esophagus Flashcards

1
Q

dysphagia becomes more common with aging and

affects up to

A

15% of persons age 65 or older

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2
Q

inability to propel
a food bolus successfully from the hypopharyngeal area through
the upper esophageal sphincter (UES) into the esophageal body is
called

A

oropharyngeal or transfer dysphagia.

Dysphagia
that occurs immediately or within one second of swallowing suggests
an oropharyngeal abnormality

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3
Q

Swallowing associated

with a gurgling noise may be described by patients with

A

Zenker diverticulum

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4
Q

Most patients with esophageal dysphagia localize their symptoms
to the

A

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

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5
Q

Esophageal dysphagia can frequently be relieved by various

maneuvers like

A

repeated swallowing, raising the arms over the

head, throwing the shoulders back, and using the Valsalva maneuver.

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6
Q

Causes of Oropharyngeal Dysphagia

A
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
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7
Q

Common Causes of Esophageal Dysphagia

A
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
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8
Q

Patients who report dysphagia with solids and liquids are more
likely to have an esophageal motility disorder than mechanical
obstruction.

A

Achalasia is the prototypical esophageal motility

disorder;

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9
Q

Episodic and nonprogressive dysphagia without weight loss

is characteristic of an

A

esophageal web or a distal esophageal

(Schatzki) ring

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10
Q

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

A

odynophagia

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11
Q

Causes of Odynophagia

A
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
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12
Q

is a feeling of a lump or tightness in the throat,

unrelated to swallowing

A

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.

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13
Q

The symptom of hiccups (hiccoughs, singultus) is caused by a

combination of

A

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

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14
Q

Esophageal chest pain is usually described as a

A

squeezing or
burning substernal sensation that radiates to the back, neck, jaw,
or arms.

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15
Q

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

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

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16
Q

Extraesophageal Manifestations of GERD

A
Asthma
Chronic cough
Excess mucus or phlegm
Globus sensation
Hoarseness
Laryngitis
Pulmonary fibrosis
Sore throat
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17
Q

Dyspepsia is derived from the Greek words “δυς-” (dys-) and

“πέψη” (pepse) and literally means

A

“difficult digestion.” In current
medical terminology, dyspepsia refers to a heterogeneous group of
symptoms in the upper abdomen.

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18
Q

Only 4 symptoms

are now considered to be specifically of gastroduodenal origin

A

(postprandial fullness,

early satiation, and epigastric pain or epigastric burning)

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19
Q

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.

A

uninvestigated dyspepsia

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20
Q

The risk of esophageal cancer is increased in

A

men,
smokers, persons with high alcohol consumption, and those with
long-standing heartburn

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21
Q

Diagnostic criteria* for

functional dyspepsia†

A
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

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22
Q

Diagnostic criteria* for
postprandial distress
syndrome (PDS)

A

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

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23
Q
Diagnostic criteria*
for epigastric
pain
syndrome
(EPS)
A

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

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24
Q

, defined as abnormally enhanced perception
of visceral stimuli, is considered one of the major pathophysiologic
mechanisms in functional GI disorders

