GI Conditions - Esophagus - Prof. Wall Flashcards
Esophagus
GERD
Return of stomach contents into esophagus (w/ symptoms)
Most Common D/O of Esophagus
Esophagus
GERD
Lower esophageal sphincter is weak or relaxes inappropriately
Esophagus
GERD
+
Hiatal Hernia
When the LES & Upper Stomach Portion move up into chest wall through small opening in diaphragm
Causes GERD more often
Esophagus
GERD
+
Epidemiology
- Affects 15-20% of population (report weekly heartburn)
- Caucasians & Pregnancy
- N. America & Europe
Esophagus
GERD
+
Signs & Symptoms
- Heartburn
- Odynophagia
- Dysphagia
- Regurg
- Bleching
- Nausea
- Anorexia/Weight Loss
Esophagus
GERD
+
Atypical Signs & Symptoms
- Sore Thorat
- Dental Caries
- Chronic Cough
- Asthma
- Hoarseness
- Recurrent Pneumonia
- Chest Pain
Esophagus
GERD
+
Diagnostics
- Empircally
- Upper endoscopy w/ bx (esophagogastroduodenoscopy)
- Barium Esophagogram
- Ambulatory esophageal pH monitoring
Esophagus
GERD
+
Complications
- Esophagitis
- Atypical symptoms
- Stricture - GE Junction
-
Barret’s Esophagus!
- Neoplastic changes
- Risk: 40-100x greater than general population
Esophagus
GERD
+
Management
- Repeat Endoscopy every 2 years w/ biopsy
- Surgical resection - if high grade dysplasia >25%
- Stay on Proton Pump Inhibitors FOREVER!
Esophagus
GERD
+
Treatment Goals
- Provide symptom relief
- Heal damage
- Prevent complications
Combo of Pharm & Non-Pharm Tmts
Esophagus
GERD
+
Non-Pharm Tmts
- Lifestyle!!!
- Avoid certain foods & drink
- Decrease portion size
- Lose weight
- Elevate head of bed
- Avoid eating 2-3 hours before bed
Esophagus
GERD
+
Pharm Tmts
-
Antacids
- Mg, Ca, Al
- *May cause constipation in elderly
-
Sialogogues
- Gum
-
H2 Receptor Agonists
- 30 min to work & last 8 hours
-
PPIs
- $$$
- Once daily dosing
Esophagus
GERD
+
Pharm Tmts
-
Antacids
- Mg, Ca, Al
- *May cause constipation in elderly
-
Sialogogues
- Gum
-
H2 Receptor Agonists
- 30 min to work & last 8 hours
-
PPIs
- $$$
- Once daily dosing
Esophagus
GERD
+
PPIs for Severe Disease!!!!
-
PPIs
- 1-2x daily
- Therapy course: 8-12wks
- Most pts relapse & continue with tmt
Esophagus
Esophageal Spasm
- Motility D/O
- Assc. w/
- Chest Pain
- Dysphagia
Esophagus
Esophageal Spasm
Nutcracker Esophagus
- Hypertensive Peristalsis
- Increased contraction pressure
- >180mmHg during Peristalsis
Esophagus
Esophageal Spasm
Treatment
- Nitrates
- CCBs
- Diltiazem
Diagnostics
Esophageal Manometry
Evaluates Peristalsis
Upper & Lower Esophageal Sphincters
Diagnostics
Esophageal Manometry
Examples
- Achalsia
- No Relaxation at LES
- Lack of Peristalsis
- Nutcrack Esophagus
- Hyper-contractile especially at LES
Esophageal Dysphagia Algorithm
- Solid Foods -
- Mechanical Obstruction
- Solid Food & Liquirds -
- Neuromsk Obstruction
Esophagitis
Inflammation of the Esophagus
Esophagitis
+
GERD
50% of those w/ GERD develop Esophagitis
Incidence increases with Age
Esophagitis
+
Risk Factors
- GERD
- Infectious
- Viral, fungal, bacterial, parasitic
- Pill/Med-Induced
- Abx, KCl, Bisphosphonates
Esophagitis
Signs & Symptoms
- Odynophagia
- Dysphagia
- Substernal Chest Pain
- Oral Thrush
- Herpes Labialis
- Retinitis (CMV)
Esophagitis
Herpes Simplex Esophagitis
Signs & Symptoms
- Nausea
- Vomiting
- Fever
- Chills
- +/- Herpetic Vesicles on Nose & Lips
- Painful!
