Lec 1 Esophagus Flashcards
What two muscles compose the upper esophageal sphincter?
- cricopharyngeus
- inferior pharyngeal constrictor
What kind of muscle is the UES?
skeletal muscle
When is UES relaxed? contracted?
- tonically closed at rest
- relaxed during swallowing
WHat is normal amplitude of peristaltic wave in esophagus?
60-100 mmHg
What is purpose of primary, secondary, tertiary peristalsis?
primary = clears the bolus
secondary = sweepers; wipe up any refuxed food also propulsive
tertiary = non propulsive, spontaneous not triggered by bolus
What causes relaxation of LES?
NO = inhibitory neurotransmitter
Why can you have negative pressure in the esophagus?
b/c thoracic cavity under negative pressure
What are some neural factors that decrease lower esophageal sphincter pressure
- cholinergic antagonists
- alpha adrenergic blockers
- beta adrenergic agonists
- nitric oxide
What are 4 hormones that decrease lower esophageal sphincter pressure?
- secretin
- CCK
- somatostatin
- progesterone [pregnancy]
What are 4 foods that decrease lower esophageal sphincter pressure?
- fats
- chocolate
- ethanol
- peppermint
What are some drugs that decrease lower esophageal sphincter pressure?
- theophylline
- Ca channel blockers
- morphine
- diazepam
- serotonin
What are symptoms of esophageal disorder?
- dysphagia
- heartburn
- odynophagia
- chest pain
- regurgitation
What is dysphagia?
sense of impaired transport of bolus through esophagus?
What causes heartburn? What makes it better/worse?
due to reflux fo gastric contents into esophagus
worse after meals, with bending
relieved by antacids
What is odynophagia?
pain on swallowing
What are some atypical symptoms of esophageal disorder?
- hoarseness
- cough
- wheeze
- sore throat
What are x diagnostic tests for esophageal disorders?
- barium esophagram
- endoscopy w/ biopsy
- endoscopic ultrasound
- esophageal manometry
- acid reflux [pH] studies
What does a barium esophagram [barium swallow] tell you?
evaluates structural lesions [strictures, web, hiatal hernia]
What does endoscopy tell you?
directly visualizes esophageal mucosa
allows you to do biopsy for tissue diagnosis
What does endoscopic ultrasound [EUS] tell you?
useful for imaging lesions in esophageal wall or immediately adjacent to esophagus
What does esophageal manometry tell you?
- measures pressure, contractile activity, and sphincter function
- useful for motility disorders
- can demonstrate tendency for GE reflux
What does acid reflux study tell you?
- measures esophageal pH
- have 24 hrs pH probe can quantify amount and duration of reflux and correlate w/ symptoms
What is gastroesophageal reflux disease?
- reflux of gastric contents into esophagus
- commonly presents as heartburn and regurgitation w/ lying down
- due to decrease in LES tone
What are symptoms of GERD?
- heartburn [worse w/ food, lying, better w/ antacids]
- chest pain
- dysphagia
- nocturnal cough/dyspnea
What is diagnostic test for GERD?
- 24 pH monitoring to demonstrate reflux
- endoscopy to looks for erythema, linear ulcers that suggest effects of reflux
What are physiologic defensive factors that prevent GERD?
- LES = anti-reflux barrier
- esophageal acid clearance via gastric emptying, esophageal peristalsis, saliva
How does a hiatal hernia effect GERD?
increase in transient LES relaxations
have acid pocket in proximal stomach and no longer have diaphragm “pinching” at the GE junction
== increases risk for GERD
What are the 2 types of hiatal hernia?
- sliding = GE junction just slides up
- para esophageal = GE junction in normal place but there is a true hernial sac that goes up above the diaphragm
What is a hiatal hernia?
part of top of stomach herniates above the diaphgram
What are some possible complications of GERD?
- ulceration/esophagitis
- stricture
- barrett’s esophagus
What role does saliva play in protecting from GERD?
rich in bicarbonate, acts as endogenous antacid
What are 2 tests that indicate potential for reflux?
