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(J2) GI II Test 1 > Esophagus > Flashcards

Esophagus Flashcards

1
Q

What is the blood supply of the upper, middle, and lower thirds of the esophagus?

A

Upper - inferior thyroid

Middle - branches of thoracic aorta

Lower - left gastric artery

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2
Q

What causes of dysphagia are progressive?

A
  • SCC/adenocarcinoma
  • systemic sclerosis/CREST
  • esophageal strictures
  • achalasia
  • Zenker diverticulum
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3
Q

What are examples of functional esophageal dysphagias?

A
  • nutcracker esophagus
  • diffuse esophageal spasm
  • systemic sclerosis/CREST syndrome
  • GERD
  • achalasia
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4
Q

What is nutcracker esophagus?

(symptoms and diagnosis)

A

Functional esophageal obstruction

-nomral coordination of contractions, but with increased LES pressure

Symptoms:

  • dysphagia (intermittent)
  • chest pain

Diagnostic:

-manometry wil show elevated LES pressure (>180 mmHg)

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5
Q

What is diffuse esophageal spasm?

(symptoms and diagnosis)

A

Functional esophageal obstruction

-uncoordinated contractions, normal LES tone

Symptoms:

  • dysphagia (intermittent)
  • chest pain

Diagnostic:

-barium swallow study show “corkscrew” or “rosary bead” esophagus

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6
Q

What are examples of structural esophageal dysphagias?

A
  • esophageal webs
  • Schatzki rings
  • strictures
  • Zenker diverticulum
  • cancer
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7
Q

What are esophageal webs and Schzatzki rings?

(epi and compare)

A

diaphragm-like protrusion of mucosa in the esophagus

both more common in females

can be associated with GERD

Webs:

  • proximal and not fully circumferential
  • associated with Plummer-Vinson syndrome

Schatzki rings:

-distal and fully circumferential

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8
Q

How are esophageal webs and Schatzki rings diagnosed and treated?

A

Diagnosed:

-barium swallow

Treatment:

  • dilation
  • if persistent, PPI for GERD
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9
Q

What is Plummer-Vinson syndrome?

What condition is it associated with and increased risk of?

A

Triad:

  • iron deficiency anemia
  • beefy red tongue (glossitis w/ angular chelitis)
  • esophageal webs (dysphagia)

increased risk of esophageal SCC

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10
Q

What are esophageal strictures?

What odd feature is present in its course?

A

complication of esophagitis (most commonly GERD) resulting in fibrosis and narrowing of esophagus

-most frequently occurs at the gastroesophageal junction

As stricture worsens -> GERD improves (stricture prevents reflux)

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11
Q

What is Zenker’s diverticulum?

(symptoms and diagnosis)

A

herniation of the esophageal mucosa and submucosa (false diverticula) posteriorly through cricopharyngeus muscle in Killian’s triangle, just above the UES

Symptoms:

  • coughing or discomfort
  • dysphagia (progressive)
  • entrapment of food
  • halitosis (bad breath)
  • aspiration

Diagnosis:

  • video esophagography
  • barium swallow
  • no EGD -> risk of perforation
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12
Q

What is achalasia?

(etiology)

A

loss of NO producing inhibitory neurons -> increased LES tone and loss of peristalsis in lower 2/3 of esophagus

Primary/idopathic:

-loss of ganglion cells in myenteric plexus of esophagus

Secondary:

-most commonly from Chagas disease leading to destrucion of ganglion

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13
Q

How is achalasia diagnosed and treated?

A

Diagnosis:

  • “bird beak” esophagus on barium swallow; constriction of LES with proximal dilation
  • manometry confirms; absence of peristalsis w/ incompelete LES relaxation during swallowing
  • peripheral smear to detect T. cruzi

Treatment:

  • nitrates and calcium channel blockers
  • dilation
  • myotomy (risk of GERD development)
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14
Q

What is pseudoachalasia?

A

tumor at the gastroesophageal junction causing obstructive “bird beak” pattern similar to achalasia

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15
Q

What are the common types of esophageal bleeding?

