Esophagus, Stomach, Pharynx, Oral Cavity Flashcards
“Nocturnal asthma”
Presentation of GERD where patient presents with paroxysmal nocturnal coughing and hacking, ONLY at night. Due to reflux and burning/irritation of larynx.
Step ladder for GERD management
-
If no alarm Sx:
- Lifestyle modification
- H2 blocker or PPI
- Consider Nissen fundoplication
-
If alarm Sx present OR above fails:
- Alarm Sx: N/V, weight loss, anemia
- EGD w/ biopsy (to make sure there is no cancer)
- If GERD w/ normal biopsy: Consider Nissen fundoplication
- If GERD w/ metaplasia (Barrett’s): High dose PPI OR Nissen fundoplication
- If GERD w/ dysplasia: Ablation
- If GERD w/ adenocarcinoma: Resect
Patient with pretty bad GERD who spontaneously gets better without PPIs
This should make you concerned for metaplasia. They have gotten better in terms of symptoms because they now have metaplastic mucosa lining the esophagus, which is more resistant to acid burns.
Most reliable test for GERD
24h pH monitor w/ symptom journal
Rarely necessary, BUT it is required prior to Nissen fundoplication
Workup for suspected achalasia / dysphagia
- 1st step: Bartium swallow (may see bird’s beak sign)
- 2nd step: Manometry to confirm diagnosis
- 3rd step: Endoscopy w/ biopsy to rule-out pseudoachalasia (cancer)
Best treatment for achalasia
Myotomy!!!
Botox only for poor surgical candidates
Cancers of the esophagus
-
Squamous cell carcinoma:
- Upper 1/3 of esophagus
- Risk factors: Drinking lots of hot liquids, smoking
-
Adenocarcinoma:
- Related to GERD (often precursor of Barret’s)
Features of dysphagia suggestive of cancer
- Progressive dysphagia:
- First to large things (solid)
- Later to small things and liquids
“Weekend warrior” presentation
- Person goes out on Saturday night
- Drinks a bunch of beer
- vomits a bunch of beer
- vomits more beer
- vomits blood
- vomits blood
- vomits bile
- Typically this is a repeated presentation – people who come presenting with Mallory Weiss have probably had it before
- This person has Mallory-Weiss syndrome. It is a clinical diagnosis, but you have to rule out other causes of GI bleed with upper endoscopy. Does not really require treatment apart from behavior change.
Hamond’s crunch
The crepitus that results from a heartbeat in someone with pneumomediastinum. Classically this occurs in Boerhaave’s syndrome.
Compared to people with Mallory Weiss, people with Boerhaave’s are. . .
. . . sick as shit
They will have mediastinitis and sepsis, have a wretching cough, and be febrile and probably hypotensive. Mallory Weiss patients will have a GI bleed, but they will be generally stable.
Dx and Tx of Boerhaave’s
- If patient is stable: Three tests, DO NOT PROGRESS unless the previous test was negative
- Gastrographin swallow (less irritating to the mediastinum, which is why it is first)
- Barium swallow (better test, but more caustic to mediastinum)
- EGD (only in cases where above are negative. We like to avoid this because we do NOT want to put the EGD scope into the mediastinum by accident)
- If patient is unstable or unable to undergo contrast enterography: CT scan
- Treatment:
- Uncomplicated (confined to mediastinum, no signs of infection or hemodynamic instability, no comorbid medical conditions): Conservative management with NPO, parenteral nutrution, IV PPIs, analgesia, prophylactic ampicillin-sulbactam
- Complicated: Emergent surgery
Gastrographin vs Barium swallow studies
Gastrographin: More irritating to lungs if aspirated, but less irritating to mediastinum
Barium: Less irritating to lungs if aspirated, but more irritating to mediastinum
So, we do gastrographin if we think that Boerhaave’s is most likely. We do barium if we think that dysphagia or Mallory Weiss is most likely.
Approach to hard palate masses
- Torus palatinus: smooth, bony hard, and nontender mass. Bony tumor that often occurs in adolescents or young women.
- Palatal pleomorphic adenomas: painless, firm (but not bony) mass and may involve the minor salivary glands of the palate. Common in age 40-60 with Hx ionizing radiation or chemical exposure.