A

Visceral hypersensitivity

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25
In a population with a high prevalence (>20%) of Hp infection, the test-and-treat approach remains attractive because patients with PUD will be cured.
The tests of choice are the urea breath test | or the fecal antigen test.
26
constructed as an 18- to 26-cm long hollow muscular tube with an inner “skin-like” lining of stratified squamous epithelium
The esophagus
27
Between swallows the esophagus is collapsed, but the lumen distends up to 2 cm anteroposteriorly and 3 cm laterally to accommodate a swallowed bolus. Structurally, the esophageal wall is composed of
4 layers: innermost mucosa, submucosa, muscularis propria, and outermost adventitia; unlike the remainder of the GI tract, the esophagus has no serosa
28
The muscularis propria is responsible for carrying out the organ’s motor function.
The upper 5% to 33% is composed exclusively of | skeletal muscle, and the distal 50% is composed of smooth muscle.
29
Proximally, the esophagus begins where the inferior pharyngeal constrictor merges with the cricopharyngeus, an area of skeletal muscle known functionally as the
upper esophageal sphincter (UES) The UES is contracted at rest and, hence, creates a high-pressure zone that prevents inspired air from entering the esophagus. Below the UES, the esophageal wall is composed of inner circular and outer longitudinal layers of muscle
30
The esophageal body | lies within the posterior mediastinum behind the
trachea and left mainstem bronchus and swings leftward to pass behind the heart and in front of the aorta.1
31
At the T10 vertebral level the esophageal body leaves the thorax through a hiatus located within the right crus of the diaphragm (see Fig. 43.1).
Within the diaphragmatic hiatus the esophageal body ends in a 2- to 4-cm length of asymmetrically thickened circular smooth muscle known as the lower esophageal sphincter (LES
32
The venous drainage of the upper esophagus is through the superior vena cava,
the midesophagus through the azygos veins, and the distal esophagus through the portal vein by means of the left and short gastric veins. The submucosal venous anastomotic network of the distal esophagus is important because it is where esophageal varices emerge in patients with portal hypertension
33
The lymphatic system of the esophagus is also segmental; the | upper esophagus drains to the deep cervical nodes,
the midesophagus to the mediastinal nodes, and the distal esophagus to the celiac and gastric nodes
34
multilayered epithelium consists of 3 functionally distinct layers: stratum corneum, stratum spinosum, and stratum germinativum
The upper esophagus is supplied by branches of the superior and inferior thyroid arteries, the midesophagus by branches of the bronchial and right intercostal arteries and descending aorta, and the distal esophagus by branches of the left gastric, left inferior phrenic, and splenic arteries
35
In the most common TEF, the trachea communicates with the distal segment of the atretic esophagus (B).
The next most common type is the H-type TEF, in which the trachea communicates with an otherwise normal esophagus Esophageal atresia occurs as an isolated anomaly in only 7% of cases; the rest are accompanied by a form of tracheoesophageal fistula, most often (89%) a distal-type fistula (see Fig. 43.7B) and rarely (3%) the H-type fistula
36
Dysphagia lusoria is the term given for symptoms arising from vascular compression of the esophagus by an aberrant right subclavian artery
``` A, Interface between lumen and mucosa; B, mucosa; C, submucosa; D, muscularis propria; E, adventitia.) Note that ``` A, C, and E are hyperechoic, and B and D are hypoechoic.
37
The distal esophagus may contain 2 “rings,” the A and B (Schatzki) ring, that demarcate anatomically the proximal and distal borders of the esophageal vestibule.
``` The A (muscular) ring is located at the proximal border (see Fig. 43.3). It is a broad (4 to 5 mm) symmetrical band of hypertrophied muscle that constricts the tubular esophageal lumen at its junction with the vestibule ``` In this location the A ring, which is covered by squamous epithelium, corresponds to the upper end of the LES.55 The A ring is rare,
38
Symptomatic A rings can be treated by
passage of a large-caliber mercury-weighted esophageal dilator, injection of botulinum toxin, or by peroral endoscopic myotomy
39
The B ring, otherwise known as the mucosal or Schatzki ring, is very common, and found in 6% to 14% of subjects having a routine upper GI series
On barium study it is always found in association with a hiatal hernia and is recognized as a thin (2-mm) membrane that constricts the esophageal lumen at the junction of the vestibule and gastric cardia
40
The Schatzki ring has squamous epithelium on its upper surface and columnar epithelium on its lower surface and so demarcates the squamocolumnar junction.
The ring itself is composed of only mucosa and submucosa; there is no muscularis propria. Schatzki rings can be congenital or acquired, and a relationship to GERD is likely
41
Most B rings are asymptomatic, yet when the diameter of the | esophageal lumen is narrowed to
13 mm or less, rings commonly are the cause of intermittent dysphagia for solids or unheralded acute solid-food impactions
42
are developmental anomalies characterized by 1 or more thin horizontal membranes of stratified squamous epithelium within the upper (cervical) esophagus and midesophagus
Esophageal webs Unlike rings, these anomalies rarely encircle the lumen but instead protrude from the anterior wall, extending laterally but not to the posterior wall Webs are fragile membranes and so respond well to esophageal bougienage with mercury-weighted dilators.
43
refers to the appearance on endoscopy of a small (0.5 to 2 cm) distinctive, velvety red island of heterotopic gastric mucosa amid a lighter pink squamous mucosa, generally localized immediately below the UES
inlet patch
44
In rare instances, an inlet patch is found in association with an esophageal web or stricture74 or ulcer, the latter resulting in bleeding or perforation.69
Adenocarcinoma arising in an inlet patch is a rare complication, although there is a statistically significant association between inlet patches and proximal esophageal adenocarcinomas
45
Diverticula are outpouchings from tubular structures. True diverticula involve all layers of the intestinal wall, whereas
false diverticula are due to herniation of mucosa and submucosa through the muscular wall True diverticula are often assumed to be congenital lesions, and false diverticula are assumed to be acquired, but this is not always the case. Some authors reserve the terms false diverticula or pseudodiverticula for diverticula caused by an inflammatory process.
46
The prevalence of Zenker diverticula has been estimated to | be between 0.1% and 0.01%.
Patients generally present in the seventh or eighth decade of life. Twice as many men as women develop Zenker diverticula
47
Zenker diverticula are acquired. They develop when abnormally high pressures occur during swallowing, leading to mucosa that protrudes through an area of anatomic weakness in the pharynx known as
Killian triangle (`
48
Killian triangle is | located posteriorly where the
transverse fibers of the cricopharyngeus muscle of the upper esophageal sphincter (UES) intersect with the oblique fibers of the inferior pharyngeal constrictor muscle. With a Zenker diverticulum, opening of the UES is impaired, generating high pressures with swallowing
49
are seen just below the cricopharyngeus and have a similar presentation to Zenker diverticula.
Killian-Jamieson diverticula
50
, a palpable nodule or swelling on the left anterior | neck that may gurgle on palpation, can be found
Boyce sign
51
Zenker diverticulum can be suspected from a careful history.
Barium swallow is the most useful diagnostic study Barium swallow in the lateral view using video fluoroscopy is helpful for detecting small diverticula
52
During endoscopy, Zenker diverticulum should be | suspected if, on entering the pharynx, the UES cannot be located.
In such cases, the endoscopy should be stopped, and the patient sent for a barium study.
53
Presenting Symptoms in Patients with a Zenker | Diverticulum
``` Aspiration Choking Dysphagia Halitosis Regurgitation Voice changes Weight loss ```
54
Squamous cell cancer may develop in Zenker diverticula;
the estimated | incidence is 0.4% to 1.5%.
55
Zenker diverticula may be treated by open surgical procedures or by transoral endoscopic techniques using rigid or flexible endoscopes
Open surgery for Zenker diverticula is typically performed through the left neck in patients with large (>5 cm) diverticula that extend into the thorax
56
Large diverticula can be resected, inverted, or suspended (diverticulopexy).
Cricopharyngeal myotomy is performed to treat the hypertonic cricopharyngeus muscle, and is the key aspect to treating this disorder; the hypertonic cricopharyngeus muscle must be divided to relieve distal obstruction.
57
If diverticula are | resected without myotomy,
there is an increased risk of postoperative | leaks and an increased frequency of recurrence.
58
Complications of open surgery include anastomotic leaks, mediastinitis, esophagocutaneous fistula, and vocal cord paralysis from injury to the recurrent laryngeal nerve, which runs in the tracheoesophageal groove.
Endoscopic treatment of Zenker diverticulum can be performed using a rigid endoscope or flexible endoscope, with division of the fibrotic septum between the esophagus and the diverticulum Endoscopic techniques are suitable for patients with medium-sized diverticula (2 to 5 cm).
59
This septum is composed of the posterior wall of the esophagus and the anterior wall of the diverticulum and includes the UES.
The muscular layers of this | septum (and UES) are incised, restorating a single lumen.
60
Traction diverticula are related to an inflammatory, | fibrotic, or neoplastic process outside of the esophagus.
Traction diverticula are often related to mediastinal inflammation associated with tuberculosis or histoplasmosis
61
Pulsion diverticula are typically caused by motility disorders. The most common type of pulsion diverticula is an epiphrenic diverticula, which is located near the diaphragmatic hiatus (
About 80% of epiphrenic diverticula are associated with esophageal motility disorders such as achalasia or distal esophageal spasm,
62
Epiphrenic diverticula have been reported as a complication of band-based obesity surgery,
due to obstruction of the esophagus and upper | stomach by the band
63
Squamous cell carcinoma has been reported in epiphrenic diverticula. 44,45
As with Zenker diverticula, accumulation of radioactive iodine tracer in esophageal diverticula has been mistaken for metastatic thyroid cancer To prevent gastroesophageal reflux after myotomy, a partial posterior (Toupet) or anterior (Dor) fundoplication may be performed.
64
EIP most commonly in their sixth or seventh decades. The condition is slightly more common in men than in women.54
EIP are abnormally dilated ducts of submucosal glands. They are thought to be acquired and are often associated with conditions that cause chronic esophageal inflammation.
65
A hernia is a protrusion of an organ or structure into an opening or pouch. Abdominal wall hernias protrude through the muscular and fascial walls of the abdomen and have 2 parts:
(1) the orifice or defect in the aponeurotic wall of the abdomen, and (2) the hernia sac, which consists of peritoneum and abdominal, contents.
66
Abdominal wall hernias are external if the sac protrudes through the abdominal wall or interparietal if the sac is contained within the abdominal wall.
Internal hernias are contained within | the abdominal cavity and do not always have a hernia sac
67
Hernias are reducible when the protruding contents can be returned to the abdomen and irreducible or incarcerated when they cannot.
A hernia is strangulated when the vascular supply | of the protruding organ is compromised,
68
where only one side of the bowel (most often the antimesenteric side) protrudes through the hernia orifice.
Richter hernia,
69
3 main types of diaphragmatic hernias:
hiatal and paraesophageal hernias (both involve the hiatus), congenital hernias, and traumatic hernias most common diaphragmatic hernias are sliding hernias of the stomach through the esophageal hiatus hiatal and paraesophageal hernias.
70
Sliding hiatal hernias (type I) occur when the gastroesophageal junction and some portion of the stomach are displaced above the diaphragm, but the orientation of the stomach axis is unchanged.
The frequency of sliding hiatal hernias increases with age. The phrenoesophageal membrane anchors the gastroesophageal junction to the diaphragm Hiatal hernias may be caused by age-related deterioration of this membrane, combined with normal positive intra-abdominal pressure and traction of the esophagus on the stomach as the esophagus shortens during swallowing
71
``` Paraesophageal hernias (type II) occur when the stomach protrudes through the esophageal hiatus alongside the esophagus (Fig. 27.1A). ```
The gastroesophageal junction remains in a normal position at the level of the diaphragm, because there is preservation of the posterior phrenoesophageal ligament and normal anchoring of the gastroesophageal junction, and only the stomach moves proximally
72
Most paraesophageal hernias contain a sliding hiatal component
in addition to the paraesophageal component and are thus | mixed diaphragmatic hernias (type III
73
other intra-abdominal structures (e.g., | omentum, colon, spleen) may also herniate
(type IV cross sectional imaging with CT scan will be the test of choice to document a type IV defect, as the barium study may not reveal adjacent colon or pancreas through the hiatus.
74
Does the gastroesophageal junction lie at or above the hiatus? (2) Does the stomach or any other visceral structure lie above the gastroesophageal junction?
For example, if the gastroesophageal junction is above the hiatus and there is stomach above it, the patient has a type III (mixed) hernia
75
14% to 84% of patients examined, depending on the | patient population, method of diagnosis, and symptoms present.
In general, hiatal hernias are more frequent in patients with GERD. About 90% to 95% of hiatal hernias found by radiograph are sliding (type I) hernias; the remainder are paraesophageal hernias.
76
With chest radiography, a hiatal hernia may be noted as a soft tissue density or an air-fluid level in the retrocardiac area
Hiatal hernias are sometimes diagnosed on | UGI barium studies.
77
