esophagus pathophysiology Flashcards
- Understand the anatomy and function of the oropharynx and its associated structures.
includes teeth, lips, mouth (mastication and saliva), tongue, pharynx (movement of bolus from mouth to upper esophagus). Protection of airway and nasal passages via clsoure of nasopharynx (soft palate elevation), elevation of posterior tongue and epiglottis/vocal cord closure
Phases of deglutition (swallowing)
oral phase: voluntary, chewing and moving bolus to back of tongue. Pharyngeal phase: involuntary, bolus on upper pharynx, pharynx changes shape and contracts while UES relaxes, bolus transits from oropharynx to esophagus
Oropharyngeal dysfunction symptoms
•Oropharyngeal (transfer) dysphagia = inability to initiate a swallow or transfer food bolus into esophagus. Nasal regurgitation, aspiration into airway/lungs (coughing, choking, stridor, wheezing, cyanosis), aspiration pneumonitis (SOB or hypoxia) or pneumonia
Causes of oropharyngeal dysphagia
obstruction or neuromuscular (motility disorder)
aspiration pneumonitis vs pneumonia
Aspiration pneumonitis = lung injury from acidic or lipophilic properties food. Pneumonia if bacterial colonization occurs
Conditions which cause oropharyngeal disease
Neurologic: Stroke, Amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Multiple sclerosis, Polio. Muscular: Myasthenia gravis, muscular dystrophy Muscle injury (surgery, radiation therapy). Structural: Zenkers diverticulum, crycopharyngeal bar, thyromegaly, fibrosis, head and neck cancersNeurologic: Stroke, Amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Multiple sclerosis, Polio. Muscular: Myasthenia gravis, muscular dystrophy Muscle injury (surgery, radiation therapy). Structural: Zenkers diverticulum, crycopharyngeal bar, thyromegaly, fibrosis, head and neck cancersNeurologic: Stroke, Amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Multiple sclerosis, Polio. Muscular: Myasthenia gravis, muscular dystrophy Muscle injury (surgery, radiation therapy). Structural: Zenkers diverticulum, crycopharyngeal bar, thyromegaly, fibrosis, head and neck cancers
What is Zenkers diverticulum
–– outpouching of esophagus leading to food regurgitation or bacterial colonization (halitosis)
Oropharyngeal dysfunction diagnosis
history and PE!!! Also, modified barium swallow using X ray video, or neuro consult
Symptoms of esophageal motility disorders
dysphagia to solids and liquids, chest pain
Etiology of esophageal motility disorders
- Achalasia: abnormal peristalsis, failure of LES relaxation. 2. Spastic Disorders of the Esophagus. 3. Weak Peristalsis. 4. Scleroderma
Diagnosis of esophageal motility disorders
Upper endoscopy or barium esophagram to exclude structural lesion, and esophageal manometry
Types of Achalasia and their manometry findings
- Type I (Classic): Swallowing - no significant change in esophageal pressurization. 2. Type II: Swallowing - simultaneous pressurization spanning entire esophagus length. 3. Type III (Spastic): Swallowing - abnormal, lumen obliterating contractions/spasms
treatment of achalasia
Type II: Botox injections, pneumatic dilation, surgical myotomy work best. Type III: Botox injections, pneumatic dilation, surgical myotomy have poor outcomes
Pathophysiology of achalasia
LES pressure & relaxation regulated by excitatory and inhibitory neurotransmitters. Loss of inhibitory neurons in myenteric plexus causes hypertensive, non-relaxed lower esophageal sphincter
What is pseudoachalasia
Type of secondary achalasia due to direct mechanical obstruction of LES. Caused by Infiltrative submucosal invasion (esophageal/gastric malignancy), paraneoplastic tumors express neuronal Ag so T cells and Abs attack neurons of myenteric plexus (small cell lung cancer, pancreatic, prostate), or Chagas disease
Achalasia treatment
Surgical myotomy, Botox injections at GE junction (inhibits Ach release from nerve), balloon dilation to tear LES muscle fibers, Per-oral endoscopic myotomy, medical if contraindication for others (nitrates, Ca channel blockers, sildenafil)
What is scleroderma/progressive systemic sclerosis?
