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GI II Exam 2 EH > Lecture 1 - Esophageal Disorders > Flashcards

Lecture 1 - Esophageal Disorders Flashcards

1
Q

What is the diagnostic study of choice for oropharyngeal dysphagia?

A

Video Esophagography (aka videofluoroscopy - rapid sequence)

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2
Q

List 3 ways that Upper Endoscopy (aka esophagogastroduodenoscopy (EDG)) is both diagnostic and therapeutic?

A

1) Direct visualization
2) Allows biopsy of mucosal abnormalities and of normal appearing mucosa
3) Allows for dilation of strictures

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3
Q

What is the diagnostic study of choice for persistent heartburn?

A

Upper Endoscopy - aka esophagogastroduodenoscopy (EDG)

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4
Q

Which diagnostic study is more sensitive for detecting subtle esophageal narrowing due to rings, webs, achalasia, and proximal esophageal lesions?

A

Barium Esophagography (aka barium swallow x-ray/barium esophagram)

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5
Q

Which diagnostic study can be used to differentiate between mechanical lesions and motility disorders?

A

Barium Esophagography (aka barium swallow x-ray/barium esophagram)

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6
Q

In a patient with suspected achalasia in whom a mechanical obstruction cannot be found after endoscopy or barium study, which diagnostic study can be used?

A

Esophageal Manometry - assesses motility

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7
Q

List neurologic disorders which may be causes of oropharyngeal dysphagia?

A
  • Brainstem cerebrovascular accident; mass lesion
  • ALS, MS, Pseudobulbar palsy, Post-poli syndrome, Guillain-Barre syndrome
  • PD, HD, and dementia
  • Tardive dyskinesia
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8
Q

List the muscular and rheumatologic disorders which may be causes of oropharyngeal dysphagia?

A
  • Myopathies, polymyolitis
  • Oculopharyngeal dystrophy
  • Sjogren Syndrome
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9
Q

List 4 metabolic disorders which may be causes of oropharyngeal dysphagia?

A
  • Thyrotoxicosis
  • Amyloidosis
  • Cushing disease
  • Wilson disease
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10
Q

List 2 types of medications which may have side effects causing oropharyngeal dysphagia?

A
  1. Anticholinergics
  2. Phenothiazines - used to treat serious mental and emotional disorders, including schizophrenia and other psychotic disorders.
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11
Q

What are 7 infectious agents which may cause oropharyngeal dysphagia?

A
  • Polio
  • Diptheria
  • Botulism
  • Lyme Disease
  • Syphilis
  • Candida
  • Herpes
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12
Q

Intermittent dysphagia that is not progressive is a clue for what type of mechanical obstruction?

A

Schatzki ring

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13
Q

Chronic heartburn with progressive dysphagia that is worse for solid foods is a clue for what type of mechanical obstruction of the esophagus?

A

Peptic stricture

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14
Q

A patient presents with odynophahia (painful swallowing), especially with solid foods, and localized to the esophagus, what are 2 common etiologies for this type of presentation?

A
  1. Pill esophagitis
  2. Infection esophagitis
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15
Q

What are 7 alarm features (sx’s) of someone presenting with GERD that indicates the need for endoscopy (or abdominal imaging)?

A
  1. Weight loss (especially unintentional)
  2. Persistent vomiting
  3. Constant or severe pain
  4. Dysphagia/odynophagia
  5. Hematemesis
  6. Melana
  7. Anemia (iron deficiency)
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16
Q

What are 6 of the atypical or extraesophageal manifestations associated with GERD?

A
  • Asthma
  • Chronic cough
  • Chronic laryngitis (laryngeoesophageal reflux)
  • Sore throat
  • Non-cardiac chest pain
  • Sleep disturbances
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17
Q

Are initial diagnostic studies warranted for patients with typical GERD symptoms suggesting uncomplicated disease?

A
  • No
  • Only if “alarm features” present
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18
Q

Which type of diagnostic imaging should be used for someone with persistent GERD or alarm features and for detecting GERD complications?

A

Upper endoscopy - EGD

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19
Q

When would esophageal impedance-pH testing be warranted in a patient with GERD?

A

When extraesophageal sx’s persist after 3 months of 2x daily PPI therapy

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20
Q

Dysphagia occurs in 1/3 or patients with GERD and may be attributed to what 3 underlying issues?

A
  1. Erosive esophagitis
  2. Abnormal esophageal peristalsis
  3. Development of an esophageal stricture
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21
Q

What are 5 complications which can arise from GERD?

