Esophagus DDX Flashcards
Pyrosis
Heartburn
Voluntary phase of swallow
Oral: tongue pushes the food bolus into the oropharynx
Involuntary phase of swallow, Pharyngeal phase:
1 food bolus stimulates receptors in pharynx
2 breathing is interrupted
3 elevation of the soft palate
4 glottis is pulled under the epiglottis
5 when the bolus reaches the esophagus the upper esophageal sphincter relaxes then closes behind the food bolus
Esophageal phase of swallow, Primary P
Primary peristalsis: vagal sense and motor until reaching the LES resulting in relaxation of the LES
Esophageal phase of swallow, Secondary P
Repetitive waves required to clear the esophagus of food
Saliva is acidic or alkaline?
Alkaline
GERD affects 20 percent of adults weekly and 10% daily
usually mild
Damage in GERD is usually in up to …% of pt’s
33%
Contents that could be included in GERD?
Most cases: Acidic gastric fluid
other: Bile or alkaline pancreatic secretions may contribute
Common timeframe that there is an issue with GERD
post-prandial, acidic reflux episodes after meals when acid is poorly mixed with food in the proximal stomach
GJD: 3 aspects:
Gastroesophageal Junction Dysfunction
1anti-reflux barrier depends on LES pressure
2intra-abdominal location of the sphincter(flap-valve)
3sphincter by the crural diaphragm
Most reflux occurs during the…
transient relaxation of the LES
An incompetent LES can happen when:
and how often
An increase in acid reflux.
Usually when supine or with increased intra-abdominal pressures.
Present in up to 50% of pt’s with severe erosive GERD
Hiatal Hernia 25,75,90.
caused by?
(GJD type)
25% of pt’s with non-erosive GERD.
75% of pt’s with severe erosive esophagitis.
90% of pt’s with Barrett esophagus.
-Caused by movement of the LES above the diaphragm
-associated with higher amounts of acid reflux and delayed esophageal acid clearance
Truncal obesity causes GJD how?
Increased intra-abdominal pressure.
Abnormal esophageal clearance occurs when…
acid is not cleared as it is normally by esophageal peristalsis and neutralized by salivary bicarbonate
50% of GERD pt’s have….
Hypotensive peristaltic contractions (leading to abnormal esophageal clearance)
Impaired salivation can occur from…
Sjogren syndrome, anticholinergic medications and oral radiation therapy
Signs and symptoms of GERD
Heartburn Regurgitation Dysphagia(33%) Extra-esophageal manifestations(rarer) PE and labs are normal in uncomplicated cases
Style of heartburn in GERD
30-60 min after meals
reclining
relief with antacids or baking soda
severity not correlated with degree of tissue damage
Dysphagia in GERD
(33%)
erosive esophagitis
abnormal esophageal peristalsis
stricture
Extra-esophageal manifestations of GERD:
asthma chronic cough chronic laryngitis sore throat non-cardiac chest pain (In the absence of heartburn or regurgitation, atypical symptoms unlikely to be related to GERD)
Alarming features during GERD ddx
troublesome dysphagia,
odynophagia,
weight loss,
iron deficiency anemia
Endoscopy results of GERD
- up to 33% with visible mucosal damage
- may be healed win patients treated with prior empiric PPI
- detect other gastroesophageal lesions
- esophageal stricture
- barrett esophagus
- esophageal adenocarcinoma
DDX of GERD
Esophageal motility disorders
- Peptic ulcer
- Angina pectoris
- Functional disorders
- Pill-induced damage
- Eosinophilic esophagitis
- Infections like CMV, Herpes, Candida
Tx of mild GERD
Lifestyle, Eating smaller meals, Elimination of acidic foods, Elimination of foods known to cause reflux(fatty foods, chocolate, peppermint, alcohol) Smoking cessation Weight loss as indicated
Patients with nocturnal symptoms should…
- avoid eating 3 hours prior to laying down and elevate the head of the bed.
PRN meds for GERD
Antacids -rapid 2 hour relief
OTC oral H2 receptor antagonists - delayed onset, longer relief 8hrs
Tx for troublesome symptoms or with known complications:
Once daily PPI for 4-8 weeks
10-20 % do not achieve relief and require BID PPI dosing.
If still inadequate relief, evaluation with upper endoscopy is indicated.
