Intro and Esophagus Flashcards
Where does normal digestion begin and how?
In the mouth- mechanical: breaking down food by teeth into smaller pieces. And chemical- salivary amylase from saliva breaks down starch to sugar
How much saliva is produced DAILY?
1-1.5L
The esophagus is a hollow tube of muscle that is how long?
25-30 cm. long
List the segments within the esophagus
Pharygoesophageal, cervical, thoracic, and abdominal segments
List the 2 sphincters associated with the esophagus
Upper and lower esophageal sphincters
What is gastric juice secreted by?
Chief cells, parietal cells, and mucus cells
What is produced by the stomach to help with vitamin B12 absorption?
Intrinsic factor produced by stomach
What stores and concentrates bile vs. manufacturing bile?
Liver manufactures bile, gallbladder stores and concentrates bile
What organ has both endocrine and exocrine functions?
Pancreas
What is the pancreas’s exocrine function?
Producing digestive enzymes (pancreatic juice) and releasing them through the pancreatic ducts into the duodenum
What is the pancreas’s endocrine function
Producing multiple enzymes that are released into the bloodstream (insulin, gastrin, etc)
How much fluid enters small intestine a day
8-10 L of fluid/day. Of that, 500 ml enters the colon
How is chloride absorbed into the proximal?
Passive diffusion
Vitamin absorption in small intestine
Duodenum- Iron. Proximal intestine- B1, B2, B6, C, Calcium. Ileum-Vitamin B12. Throughout small I- K, Mg, Phos, and Fat soluble vitamins ADEK
How is calcium absorbed into the proximal small intestine?
Via active transport facilitated by Vitamin D
How would deficiency in Vitamin D affect absorption in small intestine?
Affects calcium absorption in S.I
Defecation involves contraction and relaxation of…
contraction of rectal muscles and relaxation of anal sphincters
Length of rectum
15 cm
Dentate line
Interface between internal and external anal mucosa
Innervation around dentate line
Superior to dentate line- viscera, dull innervation. Inferior to dentate line- sharp, somatic innervation.
Internal and external anal sphincters voluntary/involuntary control-
Internal is NOT under voluntary control, but external is.
Diagnostic tests to evaluate esophagus problems (dysphagia, reflex or frequent heartburn, non-cardiac chest pain)
Mannometry, 24 hour pH probe or Bravo pH 48-hour probe, EGD, and esophagogram or UGI
Final score of pH probe determined by…
DeMeester score
Why is diary of eating, drinking, and pain episodes kept in people that get the pH probe?
So that pain episodes and acid level readings of pH probe can be correlated and interpreted
Patient presents with frequent heartburn that does not away despite pills that have been prescribed. You decide to do Bravo 48-hour pH probe and give them diary to record pain episodes. Before you do this, what precaution must you take in relation to medications?
Patient must be off of their ppi/h2 blockers for 1 week prior to test. Calcium carbonate can be taken up until the day before. Otherwise, can cause constipation.
Best test to order if worried about functional problem with esophagus (structure looks fine, but does not work properly)
Mannometry
Best test to order if worried about structural, physical problem in patient’s esophagus?
EGD
What test would be best if you want to r/o Barrett’s esophagus
EGD because will detect mucosal changes in esophagus
Procedure in esophagogram
Barium swallowed and observed under fluoroscopy
What is the most common cause of esophageal chest pain?
Reflux esophagitis
If patient has GERD, what med would you prescribe for them?
PPI
If patient presents with persistent GERD despite PPI medication, what diagnostic test would you recommend?
EGD
Refux esophagitis is caused by…
GERD
Mucosa changes in Barrett’s esophagus
Metaplasia from squamous mucosa to columnar epithelium in DISTAL esophagus
Why must Barrett’s esophagus be taken very seriously?
Potential to turn into dysplasia and then adenocarcinoma of the esophagus
How to monitor Barrett’s esophagus
EGD EVERY 2 YEARS to check for progression to dysplasia and esophageal adenocarcinoma
What will NOT reverse Barrett’s esophagus or prevent progression of the disease?
Anti-reflux procedures
Cancers in middle vs. lower esophagus
Lower- adenocarcinoma of esophagus (1% of Barrett’s esophagus develops into this). Middle esophagus affected in Squamous cell carcinoma
Squamous cell carcinoma of esophagus associated with
HPV, smoking, alcohol
What layer does esophageal cancer lack resulting in cancer spreading?
