Lecture 1 - Esophageal Disorders Flashcards
1
Q
What is the diagnostic study of choice for oropharyngeal dysphagia?
A
Video Esophagography (aka videofluoroscopy - rapid sequence)
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
3
Q
What is the diagnostic study of choice for persistent heartburn?
A
Upper Endoscopy - aka esophagogastroduodenoscopy (EDG)
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)
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)
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
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
8
Q
List the muscular and rheumatologic disorders which may be causes of oropharyngeal dysphagia?
A
- Myopathies, polymyolitis
- Oculopharyngeal dystrophy
- Sjogren Syndrome
9
Q
List 4 metabolic disorders which may be causes of oropharyngeal dysphagia?
A
- Thyrotoxicosis
- Amyloidosis
- Cushing disease
- Wilson disease
10
Q
List 2 types of medications which may have side effects causing oropharyngeal dysphagia?
A
- Anticholinergics
- Phenothiazines
11
Q
What are 7 infectious agents which may cause oropharyngeal dysphagia?
A
- Polio
- Diptheria
- Botulism
- Lyme Disease
- Syphilis
- Candida
- Herpes
12
Q
Intermittent dysphagia that is not progressive is a clue for what type of mechanical obstruction?
A
Schatzki ring
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
14
Q
A patient presents with odynophahia, especially with solid foods, and localized to the esophagus, what are 2 common etiologies for this type of presentation?
A
- Pill esophagitis
- Infection esophagitis
15
Q
What are 7 alarm features (sx’s) of someone presenting with GERD that indicates the need for endoscopy (or abdominal imaging)?
A
- Weight loss (especially unintentional)
- Persistent vomiting
- Constant or severe pain
- Dysphagia/odynophagia
- Hematemesis
- Melana
- Anemia (iron deficiency)
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
17
Q
Are initial diagnostic studies warranted for patients with typical GERD symptoms suggesting uncomplicated disease?
A
- No
- Only if “alarm features” present
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
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
20
Q
Dysphagia occurs in 1/3 or patients with GERD and may be attributed to what 3 underlying issues?
A
- Erosive esophagitis
- Abnormal esophageal peristalsis
- Development of an esophageal stricture
21
Q
What are 5 complications which can arise from GERD?
A
- Laryngopharyngeal reflux (LPR)
- Esophagitis
- Stricture
- Barrett’s esophagus
- Adenocarcinoma
22
Q
What is the hallmark of scleroderma?
A
- Thickening and hardening of the skin
- Microangiopathy and fibrosis of the skin and visceral organs
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
24
Q
What is the diagnostic study of choice for Zenker Diverticulum?
A
Barium esophagography (aka barium swallow)
25
Sjogren's syndrome has a strong association with what type of cancer?
B-cell Non-Hodgkin lymphoma
26
What are 2 risk factors for the development of Barrett Esophagus?
1. Chronic reflux (GERD)
2. **Truncal obesity** independent of GERD
27
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
28
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
29
Which type of cancer is a long-term complication of Barrett Esophagus?
Adenocarcinoma
30
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+
31
Where are most peptic strictures found?
GE junction
32
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
33
What is mandatory for the diagnosis of a Peptic Stricture?
Endoscopy w/ **biopsy** to differentiate peptic stricture from stricture by esophageal carcinoma
34
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
35
What are 7 risk factors for SCC of the esophagus?
Which risk factors are synergistic?
1. Heavy smoking (**synergistic w/ alcohol!**)
2. Alcohol
3. Achalasia
4. Plummer-Vinson Syndrome
5. **Tylosis**
6. Lye ingestion
7. Hot beverags
36
Who is at the highest risk of SCC of the Esophagus?
Males \> Females and **AA** \> Caucasians
37
Which race is at the highest risk for Esophageal Adenocarcinoma?
Caucasians \> AA
38
What are some of the most common medications implicated in Pill-induced Esophagitis?
- NSAIDs
- **Potassium chloride pills**
- **Bisphosphanates:** Alendronare and Risedronate
- Antibiotics
39
What may be seen on endoscopy of a person w/ Pill-induced Esophagitis?
Several discrete ulcers that may be shallow or deep
40
What is the Tx for Pill-Induced Esophagitis?
Remove the offending agent --\> healing occurs rapidly
41
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
42
What are 3 of the most common pathogens responsible for Infectious Esophagitis?