Cameron lesions or linear erosions may develop in patients | with sliding hiatal hernias, particularly large hernias
These mucosal lesions are usually found on the lesser curve of the stomach at the level of the diaphragmatic hiatus This is the location of the rigid anterior margin of the hiatus formed by the central tendon of the diaphragm Cameron lesions may cause acute or chronic UGI bleeding with a poor response to acid suppression therapy.14 Iron deficiency anemia due to chronic bleeding is seen in 30% to 40% of patients with paraesophageal hernia
78
Gastric volvulus is a life-threatening complication of paraesophageal hernia.
Symptoms include acute abdominal pain and | retching, and it can progress rapidly to a surgical emergency (
79
Simple sliding hiatal hernias do not require treatment, unless symptomatic from reflux (see Chapter 46). Patients with symptomatic giant sliding hiatal hernias, paraesophageal, or mixed hernias should be offered surgery.
When closely questioned, most | patients with type II, III, or IV hernias will have symptoms
80
motility disorders, the surgeon may elect to perform | a loose anterior wrap
(Dor fundoplication) or use a gastrostomy | tube or gastropexy to fix the stomach intra-abdominally
81
The principles of surgery for repair of hiatal or paraesophageal hernias include 4 main elements:
(1) reduction of the hernia from the mediastinum or chest, with excision of the hernia sac; (2) reconstruction of the diaphragmatic hiatus, with simple posterior closure with or without bolstering with prosthetic mesh; (3) providing bulk at the hiatus to prevent prolapse into the chest with a fundoplication, which can lessen postoperative reflux; and (4) addition of a gastropexy or gastrostomy tube to provide an additional tacking mechanism for the stomach intraabdominally.
82
Patients with sliding hiatal or paraesophageal hernias may have shortening of the esophagus. This makes it difficult to restore the gastroesophageal junction below the diaphragm without tension, a key factor in decreasing recurrence.
In such cases, an extra length of neoesophagus can be constructed from the proximal stomach (Collis-Nissen procedure
83
Recurrence is higher in obese patients and many will favor a
Roux-en-Y gastric bypass (RYGB) procedure in those that have a BMI greater than 35kg/m2
84
Hernias manifesting in neonates are most often
Bochdalek The key finding is a posterior chest mass, as the defect of Bochdalek is posterior Morgagni hernias are anterior,
85
are ingested materials (food or | other materials) that accumulate in a normal or abnormal stomach.
Bezoars
86
The most common patient group that unintentionally ingests | foreign bodies is children, particularly those between
ages 6 months and 3 year Children account for 80% of true foreign body ingestions Coins are the most common objects swallowed by children, but other frequently swallowed objects include marbles, small toys, crayons, nails, and pins
87
The most common groups that intentionally ingest foreign | bodies are
psychiatric patients and prisoners,21 in whom ingestion | is often done for secondary gain
88
The vast majority (75% to 100%) of patients with | an esophageal food impaction have an underlying predisposing
esophageal pathology,25,26 most often peptic strictures, Schatzki rings, and increasingly eosinophilic esophagitis (EoE Food impactions most commonly occur in adults in their fourth or fifth decade of life but are becoming more prevalent in young adults because of the rising incidence of eosinophilic esophagitis
89
``` The majority (≈ 80% to 90%) of GIFBs pass through the GI tract without any clinical sequelae and cause no harm to the patient.1,35 ```
The remaining 10% to 20% of GIFBs will require endoscopic | intervention, and 1% of GIFBs may require operative therapy.
90
The pharynx is the first area where foreign bodies | may become entrapped and cause complications.
In the hypopharynx, short sharp objects like fish bones and toothpicks may lacerate the mucosa or become lodged
91
Once in the esophagus, there are 4 areas of narrowing where | food boluses and foreign bodies become lodged:
upper esophageal sphincter, level of the aortic arch, level of the mainstem bronchus, and esophagogastric junction These areas all have luminal narrowing to 23 mm or less.4
92
Foreign body and food impaction in the esophagus have the highest incidence of overall adverse events, with the complication rate directly proportional to how long the object is lodged in the esophagus.
Esophageal foreign bodies in children have a significantly lower spontaneous passage rate, as low as 12% compared with other GIFBs
93
``` Large objects (>2.5 cm [1 inch] in diameter) may not be able to pass through the pylorus. ```
Long objects (>5 cm [2 inches]) such as pens, pencils, and eating utensils may not negotiate around the duodenal sweep or through the pylorus
94
Inserted rectal objects are often tenaciously retained because of anal sphincter spasm and edema, making spontaneous passage of the object difficult.
The angulation and valves of Houston may | also impede passage of objects through the rectum.
95
Diagnostic upper endoscopy for foreign bodies is relatively contraindicated when there are clinical or radiographic signs of perforation. Once an ingested foreign object has passed the ligament of Treitz, endoscopy is generally not indicated, because these objects will typically pass unimpeded with notable exceptions (see later).
Similarly, most small (<2.5 cm) blunt objects in an adult patient’s stomach do not require endoscopic retrieval; most will pass without complication
96
80% to 90% of GIFBs will spontaneously pass through | the GI tract without complication
smooth muscle relaxant glucagon is the most widely used and studied drug for the treatment of esophageal food and foreign object impactions. Glucagon, given in intravenous doses of 0.5 to 2 mg, can produce relaxation of the lower esophageal sphincter Nifedipine and nitroglycerin are not recommended because of hypotension-related side effects and questionable efficacy.
97
Ideally, no object should be left in the esophagus | longer than
24 hours. Objects longer than 5 cm and round objects wider than 2.5 cm also may not be passed and should be removed from the stomach with an endoscope at presentation or if they have not progressed in 3 to 5 days.
98
More than 75% of patients with food impactions have associated esophageal pathology,5,26 and about half of patients with food bolus impactions have abnormal 24-hour esophageal pH studies and/or esophageal manometry.
If an esophageal stricture or Schatzki ring is present after the food bolus is cleared, it can be safely and effectively dilated concurrently if circumstances allow. More often, mucosal abrasions or erythema from the food dwelling in the esophagus for an extended period exists, and dilation is delayed for 2 to 4 weeks, during which patients should be prescribed proton pump inhibitor therapy
99
Sharp and pointed objects may cause a perforation in up to 15% to 35% of patients and account for one third of all perforations from GI foreign bodies, with a 2.5-fold greater risk of complications compared to other GIFB
Sharp and pointed objects retained in the esophagus are considered a medical emergency and should be removed within 6 to 12 hours.
100
Ingested objects longer than 5 cm (2 inches), especially those
longer than 10 cm (4 inches), have difficulty passing through the pylorus and duodenal sweep and can get hung up, causing obstruction or perforation at these locations Long objects should be grasped at one end and oriented longitudinally to permit removal. For extraction of long objects, use of the 60-cm overtube endoscope assembly, as described earlier, should be considered
101
In adults, the pylorus will allow passage of most blunt objects up to 25 mm in diameter, which includes all coins except half-dollars (30 mm) and silver dollars (38 mm
once in the stomach, a regular diet is appropriate, with radiographic monitoring every 1 to 2 weeks to confirm progression or elimination. If after 3 to 4 weeks a blunt object has not passed, endoscopic removal should be performed.
102
Half of patients with disc batteries in the stomach have mucosal damage and thus gastric batteries should also be removed via the endoscope.127 Once in the small intestine, disc batteries rarely cause clinical problems and can be observed radiographically, with 85% passing through the GI tract within 72 hours
Body stuffers are drug users or traffickers who quickly ingest small amounts of drugs, but in poorly wrapped or contained packages that are prone to leakage. Body packers are “mules” used by drug smugglers for drug transport; they ingest large quantities of carefully prepared packages intended to withstand GI transit
103
Bezoars are collections of indigestible material that accumulate in the GI tract, most frequently in the stomach.
The 3 most common types of bezoars encountered are phytobezoars, composed of vegetable matter; trichobezoars, made up of hair or hair-like fibers; and medication bezoars (pharmacobezoars) Phytobezoars are the most common type of bezoar. Offending fruits and vegetables include celery, pumpkin, prunes, raisins, leeks, beets, and persimmon
104
is a term used to describe trichobezoars located primarily in the stomach that extend past the pylorus and into the duodenum, causing bowel obstruction or even jaundice or pancreatitis because of obstruction at the level of the ampulla of Vater.
Rapunzel syndrome
105
Alkaline ingestion causes a liquefactive necrosis that very rapidly extends through the mucosa, submucosa, muscularis of the esophagus, and stomach
Vascular thrombosis occurs following | the necrosis.
106
Acidic agents cause a coagulative necrosis, with thromboses of mucosal blood vessels and a more limited superficial necrosis.
Acidic agents are more apt to damage the stomach, particularly the antrum, more than the esophagus With alkali ingestion, the esophagus is most affected; neutralization by gastric acid limits damage in the stomach. Acidic agents tend to be ingested in smaller quantities because of their offensive taste and immediate pain, so they are associated with less overall damage than alkali agents.
107
TABLE 28.1 Endoscopic Grades of Caustic Injury Grade Endoscopic Findings Grades I and IIA burns, which correspond to first- and second-degree burns, will usually heal without sequelae.
I Edema and erythema IIA Hemorrhage, erosions, blisters, ulcers with exudate IIB Circumferential ulceration III Multiple deep ulcers with brown, black, or gray discoloration IV Perforation strictures will develop in 70% to 100% of patients with grade IIB injury, which causes circumferential ulceration, and grade III injury with associated necrosis. Grade IV injury with perforation carries a mortality rate of up to 65% and requires urgent surgery
108
Up to one third of caustic ingestion patients will develop esophageal stricture after initial recovery (see Fig. 28.13)
Stricture formation presents most commonly at 2 months after injury but can occur at any time from 2 weeks to many years after the initial injury. Perforation 24-72 hours Endoscopic injection of triamcinolone into the stricture or use of topical mitomycin has been reported to be beneficial in treating caustic strictures
109
Alkaline caustic ingestion, in particular, is associated with an increased risk for squamous cell cancer of the esophagus.
atients with a history of lye ingestion have a 1000-fold increased risk of developing esophageal cancer, with a lag time from injury of approximately 40 years
110
is the most specific to the eosinophil lineage and is | responsible for the selective differentiation of eosinophils
IL-5 hypereosinophilic syndrome (HES)121; this syndrome is defined by sustained, severe peripheral blood eosinophilia (>1500 cells/ mm3) and the presence of end organ involvement in the absence of known causes for eosinophilia
111
EoE representing the second most common | cause of chronic esophagitis.
The etiology of EoE is poorly understood, but food allergy has been implicated as a primary contributor.
112
The diagnostic criteria for EoE in 2011,83 emphasized | that EoE requires finding
15 or more eosinophils/HPF (peak value) in the esophagus. This definition is based on a 2017 consensus recommendation that PPI-responsiveness is not considered in the diagnosis of EoE, as PPI-REE has phenotypic, genetic, and molecular features that overlap with PPI-resistant esophageal eosinophilia. With few exceptions, 15 eosinophils/ HPF (peak value) is considered a minimum threshold for a diagnosis of EoE.
113
Solid-food dysphagia | continues to be the most common presenting symptom.142
Food impaction necessitating endoscopic bolus removal occurs in 33% to 54% of adults with EoE presence of 15 or more eosinophils/HPF, dilated intercellular spaces and in some cases also elongated papillae, and inflammation and fibrosis in the lamina propria
114
Endoscopic Eosinophilic Esophagitis Reference Score EoE Major Features Edema (Also referred to as decreased vascular markings, mucosal pallor) Grade 0: Absent. Distinct vascularity present Grade 1: Loss of clarity or absence of vascular markings Fixed rings (Also referred to concentric rings, corrugated esophagus, corrugated rings, ringed esophagus, trachealization) Grade 0: None Grade 1: Mild-subtle circumferential ridges Grade 2: Moderate-distinct rings that do not impair passage of a standard diagnostic adult endoscope (outer diameter 8-9.5 mm) Grade 3: Severe-distinct rings that do not permit passage of a diagnostic endoscope
Exudates (Also referred to as white spots, plaques) Grade 0: None Grade 1: Mild-lesions involving less than 10% of the esophageal surface area Grade 2: Severe-lesions involving greater than 10% of the esophageal surface area Furrows (Also referred to as vertical lines, longitudinal furrows) Grade 0: Absent Grade 1: Vertical lines present Stricture Grade 0: Absent Grade 1: Present (specify estimated luminal diameter) Minor features Crepe paper esophagus (Mucosal fragility or laceration upon passage of diagnostic endoscope but not after esophageal dilation) Grade 0: Absent Grade 1: Present Narrow-caliber esophagus (Reduced luminal diameter of the majority of the tubular esophagus) Grade 0: Absent Grade 1: Present
115
histologic scoring system (HSS) for EoE was validated. In addition to identifying 15 or more eosinophils/HPF, 8 other histologic features were shown to differentiate treated from untreated patients and that the HSS outperforms esophageal eosinophil levels for disease diagnosis and monitoring.
