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PT1 B3 > Lecture 78 - Esophageal Disease > Flashcards

Lecture 78 - Esophageal Disease Flashcards

1
Q

Symptoms of esophageal diseases:

A

Heartburn (pyrosis) –
Regurgitation – acidic fluid in mouth with recumbency or bending over
Chest pain –
Dysphagia – difficulty swallowing
Odynophagia – retrosternal pain with swallow

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2
Q

Differences in dysphagia: motor vs mechanical

A

Mechanical Dysphagia = Narrowing of the esophagus
Progression of dysphagia starting with solids

Motor Dysphagia == movement disorder of the esophagus 
	Presents gradually; can be with solids or liquids
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3
Q

GERD:
What is it?
risk factor for…

describe the pathophysiology in relation to two anatomic/functional barriers of reflux

A

Symptoms and or esophageal mucosal damage secondary to reflux of normal gastric content

Risk factor for adenocarcinoma

	Two barriers for Anti-Reflux: The Crura of the Diaphragm; Lower esophgeal Sphincter 

	Primary problem: most commonly related to transient lower esophageal sphicter relaxation

	Other Reasons: Hiatal hernia --
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4
Q

aside from LES Tone and a hiatal hernia, what other co-factors can contribute to GERD?

A

Poor Esophageal Clearance – (eg body position, perstalisis, poor salivation)

		Gastric factors -- acid, gastric distention, poor gastric emptying 

		External factors -- medications can effect LES tone, diet, smoking, obesity 
			These are preventable and treatable with life style modifications
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5
Q

Briefly describe the presenation differences between classic GERD, extra esophgeal GERD, and complicated GERD …

how does this affect how you would proceed with diagnosis?

A

Classic GERD — all the typical esophageal symptoms (heart burn, post prandial, worse with laying down)

Extra esophgeal GERD: asthma, hoarse voice, etc

Complicated GERD: dysphagia, odynophagia, bleeding –

the latter requires immediate attention via endocoscpy

the first two – proceed with empiric therapy, and assess effectiveness

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6
Q

Treatment of GERD

A

Life style Modification: diet, weight loss, sleeping with elevated HOB

Medical: H2RA, PPI

Maintenance therapy is required

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7
Q

Diagnosis of GERD:

clinical dx strategy vs potential diagnostic tests

A

Empiric Therapies

tests: 
Barium Swallow (not good for GERD) 
Manometry -- not good for GERD; testing the motility of the esophagus

Endoscopy –

Ambulatory pH Monitoring for 24 hours (measuring acid)

Impedance pH Study (measuring pH and non pH reflux)

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8
Q

4 complications of GERD

A
  • Erosive/ulcerative esophagitis
  • Esophageal (peptic) stricture
  • Barrett’s esophagus
  • Adenocarcinoma
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9
Q

Peptic Stricture:

  • pathology

Treatment-

A

• Gradual narrowing of the distal esophagus due to scarring from chronic acid-induced injury and repair

patients with poorly controlled GERD

• Treatment with of aggressive medical antireflux therapy and endoscopy with dilation
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10
Q

Barrett’s Esophagus:

what is it? pathophysiology
risk factor for…

A

• Metaplastic columnar epithelium (intestinal metaplasia) replaces squamous epithelium in the distal esophagus

* GER injures squamous epithelium and promotes repair by columnar metaplasia
* Occurs in ~ 10 % of patients with GERD symptoms who have endoscopy
* Risk  factor for developing esophageal adenocarcinoma
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11
Q

what are two cancers of the esophagus?

discuss their epidemiology – (demographics); location in the esophagus they are most likely to occur

risk factors for each

A

Adenocarcinoma, – M&raquo_space; F, white > blacks, lower esophagus

Adenocarcinoma – GERD, obesity, tobacco;
Usually Barrett’s esophagus is present predating the cancer
Persons with Barrett’s – 40 -125 x increased risk

Squamous Cell Carcinoma – M>F, Blacks>whites, Mid esophagus

SCC – alcohol and tobacco,

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12
Q

Pathophysiology of Adenocarcinoma

A

Barrett’s Esophagus – evolve through a sequence of genetic alternations; which is seen as dysplasia phases and other morphology on histology
Barrett’s –> Low grade dysplasia –> High Grade Dysplasia –> Adeno

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13
Q

Presentation of Esophageal Cancer:

A

Dysphagia — Solid foods and the progresses over weeks to months to liquids

odynophagia, CP, anorexia, Weight loss

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14
Q

Treatment: of Esophageal Cancer:

A

Early / local – combined modality – radiation, chemotherapy, surgery
Late/beyond the esophagus – esophgeal dilation ( esophageal stent, laser
Provide good palliation of symptoms

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15
Q

4 Esophageal Motility Disorders:

A

Achalasia – d/o of LES relaxation
Distal Esophageal spasm – spastic or uncoordinated d/o
Nutcracker or Jackhammer Esophagus : hypercontractility d/o
Scleroderma: hypocontractility d/o

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16
Q

Key Diagnositic test for assessment of Esophageal Motility ?

