esophagus Flashcards
dysphagia becomes more common with aging and
affects up to
15% of persons age 65 or older
inability to propel
a food bolus successfully from the hypopharyngeal area through
the upper esophageal sphincter (UES) into the esophageal body is
called
oropharyngeal or transfer dysphagia.
Dysphagia
that occurs immediately or within one second of swallowing suggests
an oropharyngeal abnormality
Swallowing associated
with a gurgling noise may be described by patients with
Zenker diverticulum
Most patients with esophageal dysphagia localize their symptoms
to the
lower sternum or, at times, the epigastric region. A smaller
number of patients describe a sensation in the suprasternal notch
or higher even though the bolus stops in the lower esophagus
Esophageal dysphagia can frequently be relieved by various
maneuvers like
repeated swallowing, raising the arms over the
head, throwing the shoulders back, and using the Valsalva maneuver.
Causes of Oropharyngeal Dysphagia
NEUROMUSCULAR* Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) CNS tumors (benign or malignant) Idiopathic UES dysfunction Manometric dysfunction of the UES or pharynx† Multiple sclerosis Muscular dystrophy Myasthenia gravis Parkinson disease Polymyositis or dermatomyositis Postpolio syndrome Stroke Thyroid dysfunction
STRUCTURAL Carcinoma Infections of pharynx or neck Osteophytes and other spinal disorders Prior surgery or radiation therapy Proximal esophageal web Thyromegaly Zenker diverticulum
Common Causes of Esophageal Dysphagia
NEUROMUSCULAR (MOTILITY) DISORDERS Primary Achalasia Distal esophageal spasm Hypercontractile (jackhammer) esophagus Hypertensive LES Nutcracker (high-pressure) esophagus Other peristaltic abnormalities* Secondary Chagas disease Reflux-related dysmotility Scleroderma and other rheumatologic disorders
STRUCTURAL (MECHANICAL) DISORDERS Intrinsic Carcinoma and benign tumors Diverticula Eosinophilic esophagitis Esophageal rings and webs (other than Schatzki ring) Foreign body Lower esophageal (Schatzki) ring Medication-induced stricture Peptic stricture Extrinsic Mediastinal mass Spinal osteophytes Vascular compression
Patients who report dysphagia with solids and liquids are more
likely to have an esophageal motility disorder than mechanical
obstruction.
Achalasia is the prototypical esophageal motility
disorder;
Episodic and nonprogressive dysphagia without weight loss
is characteristic of an
esophageal web or a distal esophageal
(Schatzki) ring
True dysphagia may be seen in patients with pill, caustic,
or viral esophagitis, but the predominant complaint of patients
with these acute esophageal injuries is usually
odynophagia
Causes of Odynophagia
CAUSTIC INGESTION Acid Alkali PILL-INDUCED INJURY Alendronate and other bisphosphonates Aspirin and other NSAIDs Emepronium bromide Iron preparations Potassium chloride (especially slow-release form) Quinidine Tetracycline and its derivatives Zidovudine INFECTIOUS ESOPHAGITIS Viral CMV EBV HIV HSV Bacterial Mycobacteria (tuberculosis or Mycobacterium avium complex) Fungal Candida albicans Histoplasmosis Protozoan Cryptosporidiosis Pneumocystis jiroveci SEVERE REFLUX ESOPHAGITIS ESOPHAGEAL CARCINOMA
is a feeling of a lump or tightness in the throat,
unrelated to swallowing
Globus sensation
Globus
sensation is present between meals and swallowing of solids or
large liquid boluses may give temporary relief. Frequent dry
swallowing and emotional stress may worsen this symptom.
Globus
sensation should not be diagnosed in the presence of dysphagia
or odynophagia.
The symptom of hiccups (hiccoughs, singultus) is caused by a
combination of
diaphragmatic contraction and glottic closure.
Most
cases of hiccups are idiopathic, but the symptom has been associated
with many conditions (trauma, masses, infections, uremia)
that affect the central nervous system, thorax, or abdomen.
chlorpromazine, nifedipine, haloperidol, phenytoin, metoclopramide,
baclofen, and gabapentin
Esophageal chest pain is usually described as a
squeezing or
burning substernal sensation that radiates to the back, neck, jaw,
or arms.
day trial
of an oral PPI taken twice daily has been shown to be sensitive
and specific for the diagnosis of esophageal chest pain when compared
with ambulatory intraesophageal pH testing
A 10- to 14-
If a patient fails this trial, the next practical approach may
be a trial of agents such as imipramine or trazodone that raise the
pain threshold
Extraesophageal Manifestations of GERD
Asthma Chronic cough Excess mucus or phlegm Globus sensation Hoarseness Laryngitis Pulmonary fibrosis Sore throat
Dyspepsia is derived from the Greek words “δυς-” (dys-) and
“πέψη” (pepse) and literally means
“difficult digestion.” In current
medical terminology, dyspepsia refers to a heterogeneous group of
symptoms in the upper abdomen.
Only 4 symptoms
are now considered to be specifically of gastroduodenal origin
(postprandial fullness,
early satiation, and epigastric pain or epigastric burning)
refers to dyspeptic symptoms in persons in whom diagnostic
investigations have not yet been performed and in whom a specific
diagnosis that explains the dyspeptic symptoms has not been
determined.
uninvestigated dyspepsia
The risk of esophageal cancer is increased in
men,
smokers, persons with high alcohol consumption, and those with
long-standing heartburn
Diagnostic criteria* for
functional dyspepsia†
1. One or more of the following: Bothersome postprandial fullness Bothersome early satiation Bothersome epigastric pain Bothersome epigastric burning AND 2. No evidence of structural disease (including at EGD) that is likely to explain the symptoms
Criteria fulfilled for the previous 3 months with symptom onset at least 6 months prior to diagnosis
Diagnostic criteria* for
postprandial distress
syndrome (PDS)
Must include one or both of the following at least 3 days a week:
1. Bothersome postprandial fullness (i.e., severe enough to impact usual activities)
2. Bothersome early satiation (i.e., severe enough to prevent finishing a regular-sized meal)
3. No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations
(including at EGD)
Supportive Criteria
1. Postprandial epigastric pain or burning, epigastric bloating, excessive belching, and nausea can also be present
2. Vomiting warrants consideration of another disorder
3. Heartburn is not a symptom of dyspepsia but often may coexist with PDS
4. Symptoms that are relieved by evacuation of feces or gas should generally not be considered part of the
dyspepsia symptom complex
5. Other individual digestive symptoms or groups of symptoms (e.g., from GERD or IBS) may coexist with PDS
Diagnostic criteria* for epigastric pain syndrome (EPS)
Must include one or both of the following symptoms at least 1 day a week:
1. Bothersome epigastric pain (i.e., severe enough to impact on usual activities)
2. Bothersome epigastric burning (i.e., severe enough to impact usual activities)
No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations
(including at EGD).
Supportive Criteria
1. Pain may be induced by ingestion of a meal, relieved by ingestion of a meal, or may occur while fasting
2. Postprandial epigastric bloating, belching, and nausea can also be present
3. Persistent vomiting likely suggests another disorder
4. Heartburn is not a symptom of dyspepsia but may often coexist with EPS
5. The pain does not fulfill criteria for biliary pain
6. Symptoms that are relieved by evacuation of feces or gas generally should not be considered part of the
dyspepsia symptom complex
7. Other digestive symptoms (such as GERD and IBS) may coexist with EPS
, defined as abnormally enhanced perception
of visceral stimuli, is considered one of the major pathophysiologic
mechanisms in functional GI disorders
Visceral hypersensitivity