Lecture 1 - Esophageal Disorders Flashcards
What is the diagnostic study of choice for oropharyngeal dysphagia?
Video Esophagography (aka videofluoroscopy - rapid sequence)
List 3 ways that Upper Endoscopy (aka esophagogastroduodenoscopy (EDG)) is both diagnostic and therapeutic?
1) Direct visualization
2) Allows biopsy of mucosal abnormalities and of normal appearing mucosa
3) Allows for dilation of strictures
What is the diagnostic study of choice for persistent heartburn?
Upper Endoscopy - aka esophagogastroduodenoscopy (EDG)
Which diagnostic study is more sensitive for detecting subtle esophageal narrowing due to rings, webs, achalasia, and proximal esophageal lesions?
Barium Esophagography (aka barium swallow x-ray/barium esophagram)
Which diagnostic study can be used to differentiate between mechanical lesions and motility disorders?
Barium Esophagography (aka barium swallow x-ray/barium esophagram)
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?
Esophageal Manometry - assesses motility
List neurologic disorders which may be causes of oropharyngeal dysphagia?
- Brainstem cerebrovascular accident; mass lesion
- ALS, MS, Pseudobulbar palsy, Post-poli syndrome, Guillain-Barre syndrome
- PD, HD, and dementia
- Tardive dyskinesia
List the muscular and rheumatologic disorders which may be causes of oropharyngeal dysphagia?
- Myopathies, polymyolitis
- Oculopharyngeal dystrophy
- Sjogren Syndrome
List 4 metabolic disorders which may be causes of oropharyngeal dysphagia?
- Thyrotoxicosis
- Amyloidosis
- Cushing disease
- Wilson disease
List 2 types of medications which may have side effects causing oropharyngeal dysphagia?
- Anticholinergics
- Phenothiazines - used to treat serious mental and emotional disorders, including schizophrenia and other psychotic disorders.
What are 7 infectious agents which may cause oropharyngeal dysphagia?
- Polio
- Diptheria
- Botulism
- Lyme Disease
- Syphilis
- Candida
- Herpes
Intermittent dysphagia that is not progressive is a clue for what type of mechanical obstruction?
Schatzki ring
Chronic heartburn with progressive dysphagia that is worse for solid foods is a clue for what type of mechanical obstruction of the esophagus?
Peptic stricture
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?
- Pill esophagitis
- Infection esophagitis
What are 7 alarm features (sx’s) of someone presenting with GERD that indicates the need for endoscopy (or abdominal imaging)?
- Weight loss (especially unintentional)
- Persistent vomiting
- Constant or severe pain
- Dysphagia/odynophagia
- Hematemesis
- Melana
- Anemia (iron deficiency)
What are 6 of the atypical or extraesophageal manifestations associated with GERD?
- Asthma
- Chronic cough
- Chronic laryngitis (laryngeoesophageal reflux)
- Sore throat
- Non-cardiac chest pain
- Sleep disturbances
Are initial diagnostic studies warranted for patients with typical GERD symptoms suggesting uncomplicated disease?
- No
- Only if “alarm features” present
Which type of diagnostic imaging should be used for someone with persistent GERD or alarm features and for detecting GERD complications?
Upper endoscopy - EGD
When would esophageal impedance-pH testing be warranted in a patient with GERD?
When extraesophageal sx’s persist after 3 months of 2x daily PPI therapy
Dysphagia occurs in 1/3 or patients with GERD and may be attributed to what 3 underlying issues?
- Erosive esophagitis
- Abnormal esophageal peristalsis
- Development of an esophageal stricture
What are 5 complications which can arise from GERD?
- Laryngopharyngeal reflux (LPR)
- Esophagitis
- Stricture
- Barrett’s esophagus
- Adenocarcinoma
What is the hallmark of scleroderma?
- Thickening and hardening of the skin
- Microangiopathy and fibrosis of the skin and visceral organs
What is the typical age of onset for Scleroderma?
Which sex most affected?
More severe disease seen in which race?
- Age 30-50
- W>M
- More severe disease in blacks
What is the diagnostic study of choice for Zenker Diverticulum?
Barium esophagography (aka barium swallow)
Sjogren’s syndrome has a strong association with what type of cancer?
B-cell Non-Hodgkin lymphoma
What are 2 risk factors for the development of Barrett Esophagus?
- Chronic reflux (GERD)
- Truncal obesity independent of GERD
What is the standard treatment for Barrett Esophagus?
Reduce the risk of?
- Long-term PPI 1x or 2x daily to control reflux sx’s
- May reduce the risk of cancer
For patients with high grade dysplasia or intramucosal adenocarcinoma associated w/ Barrett Esophagus, what is the recommended treatment?
