GI: Esophagus

Question 1

What is dysphagia?

Answer 1

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

Question 2

What is oropharyngeal dysphagia?

Answer 2

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.

Question 3

What are the causes of oropharyngeal dysphagia?

Answer 3

-laryngeal nerve dysfunction
-weakness of the soft palate or pharyngeal constrictors
-Zenker diverticulum
-

Question 4

How is oropharyngeal dysphagia diagnosed?

Answer 4

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.

Question 5

How is oropharyngeal dysphagia treated?

Answer 5

Oropharyngeal forms of dysphagia are often managed with dietary adjustment and incorporation of swallowing exercises with the assistance of a speech pathologist.

Question 6

How is esophageal dysphagia often described?

Answer 6

Patients with esophageal dysphagia often localize discomfort to the lower sternum and do not report problems initiating the swallowing process.

Question 7

What does dysphagia to solid foods suggest? What about to both solids and liquids?

Answer 7

Dysphagia to solid foods suggests mechanical obstruction; dysphagia to liquids or both solids and liquids suggests a motility disorder.

Question 8

How is achalasia described by patients?

Answer 8

Patients with achalasia describe regurgitation of nonacidic undigested food in combination with dysphagia to solids and liquids.

Question 9

What are some signs or symptoms of esophageal spasm?

Answer 9

Esophageal spasm is associated with chest pain that may be triggered by consuming liquids of extreme hot or cold temperatures.

Question 10

What are some obstructive causes of esophageal dysphagia?

Answer 10

Luminal causes of obstruction may include benign strictures, malignancy, esophageal webs, or a Schatzki ring

Question 11

How is esophageal dysphagia diagnosed?

Answer 11

Upper endoscopy is the most appropriate test for esophageal dysphagia; it allows for both diagnostic intervention (biopsies and inspection) and therapeutic intervention (dilation).

Question 12

What is odynophagia?

Answer 12

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.

Question 13

What are the most common causes of odynophagia? How is the pathology diagnosed?

Answer 13

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.

Question 14

What is globs? How is it diagnosed and managed?

Answer 14

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.

Question 15

What are the hypertonic motility disorders? How are they differentiated from each other?

Answer 15

Achalasia
Pseudoachalasia
Diffuse esophageal spasm
Nutcracker esophagus

These disorders are differentiated based on manometry findings.

Question 16

What is achalasia?

Answer 16

Achalasia is a motility disorder of the esophagus that results in aperistalsis and inadequate relaxation of the lower esophageal sphincter (LES).

Question 17

What are the signs and symptoms of achalasia?

Answer 17

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.

Question 18

What diagnostic testing is performed for achalasia?

Answer 18

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).

Question 19

How is achalasia treated?

Answer 19

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.

Question 20

Diffuse esophageal spasm:

• presenting symptoms
• diagnosis
• treatment

Answer 20

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.

Question 21

Nutcracker esophagus:

• Symptoms
• Diagnosis
• Treatment

Answer 21

Symptoms; chest pain, dysphagia
Diagnosis: high-amplitude peristaltic contractions of greater than 220 mm Hg
Treatment: CCB, hydralazine, botulinum toxin, anxiolytics

Question 22

What are hypotense motility disorders? Causes–primary and secondary? Diagnosis? Treatment?

Answer 22

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.

Question 23

What is the presentation of eosinophilic esophagitis?

Answer 23

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.

Question 24

What are the surgical treatments for GERD? What are the indications for surgery?

Answer 24

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).

Question 25

What kind of testing should patients undergo prior to surgery for reflux?

Answer 25

Patients should undergo objective testing (such as pH-impedance monitoring to demonstrate true reflux with symptom correlation and manometry to rule out a motility disorder) prior to surgery.

Question 26

What is the response rate for endoscopic therapies for GERD?

Answer 26

Endoscopic therapies for gastroesophageal reflux disease have not been shown to be effective in the long term.

Question 27

How do you manage refractory GERD?

