Lecture 3: Disorders of the Esophagus Flashcards
1
Q
What are the common symptoms of an esophageal disorder?
A
- Heartburn (pyrosis)
- Dysphagia
- Odynophagia
2
Q
What are the two types of dysphagia?
A
- Oropharyngeal dysphagia: oropharynx to upper esophagus
- Esophageal dysphagia: transport of bolus to body of esophagus
3
Q
What are the 5 components of oropharyngeal swallowing?
A
- Elevate tongue
- Close nasopharynx
- Relax UES
- Close airway
- Pharyngeal peristalsis
4
Q
What is the characteristic description of oropharyngeal dysphagia?
A
- Immediate sense of food catching in the neck
- Need to swallow repeatedly to clear food
- Coughing/choking during meals
5
Q
What are the two causes of esophageal dysphagia?
A
- Mechanical obstruction
- Motility disorder
6
Q
What is odynophagia characterized by?
A
Sharp, substernal pain on swallowing that may limit oral intake
7
Q
What condition is most commonly associated with odynophagia?
A
Infectious esophagitis (Candida, herpes, CMV)
8
Q
What are the two characteristic symptoms of GERD?
A
- Heartburn
- Regurgitation
9
Q
What is the complication we are worried about with untreated GERD?
A
Barrett’s esophagus
10
Q
What are the 3 main GE dysfunctions that can malfunction and result in GERD?
A
- Transient LES relaxation
- Anatomic disruption of the GE junction (hiatal hernia)
- Hypotensive LES
11
Q
What is the characteristic symptom of GERD?
A
Heartburn
12
Q
Is severity correlated with tissue damage in GERD?
A
No
13
Q
What are the extraesophageal/atypical S/S of GERD?
A
- Asthma
- Cough
- Chronic laryngitis
- Sore throat
- Non-cardiac chest pain
- Sleep disturbances
14
Q
What are the alarm features of GERD?
A
- New onset dyspepsia in pt > 60
- Evidence of upper GI bleed
- Iron deficiency anemia
- Anorexia
- Unexplained weight loss
- Severe dysphagia/odynophagia
- Persistent vomiting
- GI cancer in first degree relatie
15
Q
What would prompt us to investigate GERD further?
A
- Failure of empiric PPI therapy
- Alarm features
16
Q
What is the diagnostic study of choice for GERD exams?
A
EGD
17
Q
What is the mechanism that occurs and results in a hiatal hernia?
A
- Movement of the LES above the diaphragm
- Dysfunction of the GE junction reflux barrier
18
Q
What is a sliding hiatal hernia?
A
- Herniation of the gastric cardia upwards
- Slides back and forth
19
Q
What is a paraesophageal hernia?
A
- Laxity of the gastrosplenic and gastrocolic ligaments
- Stomach displacement
- Greater curvature of the stomach will roll upwards
20
Q
What are the most common risk factors for hiatal hernias?
A
- Age 50 or older
- Obesity
21
Q
How does a sliding hiatal hernia typically present?
A
- Worse GERD
- Severe esophagitis
- Barrett’s
22
Q
How does a paraesophageal hernia present?
A
- Vague, intermittent symptoms
- Epigastric/substernal pain
- Postprandial fullness
- N/V
Less prevalent GERD symptoms
23
Q
What is Barrett’s esophagus?
A
Metaplastic columnar epithelium replaces the usual squamous epithelium of the esophagus
24
Q
What endoscopic finding suggests Barrett’s esophagus?
A
- Salmon-orange colored, gastric type epithelium
- Biopsy will confirm diagnosis
25
What is the management for a Barrett's patient with low-grade dysplasia?
1. Resect any areas of dysplasia
2. Repeat endoscopy in 6 months
3. Annual endoscopy until non-dysplastic
26
What is the management for a Barrett's patient with high-grade dysplasia?
1. Resect all areas
2. Repeat EGD ASAP
3. Repeat at 3, 6, 12 months
4. Yearly for 5 years, then every 3-5 years
27
For patients with mild, intermittent GERD symptoms, what is the recommended treatment?
| Mild, intermittent: < 2 episodes weekly, no esophagitis
* Lifestyle modifications
* Eat smaller meals
* Eliminate acidic foods
* Wt loss
* Avoid lying down within 3 hours of eating
* Antacids or oral H2 antagonists for heartburn
28
What is the MOA of a H2 receptor antagonist?
Decrease gastric acid secretion by reversibly binding to histamine H2 receptors on parietal gastric cells.
29
What are the H2 receptor antagonists?
* Cimetidine
* Nizatidine
* Famotidine
30
When are PPIs indicated for GERD?
* Failed BID H2RA/lifestyle
* Frequent symptoms
31
What is the MOA of a PPI?
Inhibit gastric acid secretion by irreversibly binding and inhibiting the hydrogen-K ATPase pump.
32
How do we decide what PPI to use?
Cost
| They all have similar efficacy?