Esophagitis
Herpes Simplex Esophagitis
Diagnostics
- Endoscopy:
- Vesicles
- Small, discrete superficial ulcerations
- Culture will show HSV
Esophagitis
Herpes Simplex Esophagitis
Treatment
- Oral or IV Acyclovir
- 7-21 days
- IV if complications
Esophagitis
Varicella Zoster Virus
- Kids w/ chickpox or adults w/ zoster
- Differentiate from HSV via
- Culture or Cells
Esophagitis
Varicella Zoster Virus
- Vesicles & Confluent Ulcers
Esophagitis
Varicella Zoster Virus
Treatment
- Usually resolve spontaneously
- BUT may cause Necrotizing esophagitis
- Acyclovir
Esophagitis
Cytomegalovirus
Only occurs in Immunocompromised
Esophagitis
Cytomegalovirus
- Creeping ulcer in otherwise Normal Mucosa
- May become GIANT
Esophagitis
Cytomegalovirus
Patients present with…
- Odynophagia
- Persistent chest pain
- Hematemesis
- Nausea
- Vomiting
Esophagitis
Cytomegalovirus
Treatment
- IV Ganciclovir
Esophagitis
Candidia
- Normally in throat
- Esophagitis form in Immunocompromised
Esophagitis
Candidia
Complicated by:
- Bleeding
- Perforation
- Stricture
Esophagitis
Candidia
Endoscopy shows
- Small
- Yellow-white
- Raised
- Plaques
Esophagitis
Candidia
Treatment
- Oral or IV Fluconazole
Esophageal Lesions
Mallory-Weiss Syndrome
- Intraluminal mucosal tear or distal esophagus or gastric cardia
- Arterial Bleeding
- Self-limiting (v. varices)
Esophageal Lesions
Mallory-Weiss Syndrome
Caused by:
- Intra-abdominal Pressure
Esophageal Lesions
Mallory-Weiss Syndrome
Boerhaave Syndrome
- Esophageal Rupture
Esophageal Lesions
Mallory-Weiss Syndrome
Epidemiology
- Alcoholics
- Hiatal Hernia
Can also occur after:
- Seizures
- Childbirth
- Lifting/Straining/Coughing
- Blunt Abdominal Trauma
- Bulimia
Esophageal Lesions
Mallory-Weiss Syndrome
Signs & Symptoms
Painless
-
Multiple bouts of vomiting & retching followed by Hematemesis
- __Arterial bleeding
- Abdominal pain
Esophageal Lesions
Mallory-Weiss Syndrome
Diagnosis
- Endoscopy
- CBC, PT, PTT
- BUN/Cr
- LFTs
- Type & Cross match
- +/- CXR and EKG
Esophageal Lesions
Mallory-Weiss Syndrome
Stablize!!
- Airway, Breathing, Circulation
- Transfusion
- Gastric Lavage to remove blood
Esophageal Lesions
Mallory-Weiss Syndrome
Endoscopically control Bleeding!
