- chest pn w/ nl EGD and EKG → esophageal manometry
Approach to refractory GERD
(UpToDate)
- causes: insufficient acid suppression, reflux, functional heartburn
- reassess: compliance, alarm sx
- alarm sx: EGD
- no alarm sx: pt is compliant (lifestyle, meds) - inc PPI
- if cont sx: esophageal ambulatory pH testing
Given a patient with a foreign body ingestion or caustic injury to the esophagus, understand the different populations/etiologies between adult and child ingestions.
- peak incidence between 6 mo and 6 yrs of age; coins are the majority of swallowed objects
- In adults, FB ingestions occur more commonly in those with psychiatric disorders, developmental delay, and intoxication; edentulous adults are at risk for ingestion of obstructing food boluses or dental prostheses.
- In children, caustic ingestions are typically accidental small-volume drinking of household products; in adults, they are commonly suicide attempts by large volumes creating more extensive injuries.
Given an adult or pediatric patient, describe the anatomic locations of the esophagus in which a foreign body is most likely to become lodged.
- The three sites of physiologic narrowing include the upper esophageal sphincter, the level of the aortic arch, and the diaphragmatic hiatus.
- Areas of congenital malformation (eg, tracheoesophageal fistula), or prior surgery, represent sites with increased risk of obstruction.
- The site of symptoms or discomfort does not correspond to the site of obstruction.
Given a patient with a foreign body ingestion, describe structural or functional esophageal pathology in adults with an increased risk of foreign body/food impaction in the esophagus.
- Structural: carcinoma (intrinsic or extrinsic), strictures, diverticula, hiatal hernia
- Functional: achalasia
- Eosinophilic esophagitis: can present as food impaction.
Given a patient with a caustic injury to the esophagus, recognize the importance of the characteristics of the ingested substance (alkali vs. acid, solid vs. liquid), amount, and concentration.
- Alkali (ammonia, sodium hydroxide, lye) - liquefactive necrosis that extends rapidly through the esophageal mucosa.
- Acid - superficial coagulation necrosis with thrombosis of mucosal blood vessels and formation of a protective eschar.
- Alkali ingestions tend to be more damaging to the esophagus than acidic ingestions as they are more viscous and less painful to the oropharynx thus decreasing expectoration.
Given a patient with an esophageal caustic injury or foreign body impaction, recognize the signs and symptoms of perforation.
- Oropharyngeal or proximal esophageal perforation can cause neck swelling, erythema, tenderness, or crepitus.
- Intrathoracic esophageal perforation may present with severe retrosternal chest pain, back pain, chest wall crepitus, or mediastinal crackling on cardiac auscultation (Hamman sign).
- Intra-abdominal esophageal perforation may present with epigastric or back pain, and/or peritonitis on examination.
- Maintain a high suspicion for perforation in patients with signs of severe sepsis after esophageal injury.
Recognize the appropriate use and the limitations of radiographic studies in the workup of an esophageal foreign body.
- Two-view radiographs of the neck, chest, and entire abdomen remain the initial diagnostic test of choice and can reliably elucidate metallic objects, steak bones, as well as mediastinal and/or peritoneal air.
- Radiolucent objects, such as fish and chicken bones, wood, plastic, glass, and thin metal are not seen on radiography.
- Patients with persistent esophageal symptoms with a negative radiographic examination should undergo endoscopy.
- Oral contrast examinations should NOT be performed due to the risk of aspiration and interference with subsequent endoscopy (unless attempting to diagnose perforation).
Given a patient with a caustic injury to the esophagus, determine how and when to evaluate the presence and severity of injury.
- Endoscopy should be performed promptly, within 24 hours, to evaluate the extent of injury.
- Grade 1: superficial edema/erythema
- Grade 2: mucosal/submucosal ulceration
- Grade 2A: focal ulceration, erosions, exudates
- Grade 2B: deep or circumferential ulcerations
- Grade 3: transmural ulcerations with necrosis
- Grade 3A: focal necrosis
- Grade 3B: extensive necrosis
- Of note, endoscopy is contraindicated in the setting of perforation and/or hemodynamic instability.
Given a patient with a caustic injury to the esophagus, describe initial nonoperative management and contraindicated modalities.
- Airway protection is paramount to the initial evaluation and management.
- The induction of vomiting is contraindicated as vomiting may lead to additional esophageal injury.
