Gastro - Online MedEd - esophagus Flashcards
Esophagus purpose
Peristaltic contractions that move food down
Dysphagia - approach
Trouble swallowing
Think of 2 separate categories:
1) Motility - functional: not progressive (foods and liquids at same time)
2) Mechanical - obstruction grow into lumen: progressive (first from foods, then liquids)
Diagnostic workup of dysphagia
1) Barium swallow - need to know what these look like
2) Endoscopy with biopsy *best test for both cases of dysphagia
3) Manometry - for motility (not mechanical)
Motility disorders - types
1) Achalasia/pseudoachalasia:
Absent myenteric plexus –> lower esophageal sphincter cannot relax –> bolus of food sticks at junction (GE junction at mid sternum)
2) Scleroderma - opposite achalasia - collagen deposition disease
3) Diffuse esophageal spasm - random contractions of esophagus
1 and 2 are opposites, both involve the LES
Dx of achalasia
Barium - bird’s beak
Manometry - will show that lower esophageal sphincter has abnormal tone, whereas the rest of the stomach/esophagus has normal tone
EGD with biopsy * best test - biopsy is to show the absent myenteric plexus - mostly to RULE OUT cancer
Myenteric plexus and achalasia - relationship?
Achalasia - missing this plexus
This is an inhibitory plexus
So causes lower esophageal sphincter to be abnormally contracted
Treatment of achalasia
Botox injection - doesn’t last long (terrible surgical candidate)
Dilation - perforation risk, might need to do several times (don’t do this)
Myotomy *best treatment - if take too much muscle, will develop with bad GERD (similarly treating GERD can cause achalasia)
Scleroderma - what is it?
Collagen deposition disease
Collagen REPLACES the smooth muscle of the lower esophageal sphincter, so sphincter cannot contract!
Scleroderma - presentation
CREST - calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia = systemic sclerosis also, pulmonary kidney heart involvement Relentless GERD (no lower esophageal sphincter)
Scleroderma - dx
Barium - wide open esophagus
Manometry - no contraction of LES (acid comes up and burns esophagus)
Endoscopy and biopsy
Treatment scleroderma
PPI
What is the serology associated with scleroderma
CREST = anti-centromere
Systemic GERD = anti-scl-70 (topoisomerase)
Diffuse esophageal spasm
Random contractions of the esophagus without swallowing
Presentation - esophageal spasm
MI like symptoms
Retrosternal chest pain, crushing in nature, better with nitrates (relax smooth muscle)
-Pain caused by muscle contracting hard
-So need to rule out ACS (trops etc.)
Dx of esophageal spasm
Rule out ACS
Then do: barium (cork-screw esophagus/beads on a string)
manometry (contraction at areas that are contracted, in between will be normal)
EGD and biopsy (biopsy not necessary, but get it to rule out cancer)
Treatment of esophageal spasm
Not life threatening
CCB
Nitrates as needed
Mechanical obstruction types
1) Schatzki’s ring
Schatzki’s ring - what is it
Ring at GE junction - creates a narrowed lumen, only large caliber foods get stuck
Presentation of schatzki’s ring
Steakhouse dysphagia - big piece of meat, infrequent
Dx of schatzki’s ring
Barium - narrows at ring
EGD with biopsy - benign, shows ring, no cancer
Treatment of schatzki’s ring
Lyse it open with EGD
Esophageal webs - cause
Plummer-vinson syndrome
- Woman with dysphagia
- Iron deficiency anemia
- Webs
- Eventually esophageal cancer
What does esophageal webs look like
Webs in esophagus that get in way of food –> can transform to cancer
Dx of esophageal webs
Barium - webs
Do not need to do EGD and biopsy
Treatment of eophageal webs
Iron for anemia
EGD and biopsy - to screen for cancer
Esophagectomy if develop cancer (but not just for webs)
Zenker’s diverticulum - what is it?
Outpouching from esophagus
-Patient with undigested food in zenker’s diverticulum
Zenker’s diverticulum - presentation
Older male
Halithosis - because there is undigested food stuck there
Regurgitation of UNDIGESTED food!
Dx of zenker’s
Barium will seal diagnosis
EGD and biopsy
Treatment of Zenker’s
Surgery
Need to know difference between stricture and cancer! for obstructive dysphagia
Stricture:
1) Result of GERD (Grade IV esophagitis)
2) Bottom third of esophagus
3) Patient: long standing GERD, dysphagia, has weight loss because can’t get food down (decrease food intake)
Cancer:
1) Adenocarcinoma caused by long standing GERD
2) Bottom third of esophagus
But squamous cell (caused by smoking and alcohol is in the upper third)
3) Long standing GERD, dysphagia, also weight loss (cancer stealing nutrients)
-Generally adenocarcinoma will transform to Barrett’s esophagus so GERD symptoms will improve
*important thing is cannot use pathology of symptoms to determine strictures and cancer
Main difference is diagnostic tests:
Barium:
1) Stricture - symmetric, circumferential loss of lumen
2) Cancer - asymmetric loss of lumen
EGD and biopsy - for cancer will show cancer, must do barium first to make sure you know where the cancer is
Treatment of stricture
High dose PPI
Dilation to open up
Treatment of adenocarcinoma
Chemo, radiation, surgery
