Esophagus Disorders Flashcards
Progressive solid food dysphagia
Patients enhance esophageal emptying by lifting the neck or throwing shoulders back
Regurgitation of undigested food
Achalasia
Aperistalsis in distal 2/3 of esophagus
Failure/incomplete relaxation of
the LES
Denervation of the esophagus
Achalasia
What is the cause of primary achalasia?
Result from a defect in inhibitory vagal innervation
Unknown if infectious, autoimmune, or environment is the source
What is the cause of secondary achalasia?
Chagas disease
Cancer
Lymphoma
How is achalasia diagnosed?
Barium esophagram
Endoscopy
Usually confirmed by manometry
If you see the characteristic “Bird’s beak” tapering of the esophagus on a Barium esophagram, what diagnosis is it?
Achalasia
What are some treatment options for achalasia?
Calcium channel blockers
Botulism toxin injection - Inject the LES (temporary relief (1-6 months))
Pneumatic dilation of LES
Surgical esophagomyotomy of LES
Characterized by uncoordinated, nonpropulsive contractions of the
esophagus - Uncoordinated motility
Simultaneous distal esophageal contractions with normal peristalsis (Lower esophageal sphincter normal)
Diffuse Esophageal Spasm
3-5% of patients with diffuse esophageal spasms are likely to progress to what disorder?
achalasia
What are some signs/symtpoms of esophageal spasms?
Progressive dysphagia
Odynophagia
Intermittent substernal pain
Worsen after ingesting cold fluids, large meals, or emotional stress
What are the diagnostic measures for esophageal spasms?
Barium esophagram
Esophageal manometry
If you see a “corkscrew” appearance” tapering of the esophagus on a Barium esophagram, what diagnosis is it?
esophageal spasms
What are some treatment options for esophageal spasms?
Small meals
Avoiding cold foods
Antacids
Calcium channel blockers
NTG
Inflammation of the esophagus
Three types
Esophagitis
Any patient who has trouble swallowing and hurts in their chest, what needs to be ruled out?
rule out a foreign body
What are the three types of esophagitis?
Infectious esophagitis
Pill-induced esophagitis
Caustic esophageal injury esophagitis
Infectious esophagitis will mainly be seen in what patient demographic?
Mainly in immunosuppressed patients
What are the common pathogens that cause infectious esophagitis?
Candida albicans
HSV
CMV
This endoscopic finding on EGD suggests what diagnosis?
Diffuse linear yellow-white plaques adherent to mucosa
Candida albicans
This endoscopic finding on EGD suggests what diagnosis?
Multiple small, deep ulcerations
HSV
What are some common agents that result in pill-induced esophagitis?
NSAIDs
KCl
Bisphosphonates
Iron
Vitamin C
Antibiotics (Doxycycline most common)
What is the evaluation/treatment of caustic esophageal injury esophagitis?
Admit to ICU
ENT/GI consult
Circulatory status along with airway patency and oropharyngeal mucosa should be priority
Swallowing medication causes inflammation
Occurs most commonly if swallowed without water or while supine
Self limited – no intervention
Pill-Induced Esophagitis
Accidental (children) or intentional (suicide)
Less likely to have serious gastric injury of no major symptoms
Esophageal Injury Esophagitis
Chronic immune/antigen mediated disease
Causing esophageal dysfunction and eosinophil-predominant inflammation
Most common in Caucasian men
Characterized by concentric esophageal rings
Seen in patients with established GERD
Eosinophilic Esophagitis
What is the treatment for eosinophilic esophagitis?
Treat dysphagia with EGD/dilation
PPI
Topical glucocorticoids (swallowed fluticasone)
Food allergy evaluation
Heartburn is the cardinal symptom
Firstly, rule out cardiac origin
Very common: 20% of adults have weekly symptoms of this (10%
have daily symptoms)
50% develop reflux esophagitis
Gastroesophageal Reflux Disease
What are some alarm symptoms of gastroesophageal reflux disease?
difficulty or pain with swallowing - Odynophagia is NOT common in GERD and warrants further investigation
What are some contributing factors of GERD?