A
  1. Laryngopharyngeal reflux (LPR)
  2. Esophagitis
  3. Stricture
  4. Barrett’s esophagus
  5. Adenocarcinoma
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22
Q

What is the hallmark of scleroderma?

A
  • Thickening and hardening of the skin
  • Microangiopathy and fibrosis of the skin and visceral organs
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23
Q

What is the typical age of onset for Scleroderma?

Which sex most affected?

More severe disease seen in which race?

A
  • Age 30-50
  • W>M
  • More severe disease in blacks
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24
Q

What is the diagnostic study of choice for Zenker Diverticulum?

A

Barium esophagography (aka barium swallow)

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25
Q

Sjogren’s syndrome has a strong association with what type of cancer?

A

B-cell Non-Hodgkin lymphoma

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26
Q

What are 2 risk factors for the development of Barrett Esophagus?

A
  1. Chronic reflux (GERD)
  2. Truncal obesity independent of GERD
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27
Q

What is the standard treatment for Barrett Esophagus?

Reduce the risk of?

A
  • Long-term PPI 1x or 2x daily to control reflux sx’s
  • May reduce the risk of cancer
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28
Q

For patients with high grade dysplasia or intramucosal adenocarcinoma associated w/ Barrett Esophagus, what is the recommended treatment?

A
  • Endoscopic therapy
  • Removes or ablate dysplastic Barrett epithelium, using mucosal snare resection and radiofrequency wave ablation electrocautery
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29
Q

Which type of cancer is a long-term complication of Barrett Esophagus?

A

Adenocarcinoma

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30
Q

Preventative screening for Barrett Esophagus is not recommended in patients with GERD, except for when?

A
  • Those w/ multiple risk factors for adenocarcinoma
  • Chronic GERD, hiatal hernia, obesity, white race, male, and age 50+
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31
Q

Where are most peptic strictures found?

A

GE junction

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32
Q

What are the typical symptoms of a Peptic Stricture?

A
  • Gradual development of solid food dysphagia progressive over months to years
  • Reduction in heartburn because the stricture acts as a barrier to reflux
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33
Q

What is mandatory for the diagnosis of a Peptic Stricture?

A

Endoscopy w/ biopsy to differentiate peptic stricture from stricture by esophageal carcinoma

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34
Q

What is the treatment for Peptic Stricture, both at time of endoscopy and long-term?

A
  • Dilation at time of endoscopy
  • Long-term tx w/ PPI is required to decrease likelihood of recurrence
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35
Q

What are 7 risk factors for SCC of the esophagus?

Which risk factors are synergistic?

A
  1. Heavy smoking (synergistic w/ alcohol!)
  2. Alcohol
  3. Achalasia
  4. Plummer-Vinson Syndrome
  5. Tylosis
  6. Lye ingestion
  7. Hot beverags
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36
Q

Who is at the highest risk of SCC of the Esophagus?

A

Males > Females and AA > Caucasians

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37
Q

Which race is at the highest risk for Esophageal Adenocarcinoma?

A

Caucasians > AA

38
Q

What are some of the most common medications implicated in Pill-induced Esophagitis?

A
  • NSAIDs
  • Potassium chloride pills
  • Bisphosphanates: Alendronare and Risedronate
  • Antibiotics
39
Q

What may be seen on endoscopy of a person w/ Pill-induced Esophagitis?

A

Several discrete ulcers that may be shallow or deep

40
Q

What is the Tx for Pill-Induced Esophagitis?

A

Remove the offending agent –> healing occurs rapidly

41
Q

If the offending agent of Pill-induced Esophagitis needs to be taken, what are some preventative measures that can be taken?

Known offending agents should not be given to whom?

A
  • Take pills w/ 4 oz. of water and remain upright for 30 mins after ingestion
  • Known offending agents should NOT be given to pts w/ esophageal dysmotility, dysphagia or strictures
42
Q

What are 3 of the most common pathogens responsible for Infectious Esophagitis?

A
  1. Candida albicans
  2. Herpes simplex
  3. CMV
43
Q

How is the diagnosis of Infectious Esophagitis made?

A

Endoscopy w/ brushings, biopsy, and culture

44
Q

One to several large, shallow, superficial ulcerations of the esophagus is characteristic of which pathogen?

A

CMV

45
Q

In patients with HIV infection what is the therapy of choice for CMV esophagitis?