- Coagulation techniques
- Blood clotthing agents application
Esophageal Lesions
Mallory-Weiss Syndrome
Treatment
- Most bleeding resolves spontaneously
- Benign & Self-limiting
Esophageal Lesions
Mallory-Weiss Syndrome
Admit
- Continuous or massive hemorrhage
- Hemodynamic Instability/Hypovolemic
- Age extremes
- Underlying medical condition
Esophageal Lesions
Mallory-Weiss Syndrome
Discharge
- History of minimal bleeding that has stopped
- Hemodyamically stable/Stable H+H
- Heme negative stool
Esophageal Lesions
Esophageal Ring
-
Schatzki’s Ring:
-
Ring of tissue located at junction of esophagus & stomach
- Congenital
- May be result of Chronic GERD
- Affects 4 our of 10,000
-
Ring of tissue located at junction of esophagus & stomach
Esophageal Lesions
Esophageal Ring
Symptoms
- Dysphagia
- Esp. w/ poorly chewed food boluses
- Liquids are generally okay!
- May help dislodge bolus
Esophageal Lesions
Esophageal Web
Similar to Esophageal Ring, but in Mid- to Upper- Esophagus
One or more thin membranes of squamous mucosa that can cause intermittent dysphagia to solid food
Esophageal Lesions
Esophageal Web
“Smooth, circumferential ring of squamous mucosa, often responsible for causing difficulty swallowing, which can be located anywhere along the esophagus. May be asymptomatic”
Esophageal Lesions
Esophageal Web
Etiology
Unknown
Esophageal Lesions
Esophageal Web
Plummer-Vinson Syndrome
- Webs w/ Iron Deficiency Anemia & Glossitis
- Treat with Iron!
Esophageal Lesions
Esophageal Web & Rings
Diagnosis for both:
- Barium Esophagram
- EGD
*Endoscopy is less sensitive than barium esophagram
*Esophagram is like an x-ray using contrast dye
Esophageal Lesions
Esophageal Web & Rings
Treatment
- Mechanical Dilation w/ Balloon
Esophageal Varices
Dilated submucosal veins that develop in patients with Portal Hypertension
Esophageal Varices
Most common cause…
Cirrhosis!!
Esophageal Varices
Other causes
- Portal Vein Thrombosis
- Budd Chiari Syndrome
- Infiltrative Liver Disease
Esophageal Varices
Pathophys
- Blood flow is increases through microscopic blood vessels w/in esophageal awall
- Blood flow increases
- Dilation can be profound
- Dialate, dialate, dilate then…
- RUPTURE!
Esophageal Varices
Mortality Rates
- First time varices rupture = ~40-70%
Esophageal Varices
Most common site of Rupture
- Distal Esophagus
- Varcies at GE Junction most likely to rupture (most superficial)
Esophageal Varices
Signs & Symptoms
- Hematemesis
- >50% stop bleeding spontaneously
- Melena
- Weakeness/Fatigue
- Tachycardia
- Hypotension
- Abdominal Pain
- Syncope
- Jaundice
Esophageal Varices
Labs
- CBC
- PT/PTT
- Electrolytes
- BUN/Cr
- Type & Cross
Esophageal Varices
Treatment
Immediate
- Control bleeding (if doesn’t stop on own)
- Emergent Endoscopy
- Variceal Ligation (rubber band)
- Sclerotherapy
- Balloon Tamponade
Esophageal Varices
Treatment
Long-Term Treatment
- Antibiotics (prevents Peritonitis)
- Decrease portal hypertension
- Beta-blockers (propanolol)
- Nitrates
- Shunts
- TIPS
- Liver Transplant
- Stop Drinking!!
Achalasia
Greek for: “Does not relax”
Loss of Peristalsis in distal esophagus & failure of LES to relax
Symptoms mostly occur b/c LES is NOT relaxing
Achalasia
Results in Functional Obstruction of esophagus that Persists until the pressure of the retained material causes it to move through the LES
Food backs up & ferments in the esophagus….