Serosal layer
Which has better survival rate in esophageal cancer- node-negative or node-positive disease?
Node-negative disease
How much of the esophageal lumen must be obstructed to produce dysphagia?
2/3rds
You are suspicious of esophageal cancer in patient who’s symptoms include dysphagia, coughing, and hoarseness. What specific area are you concerned with?
Tumors of cervical esophagus
Definitive diagnosis for esophageal cancer
Tissue biopsy in EGD. Can also use barium esophagogram, but not necessary
Tx in esophageal cancer
Endoluminal ultrasound- determines depth of invasion and lymph node size. Esophagectomy for resection (if has not spread and no lymph node involvement), chemo, radiation. Otherwise esophageal stenting.
Benign esophageal tumors
Leiomyomas, leiomyosarcoma, leiomyoblastomas
Origin of benign esophageal tumors
mesenchymal- GISTs (gastrointestinal stromal tumors)
oncogene in GISTs or benign esophageal tumors
cKIT oncogene
Patient in mid-20’s presents with dysphagia. UGI and EGD show constriction of the esophagus at the aortic arch and great vessels. Diagnosis?
Vascular rings
Upper esophageal webs aka
Plummer-Vinson Syndrome or Sideropenic dysphagia
Lower esophageal webs aka
Schatzki’s Ring
Patient comes in with chronic iron-deficiency anemia. She is 45 years old with koilonychia, glossitis, appears malnourished. How might the esophagus be affected?
May see UPPER esophageal webs
Upper esophageal web tx
esophageal dilation, correction of nutritional deficiency - iron supplements
Why is it very important to continue and screen for esophageal webs and take them seriously (esp. upper)
Premalignant- 10% progress to squamous cell carcinoma of esophagus, oral cavity, or hypophyarynx
Where would you expect to see Schatzki’s ring?
Squamocolumnar epithelial junction in distal esophagus- seen on barium swallow or EGD.
What symptom is commonly associated with esophageal webs?
Dysphagia
If patient presents with 20 mm. ring diameter with lower esophageal web, what symptoms would you expect?
intermittent dysphagia
If patient presents with 13 mm. ring diameter with lower esophageal web, what symptoms would you expect?
real dysphagia
Esophageal web does not involve the ….
muscle, only the mucosa and submucosa
How to treat patient with dysphagia and reflux symptoms?
serial dilations, ppi
Patients with refractory dysphagia and GERD tx
intraoperative dilation, anti-reflux procedure (Nissen)
Unable to feed baby and regurgitation present. What might you suspect?
Congenital esophageal web
Tx of congenital esophageal web
dilation, transthoracic resection
esophageal congenital cysts aka
duplication cysts
types of esophageal congenital cysts
duplications, bronchogenic cysts, and neurenteric cysts
What location are esophageal cysts usually found in
intrathoracic esophagus- posterior mediastinal mass on xray
tx for esophageal cysts
resection via VATS, thoracotomy, or endoscopic US with aspiration
Disorders of esophageal motility have functional or structural problem?
Functional- interfere with swallowing
Categories of disorders affecting esophagus motility
Upper esophageal sphincter dysfunction and motor disorders of the body of the esophagus
Patient presents with lump in throat that makes it difficult to swallow. Has history of GERD. Dysphagia occurs between the thyroid cartilage and suprasternal notch. Hoarseness, expectoration, and weight loss also seen. Diagnosis and tx?
Upper esophageal sphincter dysfunction based on barium swallow, pH probe, mannometry, EGD. Tx- cervical esophagomyotomy if persistent dysphagia and abnormal mannometry
Most common motor disorder of the body of esophagus?
Achalasia
esophageal motor body disorders range…
hypomotility (achalasia) to hypermotility (diffuse esophageal spasm)
Patient presents with dysphagia that has been getting progressively worse the past few years. Regurgitation of undigested food occurs even without acid or bile (No GERD present). The regurgitation occurs pretty effortlessly, aspiration often occurs. You observe that this patient eats very slowly and drinks a lot of water to wash their food out. Diagnosis?
achalasia
Secondary achalasia caused by
parasitic infection with Trypanosoma cruzi (Chagas disease) OR cancer- causes damage to myenteric plexus
Achalasia is caused by…
degeneration of post-ganglionic inhibitory neurons of the myenteric plexus
Diagnostic tests in achalasia
Chest xray- mediastinal mass with air-fluid level. Barium esophagogram- dilated esophagus without peristalsis and BIRD BEAD at distal esophagus. Mannometry- failure of LES to relax after swallowing, no peristalsis
Tx of Idiopathic achalasia
r/o cancer. do EGD. Nitrates, CCB. Definitive tx- myotomy, can be done thoracoscopically or transthoracically
Many people with achalasia are misdiagnosed with …
GERD- because they present with chest pain and heartburn
Patient presents with chest pain and dysphagia. Is very anxious. When eating cold liquids or cold fluids, symptoms get worse. Diagnosis, including tests?