- Bedside placement of nasogastric and orogastric tubes should be avoided.
- Antibiotics are recommended for those with esophageal perforation or grade 3 esophageal caustic injury.
- Patients with severe injury require ICU: monitor for decompensation indicating further necrosis and perforation.
- There are conflicting data regarding glucocorticoids and the prevention of future esophageal stricture.
In patients with either caustic ingestion or esophageal foreign body, evaluate airway and breathing as the first priority.
- Upper airway compromise (including dyspnea, drooling, stridor, and hoarseness) likely will require ETT.
- Signs of severe oropharyngeal or glottic edema and/or necrosis on EGD - consider intubation before continuing.
- Bronchoscopic guidance for intubation is recommended with preparation for cricothyroidotomy if unsuccessful.
Given a patient with the diagnosis of esophageal foreign body, determine which patients require emergent versus urgent, versus nonurgent endoscopy.
- Emergent endoscopy is required in patients with complete esophageal obstruction and in patients with disk batteries or sharp objects in the esophagus.
- Urgent endoscopy (within 24 hours) is recommended for patients with nonsharp esophageal foreign objects, sharp objects in the stomach or duodenum, nonobstructing esophageal food impaction, or magnets within endoscopic reach.
- Nonurgent endoscopy can be considered for asymptomatic patients with coins in the esophagus (after up to 24 hours of observation).
Given a patient with a caustic injury to the esophagus, understand the indications for emergency surgery and what procedures this entails.
- Acute surgical intervention may be indicated for a full-thickness injury that results in esophageal perforation or diffuse necrosis resulting in uncontrolled sepsis.
- Critically ill patients with significant necrosis preclude immediate reconstruction and often are managed by cervical esophagostomy, debridement, and possible esophagogastrectomy.
- Damage to the stomach can necessitate use of colon or jejunum for future reconstruction.
Given a patient with a caustic injury to the esophagus, generate appropriate follow-up short-term for strictures and long-term for increased risk of esophageal cancer.
- All patients with esophageal burns grade 2A or higher should be evaluated by contrast esophagogram 2 weeks after ingestion to evaluate for stricture.
- Approximately 2% of individuals with a history of severe caustic injury will develop squamous cell carcinoma of the esophagus.
- The American Society for Gastrointestinal Endoscopy recommends beginning endoscopic surveillance 15 to 20 years after caustic ingestion.
- Worsening dysphagia in patients with remote caustic ingestions should be evaluated promptly to exclude malignancy.
A 45-year-old woman fell asleep with her partial removable dentures in place. Later she awoke with severe throat pain and could not locate her dentures. How would you evaluate this patient?
- Recognize that airway compromise must be evaluated first.
- Recognize and assess for signs/symptoms of esophageal perforation.
- Understand the need for diagnostic studies to locate the object and rule out perforation.
- XRs AP and later throughout the GI tract until they are located.
- Endoscopy if symptomatic.
A 30-year-old man is brought into the emergency department after a suicide attempt via caustic ingestion. What is your initial approach to this patient?
- Identify the ingested agent, alkali versus acid, liquid versus solid.
- Determine the amount and concentration if possible.
- Rule out airway compromise.
- Assess clinical status.
A patient recovers from a caustic ingestion without perforation. What would you discuss with the patient regarding long-term sequelae and care?
- Discuss possible stricture formation, need for dilation, and esophageal replacement.
- Discuss the role of corticosteroids in stricture prevention (controversial).
- Discuss long-term risk of cancer if esophagus is left in place or partially resected.
Where does the esophagus begin?
at the upper esophageal sphincter - the cricopharyngeus muscle, base of the pharynx, 6th cervical vertebra
What is the narrowest point in the GI tract?
cricopharyngeus muscle - 14 mm
highest pressure
most common point of perforation in endoscopy
where Zenker diverticula occur
How long is the esophagus?
25-30cm
What is the blood supply to the cervical esophagus?
inferior thyroid arteries
What is the blood supply to the thoracic esophagus?
aorta and esophageal branches from the right and left bronchial arteries
Where does the abdominal esophagus get its blood supply?
left gastric and inferior phrenic
What is the presentation of a patient with an esophageal neoplasm?
dysphagia, weight loss, cough, hemoptysis
What is the diagnostic algorithm for dysphagia?
