Esophagus lecture Flashcards
Difficulty initiating swallow reflex
Usually neuromuscular disorder causing weakness or lack of coordination
ie… CVA, parkinsons
Oropharyngeal dysphagia
Arises in body of esophagus, LES, or cardia
Usually due to mechanical problem or motility disturbance
ie.. stricture, tumor, radiation, scleroderma
Esophageal dysphagia
Sharp substernal pain on swallowing
*usually reflects severe erosive disease
Odynophagia
3-4 cm long segment of smooth muscle at distal end of esophagus
*prevents reflux of stomach contents back into esophagus
Lower esophageal sphincter (LES)
Occurs when LES is weak or relaxes inappropriately
GERD
Severity of GERD depends on?
- acidity
- duration
- amount
…of refluxed fluid in esophagus
Occurs when the LES, upper part of stomach moves up into chest through a small opening in the diaphragm (the diaphragmatic hiatus)
*can lead to GERD
*can be detected on XRay
Hiatal hernia
- Abx (tetracycline)
- Bisphosphonates
- Iron
- NSAIDs
- Anticholinergics
- CCBs
- Narcotics
- Benzos
….do what to GERD?
Worsen GERD
MC disorder of esophagus
Mostly mild dz but 50% will develop esophagitis
Common in N. America and Europe
MC in caucasians
Common in pregnancy due to increased hormones and increased intrabdominal pressure
GERD
Presentation:
Heartburn
Odynophagia
Dysphagia
Belching
Nausea
Anorexia/wt loss
atypical sxs: sore throat, dental carries, chronic cough, asthma, recurrent pneumonia
GERD
MC sx of GERD?
Heartburn 30-60 mins after meal
Symptoms of GERD are temporarily relieved by…
Antacids
Sxs of GERD are aggravated by…
Recumbent position
Diagnostic of choice for GERD?
Upper endoscopy with biopsy
(esophagogastroduodenoscopy, EGD)
Age >50
Wt loss
Melena
Difficulty/pain swallowing
Heavy ETOH/ tobacco
Non responsive to tx
PPIs
…should pursue what?
Upper endoscopy with biopsy
(Esophagogastroduodenoscopy, EGD)
Metaplastic changes which stratified squamous epithelium change to intestinal columnar epithelium
*increases risk for developing adenocarcinoma!
Barrett’s esophagus
(a complication of GERD)
Where do changes orginally occur in Barrett’s and how do they spread?
Originate at gastroesophageal junction
Extend proximally
in Barrett’s, how frequently do you repeat endoscopy with bx?
every 2 years
What percentage of pts who undergo endoscopy for GERD have Barrett’s?
5-15 %
In Barrett’s, if high grade dysplasia risk increases to 25%, what must you consider?
Surgical resection or ablative therapy
Avoid chocolate, peppermint, ETOH, coffee and fatty foods
Avoid acidic foods: red wine, OJ
Decrease portion size
Lose weight
avoid eating 2-3 hours before bed
elevate head of bed
quit tobacco (causes hyposalivation)
Non pharm tx for GERD
“-tidine” drugs
H2 blockers
“-prazole” drugs
PPIs
Motility disorder
usually associated with CP and/or dysphagia
Nutcracker esophagus (increased pressure >180 mmHg during peristalsis)
Rx: Nitrates, CCBs (Diltiazem)
Esophageal spasm
Increased pressure >180 mmHg during peristalsis
Nutcracker esophagus
Esophageal manometry shows:
aperistalsis (no relaxation of LES)
Achalasia
Esophageal manometry shows:
hypercontractile, esp at LES
Nutcracker esophagus
HSV
Varicella Zoster
CMV
Candidia
Can all cause infectious esophagitis
Intraluminal mucosal tear of distal esophagus or gastric cardia
*a linear mucosal tear in esophagus, generally at gastroesophageal junction
*caused by increase in intra-abdominal pressure
Mallory-Weiss Syndrome
Occurs with foreceful vomiting or retching, causing hematemesis
accounts for 5-10% of upper GI bleeds
***generally occcurs with alcohol use but should always be suspected in an upper GI bleed
Mallory-Weiss Syndrome
How do you dx a Mallory-Weiss tear?