Multisystem disorder characterized by: Obliterative small vessel vasculitis and Connective tissue proliferation with fibrosis of multiple organs. GI manifestations in 80-90%: smooth muscle atrophy and gut wall fibrosis
Symptoms of scleroderma/PSS
dysphagia (weak peristalsis), GERD (weak LES), stricture (unrepentant GERD)
Spastic disorders of esophagus
peristalsis is preserved, but chest pain and dysphagia possibly due to overactivity of excitatory nerves or smooth muscle response
List structural esophageal disorders
strictures (GERD, radiation, caustic causes), Schatzkis ring, eosinophilic esophagitis (benign), compression, cancer, metastasis
Esophageal strictures cardinal symptom
dysphagia to solids
Esophageal strictures cardinal treatment
endoscopic dilation using balloons or dilator
What is eosinophilic esophagitis
•Chronic immune/antigen-mediated esophageal disease. Symptoms of esophageal dysfunction. Eosinophilic infiltrate in the esophagus. Absence of other potential causes of esophageal eosinophilia
eosinophilic esophagitis endoscopic features
fixed esophageal rings, narrow caliber esophagus, longitudinal furrows running parallel to axis, white plaques/exudates, crepe paper mucosa that tears easily
eosinophilic esophagitis treatment
Drugs (topical steroids via asthma preparations), diet (allergen free effective in children or 6-food elimination milk, eggs, wheat, soy, seafood, nuts), dilation
- Understand the pathophysiology, symptoms, and treatment for gastroesophageal reflux disease (GERD).
•Pathologic reflux of gastric juice Acid into esophagus. Symptoms: heartburn (postprandial), regurgitation with acid taste, cough, throat clearing, rarely wheezing, stridor/ treatment: antacids or anti-secretory
Causes of GERD
LES relaxation, hiatal hernia (righ crus catches on fundus causing obstruction), gastric/esophageal surgery, dysmotility, obstruction, rare: Zollinger-Ellison, Sjogrens, Scleroderma
GERD risk factors
obesity, tobacco, meds, pregnancy
Complications of GERD
erosion, Barrett’s esophagitis,
GERD diagnosis
symptoms (heartburn +/- regurg), response to acid suppressive therapy, endoscopy for refractory symptoms, transnasal catheter or wireless capsule pH testing in esophagus,
Barretts esophagus risk factors
male, white, central adiposity, advanced age, chronic gerd
Barretts treatment
esophagectomy if high grade dysplasia or cancer, ablation of Barretts tissue or endoscopic resection of visible lesions
What is Barretts a precursor to?
adenocarcinoma of esophagus
2 Main types of esophageal cancer ypes
squamous cell and adenocarcinoma
risk Factors for squamous cell carcinoma and location
age, alcohol/tobacco, caustic injuries. Anywhere is esophagus
risk factors for adenocarcinoma and locations
age, smoking, obesity, GERD, BARRETTS esophagus. Usually in distal esophagus or gastric cardia
List symptoms, examples and diagnosis of oropharyngeal obstructions
Sx: choking, cough, nasal regurg, aspiration. Dz: head and neck cancer, zenkers diverticulum, radiation therapy. Diagnosis: barium swallow
List symptoms, examples and diagnosis of oropharyngeal propulsion/motility issues
sx: Transfer Dysphagia, Cough, Nasal regurgitation, Aspiration. Dz: neuro conditions (stroke, ALS, MS, parkinsons), myasthenia gravis, muscular dystrophy. Diagnosis: barium swallow
List symptoms, examples and diagnosis of esophageal obstructions
Sx: Dysphagia to solids, Food impaction (EoE), Weight loss, Vomiting, Regurgitation. Dz: esophageal strictures, esophageal rings, EoE, extrinsic compression. Diagnosis: EGD, esophagram
List symptoms, examples and diagnosis of esophageal propulsion/motility issues
sx: solid and liquid dysphagia, chest pain. Dz: achalasia, esophageal spasm, scleroderma, esophageal cancer. Diagnosis: esophagram, EGD, esophageal manometry