- barium swallow
- lower esophageal sphincter pressure tracings
What is an esophageal stricture?
- tapered concentric narrowing of esophagus due to inflammation and fibrosis
associated w/ lye ingestion and acid reflux
What is barrett’s esophagus?
columnar metaplasia of lower esophagus [replaces normal squamous epithelium]
due to prolonged gastroesophagela reflux
What does dysphagia of solid foods only vs dysphagia of solids + liquids tell you?
solid foods only = structural problem
solids + liquids = motility problem
What does progressive solid food only dysphagia suggest?
tumor [carcinoma] or peptic stricture
tumor will have more rapid onset
What does progressive solid + liquid dysphagia with heartburn suggest?
scleroderma
What does progressive solid + liquid dysphagia w/out heartburn suggest?
achalasia
What does intermittent solid+liquid dysphagia with chest pain suggest?
esophageal spasm
What is a potential complication of barrett’s esophagus?
increases risk of adenocarcionoma within the barrett’s epithelium [lower esophagus]
What tests can tell you if there is increased acid exposure in the esophagus?
- sometimes endoscopy
- 24 hr pH
What test[s] can tell you if there is correlation with symptoms in GE reflux?
24 hr pH
What test[s] can tell you mechanisms of reflux in GE reflux?
- esophagram
- manometry
What is initial treatment for GERD?
- lifestyle changes [weight loss, dietary modification, stay upright after meals]
- remove harmful medications
- give antacids
What is most effective treatment for GERD?
proton pump inhibitors
What are some medical treatments for GERD?
- proton pump inhibitors
- H2 receptor antagonists
- prokinetics
- sucralfate
What is achalasia?
failure of relaxation of LES due to loss of myenteric [auerbach] plexus
LES remains tonically contracted
What do you see on barium swallow with achalasia?
dilated esophagus w/ an area of distal stenosis
“birds beak”
What are symptoms of achalasia?
- dysphagia
- regurgitation
- weight loss
- chest pain
What do you see on manometry with achalasia?
- high pressure LES
- impaired LES relaxation
- aperistalsis of body of esophagus [see air fluid level]
What are 3 treatments for achalasia?
- botulinum toxin
- pneumatic [balloon] dilation
- heller myotomy = surgically divide LES muscle fibers
What are 2 secondary causes that mimic achalasia [“pseudo-achalasia”]?
- chagas disease [trypanosoma cruzii]
- cancer of GE junction –> more rapid progression, older [>50], more weight loss [> 15 lb]
What is action of botox in achalasia?
blocks ACh transmission at the LES
What is diffuse esophageal spasm?
disorder of chest pain and dysphagis w/ no organic lesion that are intermittent
may be precipitated by meals or emotional stress
What do you see on xray in diffuse esophageal spasm?
corkscrew esophagus during spasm; may appear normal otherwise
What happens to esophagus in scleroderma?
loss of smooth muscle –> decrease LES pressure and dysmotility –> reflux –> replacement of smooth muscle w/ fibrosis = stricture
have loss of LES function and poor peristalsis –> leading to GE reflux
What is treatment for diffuse esophageal spasm?
muscle relaxants, Ca blockers, nitrates
What do you see on manometry with diffuse esophageal spasm?
simultaneous prolonged contractions throughout esophagus [rather than phasic]
- repetitive contrations even w/ a smile
- LES usually normal
What is nutracker esophagsu?
disorder of high amplitude peristaltic contractions
What do you see on manometry w/ nutcracker esophagus?
- high amplitude contractions (> 180 mmHg)
- normal peristalsis and LES
How do the manometric findings of scleroderma differ from achalasia?)
scleroderma = low pressure in LES
achalasia = high pressure in LES
How is esophagus effected in pregnancy?
- decreased LES pressure in pregnancy; reverts to normal after delivery
What are 3 bugs that cause infectious esophagitis?
- HSV –> infects squamous epithelium = punched out ulcers
- CMV –> infects endothelial [usually immune suppressed] = linear ulcers
- candida albicans = white