Diffuse esophageal spasm based on barium esophagogram shows classic corkscrew appearance or mannometry showing high amplitude, sustained, NON-peristaltic contractions
Bird beak on bareium esophagogram signifies
achalasia
corkscrew appearance on barium esophagogram signifies
diffuse esophageal spasm
Tx of DES and nutcracker esophagus
antispasmodics, CCB, nitrates, bougie dilation. long esophagomyotomy
nutcracker esophagus aka
super-squeeze esophagus
Patient presents with chest pain, dysphagia, and odynophagia. Mannometry shows 180mmHg pressure for more than 6 seconds signifying high pressure contractions for a long amount of time. Diagnosis?
Nutcracker esophagus
pharyngoesophageal diverticula aka
Zenker’s diverticulum
What is the most common esophagea diverticulum
Pharyngoesophageal diverticula
Patient age 65 presents with cervical dysphagia, gurgling during swallowing, regurgitation of undigested food, bad breath, aspiration. Transient incomplete opening of UES seen. Diagnosis?
pharyngoesophageal diverticula
Mannometry critera for nutcracker esophagus
180mmHg pressure for more than 6 seconds in duration
Tx of Zenker’s diverticulum
Surgery to remove diverticulum- relieves pressure at the UES
Collagen vascular diseases that result in esophageal motor disturbances
dermatomyositis, polymyositis, lupus erythematosus, scleroderma
Most serious complication of zenker’s diverticula
aspiration- surgery recommended
How is midesophageal diverticula and pharyngoesophageal diverticula diagnosed?
esophagogram
Midesophageal diverticula- traction or pulsion?
Both
Epiphrenic diverticula- traction or pulsion?
Pulsion
When to treat epiphrenic diverticula
When diverticuli become symptomatic or larger than 3cm. Tx involves surgery for removal of the diverticulum and esophagomyotomy to relieve the distal obstruction
What kind of necrosis do alkalai and acidic substances cause?
Alkalai- liquefactive necrosis, deep burning. Acidic- coagulative necrosis, prevents deep burning
Is esophagus more resistant to acidic or alkalaic burns?
Acidic
Solid alkalai vs. liquid alkalai causing caustic injury
Solid alkali tends to adhere to oropharynx- more damage proximally. Liquid alkalai readily passed to the esophagus- more damage distally
How to manage caustic injury
Figure out if acid or alkali agent ingested. Chest and abdominal Xray. EGD.
How to handle 1st degree esophageal burns
Observation
How to handle 2nd and 3rd degree esophageal burns
Admit to ICU, NPO, IVF, ABS, serial xrays, etc.
Perforation of esophagus can be…
iatrogenic, spontaneous, or traumatic
Which type of esophageal perforation is most common?
Iatrogenic- from EGD, NG, ET tube, chest thoracostomy, neck or chest surgery, etc.
Spontaneous rupture of esophagus resulting from straining or vommitting. What is it and where does it most likely occur?
Boerhaave’s syndrome- left lower posterior esophagus
Patient presents with pain, vomiting, hematamesis, dysphagia, mediastinal crunch, dullness, fever, tachycardia, tachypne, and subcutaneous emphysema. Dx?
Perforation- barium esophagogram
You suspect perforation in patient’s abdomen. You decide to use esophagogram to see the exact location. What do you use?
Abdomen- gastrograffin. If perforation in chest- use barium
When diagnosing perforation, use and avoid which tests?
Use esophagogram (either barium or gastrograffin). Chest CT ok, AVOID EGD
Varices result from..
portal hypertension d/t cirrhosis of the liver
Tx of varices
sclerotherapy, banding, blakemore tube
What might you see in belemic patient that forcefully vomits, including hematemesis? Is often self-limited.
Mallory-Weiss Tear- tear in the mucosal layer at the junction of the esophagus and stomach
Most common cause of esophageal chest pain
reflux esophagitis. also advanced achalasia and DES
