GI Goljan esophageal disorders Flashcards by Hunter Garrett

What are signs and Sx of esophageal disease?

heartburn;

dysphagia for solids and progressing to liquids

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Dysphagia for solids alone is a symptom for what? give examples

obstructive lesion;

esophageal cancer, esophageal web, stricture

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Dysphagia for solids and liquids is a Sx for what?

motility disorder

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How do the 2 different types of dysphagia differ?

Oropharyngeal => striated muscle dysmotility

Lower esophageal dysphagia => smooth muscle dysmotility

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Examples of orpharyngeal dysphagia

dermatomyositis; myasthenia gravis; stroke

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examples of lower esophageal dysphagia

systemic sclerosis; CREST syndrome; achalasia

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characteristics of TE fistula

proximal esophagus ends blindly;

distal esophagus arises from trachea (air in stomach leading to distention)

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what are the 4 clinical findings w/ TE fistula?

maternal polyhydramnios (excess amniotic fluid);
abdominal distention in newborn;
difficulty w/ feeding;
VATER syndrome

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Why is maternal polyhydramnios associated w/ TE fistula?

swallowed amniotic fluid cannot be reabsorbed in small intestine

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Define VATER syndrome associated w/ TE fistula

vertebral abnormalities;
anal atresia;
TE fistula;
Renal disease and absent radius

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What causes plummer-vinson syndrome? what are clinical signs and symptoms associated?

chronic Fe deficiency;
leukoplakia in oral mucosa and esophagus;
intermittent dysphagia for solids => esophageal web/stricture

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Differentiate true vs false diverticulum

true=> outpouching lined by mucosa, submucosa, muscularis propria, adventitia
false=> weakness in underlying muscle wall and outpouching of mucosa & submucosa into area of weakness

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Define Zenker’s diverticulum and area of weakness

false type in upper esophagus => weakness in cricopharyngeus muscle

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clinical findings w/ zenker’s diverticulum

painful swallowing;
halitosis (entrapped food);
regurgitate food through mouth;
diverticulitis

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Tx for zenker’s diverticulum

surgery

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Epidemiology of hiatal hernia

found in 50% of ppl over 50 w/ incidence increasing w/ age;

women > men

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What are the 4 associations w/ hiatal hernia?

Sigmoid diverticulosis (25%);
esophagitis (25%);
duodenal ulcers (20%);
gallstones (18%)

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define the most common hiatal hernia

slideing hernia (99%);
herniation of proximal stomach into thoracic cavity through diaphragmatic esophageal hiatus

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clinical findings w/ hiatal hernia

heartburn;
nocturnal epigastric distress from acid reflux;
hematemesis;
ulceration, stricture;
bowel sounds heard over Left lung base

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nonpharm Tx of hiatal hernia

reduce intake of foods/drugs that decrease LES tone;
avoid large quantities of food;
sleep w/ head of bed elevated

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What are examples that may decrease LES tone?

coffee, chocolate, Ca channel blockers

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what are pharm Tx of hiatal hernias?

H2 antagonists;
Proton pump inhibitors;
prokinetic agents

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Define paraesophageal or rolling hernia

GE jxn remains at level of diaphragm;

part of stomach bulges into thoracic cavity

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Define pleuroperitoneal diaphragmatic hernias

present early in life;
visceral contents extend through posterolateral part of diaphragm on L into chest cavity causes respiratory distress at birth;
loops of bowel are present in left pleural cavity on radiograph

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Epidemiology of GERD

10% adults have it daily; 80% of pregnant women; hiatal hernia in 70% w/ GERD

Risk factors for GERD

smoking, alcohol; caffein, fatty foods, chocolate; pregnancy, obesity; hiatal hernia

pathogenesis of GERD

transient relaxation of LES => reflux of acid and bile into distal esophagus; ineffective esophageal clearance of reflux material