Incompetent LES
Hiatal hernia
Irritant effects of reflux
Abnormal esophageal clearance
Delayed gastric emptying
What are some exacerbating factors of GERD?
Foods
Bending or recumbency
What is the clinical presentation of GERD?
Heartburn
Regurgitation
Nausea
Throat irritation
Atypical symptoms - asthma, cough (persistent, dry), laryngitis
Most effective agents available for GERD
Proton Pump Inhibitors (PPIs)
What are the treatment goals of GERD?
Provide symptomatic relief
Heal esophagitis
Prevent complications
What are some treatment options for GERD?
Proton Pump Inhibitors (PPIs)
H2 Antagonists
Antacids
Complicated patient - Gets EGD right away
Surgical treatment – Nissen Fundoplication
What are some alarm symptoms for GERD?
GI bleeding/anemia
Dysphagia/odynophagia
Unintentional weight loss
h/o heavy NSAID use
What are some invasive testing for GERD (either for complicated or unresponsive GERD)?
Upper endoscopy
Barium swallow
Esophageal pH monitoring
What is a complication we worry about with GERD?
Barrett’s Esophagitis
Squamous epithelium at distal esophagus replaced by metaplastic columnar epithelium
Barrett’s Esophagitis
Why are we concerned about Barrett’s Esophagitis?
Can lead to adenocarcinoma - presence of dysplasia increases the risk of progression to carcinoma
What is the treatment for Barrett’s esophagitis and why?
Treatment: long term PPI
PPIs are the only agents that heal ulcers and erosions - may reduce the risk of cancer (keeps risk of changing from metaplastic to dysplasia down)
Recommend EGD for Barrett’s screening in patients with what factors?
chronic GERD symptoms
Male
White
Hiatal hernia
Age 50+ years
What are the Barrett’s esophagitis screening guidelines?
If low grade dysplasia is found, repeat endoscopy in 6 months
If high grade dysplasia is found, repeat EGD with biopsy
EGD every 3-5 years with known Barrett’s esophagitis
What are some complications of GERD?
Barrett’s Esophagitis
Stricture
What is a common cause of GERD in neonates/infants?
Usually due to immature lower esophageal sphincter
Gastric regurgitation occurs in up to how many infants, but pathological GERD affects only 1 in 300 infants
two thirds
When should you intervene in neonates/infants who had GERD?
Regurgitation but still having weight gain 🡪 monitor (unless concerning symptoms)
Regurgitation with poor weight gain 🡪 intervene
What are the complications of GERD in neonates/infants?
Failure to thrive
Respiratory - aspiration pneumonia, chronic cough, wheezing
Mucosal tear at the GE junction
Usually caused by prolonged vomiting/retching (50% of cases)
Binge drinking can be a predisposing factor
Accounts for 5% of upper GI bleeds
Benign, self-limiting (typically)
Mallory-Weiss Tear
What is the treatment for a Mallory-Weiss tear?
Most heal uneventfully within 24-48 hours
Severe bleeds: IV fluid resuscitation, blood transfusion, endoscopic hemostatic therapy
Any ring-like structure along the length of the esophagus
Uncommon - Less than 10% of people
May be an incidental finding
Covered by squamous epithelium
Esophageal Webs and Rings
Esophageal webs and rings are covered by what type of cell?
Covered by squamous epithelium
Which type of esophageal ring/web is described below?
Connective tissue effect
Triad: IDA, dysphagia, webs
Treat IDA = web resolves
If problematic, perform EGD for endoscopic dilation
Plummer Vinson Syndrome
Plummer Vinson Syndrome is associated with what?
Iron Deficiency Anemia
Which type of esophageal ring/web is described below?
Distal esophagus - Most common ring in distal esophagus
Thin, web-like constriction near the border of LES
Common, smooth, benign, circumferential structures
Common cause of intermittent solid food dysphagia
Chronic GERD may cause a role - although pathogenesis is controversial
Schatzki’s Ring
Schatzki’s Ring is associated with what?