Initial drug used and common side effect?

A
  • Immune restoration with antiretroviral therapy is most effective
  • Initial therapy with ganciclovir –> neutropenia = frequent dose-limiting side effect
46
Q

What is the drug of choice for immunosuppressed patients with Herpes Simplex Esophagitis?

A

Oral acyclovir

47
Q

What is the treatment of choice for Candidal Esophagitis?

A

Systemic therapy (i.e., Fluconazole)

48
Q

Ingestion of what is associated w/ Caustic Esophageal injury?

A

Liquid or crystalline alkali (drain cleaners, etc) or acid

49
Q

What should the initial examination for the diagnosis of Caustic Esophageal injury be directed towards?

Which studies are appropriate in this setting?

A
  • Initial = checking circulatory status + assesing airway patency and the oropharyngeal mucosa, including laryngoscopy
  • Chest and abdominal XR looking for pneumonitis or free perforation
50
Q

Which treatments are contraindicated in someone with Caustic Esophageal injury?

A

Nasogastric lavage and oral antidotes may be dangerous

51
Q

What is the initial treatment for someone in the ICU w/ Caustic Esophageal injury?

A
  • Supportive IVF
  • IV PPI
52
Q

When should laryngoscopy be perfomed in patients with Caustic Esophageal injury?

A

Those w/ respiratory distress to assess the need for tracheostomy

53
Q

What is the risk of Esophageal SCC in patients with Caustic Esophageal injury and what does this warrant?

A
  • 2-3% increased risk
  • Warranting endoscopic surveillance 15-20 yrs after the caustic ingestion
54
Q

What treatment modality is utilized for the diagnosis of Eosinophilic Esophagitis?

What would you expect to see?

A
  • Endoscopy w/ esophageal biopsy is required
  • White exudates or papules, red furrows, corrugated concentric rings, and strictures; may be normal in some pts
55
Q

A long history of dysphagia for solid-foods and a previous episode of food impaction is characteristic of what type of benign esophageal lesion?

A

Eosinophilic esophagitis

56
Q

Which treatment modality for Eosinophilic Esophagitis leads to symptom resolution in 70% of adutls?

A

Topical corticosteroids

57
Q

When should graduated dilation of the esophagus be perfomed in someone with Eosinophilic Esophagitis?

Must be careful why?

A
  • Patients w/ dysphagia and strictures or narrow-caliber esophagus
  • Need to be cautious due to increased risk of perforation
58
Q

How can the majority of symptomatic patients with Esophageal Webs or Schatzki Rings be treated?

A

Passage of bougie dilators to disrupt the lesion or endoscopic electrosurgical incision of the ring

59
Q

How should patients with Esophageal Webs or Schatzki Rings that have heartburn or who require repeated dilations be treated?

A

Long-term acid suppressive therapy w/ PPI

60
Q

Schatzki rings are associated in almost all cases with what underlying condition?

A

Hiatal hernia

61
Q

What type of dysphagia is seen with Esophageal Webs and Schatzki Rings?

A

Intermittent and NOT progressive

62
Q

Which type of food is most likely to cause someone with a Schatzki Ring problems?

A

Large poorly chewed food boluses such as beefsteak

63
Q

What are 3 of the complications involving the lungs which may result from long-standing Zenker Diverticulum?

A
  • Aspiration pneumonia
  • Bronchiectasis
  • Lung abscesses
64
Q

What are the treatments of choice for symptomatic patients with Zenker Diverticulum?

A
  • Upper esophageal myotomy
  • Surgical diverticulectomy
65
Q

Describe the esophageal dysphagia associated with Plummer-Vinson Syndrome.

Solids vs. liquids vs. progressive vs. intermitted?

A
  • Solids > liquids
  • Intermittent symptoms
66
Q

What should be done before performing EGD?

Why?

A
  • An esophagram w/ barium imaging
  • Due to the risk of perforation with EGD
67
Q

What are 4 risk factors which increase the risk of bleeding from Esophageal Varices?

A

1) Size (>5mm)
2) Presence of red wale markings at endoscopy
3) Severity of liver disease
4) Active alcohol abuse - in pts w/ established cirrhosis

68
Q

Esophageal varices are diagnosed using which modality?

A

EGD

69
Q

Which antibiotics should be used in an ICU patient with esophageal bleeding from varices?

A

Fluoroquinolones or IV 3rd Gen. Cephalosporins

70
Q

Which drugs are used for prevention of re-bleeding in patients with Esphogeal Varices?