The 8 HSS features include eosinophil density, basal zone hyperplasia, eosinophil abscesses, eosinophil surface layering, dilated intercellular spaces, surface epithelial alteration, dyskeratotic epithelial cells, and lamina propria fibrosis. Severity and extent are scored using a 4-point scale, with 0 being normal and 3 denoting maximum change
116
Up to 7 eosinophils/HPF (400×) is most indicative of GERD, 7 to 15 eosinophils/HPF likely represents a combination of GERD and food allergy,
and at least 15 eosinophils/HPF is characteristic of EoE. dietary therapy, topical glucocorticoids, and a PPI
117
The practice of gradual esophageal dilation with a target goal of 15 to 18 mm and of limiting the progression of dilation diameter per session to
3 mm or even less if resistance is encountered is reasonable but has not been specifically addressed in patients with EoE
118
When using topical glucocorticoids in the form of fluticasone, a metered-dose inhaler without a spacer has been advocated83;
alternatively, a slurry of budesonide (in the form used for nebulizers) with sucralose (Splenda) also has been recommended
119
PPI therapy can establish histologic remission and symptom The duration of untreated EoE is a good predictor of stricture risk
amelioration in 50% and 60% of EoE patients, respectively The 2017 European guidelines use high-dose PPI for 8 weeks as a first line in the treatment algorithm for EoE.
120
EG can | be diagnosed when at least 30 eosinophils/HPF is identified in
at least 5 distinct HPFs in the stomach19 The mucosal form of EGE, the most common variant, is characterized by vomiting, abdominal pain that can even mimic acute appendicitis, diarrhea, blood loss in the stools, iron-deficiency anemia, malabsorption, protein-losing enteropathy, and failure to thrive.193,208 The muscularis form is characterized by infiltration of eosinophils predominantly in the muscularis layer, leading to thickening of the bowel wall, which may result in symptoms of GI obstruction mimicking pyloric stenosis or other causes of gastric outlet obstruction. The serosal form occurs in a minority of patients with EGE, and it is characterized by exudative ascites with higher peripheral eosinophil counts compared with the other forms
121
Acute esophageal injury is believed to be primarily related to radiation damage to the basal epithelial layer, manifested histologically by vacuolization, resulting in epithelial thinning followed by denudation
These changes manifest clinically as dysphagia, odynophagia, and substernal discomfort, usually occurring within 2 to 3 weeks following initiation of RT Abnormal peristalsis has been reported at 1 to 3 months following treatment completion, whereas most strictures occur 4 to 8 months following treatment completion. Late effects are usually not seen until 3 months following completion of RT Complete epithelial recovery from radiation effects may take 3 to 24 months
122
It is estimated that approximately half of patients receiving upper abdominal radiation will experience emesis
within 2 to 3 weeks | following radiation initiation
123
Late effects of gastric irradiation have been classified into 4 categories:
(1) acute ulceration (occurring shortly after completion of RT); (2) gastritis with smoothened mucosal folds and mucosal atrophy on endoscopy, accompanied by radiographic evidence of antral stenosis (1 to 12 months following irradiation) (see Chapter 52); (3) dyspepsia, consisting of vague gastric symptoms without obvious clinical correlate (6 months to 4 years following irradiation); and (4) late ulceration (averaging 5 months after irradiation)
124
The nasopharynx extends from the | base of the skull to the distal edge of the soft palate.
Muscles in the nasopharynx elevate the soft palate during swallowing, seal the nasopharynx, and prevent nasopharyngeal regurgitation. The oropharynx extends from the soft palate to the base of the tongue. The inferior margin of the oropharynx is demarcated by the valleculae anteriorly and the mobile tip of the epiglottis posteriorly
125
The esophagus is a 20- to 22-cm tube composed of skeletal and smooth muscle.
The proportion of each muscle type is species dependent, but in humans, the proximal 5% is striated, the middle 35% to 40% is mixed with an increasing proportion of smooth muscle distally, and the distal 50% to 60% is entirely smooth muscle
126
The outer longitudinal muscle arises from the cricoid cartilage with slips from the cricopharyngeus passing dorsolaterally to
fuse posteriorly about 3 cm distal to the cricoid cartilage. This results in a posterior triangular area devoid of longitudinal muscle, Laimer triangle.
127
The longitudinal muscle of the esophagus also contracts during peristalsis, with
the net effect of transiently shortening the structure by 2 to 2.5 cm. The esophagus is normally atonic and its intraluminal pressure closely reflects pleural pressure, becoming negative during inspiration
128
(tLESRs) are an important mechanism in GERD pathogenesis and are the most frequent mechanism for reflux during periods of normal LES pressure (see Chapter 46). tLESRs are distinguishable from swallow-induced relaxation in several ways: (1) they are prolonged (>10 seconds) and independent of pharyngeal swallowing; (2) they are associated with contraction of the distal esophageal longitudinal muscle, causing
esophageal shortening; (3) there is no synchronized esophageal peristalsis; and (4) they are associated with crural diaphragm inhibition, which is not the case with swallow-induced relaxation (Fig. 44.7).27,28 tLESRs occur most frequently in the postprandial state during gastric distention. In the setting of the completely relaxed EGJ during tLESRs, even the minimal gastroesophageal pressure gradients observed with gastric distention (3 to 4 mm Hg) are sufficient to facilitate gas venting of the stomach. Thus, tLESRs are the physiologic mechanism of belching.
129
Achalasia is the most easily recognized and best-defined motor disorder of the esophagus
affecting both genders equally | and usually presenting between 25 and 60 years of age
130
The most common structural abnormalities of the | hypopharynx associated with dysphagia are
hypopharyngeal | diverticula and cricopharyngeal bars.
131
Achalasia is characterized by impaired LES relaxation with | swallowing and aperistalsis in the smooth muscle esophagus.
If there are premature, spastic contractions in the esophageal body, the disease is referred to as spastic (type III) achalasia.
132
damage to the innervation | of the smooth muscle segment of the esophagus
(including the LES) with loss of ganglion cells within the myenteric (Auerbach) plexus.
133
Muscle strips from the circular layer of the esophageal body of achalasics contract when directly stimulated by ACh but fail to respond to ganglionic stimulation by nicotine,
indicating a postganglionic excitatory defect Regardless of excitatory ganglion neuron impairment, it is clear that inhibitory ganglion neuron dysfunction is as an early manifestation of achalasia. These neurons mediate deglutitive inhibition (including LES relaxation) and the sequenced propagation of esophageal peristalsis; their absence offers a unifying hypothesis for the key physiologic abnormalities of achalasia: impaired LES relaxation and aperistalsis Achalasics have been shown to lack NO synthase and have a marked reduction of VIP-staining neurons in the gastroesophageal junction.
134
The neuromuscular pathology responsible for DES is | unknown and there are no known risk factors.
The most striking reported pathologic change is of diffuse muscular hypertrophy or hyperplasia in the distal esophagus with thickening of up to 2 cm.
135
Chicago Classification labels this condition | “jackhammer esophagus” when
2 such contractions occur in | a manometric study
136
All patients have solid food dysphagia; the majority of patients also have variable degrees of liquid dysphagia. Clinical manifestations of achalasia may include dysphagia, regurgitation, chest pain, hiccups, halitosis, weight loss, and aspiration pneumonia
achalasia It tends to be nonbilious, nonacid, and mixed with copious amounts of saliva. neuromuscular apparatus facilitating UES relaxation as part of the belch reflex is compromise
137
The major symptoms of DES are
dysphagia and chest pain. Weight loss is rare Dysphagia is usually intermittent and sometimes related to swallowing specific substances such as red wine or liquids at extreme hot or cold temperature
138
Pseudoachalasia becomes more likely | than idiopathic achalasia with advanced age (>50 years),
abrupt and recent onset of symptoms (<1 year), and early weight loss in excess of 7 kg.
139
Dysphagia is common in the early period following fundoplication, and patients are advised to consume soft diets for the first 2 to 4 postoperative weeks.
Dysphagia that persists longer than 4 weeks should be evaluated with an upper endoscopy or barium esophagogram to assess the integrity of the wrap and evaluate for possible paraesophageal hernia.
140
Features suggesting an esophageal, as opposed to a cardiac, etiology of pain include: (1) prolonged nonexertional pain, (2) pain that interrupts sleep, (3) meal-related pain, (4) relief with antacids, and (5) additional accompanying esophageal symptoms
such as heartburn, dysphagia, or regurgitation.
141
should be the first test for evaluating newonset dysphagia, because it combines the ability to detect most structural causes of dysphagia with the ability to obtain biopsies.
Upper endoscopy
142
Achalasia
Type I: No contractility Type II: >= 20% PEP Type II: >= 20% Spasm (DL <4.5 sec) In the patient with classic achalasia (Type I), there is no significant pressurization within the body of the esophagus and EGJ relaxation is impaired; swallow from a Type II patient, the “achalasia with compression” subtype, shows rapid pan-esophageal pressurization of the fluid column trapped between the sphincters as the esophagus shortens. The pressure topography plot in the Type III patient is typical of spastic achalasia.
143
Type I (classic) 100% failed peristalsis, IRP > ULN
``` Type II (with esophageal compression) 100% failed peristalsis and panesophageal pressurization with ≥20% of swallows; mean IRP > ULN ``` Type III (spastic) No normal peristalsis, premature contractions with ≥20% of swallows, mean IRP > ULN
144
DES Mean IRP < ULN, ≥20% premature contractions with DCI >450 mm Hg•sec•cm, some normal peristalsis may be present
``` Hypercontractile (jackhammer) esophagus At least 2 swallows with DCI >8000 mm Hg•sec•cm, may involve or even localize to the LES Absent contractility Mean IRP ≤10 mm Hg, 100% absent contractility (DCI <100 mm Hg•sec•cm) ```
145
The major complication of pneumatic dilation is esophageal perforation, with a reported incidence ranging between 0% and 5% and a global average of 1%.86
With most perforations readily evident (or at least suspected) within an hour of the procedure because of persistent or severe chest pain, fever, or subcutaneous emphysema, patients should be observed for signs of an esophageal leak for at least 2 hours after pneumatic dilation.
146
per oral endoscopic myotomy | (POEM),
requires making a transverse mucosal incision in the mid-esophagus, entering it, and creating a submucosal tunnel all the way to the gastric cardia using a forward-viewing endoscope with a transparent distal cap and a triangular dissection knife Once the subcutaneous tunnel is complete, the endoscope is withdrawn and selective myotomy of the circular muscle accomplished with electrocautery tools for a variable length up the esophagus and 2 cm distal to the EGJ onto the gastric cardia. Endoclips are then used to seal the entry incision.
147
may develop in the achalasic esophagus.
Squamous cell carcinoma
148
Medications directly damage the esophageal mucosa through 1 of 4 known mechanisms:
(1) production of a caustic acidic solution (e.g., ascorbic acid and ferrous sulfate); (2) production of a caustic alkaline solution (e.g., alendronate); (3) creation of a hyperosmolar solution in contact with esophageal mucosa (e.g., potassium chloride); and (4) direct drug toxicity to the esophageal mucosa (e.g., tetracycline).
149
diffuse | sloughing appearance of the mucosa, also known as
esophageal dissecans | superficialis,
150
particularly for gelatin capsules and larger tablets,3 | the following recommendations are made:
(1) medications should be swallowed with at least 8 ounces of a clear liquid; (2) patients should remain upright for at least 30 minutes following ingestion of the medication; and (3) in patients with potential underlying increased risk for pill-induced injury (e.g., inability to follow the previous instructions, poor esophageal motility, anatomic compromise of the esophageal lumen), one should search for alternative safer medications or carefully weigh the risks and benefits of this medication against the disease for which this medication is necessary.
151
has low potential for causing esophageal injury, if at all.42 Part of this might be explained by the rapid esophageal transit and subsequently minimal contact time of the drug with esophageal mucosa
Risedronate
152
Chemotherapy given months after thoracic irradiation | to the esophagus, particularly doxorubicin, may cause a
“recall” esophagitis. Vinca alkaloid drugs are neurotoxic, and dysphagia may complicate vincristine therapy.82 Crizotinib, a tyrosinekinase inhibitor used for non–small cell lung cancer, has been reported to cause severe ulcerative esophagitis similar to a more typical pill-induced esophagitis
153
The only agent that has been shown effective in preventing postsclerotherapy strictures and in healing ulcers is sucralfate, either alone or in combination with antacids and cimetidine.102,103
Acid suppressive therapy alone, with either H2RAs or PPIs, has not been shown to be effective in preventing or healing postsclerotherapy ulcers or strictures.
154
lacerations of the gastric cardia due to forceful vomiting.140 The laceration is felt to result from shearing forces on the gastroesophageal junction and proximal stomach as it herniates through the diaphragm because of high intra-abdominal pressures due to forceful vomiting.
Mallory-Weiss syndrome this shearing force has its greatest effect when there is a hiatal hernia, thereby exposing a relatively large-volume dilated sac to a high wall tension. most tears will occur within 2 cm of the gastroesophageal junction, the likelihood of a more distal tear in the proximal portion of the stomach is increased when a larger hiatal hernia is present
155
MW tear Typically, one laceration is seen at the time of endoscopy, most commonly along the lesser curve of the cardia, although more than one tear may occur in up to 10% of patients.14
3 Bleeding is typically self-limited, but may be | massive in up to 10% of patients
