Gastro - Online MedEd - esophagus

Question 1

Esophagus purpose

Answer 1

Peristaltic contractions that move food down

Question 2

Dysphagia - approach

Answer 2

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)

Question 3

Diagnostic workup of dysphagia

Answer 3

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)

Question 4

Motility disorders - types

Answer 4

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

Question 5

Dx of achalasia

Answer 5

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

Question 6

Myenteric plexus and achalasia - relationship?

Answer 6

Achalasia - missing this plexus
This is an inhibitory plexus
So causes lower esophageal sphincter to be abnormally contracted

Question 7

Treatment of achalasia

Answer 7

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)

Question 8

Scleroderma - what is it?

Answer 8

Collagen deposition disease

Collagen REPLACES the smooth muscle of the lower esophageal sphincter, so sphincter cannot contract!

Question 9

Scleroderma - presentation

Answer 9

CREST - calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia = systemic sclerosis
also, pulmonary kidney heart involvement 
Relentless GERD (no lower esophageal sphincter)

Question 10

Scleroderma - dx

Answer 10

Barium - wide open esophagus
Manometry - no contraction of LES (acid comes up and burns esophagus)
Endoscopy and biopsy

Question 11

Treatment scleroderma

Answer 11

PPI

Question 12

What is the serology associated with scleroderma

Answer 12

CREST = anti-centromere

Systemic GERD = anti-scl-70 (topoisomerase)

Question 13

Diffuse esophageal spasm

Answer 13

Random contractions of the esophagus without swallowing

Question 14

Presentation - esophageal spasm

Answer 14

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.)

Question 15

Dx of esophageal spasm

Answer 15

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)

Question 16

Treatment of esophageal spasm

Answer 16

Not life threatening
CCB
Nitrates as needed

Question 17

Mechanical obstruction types

Answer 17

1) Schatzki’s ring

Question 18

Schatzki’s ring - what is it

Answer 18

Ring at GE junction - creates a narrowed lumen, only large caliber foods get stuck

Question 19

Presentation of schatzki’s ring

Answer 19

Steakhouse dysphagia - big piece of meat, infrequent

Question 20

Dx of schatzki’s ring

Answer 20

Barium - narrows at ring

EGD with biopsy - benign, shows ring, no cancer

Question 21

Treatment of schatzki’s ring

Answer 21

Lyse it open with EGD

Question 22

Esophageal webs - cause

Answer 22

Plummer-vinson syndrome

• Woman with dysphagia
• Iron deficiency anemia
• Webs
• Eventually esophageal cancer

Question 23

What does esophageal webs look like

Answer 23

Webs in esophagus that get in way of food –> can transform to cancer

Question 24

Dx of esophageal webs

Answer 24

Barium - webs

Do not need to do EGD and biopsy

Question 25

Treatment of eophageal webs

Answer 25

Iron for anemia
EGD and biopsy - to screen for cancer
Esophagectomy if develop cancer (but not just for webs)

Question 26

Zenker’s diverticulum - what is it?

Answer 26

Outpouching from esophagus

-Patient with undigested food in zenker’s diverticulum

Question 27

Zenker’s diverticulum - presentation

Answer 27

Older male
Halithosis - because there is undigested food stuck there
Regurgitation of UNDIGESTED food!

Question 28

Dx of zenker’s

Answer 28

Barium will seal diagnosis

EGD and biopsy

Question 29

Treatment of Zenker’s

Answer 29

Surgery

Question 30

Need to know difference between stricture and cancer! for obstructive dysphagia

Answer 30

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

Question 31

Treatment of stricture

Answer 31

High dose PPI

Dilation to open up

Question 32

Treatment of adenocarcinoma

Answer 32

Chemo, radiation, surgery