- Nasopalatine duct cyst: fluctuant, midline palatal mass, most commonly in patients aged 30–60 years
- Hyperplastic candidiasis: palpable white nodule on the oral mucosa with a rough surface. Usually on the heeks or tongue rather than the palate, but may appear there.
Zenker diverticulum
- Most common type of esophageal diverticulum
- Like all esophageal diverticulae, most commonly occurs in middle-aged to elderly men
- Etiology: abnormal esophageal motor function resulting in increased luminal pressure and resultant diverticulae
- Pres: Usually asymptomatic. If symptomatic, dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. Commonly presents as recurrent aspiration pneumonia in an old man.
- “Occasionally coughs up pieces of undigested food” is a buzz phrase. Halitosis often also present.
- Dx: Barium swallow
- Tx: Nothing if asymtpomatic. If significant symptoms, surgery
If a patient has GERD symptoms and B symptoms and you suspect esopageal cancer, your diagnostic workup should start with. . .
. . . EGD
Steps to managing Barret’s
- If suspected on EGD, biopsy
- If biopsy confirms dysplasia/metaplasia, endoscopic radioablation
Schatzki ring
- A narrowing of the lower esophagus caused by a ring of mucosal or muscular tissue resulting in dysphagia, especially to solids.
- Pathogenesis is unclear, mucosal rings may be peptic strictures occurring as a consequence of gastroesophageal reflux disease.
- Dx is with EGD
- Tx is mechanical dilation using bougie or balloon dilators
- Complications: Recurrence is common, and repeat procedures will likely be necssary.
Barium swallow vs Videofluoroscopic modified barium swallow
Barium swallow gives an esophogram at one moment in time
A videofluoroscopic modified barium swallow is a video of the whole process.
GERD sequellae
- Most common: Esophageal strictures
- Less common:
- Recurrent aspiration pneumonia and lung disease
- Barret’s -> Esophageal adenocarcinoma
Treatment for different types of hiatal hernia (if PPI unresponsive)
- Type I: Laporoscopic Nissen fundoplication with hiatoplasty
- Type II, III, IV: Laparoscopic herniotomy
Who is a good candidate for surgical management of GERD and what are the required pre-surgical tests?
-
Someone who responds to PPIs, but does not want to take them forever
- Patients who do not respond to PPIs will not respond as well to fundoplication either!
- Required tests:
- Ambulatory pH monitoring (confirm GERD)
- Esophageal manometry (rule out achalasia)
Post-op period for Nissen fundoplication
- Stay in hospital for 1 day for observation
- Go home on liquid diet and continue for 1 week until swelling in the lower esophagus resolves
Nonerosive reflux disease (NERD)
- Reflux disease that does not involve excess acid exposure, but rather involves visceral hypersensitivity
- These patients present like GERD but will not respond to the conventional medical or surgical management of GERD
- Instead, they may respond to tricyclic antidepressants, trazadone, or SSRIs
- Dx:
- EGD will demonstrate an absence of esophagitis
- Esophageal pH monitoring can rule out true GERD in these patients
Indication for hiatal hernia repair is __, not __.
Indication for hiatal hernia repair is symptoms related to the hernia, not the presence of the hernia.
Atypical GERD symptoms
- Caused by chronic microaspiration
- More likely in patients treated with antisecretory medications
- Include:
- Reactive airway
- Morning hoarseness
- Coughing spells during sleep
- Recurrent pneumonia
- Pulmonary fibrosis
Nissen fundoplication and antisecretories
While most Nissen fundoplications are performed on the basis of avoiding long-term antisecretory usage, roughly 50% of patients will develop abdominal complaints requiring placement back on an antisecretory after the procedure
GERD symptoms in a diabetic patient may be secondary to. . .
. . . diabetic gastroparesis
In these patients, a nuclear scintigraphy study (aka a gastric emptying study) may be helpful to assess stomach motility.
Importantly, this is a contraindication to Nissen fundoplication. A fundoplication would make the bloating and abdominal paib worse for these patients by overdistending the stomach.
Cervical esophageal rupture
Generally less severe than thoracic or abdominal Boerhaave’s
Typically, only supportive care, antibiotics, and drainage are required.