33
For long-term therapy regarding troublesome GERD, what are the mainstays?
* PPIs for 8-12 weeks and then a pause
* BID H2RAs for those without esophagitis
34
When is PPI therapy implemented **indefinitely**?
* GERD w/ severe erosive esophagitis
* Barrett's esophagus
35
What are the main concerns of PPI use?
* Increased risk of infectious gastroenteritis
* Iron and B12 deficiency
* Hypomagnesemia
* Hip Fx
* Dementia
36
What is surgical fundoplication?
Laparoscopic surgery that can provide very **good relief for esophagitis** in 85% of patients
37
Who can undergo surgical fundoplication?
* Patients with **extraesophageal reflux**
* **Severe reflux and unwilling to accept lifelong medical therapy**
* Large hiatal hernias and persistent regurg despite PPI therapy
38
When is gastric bypass recommended over fundoplication for GERD?
**Obese patients** with GERD
39
What is a LINX system?
Magnetic, artificial sphincter for people with **hiatal hernias < 3cm**
| small hiatal hernias only
40
When should we consult GI regarding GERD?
* Failure of empiric PPIs
* Suspected extraesophageal symptoms that do not resolve with PPIs within 3 months
* Significant dysphagia or alarm symptoms for EGD
* Barrett's
* Surgical fundoplication consult
41
What is the epithelium type of Barrett's and where does it occur?
Adenocarcinomas, most commonly in the **distal 3rd of the esophagus.**
42
What are the **primary modifiable risk factors for squamous cell carcinoma** in the esophagus?
* Chronic alcohol use
* Tobacco use
43
What is the **most common symptom in esophageal cancer**?
Significant weight loss
44
What PE findings suggest metastatic esophageal cancer?
* Supraclavicular LAN
* Cervical LAN
* Hepatomegaly
45
How do we diagnose esophageal cancer?
Endoscopy with biopsy
46
How do we treat esophageal cancer?
* "Curable": surgery w/ or w/o chemoradiation
* "Incurable": Chemo or chemoradiation. Local therapy for obstructions
| Incurable would be node spread beyond the chest.
47
What are the two important predictors of poor survival in esophageal cancer?
* Adjacent mediastinal spread
* Lymph node involvement
| AKA if it spreads, poor prognosis
48
What kind of involvement is considered metastatic in regards to esophageal cancer?
Involvement of nodes outside of the chest
| **Suggests incurable**
49
What is Zenker's diverticulum?
Sac-like outpouching of mucosa and submucosa through Killian's triangle
50
What is the suspected cause of Zenker's diverticulum?
* **Loss of elasticity of UES**, restricting the opening during swallowing
* Altered UES function
* Abnormal esophageal motility
* Esophageal shortening
51
How does Zenker's typically present?
* Insidious development of dysphagia and regurg
* **Halitosis (bad breath)**
* Spontaneous regurg of undigested food
* **Nocturnal choking**
* Neck protrusion
52
What are the main complications with Zenker's?
* Aspiration PNA
* Bronchiecstasis
* Lung abscess
53
What diagnostic study would help with Zenker's?
Barium swallow to identify size and location
54
Who should we suspect Zenker's in?
Middle/older adults with progressive dysphagia
55
How do we treat Zenker's?
Upper esophageal myotomy to restore the opening of the UES.
Eliminates the functional obstruction at the UES.
56
What is achalasia?
1. Progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall. (inflammation will occur)
2. Failure of relaxation of the LES
3. Loss of peristalsis in distal esophagus
4. **Distal narrowing of esophagus**
57
What are the S/S of achalasia?
* Gradual onset of dysphagia
* Patients may adapt their eating habits to eat properly
58
What is the primary way to **diagnose achalasia**?
**Esophageal manometry** to measure LES pressure during swallowing.
59
What CXR finding may be seen in achalasia?
Air-fluid level in the enlarged, **fluid-filled esophagus.**
60
What is the **hallmark sign of achalasia on barium esophagography**?
**Smooth, symmetric bird's beak tapering** of the distal esophagus
61
What is the **primary treatment for achalasia**?
Pneumatic dilation
62
What are the additional treatment options for achalasia?
* Botox injection (poor surgical candidates)
* Surgery via Heller myotomy (cutting outer esophageal muscles)
## Footnote
Heller myotomy often is accompanied by a fundoplication to prevent GERD.
63
What characterizes diffuse esophageal spasm?
* **Corkscrew esophagus seen on barium swallow**
* Esophageal manometry showing spastic activity, spontaneous & repetitive contractions, or high-amplitude & prolonged contractions
64
What S/S are seen in diffuse esophageal spasm?
* Dysphagia
* Retrosternal chest pain
* Heartburn
* Regurg
65
How do we treat DES?
* CCBs (Dilt)
* TCAs
* SL NTG
* Sildenafil
* Botox
| the weird esophageal disorder
## Footnote
Similar treatment to prinzmetal's, which is also a spasm-related disorder
66
What is scleroderma?