156
A more extreme version of an esophageal tear that occurs from an acute increase in intra-abdominal pressure and accentuation of
the intragastric-to-intrathoracic pressure gradient is Boerhaave syndrome In this syndrome, a transmural tear with perforation occurs. The perforation specifically occurs at the margin of the contact between “clasp” and oblique esophageal fibers The clinical presentation is often catastrophic, with shock and sepsis due to a large esophageal perforation. Not surprisingly, death occurs in up to a third of patients.170 Because of the acute presentation of severe chest pain, it is often confused with acute cardiac or pulmonary events, dissecting aortic aneurysm, or pancreatitis
157
booerhave
Diagnosis is suggested by subcutaneous emphysema with crepitus and radiographic findings of pneumomediastinum and a left pleural effusion (that may contain salivary amylase, erroneously suggesting pancreatitis) or even a frank empyema. Perforation of the esophagus may be confirmed by esophageal contrast studies using Gastrografin.
158
is a rare entity in which an abrupt bleed occurs between the mucosa and muscularis propria of the esophageal wall, often for a long length of the esophagus.
Spontaneous esophageal hematoma
159
One third of patients classically present with a triad of retrosternal chest pain, dysphagia, and hematemesis and 50% present with at least 2 of these symptoms
Spontaneous esophageal hematoma Diagnosis can be made by several means. CT of the chest demonstrates a diffusely thickened esophagus and sometimes a “double barrel” appearance with obliteration of the esophageal lumen. Endoscopically, obliteration of the esophageal lumen is seen with visualization of a long, deep, friable, blue submucosal mass with or without a visible tear
160
HSV esophagitis may be diagnosed by several methods. These include (1) characteristic viral cytopathic effect and/or demonstration of viral particles by electron microscopy on esophageal brushing or biopsy; (2) isolation by culture of HSV from mucosal biopsies; (3) HSV DNA detection in esophageal tissue by PCR; (4) demonstration of HSV through techniques of immunohistochemistry in esophageal tissue; and (5) isolation of HSV from oropharyngeal secretions in the setting of stomatitis and multiple esophageal ulcers
hsv Histologic stains of HSV-infected epithelial cells demonstrate multinucleated giant cells, ballooning degeneration, “ground glass” intranuclear Cowdry type A inclusion bodies, and margination of chromatin
161
transmitted. Esophageal infections with HPV are typically asymptomatic. HPV lesions are most frequently found in the
mid- to distal esophagus as erythematous macules, white plaques, nodules, or exuberant frond-like lesions The diagnosis is made by histologic demonstration of koilocytosis (an atypical nucleus surrounded by a ring), giant cells, or by immunohistochemical stains Treatment is often not necessary, although large lesions have required endoscopic removal. Other treatments such as those using systemic interferon (IFN)-α, bleomycin, and etoposide have yielded varying results
162
Acute esophageal necrosis (black esophagus) is a rare poorly understood disorder. Ischemia and impaired mucosal barrier are thought to play a role in its pathogenesis,241 though other etiologies suggested have included
severe reflux and CMV.242 Settings in which black esophagus have been described include diabetes mellitus, hematologic and solid organ malignancy, malnutrition, renal insufficiency, cardiovascular compromise, trauma, and hypercoagulation.
163
There is no clear association between gender and peptic stricture,5 but
men are at a greater risk of esophagitis, Barrett’s esophagus, and adenocarcinoma than women. Obesity is a major risk factor for GERD symptoms (odds ratio 1.73), erosive esophagitis (odds ratio 1.59), Barrett’s esophagus (odds ratio, 1.24), and esophageal adenocarcinoma (odds ratio 2.45) Central obesity, as measured by the waist-to-hip ratio, may be more important than BMI in association with complicated GERD
164
Certain forms of physical activity may increase GER symptoms in susceptible individuals, such as stooped posture, bicycle riding, weight lifting, and swimming.21 On the other hand, moderate, regular aerobic exercise has been inversely associated with GERD symptoms
Tobacco use is weakly associated with GERD symptoms in cross-sectional studies (summary odd ratio, 1.26).3 This relationship is supported by an 18-year longitudinal study in which decreased tobacco smoking was associated with a 3-fold decrease in GERD symptoms when compared with individuals who continued to smoke tobacco alcohol use was not strongly associated with GERD symptoms, (summary odds ratio, 1.11).3 Although patients often report worse symptoms after red wine than white (perhaps related to the tannins in red wine), a randomized trial found that red wine had less effect on LES pressure and acid reflux than white wine.
165
Tobacco is an important risk factor for erosive esophagitis | and esophageal adenocarcinoma,
but there is no relationship | between alcohol and erosive esophagitis or Barrett’s esophagus
166
The first tier of the 3-tiered esophageal defense against acid damage,
the antireflux barriers, is an anatomically complex region including the intrinsic LES, diaphragmatic crura, intra-abdominal location of the LES, the phrenoesophageal ligaments, and the acute angle of His The LES involves the distal 3 to 4 cm of the esophagus and at rest is tonically contracted
167
Increase LES Pressure Gastrin Motilin Substance P α-Adrenergic agonists β-Adrenergic antagonists Cholinergic agonists Protein ``` Antacids Baclofen Cisapride Domperidone Histamine Metoclopramide Prostaglandin F2α ```
Decrease LES Pressure ``` CCK Secretin Somatostatin Vasoactive intestinal peptide ``` α-Adrenergic antagonists β-Adrenergic agonists Cholinergic antagonists Chocolate Fat Peppermint ``` Barbiturates Calcium channel blockers Diazepam Dopamine Meperidine Morphine Prostaglandins E2 and I2 Serotonin Theophylline ```
168
The proximal portion of the LES is normally 1.5 to 2 | cm above the squamocolumnar junction,
whereas the distal segment, about 2 cm in length, lies within the abdominal cavity. This location maintains gastroesophageal competence during intra-abdominal pressure excursions. Resting LES pressure ranges from 10 to 30 mm Hg, with a generous reserve capacity because only a pressure of 5 to 10 mm Hg is necessary to prevent GER During deep inspirations and some periods of increased abdominal straining, these changes may lead to pressures of 50 to 150 mm Hg.
169
Reflux usually occurs via 4 mechanisms:
tLESR, low LES pressure, swallow-associated LES relaxation, and straining during periods of low LES pressure
170
tLESRs are the most frequent mechanism for reflux in patients with healthy sphincter pressures (Fig. 46.2)
. tLESRs occur independently of swallowing, are not accompanied by esophageal peristalsis, persist longer (>10 seconds) than swallow-induced LESRs, and are accompanied by inhibition of the crural diaphragm. Possible factors determining whether reflux occurs include abdominal straining, presence of a hiatal hernia, degree of esophageal shortening, and duration of tLESRs. The dominant stimulus for a tLESR is distention of the proximal stomach by either food or gas,
171
The dominant stimulus for tLESRs is distension of the proximal stomach,
which activates mechanoreceptors in the intraganglionic | lamellar endings of vagal afferents
172
Strained-Induced or Free Reflux Free reflux is characterized by a fall in intraesophageal pH without an identifiable change in intragastric pressure, usually occurring when LES pressure is less than 5 mm Hg. Reflux due to a low or absent LES pressure is uncommon, usually observed in patients with end-stage scleroderma or after myotomy for achalasia
This type of reflux is unlikely when the LES pressure is greater than 10 mm Hg and there is no hiatal hernia
173
requires 2 “hits” to the EGJ.42 Patients with a normal EGJ require inhibition of the LES and crural diaphragm for reflux to occur (i.e., tLESRs).
In contrast, when a hiatal hernia is present compromising the function of the crural sphincter, reflux can occur with only relaxation of the LES, during periods of LES hypotension, swallowinginduced relaxation, and straining.
174
hiatal hernia promotes reflux through several mechanisms (Fig. 46.4). Proximal displacement of the LES from the crural diaphragm into the chest reduces basal LES pressure and shortens the length of the high-pressure zone; this is primarily due to loss of the intra-abdominal LES segment.50
Hiatal hernia eliminates the increase of LES pressure that occurs during straining and increases tLESR frequency during gastric distention with gas.56,57 Hiatal hernias serve as a persistent vestibule for gastric acid (the so-called acid pocket Hiatal hernias that are large (≥3 cm) and nonreducible (hernias in which the gastric rugal folds remain above the diaphragm between swallows) are especially prone to reflux.
175
Gastric pH is usually around 2 in the fasting state.
During meals, and for approximately 90 minutes thereafter, the pH remains elevated owing to the buffering effects of the food. Herein lies a paradox because most episodes of acid reflux occur immediately after a meal. This paradox is explained by the identification of a zone in the gastric cardia that remains unbuffered, now referred to as the acid pocket In GERD patients with hiatal hernia, the acid pocket is further enlarged because of the proximal migration of the LES.
176
In addition, when the acid pocket is located about the diaphragm, especially in a hiatal hernia, more than 70% of the tLESRs were accompanied by acid reflux.
In contrast, less than 20% of tLESRs were accompanied by acid reflux when the acid pocket was below the diaphragm.
177
The second tier of protection against reflux damage is esophageal acid clearance
Primary peristalsis is elicited by swallowing. Secondary peristalsis, initiated by esophageal distention from acid reflux, is much less effective in clearing the refluxate, thus offering only an ancillary protective role
178
Peristaltic dysfunction (i.e., failed peristaltic contractions, hypotensive or weak [<30 mm Hg] peristaltic contractions that incompletely empty the esophagus) increases in frequency with the severity of esophagitis
Saliva is the second essential factor required for normal esophageal acid clearance. The stimulus for salivation appears to be the presence of acid in the proximal esophagus (20 cm above LES).68 The normal daily volume of saliva is 1.2 L, which may triple in response to persistent esophageal acidification. Saliva is a weak base with a pH of 6.4 to 7.8.
179
Cigarette smoking promotes GER. Originally attributed to nicotine’s effect on lowering LES pressure, cigarette smokers also have hyposalivation, leading to prolonged esophageal acid clearance times
third tier for esophageal defense known as tissue resistance. Conceptually, tissue resistance can be subdivided into pre-epithelial, epithelial, and postepithelial factors,
180
The pre-epithelial defense in the esophagus is poorly developed. There is neither a well-defined mucous layer nor buffering capacity by the surface cells to secrete bicarbonate ions into the unstirred water layer
The epithelial defenses consist of structural and functional components. Structural components include the cell membranes and intercellular junctional complexes of the esophageal mucosa. This structure is a 25- to 30-cell-thick layer of nonkeratinized squamous epithelium
181
dilated intercellular spaces are the earliest | markers of esophageal epithelial cellular damage
The postepithelial defense is provided by the esophageal blood supply.
182
Heartburn is the classic symptom of GERD, with patients generally reporting a burning feeling rising from the stomach or lower chest and radiating toward the neck, throat, and occasionally the back.101
It usually occurs postprandially, particularly after large meals or after ingesting spicy foods, citrus products, fats, chocolates, and alcohol. The supine position and bending over may exacerbate heartburn. Sleep deprivation as well as psychological or auditory stress may lower the threshold for symptom perception
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GERD is usually diagnosed symptomatically by the occurrence of heartburn 2 or more days a week, although less frequent symptoms do not preclude the disease
The receptor that mediates the sensation of heartburn during acid perfusion has not been identified, although the capsaicin receptor, or vanilloid receptor 1 (TRPV1), is a leading candidate.
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Water brash is the sudden appearance in the mouth of a slightly sour or salty fluid. It is not regurgitated fluid, but rather secretions from the salivary glands in response to acid reflux
The most common is pregnancy, in which 30% to 80% of women complain of heartburn, especially in the first trimester (see Chapter 40). Pregnancy increases the risk for reflux by reducing LES pressure due to the effects of estrogen and progesterone and possibly mechanical factors from the gravid uterus.
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Up to 90% of patients with scleroderma (PSS or CREST syndrome) have GERD due to smooth muscle fibrosis causing low LES pressure and weak or absent peristalsis
An empirical trial of acid suppression is the simplest method for diagnosing GERD and assessing its relationship to symptoms.
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Symptoms usually respond to a PPI trial in 1 to 2 weeks. If symptoms disappear with therapy and then return when the medication is discontinued, GERD has been established.
In empirical trials for heartburn, the initial PPI dose was high (e.g., omeprazole 40 to 80 mg/day), usually given for at least 2 weeks, and a positive response was defined as at least 50% improvement in heartburn. Using this approach, the PPI empirical trial has a sensitivity of 68% to 83% but poor specificity for determining the presence of GERD.
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The earliest endoscopic signs of acid reflux include edema and erythema, but these findings are nonspecific and dependent on the quality of endoscopic visual images.151 More reliable signs are friability, granularity, and red streaks.
Friability (easy bleeding) results from the development of enlarged capillaries near the mucosal surface in response to acid. Red streaks extend upward from the esophageal junction along the ridges of the esophageal folds.152 Erosions develop with progressive acid injury, characterized by a shallow break in the mucosa with a white or yellow exudate surrounded by erythema
