GI #5 Flashcards
What is achalasia?
-Loss of peristalsis and failure of relaxation of the LES
What is the pathophysiology of Achalasia?
Idiopathic degeneration of Auerbach’s plexus leads to increased LES pressure and impaired LES relaxation
Symptoms of achalasia
- Dysphagia to both solids and liquids at the same time
- Weight loss
- Malnutrition
- Regurgitation of undigested food
What is the MOST accurate diagnostic for achalasia?
Manometry: increased LES pressure and lack of peristalsis
What is seen on a barium esophageal for achalasia?
-Bird’s beak appearance of LES (narrowing of LES) with proximal esophageal dilation and loss of peristalsis distally
What is performed in a patient with achalasia prior to initiating treatment to rule out esophageal SCC?
Endoscopy
How to manage a patient with achalasia?
- Decrease LES pressure: Botulinum toxin, Nitrates, Surgery
- Pneumatic dilation of LES
- Esophagomyomectomy (definitive)
What is a Zenker’s Diverticulum?
Pharyngoesophageal pouch (false diverticulum) that only involves the mucosa and possibly submucosa
Zenker’s Diverticulum MC occurs in
Males in 70’s
What is the pathophysiology of Zenker’s Diverticulum?
Weakness at junction of Killian’s Triangle (between fibers of cricopharyngeal muscle and lower inferior pharyngeal constrictor muscle)
Symptoms of a Zenker Diverticulum
- Dysphagia
- Regurgitation of undigested food
- Neck mass
- Choking sensation
- Halitosis (due to food retention in pouch)
What is the initial test of choice for a Zenker Diverticulum?
-Barium Esophagram with video fluoroscopy (collection of dye behind esophagus at pharyngoesophageal junction)
However, an ________ is usually performed for surgical evaluation for a Zenker
Upper endoscopy
Management for a Zenker Diverticulum
Observation if small and asymptomatic
Diverticulectomy if large or symptomatic
Explain distal (diffuse) esophageal spasms
-Severe, non-peristaltic esophageal contractions (uncoordinated contractions)
Symptoms of diffuse esophageal spasms
- Stabbing, chest pain worse with hot or cold liquids
- Dysphagia to both solids and liquids
Definitive diagnostic for diffuse esophageal spasm
Manometry: increased simultaneous or premature contractions
What is seen on esophagram with diffuse esophageal spasm
Corkscrew esophagus: severe, non-peristaltic contractions
First-line treatment for diffuse esophageal spasms
-Anti-Spasmodics (CCB, Nitrates, TCAs)
What are other treatment options for diffuse esophageal spasms?
-Botulinum toxin, Pneumatic dilation
What is hyper contractile (jackhammer) esophagus
-Increased pressure during peristalsis
What is another name for Jackhammer Esophagus?
-Nutcracker Esophagus
Symptoms of jackhammer Esophagus
- Dysphagia to both solids and liquids
- Chest pain, retrosternal
Definitive diagnostic for jackhammer esophagus
Manometry: increased pressure during peristalsis
What tests are usually normal in jackhammer esophagus?
Upper endoscopy and esophagram
Treatment for hyper contractile esophagus
-CCB, Nitrates, Botulinum injection, TCA
What is the difference in presentation between diffuse esophageal spasm and hypercontractile esophagus?
- Diffuse: severe, non-peristaltic contractions
- Hypercontractile: increased pressure during peristalsis
Boerhaave Syndrome (esophageal perforation) is a
Full thickness rupture most commonly affecting the left posterolateral wall of the lower esophagus
What is the MC cause of Boerhaave Syndrome?
-Iatrogenic perforation during endoscopy
But other causes of Boerhaave Syndrome include
-Repeated, forceful vomiting (Bulimia, alcoholism)
Symptoms of Boerhaave Syndrome
- Chest pain worse with breathing and swallowing
- Vomiting
- Hematemesis
- Crepitus on auscultation
- Hamman’s Sign: crackling accompanying every heart beat in left lateral decubitus position
What is Hamman’s Sign?
Crackling associated with every heart beat in left lateral decubitus position
What is the diagnostic test of choice for Boerhaave Syndrome?
Contrast esophagram: Gastrografin swallow preferred
What does a CXR show in Boerhaave Syndrome?
Pseudomediastinum
Treatment for Boerhaave Syndrome?
Small and stable: IVF, NPO, H2 receptor blockers, ABX
Large or severe: surgical repair
What is a Mallory-Weiss Syndrome/Tear?
-Longitudinal superficial mucosal laceration at GEJ or gastric cardia
What is the cause of a Mallory-Weiss Tear?
Sudden rise in intraabdominal pressure or gastric prolapse into the esophagus (persistent retching or vomiting after ETOH binge)
Symptoms of a Mallory-Weiss Tear
- Upper GI bleeding: hematemesis, melena, hematochezia, syncope
- Abdominal pain, back pain
What is the test of choice for a Mallory-Weiss Tear?
Upper endoscopy: shows superficial longitudinal mucosal erosions
Treatment for Mallory-Weiss Tears (not actively bleeding vs severe bleeding)
Not actively bleeding: supportive, acid suppression with PPI
Severe bleeding: thermal coagulation, hemoclips, endoscopic band ligation, balloon tamponade