GERD
Outpouchings in the esophageal wall
Esophageal Diverticula
What are the two types of esophageal diverticula?
Zenker’s diverticulum - Pharyngeal mucosa protrusion at the pharyngoesophageal junction
Esophageal diverticulum - Mid or distal esophagus, secondary to motility disorders or strictures
Pharyngeal mucosa protrusion at the pharyngoesophageal junction
Zenker’s diverticulum
False diverticulum/outpouching
Harbors undigested food
Zenker’s Diverticulum
What are some signs/symptoms of Zenker’s Diverticulum?
Regurgitation of saliva and food particles consumed several days previously (especially in AM)
Uncoordinated swallow/occlusive episode
Dysphagia
Halitosis
Choking/gurgling
Cough
aspiration
Neck protrusion
How is Zenker’s Diverticulum diagnosed?
Barium esophagram
EGD
contrast CT neck
What is the treatment for Zenker’s Diverticulum?
Surgery if symptomatic
What are some complications of Zenker’s Diverticulum?
Aspiration pneumonia
Bronchiectasis
Enlarged venous collateral channels that dilate as a result of portal HTN
Dilated sub-mucosal veins in lower esophagus
Can be a life-threatening emergency
Esophageal Varices
What amount of patients with varices will bleed?
1/3
Highest mortality and morbidity of any upper GI bleed
Mortality rate of 30%
Esophageal Varices
Esophageal Varices is associated with what?
History of portal hypertension/cirrhotic liver disease (Present in 50% of patients with cirrhosis)
What are some causes of esophageal varices?
Alcoholism
Viral hepatitis
What are the treatment options for esophageal varices?
Fluid resuscitation
Blood transfusion/FFP transfusion if needed
Antibiotics
Octreotide (reduces portal pressure)
Emergency endoscopy within 2-12 hours (Variceal banding, Sclerotherapy)
Surgical intervention
What measures can help prevent rebleeding of esophageal varices?
ALCOHOL CESSATION
Band ligation
Beta blockers
TIPS surgery
Liver transplantation
Esophageal rupture/perforation
Secondary to severe retching/vomiting causing increase in
intraoresophageal pressure combined with negative intrathoracic pressure
Emergent surgical consult
Beorhaave’s Syndrome
What are some signs/symptoms of Beorhaave’s Syndrome?
Hematemesis with SEVERE retrosternal “tearing” pain
Subcutaneous emphysema/crepitation
In Beorhaave’s Syndrome, what finding would you expect to see on a CXR?
Mediastinal widening
What imaging do you order for suspected Beorhaave’s Syndrome?
CXR
CT chest (confirms rupture of lower esophagus)
What is the most common type of esophageal cancer worldwide?
Squamous cell carcinoma most common worldwide (90%)
What is the most common type of esophageal cancer in the US?
Adenocarcinoma 80% (associated with GERD and Barrett’s esophagitis)
Which type of esophageal cancer is described below?
Typically found in lower 1/3 of esophagus
Associated with GERD and Barrett’s esophagitis
Adenocarcinoma
Which type of esophageal cancer is described below?
Typically found in upper 2/3 of esophagus
Associated with tobacco and alcohol
Squamous cell carcinoma
What are some signs/symptoms of esophageal cancer?
Progressive solid food dysphagia - Dysphagia for solids only (90%) – tolerating soft/liquid foods
Odynophagia
Anorexia/weight loss
Voice changes/hoarseness
Anemia
Signs of metastatic disease
What methods are used to diagnose esophageal cancer?
Barium esophagogram - May only identify large lesions
Upper endoscopy with biopsy for diagnosis
What is the overall 5 year survival rate of esophageal cancer?
<15%
Why does esophageal cancer carry such a poor prognosis?
Over 60% of patients are not candidates for surgery - Present with advanced disease, have significant comorbidities