Endoscopy
Control bleeding endoscopically via coag techniques
most bleeding resolves spontaneously
*typically benign, self limiting
Mallory Weiss Syndrome
If Mallory-Weiss pt is…
- Hemodynamically unstable
- Has an extreme in age
- Has underlying medical issue
ADMIT
Dilated submucosal veins develop in pts with portal HTN
*blood flow thru liver is diminished so blood flow increases thru microscopic blood vessels within esophageal wall, which causes the vessels to dilate
Esophageal varices
MC cause of portal HTN?
Cirrhosis
(other causes= Portal vein thrombosis, Budd Chiari Syndrome, Infiltrative liver dz)
Mortality rate for first time esophagaeal varcies rupture
40-70%
Varices here are most likely to rupture bc they are superficial
GE junction
Hematemesis (>50% stop bleeding spontaneously)
Melena
Weakness/fatigue
Tachycardia
Hypotension, syncope
Abd pain
Jaundice
Esophageal varices
MUST STOP BLEEDING ASAP!
tx:
ligation with rubber band
sclerotherapy
balloon tamponade
(most stop spontaneously but ~75% mortality rate for those who continue to bleed)
Esophageal varices
The underlying cause in adults is portal HTN, MC caused by cirrhosis (either from alcohol abuse or chronic viral hepatitis)
*use of NSAIDs can exacerbate
Esophageal varices
Beta blockers and nitrates to decrease portal HTN
Shunts
Liver transplant
long term tx for?
Esophageal varices
Ring of tissue located at jxn of esophagus and stomach, Schatzki’s Ring
*usually congenital
*can be due to chronic GERD, scar tissue
sx: dysphagia (esp with solids)
Esophageal ring
Similar to esophageal rings but occur in mid to upper esophagus
lead to intermittent dysphagia of solid food
Esophageal web
Dx of esophageal web or rings
Tx?
Dx:
Barium Esophogram
EGD
Tx: mechanical dilation with balloon
Loss of peristalsis in distal esophagus and failure of the LES to relax
Food backs up and ferments in esophagus, causing it to distend and dilated
causes include: damage to nerves of esophagus, infection (Chagas), hereditary
Achalasia
MC symptom= dysphagia
Chest pain
Regurgitation
Difficulty belching
Weight loss
Achalasia
Dx of Achalasia made with…
Chest X ray
Barium swallow
Manometry
Endoscopy
Bird’s beak seen on barium swallow X ray
Achalasia
Pneumatic dilation with balloon inflation can be used in tx of…
(60-90% effective and can last for 10 years)
Achalasia
After the lower end of the esophagus is found and moved into position, the muscular ring surrounding the LES is cut, allowing it to open more easily.
95% success rate in treating achalasia
Myotomy
Surgical Procedure to Rx GERD/Hiatal Hernia
Gastric Fundus is wrapped around Lower end of Esophagus
Can be done Laproscopically
Complications: Gas Bloat syndrome (can’t belch), Dysphagia, Dumping Syndrome(Food passes thru stomach too fast)
Nissen Fundoplication
What is diagnosed more:
Adenocarcinoma or squamou cell carcinoma
(for esophageal cancer)
Pretty much equal
5 year survival rate for esophageal cancer?
10-13%
3x more common in males
6x more common in blacks
MC found in middle esophagus
Risks: smoking, ETOH
Squamous cell carcinoma
7x more common in males
4x more common in whites
MC found in distal esophagus
Risks: Barrett’s esophagus
Adenocarcinoma
Achalasia (16 fold increase)
Caustic esophageal injury due to lye (ie suicide attempt)
Partial gastrectomy
..increase risk of?
Esophageal (squamous cell) carcinoma
Obesity is a risk factor for….
Adenocarcinoma
An esophageal lumen diameter of less than 13 cm indicates…
Severe dz! (will have dysphagia)
Tracheobronchial fistulas are a late complication of….
Esophageal cancer
(fistulas caused by direct invasion thru the esophageal wall and into the main stem bronchus)
life expectancy is less than 4 weeks if this complication develops
Budd-Chiari syndrome may cause thrombosis of the portal vein, leading to…
Esophageal varices