Answer 27

The first step in treating refractory GERD is to optimize PPI therapy by verifying correct administration (30-60 minutes before meals), increasing to twice-daily dosing, or switching to another PPI. If symptoms remain unresponsive, alternative causes should be considered. In patients with typical symptoms, upper endoscopy should be performed to rule out eosinophilic esophagitis or erosive esophagitis. If the endoscopy does not reveal eosinophilic esophagitis or reflux-related changes, pH-impedance testing should be performed. A negative pH-impedance test likely indicates that PPI therapy should be discontinued and that the patient does not have GERD. For those with prominent extraesophageal manifestations, referral to an otolaryngologist, pulmonologist, or allergist should be considered.

Question 28

What is Barrett’s esophagus?

Answer 28

Barrett esophagus (BE) is present when columnar epithelium replaces the normal squamous epithelium in the distal esophagus.

Question 29

What are risk factors and protective factors of Barrett’s esophagus?

Answer 29

Risk factors associated with BE are older age, male gender, white ethnicity, GERD, hiatal hernia, high BMI, smoking, and an abdominal distribution of fat. Protective factors are moderate wine consumption and a diet rich in fruits and vegetables. BE is a consequence of GERD whether or not patients experience clinical symptoms.

Question 30

When is screening for Barrett’s esophagus indicated?

Answer 30

However, the American College of Physicians suggests that screening for BE may be appropriate in men older than 50 years with chronic GERD (symptoms for more than 5 years) and additional risk factors, including nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal fat distribution. If screening is performed and is negative for BE, no additional endoscopic screening is indicated, even for patients continuing treatment for GERD, unless other symptoms or clinical findings develop.

Question 31

How is Barrett’s esophagus diagnosed?

Answer 31

Biopsy

The diagnosis of BE is based on the endoscopic finding of columnar epithelium above the normally located gastroesophageal junction (Figure 10), followed by histologic confirmation demonstrating specialized intestinal metaplasia with acid-mucin–containing goblet cells.

Question 32

What is surveillance for Barrett’s esophagus:

• No dysplasia
• Low grade dysplasia
• High grade dysplasia

Answer 32

NO DYSPLASIA: If no dysplasia is present, repeat upper endoscopy every 3 to 5 years

LOW GRADE DYSPLASIA:
For confirmed low-grade dysplasia, high-definition endoscopy should be conducted in 8–12 weeks, after treatment with a proton pump inhibitor twice daily
If low-grade dysplasia persists, endoscopic therapy is the preferred treatment modality, although endoscopic surveillance every 12 months is an acceptable alternative

HIGH GRADE DYSPLASIA:
Endoscopic evaluation for any focal lesion (may indicate more advanced neoplasia); if present, focal lesion(s) should be removed by endoscopic mucosal resection for diagnosis and staging
Options for further management: endoscopic ablation, esophagectomy

Question 33

Is there any evidence for chemoprevention of Barrett’s esophagus?

Answer 33

Chemoprevention with a proton pump inhibitor, aspirin or NSAID therapy, or antireflux surgery has not been definitively shown to decrease the risk of progression of dysplasia or development of adenocarcinoma in patients with Barrett esophagus.

Question 34

What is the 5 year survival of esophageal cancer?

Answer 34

The overall 5-year survival rate of patients with esophageal carcinoma is between 15% and 25% depending on the stage at time of initial diagnosis.

Question 35

What are risk factors for squamous cell carcinoma of the esophagus?

Answer 35

The risk factors associated with SCC are tobacco and alcohol use, caustic injury, achalasia, past thoracic radiation, nutritional deficiencies (zinc, selenium), poor socioeconomic status, poor oral hygiene, nonepidermolytic palmoplantar keratoderma (tylosis), human papillomavirus infection, and nitrosamine exposure.

Question 36

What are the risk factors for adenocarcinoma of the esophagus?

Answer 36

Adenocarcinoma risk factors include GERD, BE, obesity, tobacco use, past thoracic radiation, diet low in fruits and vegetables, increased age, male sex, and possibly medications that relax the LES.