GI: Esophagus Flashcards
What is dysphagia?
Dysphagia is the awareness of food not passing during the swallowing process. It can occur in one of the two phases of swallowing: 1) Oropharyngeal, or, 2) Esophageal
What is oropharyngeal dysphagia?
Patients with oropharyngeal dysphagia (also known as transfer dysphagia) are unable to initiate the swallowing process despite several attempts to swallow. Choking occurs owing to failure to clear food from the epiglottis and may lead to aspiration. Oropharyngeal dysphagia often occurs within 1 second of starting the swallowing process.
What are the causes of oropharyngeal dysphagia?
-laryngeal nerve dysfunction
-weakness of the soft palate or pharyngeal constrictors
-Zenker diverticulum
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How is oropharyngeal dysphagia diagnosed?
The initial test of choice for evaluation of oropharyngeal dysphagia is a modified barium swallow, also known as videofluoroscopy. The test begins with a liquid phase, which is followed by a solid phase if the liquid phase is not diagnostic. If results of the modified barium swallow are normal, oropharyngeal dysphagia is excluded and further evaluation should focus on the possibility of esophageal dysphagia.
How is oropharyngeal dysphagia treated?
Oropharyngeal forms of dysphagia are often managed with dietary adjustment and incorporation of swallowing exercises with the assistance of a speech pathologist.
How is esophageal dysphagia often described?
Patients with esophageal dysphagia often localize discomfort to the lower sternum and do not report problems initiating the swallowing process.
What does dysphagia to solid foods suggest? What about to both solids and liquids?
Dysphagia to solid foods suggests mechanical obstruction; dysphagia to liquids or both solids and liquids suggests a motility disorder.
How is achalasia described by patients?
Patients with achalasia describe regurgitation of nonacidic undigested food in combination with dysphagia to solids and liquids.
What are some signs or symptoms of esophageal spasm?
Esophageal spasm is associated with chest pain that may be triggered by consuming liquids of extreme hot or cold temperatures.
What are some obstructive causes of esophageal dysphagia?
Luminal causes of obstruction may include benign strictures, malignancy, esophageal webs, or a Schatzki ring
How is esophageal dysphagia diagnosed?
Upper endoscopy is the most appropriate test for esophageal dysphagia; it allows for both diagnostic intervention (biopsies and inspection) and therapeutic intervention (dilation).
What is odynophagia?
Odynophagia is defined as pain with swallowing and is an indication of inflammation in the esophagus. Odynophagia is a sign of mucosal injury of the esophagus leading to ulceration.
What are the most common causes of odynophagia? How is the pathology diagnosed?
The most common causes of odynophagia are caustic ingestion, pill-induced damage, and infection with Candida, herpesvirus, or cytomegalovirus. Rarely, it has been associated with severe GERD or esophageal cancer. Upper endoscopy is the diagnostic test of choice for visual inspection and obtaining tissue biopsies.
What is globs? How is it diagnosed and managed?
Globus is the sensation of tightness or a lump in the throat. Globus occurs between swallows and is not related to meals. Stress, psychiatric disorders (anxiety, panic disorders, somatization), and frequent dry swallowing have been associated with globus. Globus should not be diagnosed in the setting of dysphagia or odynophagia. The management of globus should include ruling out an underlying pharyngeal lesion by nasal endoscopy or barium swallow. If these studies are negative, treatment with acid suppression (PPI) or cognitive behavioral therapy should be considered. Globus has been associated with GERD.
What are the hypertonic motility disorders? How are they differentiated from each other?
Achalasia
Pseudoachalasia
Diffuse esophageal spasm
Nutcracker esophagus
These disorders are differentiated based on manometry findings.
What is achalasia?
Achalasia is a motility disorder of the esophagus that results in aperistalsis and inadequate relaxation of the lower esophageal sphincter (LES).
What are the signs and symptoms of achalasia?
he clinical presentation of achalasia consists of dysphagia to both solids and liquids along with regurgitation of undigested bland food and saliva. Patients may also experience weight loss, chest pain, and even heartburn, resulting in a misdiagnosis of GERD. Symptoms of true achalasia do not respond to an empiric trial of acid reducers such as PPIs.
What diagnostic testing is performed for achalasia?
INITIAL TEST: barium esophagogram, which demonstrates dilation of the esophagus and narrowing at the gastroesophageal junction, described as a “bird’s beak”.
CONFIRMATORY TEST: Manometry should be performed to confirm the diagnosis; it is the most sensitive test to demonstrate incomplete LES relaxation and aperistalsis.
EGD: Upper endoscopy shows retained food and saliva, as well as no signs of mechanical obstruction or mass. Upper endoscopy is often performed to exclude mechanical obstruction, particularly if symptoms are concerning for underlying malignancy (shorter duration of symptoms, rapid weight loss).
How is achalasia treated?
Endoscopic pneumatic dilation and laparoscopic surgical myotomy are the primary treatments for achalasia; the choice of therapy depends on local expertise, as both have comparable success rates.
Diffuse esophageal spasm:
- presenting symptoms
- diagnosis
- treatment
Diffuse esophageal spasm is a rare motility disorder that presents with chest pain or dysphagia. Clinical manifestations are similar to those of angina pectoris. Although the cause of diffuse esophageal spasm is unknown, it may be associated with reflux. On esophageal manometry, simultaneous high-amplitude (>30 mm Hg) esophageal contractions are seen with intermittent aperistaltic contractions. The barium esophagogram finding of a “corkscrew” esophagus (Figure 5) is typical of diffuse esophageal spasm. It may progress to achalasia in some patients.
The ideal therapy is not clear, but pharmacologic therapy has included calcium channel blockers, hydralazine, botulinum toxin injections, and anxiolytics.
Nutcracker esophagus:
- Symptoms
- Diagnosis
- Treatment
Symptoms; chest pain, dysphagia
Diagnosis: high-amplitude peristaltic contractions of greater than 220 mm Hg
Treatment: CCB, hydralazine, botulinum toxin, anxiolytics
What are hypotense motility disorders? Causes–primary and secondary? Diagnosis? Treatment?
Hypotensive disorders of the esophagus can involve a hypotense LES, aperistaltic contractions, or both. A weakened LES can lead to GERD, and poor peristaltic activity can result in dysphagia. In most cases, the cause of the hypotensive esophageal disorder is unknown. However, secondary causes include smooth-muscle relaxants, anticholinergic agents, estrogen, progesterone, connective tissue disorders (such as systemic sclerosis), and pregnancy. Manometry demonstrates hypotensive or nonperistaltic contractions in the distal esophagus. Management consists of therapy for GERD to prevent complications such as erosive esophagitis and stricture formation.
What is the presentation of eosinophilic esophagitis?
Eosinophilic esophagitis (EoE) is defined as esophageal squamous mucosal inflammation caused by eosinophilic infiltration. The classic presentation of EoE is an atopic man in the third decade of life with solid-food dysphagia and food impactions requiring removal by endoscopy. EoE has been associated with food allergies, asthma, and eczema.
What are the surgical treatments for GERD? What are the indications for surgery?
Surgical treatments for GERD consist of laparoscopic fundoplication or bariatric surgery (the latter for obese patients). Indications for surgery include patient preference to stop taking medication, medication side effects, large hiatal hernia, and refractory symptoms despite maximal medical therapy (although patients with medically refractory symptoms may be less likely to benefit from surgery).