A

Nonselective beta blockers (propranolol, nadolol)

71
Q

What is a long-term treatment that can be used to reduce the incidence of rebleeding associated with Esophageal Varices?

A

Band ligation

72
Q

Many patients presenting with esophageal variceal bleeding have a coagulopathy due to underlying cirrhosis, how should this be treated?

A
  • Fresh frozen plasma or platelets
  • IV Vitamin K
73
Q

Due to its high rate of complications when is balloon tube tamponade indicated for esophageal variceal bleeds?

A

Used as temporizing measure only in pts w/ bleeding that cannot be controlled w/ pharmacologic or endoscopic techniques until more definitive therapy (i.e., TIPS) can be provided

74
Q

The use of Emergent Endoscopy for Esophageal Variceal bleeds should only be done once what has been stabilized?

Timeline?

A

Hemodynamic status has been appropriately stabilized (usually within 2-12 hours)

75
Q

What are Transvenous Intrahepatic Portosystemic Shunts (TIPS) used for in regards to Esophageal Variceal bleeds?

Indicated for which patients?

Complications?

A
  • Control acute hemorrhage w/ active bleeding from gastric or esophageal varices
  • Indicated for pts who have recurrent (2+ episodes) variceal bleeding and have failed endoscopic or pharmaco. therapies
  • Increased risk of encephalopathy
76
Q

What is used to assess candidacy for liver transplantation in patients with chronic liver disease and bleeding due to portal HTN?

A

Calculate MELD and Child Pugh Scores

77
Q

Which treatment technique achieves lower rates of rebleeding, complications, and death and should be considered the treatment of choice for a pt presenting with esophageal variceal bleeding?

A

Banding

78
Q

Do TIPS lower the risk for rebleeding and mortality in patients with esophageal varical bleeds?

A

- Lowers risk of rebleeding

- Does NOT decrease mortality

79
Q

What type of dysphagia is associated with Achalasia?

A

Gradual, progressive dysphagia for solids and liquids

80
Q

Which diagnostic technique confirms the diagnosis of Achalasia?

A

Esophageal manometry

*Complete absence of normal peristalsis and incomplete LES relaxation w/ swallowing

81
Q

What may happen to the esophagus is Achalasia is left untreated?

A

May become markedly dilated (“sigmoid esophagus”)

82
Q

What are 3 treatment options for Achalasia?

A
  1. Botulimum toxin injeciton
  2. Pneumatic dilation
  3. Surgery: pts prescribed 1x daily PPI
83
Q

Hypertensive esophagus is associated with what pathology?

A

Nutcracker esophagus

84
Q

What is the LES like in nutcracker esophagus vs. diffuse esophageal spasm?

A
  • Nutcracker = relaxes normally, but has elevated pressure at baseline
  • DES = LES function is normal
85
Q

What is the dysphagia associated with Diffuse Esophageal Spasm and Nutcracker Esophagus like?

May have atypical what?

A
  • Dysphagia to solids and liquids that is intermittent
  • Atypical chest pain
86
Q

What 2 diagnostic techniques may be used for Nutcracker Esophagus?

A
  • Manometry
  • Video fluoroscopy
87
Q

Uncoordinated esophageal contraction, “corkscrew esophagus,” or “rosary bead esophagus” is characteristic of?

A

Diffuse esophageal spasm

88
Q

What 3 diagnostic techniques may be used for Diffuse Esophageal Spasm?

A
  • Manometry
  • EGD
  • Barium swallow
89
Q

What is Iatrogenic esophageal rupture?

A

Rupture occuring post-EGD with biopsy or dilation

*This is NOT calld Boerhaave’s!!!!

90
Q

How is the diagnosis of Esophagal Perforation made?

What is used to confirm the Dx?

A
  • CT of the chest detecting mediastinal air
  • Confirmed by contrast swallow, usually Gastrografin followed by barium
91
Q

What are the treatment options for esophageal perforation?

A
  • NGT suction
  • NPO
  • Parenteral Antibiotics and Surgery
92
Q

In a patient with dyspnea possibly suggestive of pneumomediastinum, measurement of what is contraindicated?

What may be used instead?

A
  • Measuring peak expiratory flow rate = contraindicated = may exacerbate spontaneous pneumomediastinum (SPM)
  • Pulse oximetry may be used to evaluate dyspneic patients

GI II Exam 2 EH (15 decks)

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