Clinical findings of GERD

``` noncardiac chest pain (heartburn, indigestion); nocturnal cough, nocturnal asthma; acid injury to enamel; early satiety, abdominal fullness; bloating w/ belching; Barrett's esophagus ```

What are the 3 Dx tests for GERD?

24hr esophageal pH monitoring; esophageal endoscopy; manometry (LES < 10mmHg)

define a complication of GERD

Barrett's esophagus => glandular metaplasia in distal esophagus due to acid injury => gastric columnar cells and goblet cells

2 complications of barrett's esophagus

ulceration w/ stricture formation (most common); | glandular dysplasia w/ increased risk for distal adenocarcinoma

infectious esophagitis is a complication of AIDS. what are the 3 most common pathogens?

HSV (multinucleated squamous cells w/ intranuclear inclusions) CMV (basophilic intranuclear inclusions) Candida (yeasts and pseudohyphae)

How does infectious esophagitis present?

painful swallowing (odynophagia)

What happens w/ ingestion of strong alkali (lye) or acid (HCl)?

corrosive esophagitis

complications of corrosive esophagitis

stricture formation; perforation; squamous cell carcinoma

epidemiology and pathogenesis of esophageal varices

dilated submucosal left gastric veins => complication of portal HTN from cirrhosis

most common cause of esophageal varices

alcohol abuse

clinical findings of esophageal varices

rupture w/ massive hematemesis; | MOST COMMON CAUSE OF DEATH IN CIRRHOSIS

what is the initial management of esophageal varices?

endoscopy (most important Dx procedure); assess/maintain intravascular volume; insert NG tube to confirm upper GI bleeding

What is the prevention/treatment of esophageal varices from bleeding?

Beta blockers and isosorbide; transjugular intrahepatic portasystemic stent (TIPS); octreotide IV drip (somatostatin analogue) for bleeding; endoscopic ligation and scleroTx; open surgery w/ stapling

Define Mallory-Weiss syndrome. what does it cause

mucosal tear in proximal stomach and distal esophagus from retching in alcoholics and bulimia => hematemesis

Define Boerhaave's syndrome. what causes it?

rupture of distal esophagus => causes are endoscopy, retching, bulimia

Complications of Boerhave's syndrome

Pneumomediastinum=> air dissects subQ into anterior mediastinum; crunching sound on auscultation pleural effusion contains food, acid, amylase

3 motor disorders of esophagus

systemic sclerosis; CREST syndrome; Achalasia

epidemiology of achalasia

bimodal=> 20-40yr and again after 60yr; men and women affected equally; risk for esophageal cancer

4 pathogenetic causes of achalasia

1) incomplete relaxation of LES; 2) destruction of ganglion cells in myenteric plexus; 3) dilation of esophagus prox to LES w/ absent peristalsis; 4) acquired cause is Chagas's disease

What causes destruciton og ganglion cells in myenteric plexus leading to achalasia?

AI destruction of myenteric plexus => HLA-DQw1 association

What are the results of destruciton of ganglion cells in myenteric plexus?

decreases proximal smooth muscle contraction; | loss of NO synthase producing neurons leading to incomplete relaxation

How does Chagas disease lead to achalasia?

dstruction of ganglion cells by amastigotes (lack flagella)

clinical findings of achalasia

``` nocturnal regurg of undigested food; dysphagia for solids / liquids; chest pain and heartburn; frequent hiccups; nocturnal cough from aspiration; difficulty belching ```

How is achalasia diagnosed?

abnormal barium swallow (dilated bird beak tapering at distal end); abnormal esophageal manometry (detects aperistalsis and failure of LES relaxation)

Nonpharm Tx of achalasia

pneumatic dilation; esophagomyotomy

short term pharm Tx of achalasia

long acting nitrates; CCB; botox

what is most common benign tumor of esophagus

leiomyoma

What is the cause of the most common primary cancer of esophagus in US?

Barrett's esophagus causes adenocarcinoma of distal esophagus

What is the most common primary esophageal cancer of developing countries

squamous cell carcinoma

Who is most likely to get squamous cell carcinoma of esophagus?

blacks > whites; | men > women

Risks for squamous cell carcinoma of esophagus

smoking (most common); alcohol abuse, lye strictures; achalasia, plummer vinson syndrome

most common locations of scc of esophagus

upper (15%) middle (50%) lower (35%)

where does squamous cell carcinoma of esophagus spread?

local nodes 1st and then to liver and lungs

clinical findings associated w/ squamous cell carcincoma

``` dysphagia for solids initially; weight loss of short duration; painless enlargement supraclavicular nodes dry cough and hemoptysis; hoarseness; odynophagia; hypercalacemia ```

What does dry cough and hemoptysis in squamous cell carcinoma suggest?

tracheal invasion

Hoarseness in squamous cell carcinoma indicates what?

invasion of recurrent laryngeal nerve

hypercalcemia in squamous cell carcinoma indicates what?

PTH related peptide similar to squamous cancer in lungs

Px of squamous cell carcinoma of esophagus?

5yr survival is 13%