If someone presents with Boerhaave’s syndrome, you should assume that they have. . .
. . . mediastinitis
Due to the translocation of esophageal and oral flora
This is why they all get broad spectrum antibiotics
1 most common etiology of Boerhaave’s
Iatrogenic
From instrumentation, EGD, or surgery
Preferred treatment for Boerhaave’s patients with thoracic perforations
<24 hours since injury: Surgical repair
>24 hours since injury or poor surgical candidate: Esophageal diversion and drainage
With more passing time, there is increasing contamination of the mediastinum and inflammation/swelling of the tissue that makes it less amenable to surgical closure.
Size of the perforation in Boerhaave’s
Nonprognostic!
Believe it or not. This does not matter.
Things that do matter:
- Age
- Time to diagnosis/treatment
- WBC count
- Whether or not leakage is contained
Best initial and secondary tests for suspected esophageal adenocarcinoma
- Initial: EGD with biopsy
- Secondary (if confirmed):
- Local staging endoscopic ultrasound
- Systemic staging PET-CT scan
- Combined local and systemic staging: CT chest + abdomen
Nutritional supplementation options if the esophagus is blocked
- Feeding gastrostomy
- Feeding jejunostomy
- Only if the above cannot be done, TPN
“Types” of GE junction adenocarcinomas and management
- Type I
- > 1 cm above GEJ (in esophagus)
- Treat w/ esophagectomy
- Type II
- < 1 cm above GEJ to < 2 cm below GEJ (in GEJ)
- Treat w/ esophagectomy + proximal stomach resection
- Type III
- >2 cm below GEJ (in stomach)
- Total gastrectomy
Complications of a peptic ulcer
- Perforation and frank peritonitis
- GI bleed
-
Penetration:
- Special case of perforation where the ulcer penetrates into an adjacent organ (often the liver) and results in an abscess along with systemic signs of infection, but in the absence of frank peritonitis.
-
Gastric outlet obstruction:
- May be acute or chronic. Acute often manifests aggressively with subacute hematemesis, occult blood in stool, and early satiety
Blind loop syndrome
- When small intestinal bacterial overgrowth occurs due to blind intestinal loop following abdominal surgery
- Overgrowth occurs in the “blind loop” portion of the lumen that is excluded from the flow of chyme (locally decreased intestinal motility and a relative lack of acidity)
- Results in megaloblastic anemia, diarrhea/steatorrhea, weight loss
- Especially likely following Roux-en-Y or Billroth II
In most cases of H. pylori associated MALT lymphoma, you can treat the lymphoma. . .
. . . by getting rid of the H. pylori
Works ~70% of the time.
Optimal treatment of esophageal adenocarcinoma
Sandwich treatment:
Chemo, followed by surgery, followed by chemo
Best overall improvement and best disease-free survival
Role of esophageal stenting in esophageal adenocarcinoma
- Advantages: Rapid relief of dysplasia, treatment of choice for esopahgeal fistula. Short procedure time and outpatient procedure
- Disadvantages: Frequent recurrence due to stent migration, tumor overgrowth, food impaction. Transient pain following placement. GERD. Increased risk of late hemorrhage.
Single dose brachytherapy for esophageal adenocarcinoma with obstruction
Long-term dysphagia improvement is better than stenting, but takes a little while to take effect. Long term, QOL is better than with stent placement.
Photodynamic therapy with Nd:YAG laser for esophageal adenocarcinoma
- Works quite well with exophytic lesions and has low complication rates
- However, only available at specialized centers and requires repeat treatment every 4-8 weeks
Transhiatal esophagectomy
Best for distal esophageal cancers
Hazardous for tumors in mid-esophagus
Less of a physiologic insult form the respiratory standpoint
Ivor-Lewis Esophagectomy
- Operation best for midesophageal lesions
- Associated with more pain and greater degree of respiratory impact
Three Field esophagectomy
- Theoretically provides best resection of cancer, BUT outcomes are not significantly better and the procedure produces the greatest morbidity compared to other esophagectomies
Distal esophagectomy with left thoracotomy and laparotomy
- This approach causes pain and respiratory compromise
- Also limits the extent of esophageal resection
Minimally Invasive Esophagectomy
- Well tolerated by most patients, but the procedure is very cumbersome
- Effectively a laparoscopic transhiatal dissection
Esophageal squamous cell carcinoma is highly resonsive to __ therapy
Esophageal squamous cell carcinoma is highly resonsive to radiation therapy
Incidence of esophageal adenocarcinoma
Rapidly increasing among Westernized countries
Nobody knows why as of yet.
