Esophagus Flashcards
Substernal burning sensation
often radiates to the neck
Pyrosis (heartburn)
Highly specific for GERD
Difficulty swallowing?
PAINFUL swallowing?
Dysphagia
Odynophagia
Characterirized by immediate sense of bolus catching in the NECK
Need to swallow repeatedly to clear food from pharynx
Or coughing/chocking
Pharyngeal (oropharyngeal)
Pharyngeal = prompt
Esophageal dysphagia can be caused, broadly, by what?
Mechicanical obstruction (solids)
Motility disorders (more severe: solids and liquids)
Study of choice for evaluating heartburn, dysphagia, odynopahgia, structura abnormalities?
Upper endoscopy
In patients w/ suspected motility disorders (of the esophagus) what study should be performed first?
Barium swallow
barium esophagography
Mechanical causes of esophageal dysphagia…
Schatzki ring
Stricture (Peptic)
Eisonophilic esophagitis
Cancer (Esophageal )
Motility-related causes of esophageal dysphagia
Achalasia
ineffective esophageal motility (duh)
Diffuse esophageal spasm
Scleroderma
Tests function of LES?
esophageal manometry
A diagnostic study option for esophageal dysphagia but only provides info for acid reflux (no nonacid data provided)
pH testing
GERD…
- Heartburn. May be exacerbated by meals, bending, or ____?
- Typical uncomplicated cases do not require _____.
- Endoscopy demonstrates abnormalities in ____ of patients
- recumbency.
- diagnostic studies.
- one-third (so, MOST patients will NOT have abnormalities)
two most common symptoms of GERD?
heartburn and regurgitation
Etiologies of GERD?
- Dysfunction of the LES (usually due to transient relaxations of LES caused by gastric distention)
- Hiatal hernias
- Abnormal esophageal clearance
- Delayed gastric empyting (gastroparesis or obstruction)
Damage to the mucosa of the esophagus due to acidity of refluxate… gastric fluid is what pH?
4.0, which is caustic to the esophageal mucosal surface
prolonged exposure -> dysplasia
Number one symptom of GERD? When’s it appear?
Heartburn… 30-60 min pc
Or upon reclining
(relieved w/ antacids)
GERD pts also typically present w/ waterbrash
regurgitation of sour fluid or almost tasteless saliva into the mouth
GERD is one of the top three causes of?
Chronic cough
less common ssx associated w/ GERDth
Cough Dysphagia (Suggest advacned dz) Laryngitis Sore throat Chest pn Difficulty w/ sleep (pts might angle their beds)
NOTE: in the absence of heartburn, these atypical unlikley to be related to GERD!!!
Physical exam for GERD is unremarkable… but what should be in your differential diagnosis?
Esophageal motility d/o Peptic ulcer ANGINA PECTORIS functional d/o Eosinophilic esophagitis
Initially no work up for GERD is warranted unless patient presents w/ alarm freatures, which are?
Fever/chills/ns
Wt. loss
Odynophagia
Dysphagia
OR patient who doesn’t respond to (h2, PPI therapy)
They get an EGD
GERD Pt w/ alarm features OR pts who don’t respond to therapy will get an EGD.
However, a specialist may also order what?
EGD = test of choice
But also consider esophageal pH or LES manometry
Barrett’s Esophagitis (15% of pts w/ GERD)… what happens to the esophageal tissue?
(GERD complication)
Normal squamous epithelium of esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells
Development of Barret esophagus may affect ssx of GERD in what way?
Development may actuallY REDUCE ssx
Barrett esophagus increases risk for what?
esophageal adenocarcinoma
A less common (5%) complication of GERD? Presents how?
How might we treat this complication?
Peptic stricture… presetned w/ progressive food dysphagia
(can also result in reduction in heartburn as stricture acts as barrier)
(tx is endoscopic dilation)
What is a tx for ALL patients w/ GERD?
Lifestyle modifications
Smaller meals, avoidance of acidic foods or those that precipitate reflux and discontinue tobacco use
GERD Lifestyle modificatins in regards to sleep?
Avoid lying down for 3 hours after meals
Elevate the head of the bed
(also, consider wt loss)
Infrequent heartburn (less than once weekly) can be treated w/ what (in addition to lifetsyle mods)
OTC antacids (tums, rolaids, etc.) [provide rapid relief but short duration]
H2 receptor antagonists (-tidines)
Compare antacids w/ H2 receptor antagonists
OTC antacids (quick relief/short duration; contain Mg so caution in pts w/ kidney problems)
H2 receptor antagonists (onset is 30 mins, but provide 8 hrs relief)
Patients w/ troublesome ssx and pts w/ known complications of GERD (erusive, esophagitis, Barret, stricture) should be treated w/ what?
Lifestyle mods
PPIs (-prazoles) taken before breakfast
(superior to H2antagonists)
If ssx persist beyond 4 weeks w/ PPI conisder what?
PPI BID
If ssx persist beyond 4 weeks w/ PPI BID, then what?
Refer for EGD!
Any patient w/ alarm ssx of GERD gets?
What are the alarm ssx?
EGD duh
Dysphagia
Odynophagia
Wt. loss
Fever/chills/ns
Pts may discontinue use of PPI after how long?
8-12 wks if relief has been achieved. However, 80% will relapse and require PPIs again. can try a lower dose or “on-demand” pharmacotherapy
When should you cosnider a fundoplication for a pt w/ GERD?
In those who are refractory to tx or have serious dz
Three types of esophagitis?
Infectious (candida, CMV, herpes)
Pill-induced
Eosinophilic
Immunosurpressed pt w/ odynophagia, dysphagia, and chest pn?