1. ***Candida albicans***
2. Herpes simplex
3. CMV
43
How is the diagnosis of Infectious Esophagitis made?
Endoscopy w/ brushings, biopsy, and culture
44
One to several large, shallow, superficial ulcerations of the esophagus is characteristic of which pathogen?
CMV
45
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
46
What is the drug of choice for immunosuppressed patients with Herpes Simplex Esophagitis?
Oral **acyclovir**
47
What is the treatment of choice for Candidal Esophagitis?
Systemic therapy (i.e., Fluconazole)
48
Ingestion of what is associated w/ Caustic Esophageal injury?
Liquid or crystalline alkali (drain cleaners, etc) or acid
49
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**
50
Which treatments are contraindicated in someone with Caustic Esophageal injury?
**Nasogastric lavage** and **oral antidotes** may be dangerous
51
What is the initial treatment for someone in the ICU w/ Caustic Esophageal injury?
- Supportive IVF
- IV PPI
52
When should laryngoscopy be perfomed in patients with Caustic Esophageal injury?
Those w/ respiratory distress to assess the need for **tracheostomy**
53
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
54
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
55
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
56
Which treatment modality for Eosinophilic Esophagitis leads to symptom resolution in 70% of adutls?
Topical corticosteroids
57
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**
58
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
59
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
60
Schatzki rings are associated in almost all cases with what underlying condition?
Hiatal hernia
61
What type of dysphagia is seen with Esophageal Webs and Schatzki Rings?
**Intermittent** and **NOT** progressive
62
Which type of food is most likely to cause someone with a Schatzki Ring problems?
Large **poorly chewed food boluses** such as beefsteak
63
What are 3 of the complications involving the lungs which may result from long-standing Zenker Diverticulum?
- Aspiration pneumonia
- Bronchiectasis
- Lung abscesses
64
What are the treatments of choice for symptomatic patients with Zenker Diverticulum?
- Upper esophageal **myotomy**
- Surgical **diverticulectomy**
65
Describe the esophageal dysphagia associated with Plummer-Vinson Syndrome.
Solids vs. liquids vs. progressive vs. intermitted?
- Solids \> liquids
- Intermittent symptoms
66
What should be done before performing EGD?
Why?
- An esophagram w/ barium imaging
- Due to the risk of perforation with EGD
67
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
68
Esophageal varices are diagnosed using which modality?
EGD
69
Which antibiotics should be used in an ICU patient with esophageal bleeding from varices?
**Fluoroquinolones** or **IV 3rd Gen. Cephalosporins**
70
Which drugs are used for prevention of re-bleeding in patients with Esphogeal Varices?
Nonselective **beta blockers** (propranolol, nadolol)
71
What is a long-term treatment that can be used to reduce the incidence of rebleeding associated with Esophageal Varices?
Band ligation
72
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
73
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
74
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**)
75
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**
76
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**
77
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
78
Do TIPS lower the risk for rebleeding and mortality in patients with esophageal varical bleeds?
**- Lowers risk of rebleeding**
**-** Does **NOT** decrease mortality
79
What type of dysphagia is associated with Achalasia?
Gradual, **progressive** dysphagia for **solids** and **liquids**
80
Which diagnostic technique **confirms** the diagnosis of Achalasia?
Esophageal manometry
\*Complete absence of normal peristalsis and incomplete LES relaxation w/ swallowing
81
What may happen to the esophagus is Achalasia is left untreated?
May become markedly dilated ("**sigmoid esophagus**")
82
What are 3 treatment options for Achalasia?
1. Botulimum toxin injeciton
2. Pneumatic dilation
3. Surgery: pts prescribed 1x daily PPI
83
Hypertensive esophagus is associated with what pathology?
Nutcracker esophagus
84
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**
85
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
86
What 2 diagnostic techniques may be used for Nutcracker Esophagus?
- Manometry
- Video fluoroscopy
87
Uncoordinated esophageal contraction, "corkscrew esophagus," or "rosary bead esophagus" is characteristic of?
Diffuse esophageal spasm
88
What 3 diagnostic techniques may be used for Diffuse Esophageal Spasm?
- Manometry
- EGD
- Barium swallow
89
What is Iatrogenic esophageal rupture?
Rupture occuring **post-EGD** with biopsy or dilation
\*This is **NOT** calld Boerhaave's!!!!
90
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
91
What are the treatment options for esophageal perforation?
- NGT suction
- NPO
- Parenteral Antibiotics and Surgery
92
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