- Endoscopic therapy
- Removes or ablate dysplastic Barrett epithelium, using mucosal snare resection and radiofrequency wave ablation electrocautery
Which type of cancer is a long-term complication of Barrett Esophagus?
Adenocarcinoma
Preventative screening for Barrett Esophagus is not recommended in patients with GERD, except for when?
- Those w/ multiple risk factors for adenocarcinoma
- Chronic GERD, hiatal hernia, obesity, white race, male, and age 50+
Where are most peptic strictures found?
GE junction
What are the typical symptoms of a Peptic Stricture?
- Gradual development of solid food dysphagia progressive over months to years
- Reduction in heartburn because the stricture acts as a barrier to reflux
What is mandatory for the diagnosis of a Peptic Stricture?
Endoscopy w/ biopsy to differentiate peptic stricture from stricture by esophageal carcinoma
What is the treatment for Peptic Stricture, both at time of endoscopy and long-term?
- Dilation at time of endoscopy
- Long-term tx w/ PPI is required to decrease likelihood of recurrence
What are 7 risk factors for SCC of the esophagus?
Which risk factors are synergistic?
- Heavy smoking (synergistic w/ alcohol!)
- Alcohol
- Achalasia
- Plummer-Vinson Syndrome
- Tylosis
- Lye ingestion
- Hot beverags
Who is at the highest risk of SCC of the Esophagus?
Males > Females and AA > Caucasians
Which race is at the highest risk for Esophageal Adenocarcinoma?
Caucasians > AA
What are some of the most common medications implicated in Pill-induced Esophagitis?
- NSAIDs
- Potassium chloride pills
- Bisphosphanates: Alendronare and Risedronate
- Antibiotics
What may be seen on endoscopy of a person w/ Pill-induced Esophagitis?
Several discrete ulcers that may be shallow or deep
What is the Tx for Pill-Induced Esophagitis?
Remove the offending agent –> healing occurs rapidly
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?
- 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
What are 3 of the most common pathogens responsible for Infectious Esophagitis?
- Candida albicans
- Herpes simplex
- CMV
How is the diagnosis of Infectious Esophagitis made?
Endoscopy w/ brushings, biopsy, and culture
One to several large, shallow, superficial ulcerations of the esophagus is characteristic of which pathogen?
CMV
In patients with HIV infection what is the therapy of choice for CMV esophagitis?
Initial drug used and common side effect?
- Immune restoration with antiretroviral therapy is most effective
- Initial therapy with ganciclovir –> neutropenia = frequent dose-limiting side effect
What is the drug of choice for immunosuppressed patients with Herpes Simplex Esophagitis?
Oral acyclovir
What is the treatment of choice for Candidal Esophagitis?
Systemic therapy (i.e., Fluconazole)
Ingestion of what is associated w/ Caustic Esophageal injury?
Liquid or crystalline alkali (drain cleaners, etc) or acid
What should the initial examination for the diagnosis of Caustic Esophageal injury be directed towards?
Which studies are appropriate in this setting?
- Initial = checking circulatory status + assesing airway patency and the oropharyngeal mucosa, including laryngoscopy
- Chest and abdominal XR looking for pneumonitis or free perforation
Which treatments are contraindicated in someone with Caustic Esophageal injury?
Nasogastric lavage and oral antidotes may be dangerous
What is the initial treatment for someone in the ICU w/ Caustic Esophageal injury?
- Supportive IVF
- IV PPI
When should laryngoscopy be perfomed in patients with Caustic Esophageal injury?
Those w/ respiratory distress to assess the need for tracheostomy
What is the risk of Esophageal SCC in patients with Caustic Esophageal injury and what does this warrant?
- 2-3% increased risk
- Warranting endoscopic surveillance 15-20 yrs after the caustic ingestion
What treatment modality is utilized for the diagnosis of Eosinophilic Esophagitis?
What would you expect to see?
- Endoscopy w/ esophageal biopsy is required
- White exudates or papules, red furrows, corrugated concentric rings, and strictures; may be normal in some pts
A long history of dysphagia for solid-foods and a previous episode of food impaction is characteristic of what type of benign esophageal lesion?
Eosinophilic esophagitis
Which treatment modality for Eosinophilic Esophagitis leads to symptom resolution in 70% of adutls?
Topical corticosteroids
When should graduated dilation of the esophagus be perfomed in someone with Eosinophilic Esophagitis?
Must be careful why?
- Patients w/ dysphagia and strictures or narrow-caliber esophagus
- Need to be cautious due to increased risk of perforation
How can the majority of symptomatic patients with Esophageal Webs or Schatzki Rings be treated?
Passage of bougie dilators to disrupt the lesion or endoscopic electrosurgical incision of the ring
How should patients with Esophageal Webs or Schatzki Rings that have heartburn or who require repeated dilations be treated?