A
  • Mallory-Weiss syndrome
  • Boerhaave syndrome
  • ruptured varices
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16
Q

What is Mallory-Weiss syndrome?

(etiology, presentation, and treatment)

A

superficial tear of the esophagus at gastroesophageal junction

-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use and bulemia

Presentation

  • painful hematemesis
  • common cause of upper GI bleed

Treatment:

-normally self-limited

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17
Q

What is Boerhaave syndrome?

(etiology, presentation, and treatment)

A

transmural tear of the esophagus at gastroesophageal junction -> esophageal rupture

-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use

Presentation:

  • pneumomediastinum -> Hamman’s sign (crunching sound on ascultation of heart)
  • subcutaneous emphysema
  • hematemesis
  • chest pain
  • acute distress

Treatment:

  • LIFE THREATENING
  • surgery to repair
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18
Q

What are esophageal varices?

A

dilation of veins in the esophagus due to portal hypertension (cirrhosis)

-asymptomatic themselves but can rupture

19
Q

What complication is associated with esophageal varices?

(epidemiology and risk factors)

A

Variceal hemorrhage (rupture of varices)

  • occurs in 1/3 of patients with varices
  • 1/3 die and 50% recur within 1 year

Risk factors:

  • large varices (>5mm)
  • red wale marking on endoscopy
  • severe liver disease
  • alcohol abuse
20
Q

What is the presentation of variceal hemorrage?

How is it treated?

A

Presentation:

  • actue onset typically preceeded by retching/vomiting
  • upper GI bleed -> melena, hematochezia, and hematemesis
  • hypovolemia/shock

Treatment:

  • MEDICAL EMERGENCY
  • blood, FFP, and vitamin K transfusion
  • emergent EGD w/ variceal banding
  • beta-blockers and banding help prevent recurrence
21
Q

What symptom differentiates cause of esophageal bleeding?

A

painful hematemesis:

-Mallory-Weiss/Boerhaave syndrome

painless hematemesis:

-variceal hemorrhage

22
Q

What are causes of pneumomediastinum and subcutaneous emphysema?

A
  • Boerhaave syndrome
  • iatrogenic esophageal perforation
  • pulmonary causes (ie. COPD with bleb rupture)
  • trauma
23
Q

What is Hamman’s sign?

A

crunching sound that is synchronized w/ heartbeat in the setting of pneumomediastinum

24
Q

What is esophagitis?

(associated symptoms)

What are the main causes?

A

Inflammation of the esophagus

  • can cause pain with swallowing (odynophagia)
  • can cause obstruction

Causes:

  • radiation
  • chemical irritation (pills/caustic substances)
  • infections
  • eosinophilic
  • reflux
25
What are the main causes of infectious esophagitis?
- CMV - HPV - candida
26
What are the endoscopic findings for CMV, HSV, and candida based infectious esophagitis?
CMV: -shallow, **linear** **ulcers** HSV: -**punched-out** lesions Candida: -white **pseudomembrane**
27
What is eosinophilic esophagitis? (presentation)
**eosinophil infiltration** of esophagus -associated with **allergic/atopic conditions** Presentation: -**dysphagia** **-\*\*food impaction\*\*** - regurgitation - possible _asthma or atopic rash_ GERD-like presentation though slightly more severe; also more likely to present in children than GERD
28
How is eosinophilic esophagitis diagnosed and treated?
Diagnosis: - "**tracheal/feline**" **esophagus** on **EGD**; multiple esophageal rings - **eosinophil infiltrate** on **biopsy** (_15-20 eosinophils per field_); eosinophil _also seen with GERD but less numerous_ Treatment: - **swallowing,** instead of inhaling, **inhaled glucocorticoids** - allergist referral/elimination of food allergens - esophageal dilation
29
What is GERD? | (presentation)
**reflux of stomach acid** into esophagus due to **relaxation of LES** or **increased intra-abdominal pressure** Presentation: - "**heart burn**"/chest pain - dysphagia - regurgitation of gastric contents (**sour taste**)
30
What are extrapharyngeal symptoms that are rather indicative of GERD?
- nocturnal cough - nocturnal asthma
31
What are causes of GERD?
- decreased LES tone - increased intra-abdominal pressure Causes: - vagus nerve dysfunction - alcohol and tobacco - obesity - pregnancy - stress - hiatal hernia - gastroparesis
32
What are concerning features in GERD? What complications can occur?
Concerning symptoms: - s/x of UGIB -\> ulceration - constant severe pain -\> ulceration - odynophagia -\> ulceration - dysphagia -\> stricture - persistent vomiting -\> dehydration - palpable mass/weight loss -\>adenocarcinoma Complications: - ulceration - stricture - Barrett esophagus -\> adenocarcinoma
33
How is GERD treated?
No alarming features: -emperical - possible acid suppressing medications - treatment of *H. pylori* if present -lifestyle changes Alarming features: - endoscopy - imaging - surgical evaluation
34
What is a common symptom that occurs with esophageal impaction/foriegn body obstruction?
hypersalivation
35
What is Barrett esophagus? (presentaiton, diagnosis, and management)
**distal esophageal metaplasia** - **squamous** -\> **intestinal columnar w/ goblet cells** - highly associated with **GERD** Presentation: - **asymptomatic itself** - **underlying GERD symptoms** Diagnosis: - **endoscopy** ("**pink tongues**" extending from gastroesophageal juction) - metaplasia on **biopsy**; columnar epithelium w/ goblet cells Management: - _can progress to adenocarcinoma_ -\> **survelience endoscopy** - **PPI** (reduces progression risk) - **ablation** of high-grade dysplasia
36
What are the most common tumors of the esophagus? (epi)
Benign: -**leiomyoma** (smooth muscle/mesenchymal) Malignant: - **adenocarcinoma** - **SCC**
37
How do benign and malignant esophageal tumors appear different on a barium swallow?
**Benign/leiomyoma** appear as a **smooth, rounded obstruction** of the esophageal lumen **Malignant** appear as **asymmetrical, ulcerated or infiltrative masses** that obstruct lumen
38
What is the **epidemiology** of **esophageal adenocarcinoma** and **SCC**?
Adenocarcinoma: - **men** - western countries/**caucasians** (rapidly increasing prevalence) SCC: - **men** - **Asia and African Americans** - **more commonly globally**
39
What are risk factors associated with esophageal adenocarcinoma?
- GERD/**Barrett esophagus** - **H. pylori** - tobacco - achalasia - radiation
40
What is the clinical presentation of esophageal adenocarcinoma?
_Frequently goes undiscovered_ until too late unless _incidentally detected early duing evaluation of GERD_ Early presentation: -**asymptomatic** -underlying GERD s/x possible Late presentation: - **dysphagia** (progressive) - **weight loss** - chest pain - hematemesis
41
How is esophageal adenocarcinoma diagnosed and where is it typically found? (appearance)
**_EGD with biopsy_**: - glandular/mucinous appearing **high-grade dysplasia** - adjacent **Barrett mucosa** is common (columnar epithelium with goblet cells) Typically in **lower 1/3** of esophagus (due to high _association with Barrett esophagus_)
42
What are risk factors associated with esophageal SCC?
- **alcohol/tobacco** - **low fruit/vegetable intake​** - chemical/thermal injuries (**hot beverages**) - **achalasia** - radiation - tylosis - HPV - Plummer-Vinson syndrome - poverty
43
What is the **clinical presentation** and **prognosis** of esophageal SCC?
**Insidious** onset with **aggressive course**: - **dysphagia** - **odynophagia** - obstruction -\> **shift of diet from solids to liquids** **-weight loss** Frequently **caught late, after LN metastasis -\> poor survival** If **caught early** (typically through screening, not symptoms) **significant increase in surival**
44
How is esophageal SCC diagnosed and where is it typically found? (appearance)
**EGD with biopsy**: - early grey/white plaque-like thickening -\> late polypoid/exophytic growth - squamous dysplasia with keratinization/keratin pearls Typically in **middle 1/3** of esophagus

(J2) GI II Test 1 (14 decks)

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