If initial 4-8 week therapy followed by BID PPI still does not bring relief then…
endoscope
Long term therapy:
If good symptomatic relief is obtained with once daily PPI then…
D/C after 8-12 weeks
80% will experience relapse of GERD…tx options include:
tx with continuous PPI (or BID H2 blocker if no erosive esophagitis is present)
tx intermittent 2-4 week course
tx on demand, pt dosed
If twice daily dosing was required, and in pt’s with complications of GERD….
maintain on long term PPI therapy with once or BID dosing for symptom control
Esophageal pH testing in pt’s after…
3months with continued sx
Tx of Extra-esophageal manifestations
Trial twice daily PPI for 2-3 months
Tx for active erosive esophagitis found on endoscopy:
double PPI dose
Refractory esophagitis causes
gastrinoma with gastric acid hypersecretion
Pill induced esophagitis
Proton pump inhibitor resistance
Medical non-compliance
Pt’s without visible esophagitis should undergo pH monitoring to determine cause
New sx of fundoplication
dysphagia bloating increased flatulence dyspepsia diarrhea
Barrett esophagus
squamous epithelium replaced by metaplastic columnar epithelium containing goblet and columnar cells due to chronic reflux induced injury.
Specialized intestinal metaplasia
increased risk of dysplasia
Presentation rate of barrett’s with chronic reflux pt’s
10%
Pts with Barrett esoph. will complain of a…
long hx of reflux symptoms
Tx of Barrett’s esophagus:
long-term PPIs
Barrett esoph. should be surveilled every ______ to look for low or high grade _______ or ___________
3-5 years
dysplasia or adenocarcinoma
Peptic stricture pt’s complain of ________ over months to years
gradual development of solid food dysphagia
Endoscopy in peptic stricture sus pt’s is mandatory bc we need to dif btw….
peptic stricture from esophageal carcinoma
Long-term tx of peptic stricture?
PPI to decrease recurrence
Common pt cases with infectious esophagitis
AIDS, Solid Organ Transplants, Leukemia, Lymphoma, Immunosuppressive drugs.
Most common pathogens of In. Eso.
Candid albicans (uncontrolled diabetes , systemic corticosteroids , radiation therapy , abx)
Herpes simplex
Cytomegalovirus
S/S of In. Eso.
Odynophagia
Dysphagia
S/S of In. Eso.
Odynophagia Dysphagia Substernal Chest pain Occasionally asymptomatic Oral thrush in 75% in C. Albicans, 25-50% with viral Oral Ulcers
Tx of Infectious Esophagitis
Candida: Systemic empiric therapy of antifungals…non-responders within 3-5 days should undergo endoscopy with brushings, biopsy and culture.
CMV: in HIV pt’s HAART: highly active antiretroviral therapy is most effective
Herpetic esophagitis: Immunocompetent pt’s tx sx; Immunosuppressed pt’s tx with oral antivirals.
Tx of Infectious Esophagitis
Candida: Systemic empiric therapy of antifungals…non-responders within 3-5 days should undergo endoscopy with brushings, biopsy and culture.
CMV: in HIV pt’s HAART: highly active antiretroviral therapy is most effective
Herpetic esophagitis: Immunocompetent pt’s tx sx; Immunosuppressed pt’s tx with oral antivirals.
Pill-Induced Esophagitis meds:
No Pills QARI VcA NSAIDS Potassium Chloride tabs Quinidine Alendronate Risendronate Iron Vitamin C Abx: Doxy, Tetracycline, Clinda, Bactrim
Most likely to be injured by pills
bed-bound or hospitalized pt’s
S/S of pill-induced eso.
Severe retrosternal chest pain
Odynophagia
Dysphagia
Chronic injury may cause severe esophagitis(stricture, hemorrhage, perforation-taking pills with water and remaining upright for 30min after ingestion)
Caustic esophageal injury
accidental (usually children) or deliberate (suicide) ingestion of liquid or crystalline alkali (drain cleaners) or acid
s/s of Caustic esophageal injury
Severe burning Chest pain Gagging Hematemesis Dyspnea Dysphagia Drooling Aspiration(stridor, wheezing, pt's without major sx or oropharyngeal lesions have a very low likelihood of severe gastroesophageal injury)
Tests with suspected caustic eso.
radiograph - pneumonitis, free air under the diaphragm
Initial tx of caustic eso.
IV fluids, IV PPI to prevent gastric ulceration, Analgesics
Endo within ___-___ hours often shows __ ____ ____ in caustic esophagitis
12-24 hrs
no mucosal injury
Findings in pt’s with mild damage from caustic eso.
Edema Erythema Exudates Superficial ulcers Recover quickly with low risk of developing strictures
Findings in pt’s with severe injury from caustic eso.
Deep, circumferential, necrotic ulcers
High risk of acute complications like perforation with mediastinitis or peritonitis, bleeding, stricture, esophageal-tracheal fistulas
Tx of severe injury from caustic eso.
Emergency surgery with possible esophagectomy
Do not use _______ or _______ in severe caustic eso.
Corticosteroids or abx