What do you do if a peptic ulcer is perforated?
Stitch it back up, and. . . .
That’s it. The rest is medical management.
What do you do if a peptic ulcer is bleeding?
Stop the bleeding and perform a highly selective vagotomy or vagotomy with drainage.
Standard vagotomy and antrectomy are procedures of the past and are no longer performed.
Types of gastric ulcer
- Type I: Related to mucosal vulnerability in epithelium between the stomach body and antrum. May be H. pylori associated. Treat w/ distal gastrectomy or vagotomy with drainage.
- Type II: Coexistence of Type I and duodenal ulcers. Related to acid hypersecretion. Treat w/ vagotomy with drainage or highly selective vagotomy.
- Type III: Pre-pyloric (~2 cm from pylorus). Related to hyperacidity and pyloric dysfunction. Treat w/ vagotomy with drainage.
- Type IV: Within 2 cm of GEJ. Not associated with acidity, but rather mucosal vulnerability in older individuals. Treat w/ subtotal gastrectomy or ulver ecision + vagotomy with drainage.
- Type V: May occur anywhere in stomach – wherever NSAIDs land. Sometimes you can still see evidence of the pill. Surgery is rarely indicated for these ulcers.
Treatment regimens for H. pylori
Omeprazole plus [pick two: Clarithromycin, amoxacillin, metronidazole]
Treat for 2 weeks and ALWAYS, ALWAYS, ALWAYS confirm eradication at the end of treatment
Treating NSAID-mediated peptic ulcer disease
Stop the NSAID if possible
Take a PPI or H2 blocker + misoprostol for a while.
Sucralfate
Drug that complexes with pepsin and bile salts and binds to proteins in the mucosa
As a general rule, most gastric ulcers should be ___
As a general rule, most gastric ulcers should be biopsied
To rule out malignancy
Indications for surgery in PUD
- Perforation
- Gastric outlet obstruction
- Hemorrhage
- Intractable symptoms
Surgery is not recommended in patients whose symptoms do not respond to PPI unless. . .
. . . regurgitation is an accompanying symptom
Primary muscular element that generates resting UES tone and innervating nerve
Cricopharyngeus muscle
Innervated by the recurrent laryngeal nerve
Auerbach vs Meissner
- Auerbach: Between two muscular layers, respondible for peristalsis
- Meissner: In submucosa, resposible for afferent sensory input
Laryngopharyngeal reflux
- Variant of GERD that involves the larynx/pharynx
- Symptoms include hoarseness, chronic cough, sore throat, globus pharyngeus, and excessive throat clearing
- Over 50% of patients who present with voice complaints have LPR
- The larynx lacks the protective mucosa that the distal esophagus has, making it highly vulnerable to acid damage as well as pepsin, bile acids, and pancreatic lipases (if they make it up that far)
Impedance monitoring
- Esophageal 24-hour pH/impedance reflux monitoring measures the amount of reflux (both acidic and non-acidic) in your esophagus during a 24-hour period, and assesses whether your symptoms are correlated with the reflux.
Salivary pepsin assay
Can be used to support or suggest against a diagnosis of reflux
Very similar design to a pregnancy test
__ is considered the best diagnostic test for laryngopharyngeal reflux
2x/day PPI challenge is considered the best diagnostic test for laryngopharyngeal reflux
Predictors of good response to surgery in LPR
- Presence of hiatal hernia
- Reporting of baseline reflux symptoms (not episodic)
- Concommitant presence of regurgitation
Laryngoscopy for LPR
Not as helpful as one might expect
No specific findings for LPR and high inter-rater variability. Neither sensitive nor specific for the diagnosis.
Eosinophilic esophagitis
- Often involves PPI-refractory reflux symptoms and acute presentation from food impaction due to stricture formation