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Most patients with GERD are treated initially with PPIs and | without endoscopy.
The important exception is the patient experiencing “alarm” symptoms: dysphagia, odynophagia, weight loss, vomiting, and GI bleeding
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Other indications include typical GERD symptoms that persist despite a 4- to 8-week trial of twice-daily PPI therapy,
and patients with severe esophagitis after a 2-month | PPI course,
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Classic changes of basal cell hyperplasia and increased height of the rete peg, both representing increased epithelial turnover of the squamous mucosa, are sensitive but not specific histologic findings for GERD
Acute inflammation characterized by the presence of neutrophils and often eosinophils (Fig. 46.8) is very specific for esophagitis;
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Los Angeles Endoscopic Classification System for | Esophagitis
Grade A One or more mucosal breaks confined to folds, ≤5 mm Grade B One or more mucosal breaks >5 mm confined to folds but not continuous between the tops of mucosal folds Grade C Mucosal breaks continuous between tops of 2 or more mucosal folds but not circumferential (<75%) Grade D Circumferential mucosal break (at least 75%)
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GERD exists as a spectrum of disease | severity or as a categorical disease in 3 distinct groups:
erosive, | nonerosive, and Barrett’s esophagus
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Esophageal pH testing identifies 3 distinct subsets of nonerosive GERD patients.
First are the patients with excessive acid reflux who usually respond to PPI therapy. Second are the patients with normal acid reflux parameters but a good correlation between their symptoms and acid reflux episodes. This group represents 30% to 50% of nonerosive GERD patients and, based on recent Rome IV criteria, is classified as “reflux hypersensitivity.” These patients probably have heightened esophageal sensitivity to acid and are less likely to respond to antireflux therapy The third group is characterized by normal acid exposure times and poor symptom correlation. This group is classified as “functional heartburn.
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Patients with erosive esophagitis tend to be male, older, and overweight and are more likely to have hiatal hernias
85% of patients with erosive GERD and given no maintenance reflux therapy will relapse within 6 months of stopping PPI therapy
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The most common fatal causes are hemorrhagic esophagitis, aspiration pneumonia, ulcer perforation, and rupture with severe esophagitis
Strictures occur in 7% to 23% of patients with untreated reflux esophagitis. They are commonly seen in older men194 and linked to chronic NSAID use.195 Stricture formation is complex, starting as reversible inflammation with edema, cellular infiltration, and vascular congestion, progressing to collagen deposition, and ending in irreversible fibrosis
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Peptic strictures are smooth-walled, tapered, circumferential narrowings in the lower esophagus, usually less than 1 cm long but occasionally extend to 8 cm
today a Schatzki’s ring is considered a forme fruste of an early peptic stricture.196 All stricture patients should undergo endoscopy to confirm the benign nature of the lesion and take biopsies to exclude EoE, cancer, and Barrett’s esophagus.
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Antacids increase | LES pressure but work primarily by buffering gastric acid, albeit
Gaviscon, containing alginic acid and antacids, mixes with saliva to form a highly viscous solution that floats on the gastric pool, acting as a mechanical barrier. Recent studies found that the raft colocalized with the postprandial acid pocket and displaced it below the diaphragm, resulting in significant suppression of postprandial acid reflux.
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Currently, the only medication available that decreases | tLESRs is
baclofen, a GABAB agonist used for many years to treat spasticity. Baclofen (5 to 20 mg 3 times daily) significantly reduces tLESRs, decreases both acid and duodenal reflux, and improves symptoms in GERD patients treated for 4 weeks to several months Side effects including drowsiness, dizziness, nausea, and vomiting require discontinuation in up to 20% of patients Other GABAB agonists with improved tolerability have been developed (lesogaberan, arbaclofen placarbil) but were abandoned mainly because of limited clinical efficacy
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These drugs (cimetidine, ranitidine, famotidine, and nizatidine) are more effective in controlling nocturnal than meal-stimulated acid secretion
The 4 H2RAs are equally effective when used in proper doses, usually twice a day before meals. GERD trials H2RAs given at bedtime successfully eliminated this problem in a study, suggesting a new indication for H2RAs in the PPI era
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PPIs inhibit meal-stimulated and nocturnal acid secretion to a significantly greater degree than H2RAs but rarely render patients achlorhydric.
PPIs should be taken before the first meal of the day, when most proton pumps become active. Because not all pumps are active at any given time, a single PPI dose will not inhibit all pumps. A second dose, if necessary, can be taken before the evening meal; however, this is an off-label indication. PPIs do not “cure” reflux disease, rather they treat GERD in an indirect way by decreasing the number of acid reflux episodes. In exchange, the weakly acidic (pH > 4) episodes are increased, while the total number of reflux episodes and proximal extent are not affected by PPI therapy
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PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole) have superior efficacy compared with H2RAs on the basis of their ability to maintain an
intragastric pH greater than 4 from 10 to 14 hours daily compared with approximately 6 to 8 hours daily with the H2RAs PPIs are superior to H2RAs in completely relieving heartburn symptoms in patients with severe GERD, usually within 1 to 2 weeks
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PPIs are well tolerated, with headaches and diarrhea being the most common side effects. Fasting serum gastrin levels increase with all the PPIs, but the elevations generally do not exceed the normal range and return to baseline values within 1 to 4 weeks of drug discontinuation.
Omeprazole decreases the clearance of diazepam, warfarin, and clopidogrel owing to competition for the cytochrome P450 isoenzyme P2C19.
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After esophagitis is healed, recurrence within 6 months of stopping medication occurs in more than 80% of patients with severe esophagitis and in 15% to 30% of those with milder esophagitis
Fundic gland polyps are the most common gastric polyp found at endoscopy Chronic use of PPIs is purported to affect the absorption of calcium, vitamin B12, magnesium, and iron. increased risk of enteric infections (Salmonella, Campylobacter, and Clostridioides difficile) and of spontaneous bacterial peritonitis253,254 with acid suppression
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performed laparoscopically through the abdomen, are | the
Nissen 360-degree fundoplication and the Toupet partial | fundoplication
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Barrett esophagus is diagnosed by endoscopic examination, and 2 criteria must be fulfilled.
First, the endoscopist must ascertain that columnar epithelium lines 1 cm or greater of the distal esophagus. Second, biopsy specimens of that columnar epithelium must show evidence of metaplasia, which is a change from one adult tissue type to another. To ascertain that columnar epithelium lines the distal esophagus, the endoscopist first must locate the esophagogastric junction (EGJ), which is recognized as the most proximal extent of the gastric folds, and then determine that columnar epithelium extends 1 cm or greater above the EGJ into the esophagus Endoscopically, columnar epithelium has a reddish color and velvet-like texture that can be distinguished readily from normal esophageal squamous epithelium, which is pale and glossy
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Barrett esophagus can be further categorized as long segment (when the metaplastic epithelium extends at least 3 cm above the EGJ) or short segment (when <3 cm of metaplastic epithelium lines the distal esophagus).6
Short-segment Barrett esophagus, | which is by far the most common form of the disease
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Barrett esophagus typically is discovered during endoscopic examinations performed for the evaluation of GERD symptoms in middle-aged and older adults
The average age at the time of diagnosis is approximately 55 years White men predominate in most series, and, for unknown reasons, Barrett esophagus is uncommon in black and Asian populations
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cigarette smoking and alcohol consumption are very strong risk factors for squamous cell carcinoma of the esophagus, cigarette smoking only modestly increases the risk for esophageal adenocarcinoma and alcohol does not appear to affect that risk at all.
Metaplastic Barrett cells first acquire | mutations leading to inactivation of p53.
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To find dysplasia in Barrett esophagus, endoscopists traditionally have used the “Seattle biopsy protocol,” a random biopsy sampling system in which 4-quadrant biopsies are taken at 1- to 2-cm intervals throughout the length of Barrett metaplasia.
latest guideline on the management of Barrett esophagus by the ACG recommends that Barrett patients should receive once-daily PPI therapy for chemoprevention
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Medical societies currently do not recommend the routine prescription of aspirin or other NSAIDs for chemoprevention in patients with Barrett esophagus, because it is not clear that the potential benefits of NSAIDs outweigh their risks of serious GI and cardiovascular side effects
of endoscopic screening for Barrett esophagus only for patients who have multiple risk factors for esophageal adenocarcinoma, including chronic GERD, age 50 years or older, male gender, white race, hiatal hernia, intra-abdominal body fat distribution (central obesity), smoking history, and history of Barrett esophagus or adenocarcinoma in a first-degree relative
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2 general types of endoscopic therapies available for the treatment of Barrett esophagus: (1) endoscopic ablative therapy, which uses heat (delivered by laser, electrocoagulation, argon plasma coagulation [Video 47.1], or radiofrequency energy), cold (cryotherapy, delivered by spraying cold carbon dioxide or nitrous oxide gas), or photochemical energy (photodynamic therapy [PDT]) to destroy the Barrett epithelium; and
(2) endoscopic resection including EMR (Video 47.2) and endoscopic submucosal dissection, in which a diathermic snare or endoscopic knife is used to remove a large segment of Barrett mucosa with submucosa. After these endoscopic treatments, patients are treated with PPIs
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RFA is now widely regarded as the procedure of choice for ablating Barrett esophagus with dysplasia, both high grade and low grade
Because of the high risk for lymph node metastases when Barrett neoplasms involve the submucosa, accurate T-staging of tumors is crucial to determine whether endoscopic therapy is feasible. EUS had been considered the most accurate diagnostic modality for T-staging, but a number of studies have shown that EUS has very limited accuracy for T-staging early neoplasia in Barrett esophagus
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nodular lesions and other visible irregularities in Barrett esophagus should be removed by EMR for T-staging prior to performing endoscopic ablation. If the EMR specimen shows submucosal invasion, then further endoscopic therapy is not advised.
EET now is widely regarded as the procedure of choice for treating mucosal neoplasia in Barrett esophagus, including low-grade dysplasia, high-grade dysplasia, and intramucosal carcinoma. EET generally is not recommended when EMR reveals submucosal invasion, because of the high frequency of lymph node metastases in this situation
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Recurrences of Barrett metaplasia and dysplasia are most frequent in the first year after achieving CE-IM by EET
Patients with Barrett esophagus should be treated with PPIs in whatever dose is necessary to control GERD symptoms and eliminate endoscopic signs of reflux esophagitis. Asymptomatic patients without reflux esophagitis can be treated with once-daily PPI therapy for chemoprevention
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nondysplastic Barrett esophagus, the risks and benefits of endoscopic surveillance should be presented in detailed discussion. Those who opt for surveillance should have it performed at intervals of every 3 to 5 years.
appear irregular or suspicious for neoplasia, the endoscopists should take targeted biopsies or, preferably, the suspicious area should be removed by EMR. In addition to these targeted specimens, the endoscopist should take 4-quadrant biopsy specimens every 2 cm throughout the length of the Barrett metaplasia. In patients already known to have dysplasia, 4-quadrant biopsy specimens should instead be taken every 1 cm throughout the length of the Barrett metaplasia.
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“indefinite for dysplasia,” PPI therapy should be optimized and endoscopy repeated in approximately 8 weeks, with biopsy specimens taken at 1-cm intervals. If the diagnosis of indefinite for dysplasia persists, management options include surveillance endoscopy every 12 months or referral to a center with special expertise in managing Barrett esophagus.
After achieving CE-IM for patients with high-grade dysplasia or intramucosal carcinoma in Barrett esophagus, endoscopic surveillance is performed every 3 months for the first year, every 6 months in the second year, and annually thereafter. After achieving CE-IM for patients with low-grade dysplasia, endoscopic surveillance is performed every 6 months for the first year, and annually thereafter