Distention & Dilation
Achalasia
Causes
- Damage to nerves of esophagus
- Infection
- (Chagas)
- Hereditary Factors
Achalasia
Incidence
- Frequency increase with older age
- Incidence:
- 2 out of 10,000 people
Achalasia
Signs & Symptoms
- Dysphagia = MOST COMMON SYMPTOM
- Chest Pain
- Regurgitation
- Difficulty Belching
- Weight Loss
Achalasia
Diagnosis
- Chest XR
- Barium Swallow
- “Bird’s Beak”/”Parrot’s Beak” appearance
- Manometry
- pressure gradient
- Endoscopy
Achalasia
Treatment
- Nitrates/CCBs
- Botulinum toxin
- Pneumatic Dilation
- Balloon is inflated in LES, reducing pressure
- 60-90% effective; last 10 years
- Myotomy
- Muscular ring around LES cute
- 95% success rate
Hiatal Hernia & GERD Treatment
Nissen Fundoplication
- Surgical procedure
- can be laproscopic
- Gastric fundus is wrapped around lower end of esophagus
- Complications:
- Gas Bloat Syndrome
- Dysphagia
- Dumping Syndrome
Have an Elderly Patient who just keeps getting Pneumonia?
Pearl
- Order a Modified Barium Swallow
ESOPHAGEAL CANCER
- Most are:
- Squamous cell*, or
- Adenocarcinoma**
- SCC* is decreasing in US, Adeno** is Rising ALOT!!!
ESOPHAGEAL CANCER
Prognosis
- Poor
- 5-year survivial: 10-13%
- Patients diagnosed w/ early stage may be cured
Esophageal Cancer
Squamous Cell
- Middle esophagus
- More common in MALES
- More common in BLACKS
- Common causes: Smoking & Alcohol
Esophageal Cancer
Squamous Cell
Causes
- 90% attributable to smoking, alchohol and lack healthy diet
- Underlying esophageal disease
- Achalasia (16x increase)
- Lye exposure
- Partial gastrectomy
- Upper aerodigestive tract cancer
Esophageal Cancer
Adenocarcinoma
- Distal esophagus
- Barret’s esophagus
- More common in MALES
- More common in WHITE PEOPLE
Esophageal Cancer
Adenocarcinoma
Increasing in Frequency & GERD!
- Past 3 decades adenocarcinoma increasing in Frequency!!
- GERD!!!!!!
- Most, if not all, esophageal adenocarcinoma is from Barret’s metaplasia!
- Risk greatest in those w/ long-standing 20+ years w/ severe symptoms
Esophageal Cancer
Adenocarcinoma
Other Causes
- Smoking… increases risk
- Even after cessation… remains high!
- Obesity!
- 2.78x greater chance of Adeno if BMI >30
-
H. pylori infection
- Controversial, but may cause inflammation & metaplasia
Esophageal Cancer
Adenocarcinoma
versus
Squamous Cell
- AC = disease of Caucasians & Males
- Alcohol =
- Important factor in SCC, not so much in Adeno
- Obesity
- Factor in Adeno, not SCC
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
Symptoms
- Have similar clinical presentations
- Progressive solid food dysphagia
- weight loss
- Early symptoms = subtle & non-specific
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
More Severe/Later Stage Symptoms
- Dysphagia occurs once esophageal lumen diameter is
- Retro-sternal discomfort, or burning sensation
- Most early cancers detected by chance, or during screening for Barrett’s
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
Late Stage Symptoms
- Chronic gastrointestinal blood loss
- May result in Fe Deficiency Anemia
- Upper GI bleed = rare
- Result of tumor erosion
- Tracheobroncial fistulas = late complication
- Direct invasion through esophageal wall into main stem bronchus
- Intractable coughing & frequent pneumonia
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
Life Expectancy
- <4 weeks following development
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
Diagnosis
- Barium Studies
- Endoscopy
Esophageal Cancer
Adenocarcinoma
+
Squamous Cell
Pre-Op Staging Evaluation
- CT Scan of chest & upper abdomen
- Endoscopic US
- PET scan
- Bronchoscopy
