intro & Esophageal disorders Flashcards
older pt with new swallowing/heartburn complaint.. think?
RED FLAG
who do you refer to for pharynx/swallowing problems?
ENT and/or speech pathology
are the sphincters of the esophagus true sphincters?
NO
cause of GERD
incompetent LES (lower esophageal sphincter) allowing gastric contents to reflux into esophagus
typical GERD sxs, atypical sxs (3), and 4 GERD red flags/ alarm symptoms
typical: postprandial HEARTBURN, increased with supine position and can be relieved with antacids. can have regurgitation into throat, lungs or mouth atypical: hoarseness, asp pneumo, wheezing odynophagia, dysphagia, weight loss, bleeding
how do you diagnose GERD?
CLINICAL gold standard: 24 hr ambulatory pH monitoring if symptoms are persistent, refractory to med trial or if there are alarm symptoms then do EGD
3 Goals for GERD txt
prevent reflux, lower acid secretion, prevent complications of esophagitis
txt for GERD
lifestyle modifications (diet, elevate bed with blocks, weight loss, stop smoking/alc) in combination with medications (antacid, PPI, H2 blocker) -<2 episodes per week = PRN antacids or H2 blockers - 2 or more episodes per week = PPI surgery (fundoplication) in medication-refractory pts
what is a Nissen fundoplication?
fold fundus of stomach and wrap around esophagus to prevent reflux (increase pressure)
GERD complications: 4
esophagitis, stricture (narrowing from acidic damage), barrett esophagus (MOST IMPORTANT), and adenocarcinoma
how can GERD cause asthma exacerbation?
microaspiration
antacids ____ but do not _____ acids.
neutralize but do not suppress
what are the antacids? antacids should be taken when?
BASIC components to neutralize acid: Mg++, Al++, Ca++ salts immediately after meals (when you have symptoms)
what do H2 blockers do for GERD?
block production of acid by gastric parietal cells
when are PPIs taken?
before you eat (this is when the enzyme works best)
one downside to PPIs?
inc risk for infection cause its taking away the acid that normally neutralizes bacteria that comes with food.
what is pH ambulatory monitoring and who is it good for?
Useful in Pts who have not benefited from a trial of anti-secretory meds or have refractory problems, or has a normal endoscopy and cont’d symptoms. **useful in GERD
how do you take PPIs? efficacy between PPIs? usual starting dose?
step-up and step-down approach, taken before meals, no difference in efficacy among the PPIs OTC omeprazole 20 mg qd is usual starting dose.
___ have good healing action for ulcers (GERD)
PPIs
txt for barrett’s
resection of that part of the esophagus (b/c does not get better with acid suppression, neoplastic change has already occurred)
what is a haital hernia? symptomatic?
protrusion of portion of the stomach through the haitus of the diaphragm into the thoracic cavity - usually asymptomatic
three types of esophageal motility disorders?
achalasia, diffuse esophageal spasm, and hypercontractile (jackhammer esophagus)
what is achalasia? CP for this?
*esophageal motality disorder* absence of peristalsis in lower 1/2 of esophagus (degeneration of auerbach’s plexus) and failure of LES to relax CP: leads to progressive dysphagia (both solids and liquids), regurg of undigested food, weight loss and halitosis (b/c food gets trapped)
how to Dx achalasia?
1). barium swallow (esophagram)- dilated tapering to “birds beak” appearance of esophagus (barium settles in trapped esophagus) 2). most accurate is manometry (shows increased LES pressure and loss of peristalsis)
txt for achalasia?
Decrease LES pressure: botox, nitrates Surgery is more effective: balloon dilation of LES, esophagomyotomy (cuts in muscle)
what is achalsia a risk factor for?
squamous cell carcinoma **EGD usually performed before initiating tx
what diffuse esophageal spasm? common CP?
*esophageal motility disorder* severe non-peristaltic esophageal contractions CP: stabbing chest pain worse with hot or cold food (similar to angina but not exertional), dysphagia to both foods and liquids, “stuck in throat” sensation
dx and txt for diffuse esophageal spasm
dx: esophagram “corkscrew esophagus” definitive dx: manometry (increased or premature contractions in distal esophagus) tx: CCB first-line, nitrates, TCAs
what is hypercontractile esophagus?
“jackhammer/nutcracker esophagus” *esophageal motility disorder* increased pressure during peristalsis with NORMAL sequential contractions
common CP and Dx for hypercontractile esophagus?
CP: dysphagia to both solids and liquids, chest pain similar to distal esophageal spasm Dx: manometry is definitive (increased pressure during peristalsis) **manometry is important in differentiating between this and diffuse esophageal spasm -EGD and esophagram is usually normal
what is scleroderma (related to esophagus)?
subQ tissue becomes progressively calcified and stiffened. -peristalsis wave defect -reduced LES pressure
tx for hypercontractile esophagus
lower the esophageal pressure with CCB, nitrates
what % of patients with scleroderma have GI issues?