A

Esophageal Manometry

17
Q

Conventional vs High Resolution Manometry

what is being measured and by what parameters

A

Conventional – LES pressure, LES relaxation, Wave Progression (is it peristaltic), Wave amplitude (relaxation/contraction force),

High Resolution
Distal Contractility Integral – Used to assess contractile strength over time (similar to amplitude)

Integrated Relaxation Pressure – assessment of relaxation after swallowin

18
Q

Achalasia

Patholophysiology

Diagnosis (characteristic appearance of the LES)

Treatment

A

failure of relaxation of the LES due to loss of inhibitory motor neurons (ganglion cells; myenteric/aurbach plexus) in the body of the esophagus at the LES

leading to dysphagia (solids and liquids together)

Diagnosis: dilated esophagus with debris;
Tight lower esophageal sphincter

Birds Beak – tight narrowing of the LES,

Treatment:
Myotomy
Pneumatic dilation

19
Q

Uncoordinated/spastic d/o: (Diffuse Esophageal Spasm)

&

Hypercontractile d/o (nutcracker or jackhammer esophagus)

who gets these?
Commonly associated with?
most common symptom?

A

EPI — ages 30-40; Female Predominance; Frequenctly seen with IBS and psychiatric d/o

Symptoms
Chest pain – atypical, non-cardiac — in 80 - 90 % of cases
Dysphagia
Heart Burn

20
Q

Dx and evaluation DES/nutcracker/jackhamer

what is required for the dx?
what might be seen on barium swallow?

A

manometry is required for dx

barium swallow:
DES - -might corksscrew

Cardiac eval – rule out heart disease

21
Q

manometry of:
Diffuse Esophageal Spasm
vs
Nutcracker/Jackhammer esophagus

A

DES – Manometry
intermeittent normal peristalsis with intermittent spastic contractions

Nutracracker or JackHammer Manometry:
Normal Peristalsis with very high contractile index (Amplitude)

22
Q

Treatment of Diffuse Esophageal Spasm
vs
Nutcracker/Jackhammer esophagus

A

Treatment: Reassurance – this isn’t heart disease

Pharmacotherapies – don’t work that well

Endoscopic/surgical – sometimes

23
Q

Hypocontractile d/o— Scleroderma:

what is it?
what is seen on manometry?

A

Systemic connective tissue d/o with esophageal motor dysfunction

Manometry:
Weak contractions of the esophagus (similar to achalasia)

Almost absent LES tone (opposite of achalasia)

therefore present with GERD symptoms

24
Q

three other causes of esophagitis?

A

Infectious –viral (CMV, HSV); fungal (candida)

Pill esophagitis

Eosinophilic esophagitis

25
Q

Viral vs fungal esophagiits –

presenting symptom for each?

treatment

A

Tx – Oral antifungall – fluconazole
Tx – antivirals (acyclovir)

Viral -- present odynaphagia 
Fungal -- candida; usually presents with dysphagia
26
Q

Eosinophilic Esophagitis

  • who gets it?
  • Clinical Presentation
    Diagnosis
    Treatment
A

occurs in men with other allergic symptoms (asthma, dermatitis)

dysphagia with recurrent food impaction

barium swallow, endoscopy, biopsy

Dietary elimination of allergens
Swallowed steroids

27
Q

Schatzkin’s Ring: Esophageal Ring

  • where in the esophagus does it occur?
  • common presentation?
  • treatment?
A

Distal esophagus
Intermittent dysphagia of solids of the distal esophagus
“steakhouse syndrome” – meat impaction

Treatment: rupture the ring via dilation
28
Q

Zenker’s Diverticulum

What is it?
PResentation
Treatment

A

Diverticulum just above the Upper esophageal sphincter which impinges upon the proximal esophagus

Presentation: Dysphagia, neck mass, regurgitation of food into mouth 
Treatment: treat the UES and remove the diverticulum

PT1 B3 (16 decks)

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