What you think and how do you diagnose?
Infectious esophagitis
Diagnose w/ endoscopy w/ biopsy
What are the common etiological agents of Infectitous esophagitis? How do get a specific diagnosis?
Candidia (#1)
CMV
Herpes
Get a endoscopy w/ biopsy for specific diagnosis
Infectitous esophagitis tx is directed at the specific agent. For fungal, whats the tx?
Empirically, w/ antifungal (fluconazole)
If no response in 5 days, schedule an EGD
What are some common offending agents for pill-induced esophagitis?
How do we fix?
NSAIDs
K-Cl pills
quinidine
Abx (doxy, tetra, clinda, TMP-SMX)
Vitamin C
(patients should remain upright for 30 mins to avoid)
Eosinophilic esophagitis ssx? Dx? Tx?
Dysphagia w/ solid foods AND heartburn
Dx w/ EGD w/ mucosal biopsy which should show eisinophilic infiltrates.
What should you ask a pt w/ suspected eosinophilic esophagitis?
Ask about a history of ashtma/allergies/atopic dermatitis
Tx for eosinophilic esophagitis?
- First line = PPI BID for 2 months
- Referall to allergist/immunologist
- Topical corticosteroids (swallowed/inhaled Fluticasone)
Esophageal webs… thin membranes of squamous epithelium. Mosty asymptomatic, but may cause?
intermittent dysphagia
Schtazki/esohageal rings… assocaited w/? Ssx?
Similar to webs, usually asymptomatic, but may cause dysphagia or GERD like symptoms
Associated w/ hiatal hernia
Diagnosis and tx for esophgeal webs/rings?
Barium swallow…
Tx is w/ endoscopic dilation (balloon dialtion)
Ssx of zenker diverticulum?
Dx w/?
Progressive dysphagia
Sensation of food sticking
Halitosis
Regurgitation of undigested bolus
Diagnose w/ barium swallow
Gradual, progressive dysphagia for solids and liquids.
Regurgitation of undigested food.
Barium esophagogram with “bird’s beak” distal esophagus.
Esophageal manometry confirms diagnosis.
achalasia
Where does the peristalsis of achalasia occur?
And what’s is impaired?
Peristalsis is in distal 2/3… relaxation of LES is impaired
Progessive dysphagia for solids AND liquids
Regurge of undigested food
Substernal discomfort after eating
Adotoption of emptying manuevers
Wt loss
achalasia
PE is unremarkable but a barium swallow will show a birds beak deformity
achalasia
How do you confirm achalasia?
EGD and manometry
A differential that should be considering in idiopathic achalasia?
Chagas dz (consider if recent travel to S/C America)
more rapido in onset
Tx for achalasia?
- Botulinum toxin (but will likely relapse)
- Pneumatic dilation
- Surgery (cardiomyotomy + fundiplication + PPI)
Develop secondary to portal hypertension.
Found in 50% of patients with cirrhosis.
One-third of patients with _____develop upper gastrointestinal bleeding.
Diagnosis established by upper endoscopy.
esophageal varices
Dilated submucosal veins that develop 2* to portal HTN?
esophageal varices
Risk factors for increased risk of esophageal bleed….
(1) the size of the varices
(2) the presence at endoscopy of ____ (longitudinal dilated venules on the varix surface)
(3) the severity of liver disease (as assessed by Child scoring)
(4) active _____
- red wale markings
4. alcohol abuse
Tx of an esophageal varice bleed?
Hemostasis/stablization
After stablization of esohageal varices, what’s the follow on tx?
Consider prophylatic abx…
Reduce portal HTN! (ocreotide)
Propanol (beta blockade)
Variceal band ligation
Hematemesis; usually self-limited.
Prior history of vomiting, retching in 50%.
Endoscopy establishes diagnosis.
Mallory weiss tear
Non penetrating mucosal tear a GEJ?
Mallory weiss tear
For MWT, what’s the order of tx?
Stablize then upper endoscopy
Tx for MWT also includes?.
Endoscopic hemostatic agents (epi, cautery, endoclip)
Complete rupture of the esophagus
Shock, pneumomediastinum
Boerhaave syndrome
Esophageal carcinoma…
Relatively form of cancer
3:1 male to female ratio…
Maybe ____ or _____
squamous cell or adenocarcinoma
When do esophageal carcinomas present?
Late, w/ advanced disease
Progressive food dysphagia
Odynophagia
Significant unexplained weight loss
May have aches/pains
Esophageal carcinoma
aches/pains from mets
Dx of esopahgeal carcinoma?
Non specific lab findings
Barium swallow to asses dysphagia
EGD establishes dx…
Tx of esophageal carcinoma?
Depends on staging… usually involves combo of surgery/chemo/rad
(poor prognosis)
How do you confirm the Dx of achalasia?
Esophageal Manometry
Barium esophagography discloses characteristic findings, including esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying, and a smooth, symmetric “bird’s beak” tapering of the distal esophagus.
What do we do next?
After esophagography, endoscopy is always performed to evaluate the distal esophagus and GEJ to exclude a distal stricture or a submucosal infiltrating carcinoma. The diagnosis is CONFIRMED by esophageal manometry.
what is esophageal manometry? What does it confirm?
Manometry will indicate how well the esophagus can perform peristalsis. Manometry also allows the doctor to examine the muscular valve connecting the esophagus with the stomach, called the lower esophageal sphincter, or LES.
Confirms the dx of achalasia
which study would I do on the esophagus to measure pH continuously for 24-48 hours?
Esophageal pH recording and Impedance Testing
Great for measuring acid reflux, but not nonacid reflux.