90%
txt for scleroderma?
depends on symptoms (txt with reflux or motility medications)
5 types of esophagitis
GERD- MC cause Infectious- Candida (MC), CMV, HS *usually immunosuppressed pts Eosinophilic- children with atrophic triad with allergies Pill-induced esophagitis Caustic esophagitis: due to acidic or basic substance
early/mild esophagitis vs erosive/severe
early: reddened severe: has gone into submucosa
pill-induced esophagitis: what is it and what pills usually cause it?
caused by delayed transit time in esophagus bisphosphonates, ASA, NSAIDS, Ferrus Sulfate, Tetracyclines*** (alendronate/fosamax)
caustic esophagitis examples of substances
strong alkali and acids (drano, lye, bleach) *alkali injury generally worse than acid -can lead to death, strictures, etc.
txt for caustic esophagitis
Supportive: IV fluids and H2 blockers, pain meds (DON’T try to neutralize, just flush out)
eosinophilic esophagitis: what is it and how does it present?
allergy in esophagus - almost always present with dysphagia/regurg/food impaction with GERD-like complaints
txt: eosinophilia esophogitis
remove allergic agents and some need topical steroids
only test of cure for eosinophilia esoph. is what?
re-biopsy, so we often just txt symptoms
symptoms for infectious esoph.
dysphagia and odynophagia (very painful)
txt for infectous esoph.
txt underlying condition, appropriate anti-infectives (usually antifungals)
how to diagnose esophagitis?
EGD
what is barretts esophagus?
longterm acid exposure predisposes for adenocarcinoma -metaplastic columnar epithelial cells replace squamous epithelium -not a Cancer but neoplastic changes that inc. the risk for cancer
esophageal rings: what are they? MC location? etiology? Sx? Dx? Txt?
circular diaphragm of tissue that protrudes into esophageal lumen -location: lower esophagus (SC junction) -etiology: varied (reflux, hiatal hernia, etc) -Sx: MOST AS, if sxs then EPISODIC dysphagia esp to solids (bolus of foods may get stuck) -Dx: barium esophagram (more sensitive)- circumferential ridge above diaphragm hiatus -txt: if sxs then dilation and txt underlying cause **control reflux to prevent worsening
esophageal webs are more ___ while rings are more ____
webs: mucosal rings: muscular
what is esophageal web?
non circumferential thin membrane in mid-upper esophagus CP: Many are AS, dysphagia especially to solids Dx: barium esophagram test of choice Tx: dilation of area if severe sxs (PPI therapy after dilation may decrease risk of recurrence)
esophageal diverticula (aka ____)
Zenker’s : caused by motility d/o of upper esophagus; relaxation/contraction problems, causes high pressures that result in diverticuli (pouches/herniation in muscular wall of pharynx)
symptoms of esophageal diverticula? txt?
regurg and really FOUL breath txt: excision
two types of esophageal cancer, where is each found in esophagus, and risk factors
adenocarcinoma: MC in US, found in distal esophagus *RFs: Barrett’s esophagus, smoking, obese squamous cell: MC worldwide, found in upper third *RFs: smoking and alcohol
esophageal cancer: presentation and Dx
CP: PROGRESSIVE dysphagia (solid to eventual liquids too) and late odynophagia, weight loss, anorexia, iron deficiency **advanced disease upon presentation Dx: EGD with biopsy **endoscopic US preferred method for locoregional staging
txt for esophageal cancer
early detection and prevention major surgery for resection, maybe radiation/chemo, palliative stenting for dysphagia
what is mallory-weiss syndrome? what is it due to? common CP? how to dx?
longitudinal mucosal lacerations at the gastro-esophageal junction or gastric cardia PP: sudden rise in intraabdominal pressure (i.e. persistent retching or vomiting) CP: Hematemesis associated with persistent retching and vomiting, often following an alcoholic binge Dx: EGD is test of choice
mallor weiss syndrome tx: Majority of patients heal _______ with only minor blood loss, but ~__% may have more serious sequelae (active vs non active bleeding)
heal spontaneously 10% shock, need for transfusion not active: SUPPORTIVE (PPIs for 1-2 weeks to promote acid suppression, anti nausea med, transfuse if Hb <8) active bleed: transfuse, hemoclips/band ligation, balloon tamponade
what are esophageal varices? what is the most common cause?
dilation of esophago-gastric venous plexus (from elevated portal HTN) Cause: cirrhosis
presentation of esophageal varices?
usually an acute rupture with active bleeding (hematemesis) *may develop signs of shock/hypovolemia
how to diagnose and tx esophageal varices?
dx: EGD to diagnose and treat (esp acutely) tx: 1). acute variceal bleed: stabilize the patient (IVs, fluids), octreotide, endoscopic intervention (variceal ligation) or surgical intervention (TIPS) if endoscopy is unsuccessful, ABX proph (rocephin) 2). chronic: improving the liver (dec alc, tx hepatitis) and BB to prevent rebleeding (propranolol)