Autoimmune condition that affects skin, lungs, heart and GI tract.
67
How does scleroderma esophagus typically present?
* Hypotensive LES and absent esophageal peristalsis
* **Reflux is often the only identifiable association**
68
How does someone with scleroderma esophagus compensate for their dysphagia?
* Eat upright
* Use liquids to help swallow
69
How do we treat scleroderma esophagus?
* PPI for GERD
* Metoclopramide for dysmotility
| meto makes you move
## Footnote
Sclerodermaesophagus = GERD + poor motility of esophagus
70
What is a mallory-weiss tear?
**Non-penetrating mucosal tear** at GE junction.
71
What are the risk factors for mallory-weiss tears?
* Alcoholics
* Lifting, retching, or vomiting
72
What are the S/S of a mallory-weiss tear?
* Acute onset of GI bleeding with hematesis or coffee ground emesis.
* Epigastric pain or LBP
* Hx of retching, vomiting, or straining
73
What is the **primary diagnostic method and finding** for mallory-weiss tears?
**EGD** identifying a 0.4cm-0.5cm linear tear
74
What kind of HTN may predispose someone to keep bleeding from mallory-weiss tears?
Portal HTN
75
What is the initial management for a mallory-weiss tear?
Fluids and transfusions
76
How do we provide hemostatic therapy for mallory-weiss tears?
* Injection with epi
* Cautery
* Mechanical compression
77
What is **last-resort for mallory-weiss tear** treatment?
Angiographic arterial embolization
78
What med is often given in mallory-weiss tears?
PPIs
79
What are esophageal webs and where do they commonly occur?
Thin, diaphragm-like membranes of squamous membrane found in the **mid or upper esophagus.**
| Narrows the esophagus
80
What are schatzki rings and where do they occur?
Smooth, circumferential rings in the lower/distal esophagus
| S comes after E, so schatzki is lower than esophageal webs.
81
How do webs and rings typically present?
* Intermittent dysphagia
* Large food boluses most likely to cause symptoms
82
How do we treat webs and rings?
* Dilators
* Electrosurgical incision
* PPIs if persistent dilators are used.
83
What are esophageal varices?
Dilated submucosal veins due to underlying portal HTN.
## Footnote
Veins are attempting to decompress the portal vein by taking on the pressure.
84
What is the main concern with esophageal varices?
Distal bleeding of the esophagus that is very serious
85
What is the MCC of portal HTN?
Cirrhosis
86
What are the 4 bleeding risk factors for esophageal varices?
* **Large varices > 5 cm**
* **Red whale markings** on endoscopy
* Severity of liver disease (high Child's score)
* Active **alcohol abuse**
87
How does variceal bleeding typically present?
* Hematesis
* Melena
* Hypovolemia with shock symptoms
| Life-threatening
88
What is the initial management for variceal bleeding?
Acute resuscitation w/ ABX and vasoactive drugs
## Footnote
ABX: rocephin
Vasoactive drug: Octreotide
89
What are the medications given to someone with active variceal bleeding?
* IV rocephin for a week
* Octreotide to reduce hepatic blood flow
* Vit K for cirrhotic patient with abnormal PTT
* Lactulose (absorb and prevent ammonia buildup)
90
Once a patient is **hemodynamically stable from variceal bleeding**, what is the next step?
Emergent endoscopy to locate the varices for banding.
| Keep repeating every 2-4 weeks until the varices all become necrotic.
91
How do we prevent rebleeding of varices?
Combo BBs and variceal band ligation
92
How do we prevent the first episode of bleeding from varices?
Anyone with cirrhosis should have an endoscopy and go on BBs if varices are present.
93
What are the last resorts for variceal bleeding treatment?
* Balloon tamponade (can't use more than 24h)
* Transvenous intrahepatic portosystemic shunts (TIPS)
| Can't use for a long-time
94
Who is infective esophagitis MC in?
Immunosuppressed patients
95
What are the MCC organisms that cause infective esophagitis?
* C. albicans
* HSV (**can affect normal ppl**)
* CMV
96
What are the S/S of infective esophagitis?
* Odynophagia and dysphagia
* Substernal chest pain
* Esophageal CMV may have colon or retinal smyptoms
* Oral ulcers with HSV1
97
How do we diagnose infective esophagitis?
Endoscopy with biopsy and brushings.
98
How do we treat candidal esophagitis?
Systemic fluconazole
| Fungi
99
How do we treat CMV esophagitis?
Antiretroviral if HIV is present
100
How do we treat herpetic esophagitis?
Oral acyclovir
101
What is EGD best for?
Examining upper GI mucosa and getting samples
102
What is barium swallow good for looking at?
Pharynx and esophagus
103
What does esophageal manometry measure?
* Motility testing to check esophageal motility.
* Pressure of contractility during swallowing
104
What is ambulatory esophageal pH monitoring used for?
Amount of reflux and correlation of symptoms to reflux.
| Catheter or wireless