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ESCC is the most common form of esophageal cancer worldwide
In industrialized countries, the 2 most important risk factors are tobacco use and excess alcohol consumption (Box 48.1).16-19 Furthermore, these 2 independent risk factors have a synergistic effect on cancer incidence The risk of developing ESCC with active tobacco smoking increases 3- to 9-fold the highest risk has been reported with smoking cigarettes Alcohol use has been reported to have a slightly lower risk compared to tobacco, increasing risk of ESCC by 3- to 5-fold
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The risk increases significantly with alcohol intake above the maximum recommended U.S. dietary guidelines of 140 g/week.1 Acetaldehyde, the first metabolite of ethanol metabolism, is a class I carcinogen.
Zinc deficiency is thought to potentiate the carcinogenic effect of nitrosamines. Selenium supplementation is also thought to have chemo-preventive effects against ESCC. After a 10-year follow-up, a study showed that selenium supplements (along with β-carotene and vitamin E) reduced risk of esophageal cancer death by 17% among participants younger than 55 years old.
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``` ESCC Tobacco Alcoholic beverages Low consumption of fruits and vegetables Low socioeconomic status Micronutrient deficiencies High-temperature foods Achalasia Lye ingestionw Rare disorders (Plummer-Vinson syndrome, Fanconi anemia, and tylosis) ```
EAC Tobacco GERD Obesity
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fact, a large achalasia cohort from Sweden was shown to have an increased risk for both ESCC and EAC.46 The mechanism is likely due to stasis of food material in the esophagus, leading to chronic inflammation
EAC is the second most common form of esophageal carcinoma | worldwide
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The anatomic distribution of esophageal cancer has shifted from the upper third of the esophagus to the lower third. The lower third of the esophagus, the location where adenocarcinoma usually arises, was the only esophageal location with an increased incidence.
GERD is the most important risk factor for the development | of EAC
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BE is the only identifiable premalignant condition for EAC and is defined by the replacement of the normal stratified squamous epithelium with a columnar-lined distal esophagus with intestinal metaplasia
EAC, there is a gradual accumulation of somatic-cell genetic abnormalities that occur during the metaplasia-dysplasia-carcinoma sequence in the esophageal epithelium
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ESCC, on the other hand, is thought to arise from hyperproliferative epithelium that progresses to low-, intermediate-, and high-grade dysplasia (HGD) leading, ultimately, to invasive cancer
HER2/ neu) is a prognostic factor in esophageal cancer.116-118 HER2/ neu gene amplification correlates with shortened patient survival and independently predicts poor outcomes in patients with EAC Expression of the tumor-suppressor gene TP53 in ESCC is an independent prognostic factor. Tumors with low p53 staining are associated with significantly longer survival than tumors with high p53 protein expression
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ESCC, expression of cyclin D1, a key cell cycle regulator (see Chapter 1), has been associated with shorter patient survival compared to cyclin D1-negative patients
p21 staining in ESCC has been associated with an improved survival,126,127 and ESCC patients whose tumors had high levels of p16 had longer survival
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Survivin, another member of the inhibitor of apoptosis gene family, has been found to be a useful predictive factor in neoadjuvant therapy for esophageal cancer. Specifically, partial responders to neoadjuvant chemotherapy have lower survivin expression than nonresponders.
High expression of VEGF is an independent, negative prognostic factor in ESCC, although a correlation in EAC has not been demonstrated.136 COX-2 is known to increase progressively as the tissue progresses through Barrett metaplasia, to dysplasia, and to frank EAC.132 In ESCC, COX-2 overexpression correlates with depth of tumor invasion, tumor stage, and reduced survival Amplification of fibroblast growth factor receptor 1 was shown to be an independent adverse prognostic factor in ESCC.138
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EAC and ESCC have a similar clinical presentation despite the differences in demographics and risk factors. progressive dysphagia and weight loss are the most common symptoms
Odynophagia is a less common symptom and usually indicates the presence of an ulcerated lesion.
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anemia (iron deficiency or chronic disease type), hypoalbuminemia, and/or hypercalcemia (usually associated with osteolytic metastasis). Although paraneoplastic syndromes are rare with esophageal cancer, ESCC rarely can cause hypercalcemia due to tumoral production of a circulating parathyroid hormone-related protein
The diagnosis of esophageal cancer is primarily made by endoscopic biopsies in a patient presenting with progressive dysphagia to solids (Fig. 48.2). The endoscopic appearance is similar between advanced ESCC and EAC; however, approximately three quarters of all EAC lesions are found in the distal esophagus whereas ESCC is more frequent in the proximal to middle esophagus
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It is critical for endoscopists to spend adequate time inspecting the esophagus and document landmarks such as the gastroesophageal junction, extent of BE using the Prague C (circumferential) and M (maximal extent) criteria, the presence or absence of extension into the stomach, and the exact location of the tumor
Conventional chromoendoscopy involves the use of special stains to highlight subtle architectural changes to help direct biopsies and predict histology. Lugol’s iodine, methylene blue, acetic acid, crystal violet, and indigo carmine are the most commonly used stains.
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Lugol’s iodine solution consists of a 0.5% to 3.0% aqueous solution of potassium iodide. Iodine stains glycogencontaining cells of the normal esophageal epithelium and is not taken up by dysplastic or malignant cells that are glycogen depleted (“pink color sign”).
Chromoendoscopy with Lugol’s iodine staining has become the standard of care for screening of ESCC in high-risk populations and has been shown to have a high sensitivity rate of 89% to 100% with highly variable specificity rates due to false positive lesions
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In contrast, methylene blue, acetic acid, and indigo carmine staining are more useful in the detection of glandular abnormalities, as seen in EAC. These stains are sprayed in the esophagus with the intent of improving characterization of the mucosa resulting in selective uptake (vital staining—methylene blue) or enhancement of mucosal surface pattern (contrast staining— indigo carmine, acetic acid
Optical chromoendoscopy is another modality to detect signs of dysplasia and cancer by using selective light filters to highlight subtle architectural and vascular changes in the mucosa.
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NBI is an imaging technique that is based on | the optical phenomenon that the depth of light penetration into
NBI is the most widely studied electronic chromoendoscopy technique to predict histology during surveillance, improve detection of dysplasia, and guide endoscopic eradication therapies.
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AFI involves a technique that uses short-wavelength blue or ultraviolet light to stimulate biological fluorophores (e.g., collagen, porphyrins, flavins, aromatic amino acids) in the esophagus
CLE allows real-time, in vivo microscopic imaging of the esophageal mucosa. It involves IV administration of a fluorescent dye (most commonly fluorescein sodium) that is taken up by normal mucosal cells. Fluorescent dye uptake is not seen in dysplastic cells, and thus they appear dark
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Optical coherence tomography emits near-infrared light to provide cross-sectional images of tissue, which also has the potential advantage of identifying submucosal lesions
Cost-benefit studies have been carried out to assess esophageal cancer screening strategies.170 One study found that a strategy of 1-time screening at age 50 would be the best approach in underdeveloped high-risk areas, whereas a 3-time screening strategy starting at age 40 (10-year intervals) would be preferable in areas with better health care resources
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1. One-time Lugol’s chromoendoscopy for high-risk Asian and African populations beginning at the age of 40. 2. Endoscopy with Lugol’s or NBI every 6 months to 1 year after completion of therapy for head and neck squamous cell cancer, for 10 years. 3. Screening could also be considered for patients at high risk (tylosis, achalasia, and caustic injury).
T1cancer that invades the lamina propria, muscularis mucosae, or submucosa and is subcategorized into T1a (cancer that invades the lamina propria or muscularis mucosae) T1b (cancer that invades the submucosa); T2 cancer that invades the muscularis propria T3 cancer that invades the adventitia; T4 cancer that invades the local structures, and is subcategorized as T4a (cancer that invades adjacent structures such as the pleura, pericardium, azygos vein, diaphragm, or peritoneum) and T4b (cancer that invades the major adjacent structures, such as the aorta, vertebral body, or trachea). N1 (regional lymph node metastases involving 1 or 2 nodes), N2 (regional lymph node metastases involving 3 to 6 nodes), and N3 (regional lymph node metastases involving 7 or more nodes
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esophagogastric junction such that cancers involving it with epicenters no more than 2 cm into the gastric cardia are staged as EAC and those with >2 cm involvement of the gastric cardia are staged as gastric cancers.
Further classification for T1a includes M1 (intraepithelial cancer), M2 (invasion into the lamina propria), and M3 (invasion to the muscularis mucosa). T1b lesions also can be subdivided into SM1 (invasion into the upper third of the submucosa), SM2 (invasion into the middle third), and SM3 (invasion into the lower third). Tis and T1a lesions have a predicted lymph node metastasis rate up to 8% compared to T1b lesions, which have up to a 56% lymph node metastasis rate
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The risk of lymph node involvement is related to several factors (in decreasing order of frequency): grade III histology, SM3 invasion, lymphatic invasion, vascular invasion, SM2 invasion, and SM1 invasion
In ESCC, the best predictors of lymph node invasion are SM3 invasion and vascular invasion, whereas in EAC, the most important predictor is lymphatic invasion
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determine the histologic type (ESCC or EAC) and the histologic grade (degree of differentiation).189 The sensitivity for mucosal biopsies reaches 96% when multiple biopsies are taken (typically 6 to 8)
EUS is increasingly used to assess the depth of tumor invasion and to distinguish T1 lesions from deeper infiltration. This distinction helps to choose candidates for stage-appropriate therapies. EUS is the only imaging modality that can clearly delineate the different esophageal wall layers. It is considered by most experts to be the best staging modality for T stage and locoregional lymph node (N) staging (
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Endosonographic features of malignant lymph nodes include lesions that are hypoechoic with a rounded and smooth surface, lesions >10 mm, and lesions located in close proximity to the tumor
Surgery is the standard treatment for a medically optimized surgical candidate with a localized, non-superficial tumor. For a patient with a localized tumor who is not a surgical candidate, definitive chemoradiation with curative intent may be considered. For all others (metastatic disease), palliation is recommended.
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Guidelines, surgery alone is considered the standard of care and treatment of choice for T1b and T2 cancers without nodal involvement or distant metastasis. Surgery in conjunction with a multimodal approach is indicated for T1 to T4a tumors with lymph node metastases
Esophagectomy has the potential for high perioperative morbidity (40% to 50%) and mortality (3% to 13%). Lymph node status is an independent predictor of survival in esophageal cancer In patients undergoing esophagectomy without neoadjuvant chemoradiation, the NCCN guidelines recommend that 15 or more lymph nodes be removed for adequate staging
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``` The role of endoscopic treatment of esophageal cancer can be either for curative intent or palliation. The former is reserved to mucosal tumors (T1a) confined to the mucosa (M1 or intraepithelial), the lamina propria (M2), or the muscularis mucosae (M3). These tumors have an extremely low chance of harboring lymph node metastasis ```
In contrast to T1a tumors, T1b tumors involving the submucosa have a higher risk of lymph node metastasis, up to 56% in SM3 tumors Ablation can be achieved with radiofrequency ablation (RFA) or cryotherapy
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The best predictors of esophageal cancer survival are depth of invasion (T stage) and lymph node involvement (N stage).
Esophageal papillomas are asymptomatic, benign epithelial tumors characterized endoscopically by a solitary, exophytic lesion in the lower third of the esophagus (Fig. 48.18). They tend to have a white or pink color. They have a soft consistency and a smooth or slightly rough surface
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Adenomas of the esophagus are rare and almost exclusively associated with Barrett metaplasia
Leiomyosarcomas are the most common | subtype and can be difficult to distinguish from benign leiomyomas.
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GISTs are the most common mesenchymal tumor of the GI tract
The 2 most common cancers to metastasize to the esophagus are melanoma and breast cancer.