Long-term acid suppressive therapy w/ PPI
Schatzki rings are associated in almost all cases with what underlying condition?
Hiatal hernia
What type of dysphagia is seen with Esophageal Webs and Schatzki Rings?
Intermittent and NOT progressive
Which type of food is most likely to cause someone with a Schatzki Ring problems?
Large poorly chewed food boluses such as beefsteak
What are 3 of the complications involving the lungs which may result from long-standing Zenker Diverticulum?
- Aspiration pneumonia
- Bronchiectasis
- Lung abscesses
What are the treatments of choice for symptomatic patients with Zenker Diverticulum?
- Upper esophageal myotomy
- Surgical diverticulectomy
Describe the esophageal dysphagia associated with Plummer-Vinson Syndrome.
Solids vs. liquids vs. progressive vs. intermitted?
- Solids > liquids
- Intermittent symptoms
What should be done before performing EGD?
Why?
- An esophagram w/ barium imaging
- Due to the risk of perforation with EGD
What are 4 risk factors which increase the risk of bleeding from Esophageal Varices?
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
Esophageal varices are diagnosed using which modality?
EGD
Which antibiotics should be used in an ICU patient with esophageal bleeding from varices?
Fluoroquinolones or IV 3rd Gen. Cephalosporins
Which drugs are used for prevention of re-bleeding in patients with Esphogeal Varices?
Nonselective beta blockers (propranolol, nadolol)
What is a long-term treatment that can be used to reduce the incidence of rebleeding associated with Esophageal Varices?
Band ligation
Many patients presenting with esophageal variceal bleeding have a coagulopathy due to underlying cirrhosis, how should this be treated?
- Fresh frozen plasma or platelets
- IV Vitamin K
Due to its high rate of complications when is balloon tube tamponade indicated for esophageal variceal bleeds?
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
The use of Emergent Endoscopy for Esophageal Variceal bleeds should only be done once what has been stabilized?
Timeline?
Hemodynamic status has been appropriately stabilized (usually within 2-12 hours)
What are Transvenous Intrahepatic Portosystemic Shunts (TIPS) used for in regards to Esophageal Variceal bleeds?
Indicated for which patients?
Complications?
- 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
What is used to assess candidacy for liver transplantation in patients with chronic liver disease and bleeding due to portal HTN?
Calculate MELD and Child Pugh Scores
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?
Banding
Do TIPS lower the risk for rebleeding and mortality in patients with esophageal varical bleeds?
- Lowers risk of rebleeding
- Does NOT decrease mortality
What type of dysphagia is associated with Achalasia?
Gradual, progressive dysphagia for solids and liquids
Which diagnostic technique confirms the diagnosis of Achalasia?
Esophageal manometry
*Complete absence of normal peristalsis and incomplete LES relaxation w/ swallowing
What may happen to the esophagus is Achalasia is left untreated?
May become markedly dilated (“sigmoid esophagus”)
What are 3 treatment options for Achalasia?
- Botulimum toxin injeciton
- Pneumatic dilation
- Surgery: pts prescribed 1x daily PPI
Hypertensive esophagus is associated with what pathology?
Nutcracker esophagus
What is the LES like in nutcracker esophagus vs. diffuse esophageal spasm?
- Nutcracker = relaxes normally, but has elevated pressure at baseline
- DES = LES function is normal
What is the dysphagia associated with Diffuse Esophageal Spasm and Nutcracker Esophagus like?
May have atypical what?
- Dysphagia to solids and liquids that is intermittent
- Atypical chest pain
What 2 diagnostic techniques may be used for Nutcracker Esophagus?
- Manometry
- Video fluoroscopy
Uncoordinated esophageal contraction, “corkscrew esophagus,” or “rosary bead esophagus” is characteristic of?
Diffuse esophageal spasm
What 3 diagnostic techniques may be used for Diffuse Esophageal Spasm?
- Manometry
- EGD
- Barium swallow
What is Iatrogenic esophageal rupture?
Rupture occuring post-EGD with biopsy or dilation
*This is NOT calld Boerhaave’s!!!!
How is the diagnosis of Esophagal Perforation made?
What is used to confirm the Dx?
- CT of the chest detecting mediastinal air
- Confirmed by contrast swallow, usually Gastrografin followed by barium
What are the treatment options for esophageal perforation?
- NGT suction
- NPO
- Parenteral Antibiotics and Surgery
In a patient with dyspnea possibly suggestive of pneumomediastinum, measurement of what is contraindicated?
What may be used instead?
- Measuring peak expiratory flow rate = contraindicated = may exacerbate spontaneous pneumomediastinum (SPM)
- Pulse oximetry may be used to evaluate dyspneic patients