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Leiomyomas are the most common benign esophageal tumors EUS is the diagnostic test of choice; a leiomyoma is seen typically arising from the muscularis propria. Only large (>5 cm), symptomatic lesions require excision, which can be done endoscopically for smaller tumors (using ESD techniques) or surgically
Fibrovascular polyps are benign esophageal lesions (Fig. 48.19). They are almost exclusively seen in the cervical esophagus, likely because of the relatively loose submucosal tissue and redundant mucosa in this anatomic region They are typically pedunculated polyps consisting of blood vessels, adipose cells, and stroma covered by normal squamous epithelium Some recommend EUS of larger polyps to determine the presence of large blood vessels prior to excision.
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Often, esophageal lipomas exhibit the “pillow” sign—indentation or cushioning with “palpation.” Superficial mucosal biopsies will usually be nondiagnostic. Deeper samples from the submucosa will reveal welldifferentiated adipocytes.
On EUS, a homogeneous, hyperechoic | submucosal lesion with smooth outer margins is seen
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A variceal pressure greater than 18 mm Hg during a bleeding episode is associated with failure to control bleeding and predicts early rebleeding
In patients in whom no varices are detected on initial evaluation, endoscopy to screen for varices should be repeated in 2 to 3 years. If small varices are detected on the initial examination, endoscopy should be repeated in 1 to 2 years
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Red color signs include red “wale” markings, which are longitudinal whip-like marks on the varix; cherry-red spots, which usually are 2 to 3 mm or less in diameter; hematocystic spots, which are blood-filled blisters 4 mm or greater in diameter; and diffuse redness. The color of the varix can be white or blue.
Esophageal varices may be small and straight (grade I), tortuous and occupying less than one third of the esophageal lumen (grade II), or large and occupying more than one third of the esophageal lumen (grade III).
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Small varices are 5 mm or less in diameter, whereas | large varices are greater than 5 mm in diameter
``` Patients with large esophageal varices, Child-Pugh class C cirrhosis (see later), and red color signs on varices have the highest risk of variceal bleeding within one year ```
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have demonstrated that a portal vein diameter greater than 13 mm and the absence of respiratory variations in the splenic and mesenteric veins are sensitive but nonspecific markers of portal hypertension
A combination of liver and spleen stiffness measured by acoustic radiation force impulse elastography may also identify patients at risk for esophageal varices
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``` Causes of Portal Hypertension COMMON Cirrhosis Schistosomiasis Extrahepatic portal vein thrombosis Idiopathic portal hypertension Cardiac fibrosis ```
``` LESS COMMON Nodular regenerative hyperplasia Partial nodular transformation of the liver Fibropolycystic liver disease Sarcoidosis Malignancy Splanchnic arteriovenous fistula HHT ```
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DRUGS THAT DECREASE PORTAL BLOOD FLOW Nonselective β-adrenergic blocking agents (e.g., propranolol, nadolol) Somatostatin and its analogs Vasopressin and terlipressin DRUGS THAT DECREASE INTRAHEPATIC RESISTANCE α1-Adrenergic blocking agents (e.g., prazosin) Angiotensin receptor blocking agents Nitrates
Following a single 250-μg bolus injection of somatostatin, portal and azygos blood flow decrease, but the effect lasts only a few minutes Following IV administration, octreotide has a half-life in the circulation of 80 to 120 minutes
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Nonselective beta blockers such as propranolol or nadolol are preferred. Blockade of β1-adrenergic receptors in the heart decreases cardiac output. Blockade of β2-adrenergic receptors, which cause vasodilatation in the mesenteric circulation, allows unopposed action of α1-adrenergic receptors and results in decreased portal flow. The combination of decreased cardiac output and decreased portal flow leads to a decrease in portal pressure. Nadolol has advantages over propranolol in that it is excreted predominantly by the kidney, has low lipid solubility, and is associated with a lower risk of CNS side effects such as depression
An acute hemodynamic response (decrease in HVPG to <12 mm Hg, or by 10%) 20 minutes after administration of IV propranolol may predict the long-term reduction in bleeding risk
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Carvedilol is a drug that has both nonselective beta blocker and weak α-receptor blockade activity. α-Receptor activity normally increases resistance within the intrahepatic circulation. Therefore, blockade of the α-receptor decreases intrahepatic vascular resistance, which results in a further reduction in portal pressure. Carvedilol may be associated with hypotension and renal sodium retention and should be used cautiously in patients with Child-Pugh class C cirrhosis.
Carvedilol is also known to have antioxidant as well as antiproliferative actions and may be superior to endoscopic variceal ligation in the prevention of a first variceal bleed.62 In addition, carvedilol may delay progression of small esophageal varices to large esophageal varices in patients with cirrhosis Carvedilol is started at a dose of 3.125 mg twice daily, and the dose is increased stepwise to a maximum of 25 mg daily
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Endoscopic variceal ligation is the preferred endoscopic modality for control of acute esophageal variceal bleeding and prevention of rebleeding; however, the utility of band ligation in the treatment of gastric varices is limited.
``` DURING PROCEDURE Aspiration pneumonia Retrosternal chest pain FOLLOWING PROCEDURE Bleeding Esophageal dysmotility Esophageal stricture Esophageal ulcers Mediastinitis Perforation SYSTEMIC (USUALLY WITH SCLEROTHERAPY) Mesenteric venous thrombosis Pulmonary embolism Sepsis ```
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The Sengstaken-Blakemore tube is a triple-lumen tube: one tube is for aspirating gastric contents, another allows inflation of a gastric balloon to 200 to 400 mL in volume, and the third inflates an esophageal balloon.
The Minnesota tube is a modified Sengstaken-Blakemore tube, with the modifications being a larger gastric balloon (500 mL) and provision of an additional lumen for esophageal aspiration. The Linton-Nachlas tube has a single 600- mL gastric balloon with lumens for aspirating both the stomach and esophagus
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Balloon tamponade can control bleeding for up to 24 hours in approximately 80% to 90% of patients. The risk of pulmonary aspiration is reduced by placement of an endotracheal tube.
A TIPS reduces elevated portal pressure by creating a communication between the hepatic vein and an intrahepatic branch of the portal vein. A percutaneous transjugular approach is used to insert the shunt.
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TIPS functions as a side-to-side portacaval shunt and has been used to treat complications of portal hypertension, mainly variceal bleeding and refractory ascites, as well as Budd-Chiari syndrome and hepatic hydrothorax
A platelet count greater than 60,000/mm3 and an INR less than 1.5 are recommended but are not essential in an emergency The most common indication for placement of TIPS is refractory variceal bleeding.
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The use of early TIPS (within 72 hours of control of variceal bleeding) in patients at high risk of rebleeding (Child-Pugh class C, class B with active bleeding, or a MELD score greater than 18 and a transfusion requirement of greater than 4 units of red blood cells [RBCs]) is associated with a reduced rate of treatment failure and mortality, without an increased risk of hepatic encephalopathy, compared with continued pharmacologic and endoscopic therapy.
TIPS may worsen liver function by depriving the liver of portal venous blood, thereby increasing the risk of hepatic encephalopathy, with decreased survival in some patients. Factors associated with a poor prognosis include a serum ALT level greater than 100 U/L, serum bilirubin level greater than 3 mg/dL, and pre-TIPS hepatic encephalopathy unrelated to bleeding
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Child-Turcotte-Pugh Scoring System and Child-Pugh Classification Ascites None Slight Moderate/severe Encephalopathy None Slight/moderate Moderate/severe Bilirubin (mg/dL) <2 2-3 >3 Albumin (g/dL) >3.5 2.8-3.5 <2.8 Prothrombin time (seconds increased) 1-3 4-6 >6
Total Numerical Score Child-Pugh Class 5-6 A 7-9 B 10-15 C
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Esophageal varices are present in approximately 40% of patients with cirrhosis and in as many as 60% of patients with cirrhosis and ascites
The best clinical predictor of bleeding appears to be variceal size. The risk of bleeding in patients with varices less than 5 mm in diameter is 7% by 2 years, and the risk in patients with varices greater than 5 mm in diameter is 30% by 2 years
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Even more important, however, is the HVPG, because the risk of bleeding is virtually absent when the HVPG is below 12 mm Hg
Approximately half of patients with a variceal bleed stop bleeding spontaneously because hypovolemia leads to splanchnic vasoconstriction, which results in a decrease in portal pressure. Excessive transfusions may, in fact, increase the chance of rebleeding
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Active bleeding at endoscopy, a lower initial hematocrit value, higher serum aminotransferase levels, higher Child-Pugh class, bacterial infection, an HVPG above 20 mm Hg, and portal vein thrombosis are associated with failure to control bleeding at 5 days
Of patients who have stopped bleeding, approximately one third will rebleed within the next 6 weeks.
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Of all rebleeding episodes, approximately 40% will take place within 5 days of the initial bleed.216 Predictors of rebleeding include active bleeding at emergency endoscopy, bleeding from gastric varices, hypoalbuminemia, renal insufficiency, and an HVPG greater than 20 mm Hg.209 The risk of death associated with acute variceal bleeding is 5% to 8% at 1 week and about 20% at 6 weeks
Alcohol as the cause of cirrhosis, a higher serum bilirubin level, a lower serum albumin level, hepatic encephalopathy, and HCC are additional factors associated with an increased 6-week mortality rate.
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All patients with large varices (diameter >5 mm) should be considered for prophylactic therapy (primary prophylaxis) to prevent variceal bleeding. The presence of additional endoscopic signs such as red wales does not influence the decision regarding prophylactic therapy.
A resting systolic blood pressure less than 90 mm Hg indicates that the patient is likely to be intolerant of beta blockers. In other patients, the HVPG ideally should be measured at baseline (Fig. 92.13). A long-acting preparation of propranolol or nadolol may be started; the usual starting dose of long-acting propranolol is 60 mg once daily and that of nadolol is 20 mg once daily.
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The dose of propranolol or nadolol can be increased gradually every 3 to 5 days until the target heart rate of 25% below baseline, or 55 to 60 beats/min, or the maximum tolerated dose is reached,
Acute esophageal variceal bleeding Two large-bore IV access lines should be inserted immediately. RBCs should be transfused with the goal of maintaining the hematocrit value around 25%. A restrictive strategy of transfusing RBCs only when the Hgb level drops below 7 g/dL is associated with improved survival in patients with Child-Pugh class A and B cirrhosis, as compared with a strategy of transfusing when the Hgb level drops below 9 g/dL
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Excessive RBC transfusions may be associated with risks of massive transfusion, including an increased risk of hypocoagulability; on the other hand, excessive use of saline is associated with ascites and the risk of abdominal compartment control
In patients with active bleeding, the airway needs to be protected, and endotracheal intubation is advised. Antibiotics should be administered to all patients to prevent bacteremia and spontaneous bacterial peritonitis (see Chapter 93). Norfloxacin, 400 mg orally twice daily for 7 days, has been the preferred choice. When norfloxacin is not available (as in the USA), ciprofloxacin 500 mg orally twice daily for 7 days may be administered
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IV ceftriaxone, 1 g every 24 hours for 7 days; ciprofloxacin, 400 mg every 12 hours; or levofloxacin, 500 mg every 24 hours is recommended
Terlipressin is the first choice in many other countries because it has been associated with improved survival.235 Pharmacologic treatment should be continued for up to 5 days to prevent early rebleeding; however, a 24-hour course and a 72-hour course of terlipressin may be equally effective when used in conjunction with variceal ligation
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Bleeding cannot be controlled in approximately 10% to 15% of | patients, as defined by any of the following 3 criteria:
(1) transfusion of 4 units of RBCs or more to maintain the hematocrit value above 25%, (2) inability to increase the systolic blood pressure by 20 mm Hg or to greater than 70 mm Hg, or (3) persistence of a heart rate greater than 100 beats/min
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Rebleeding is defined as recurrence of bleeding after initial control for 24 hours during which the vital signs and Hgb level are stable. carried out
When 2 sessions of endoscopic treatment within a 24-hour period have failed to control variceal bleeding, salvage therapies such as TIPS should be
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In practice, the first endoscopic session is carried out 7 to 14 days after the initial variceal ligation to control bleeding.
One-week ligation intervals may lead to more rapid eradication of varices than 2-week intervals but without a reduced risk of bleeding.