Oropharynx & Eso Pathophys Flashcards
BENIGN STRUCTURAL
Zenker’s Diverticulum
(Info/Cause)
Outpouching of lower oropharynx due form muscle wall defect
ANY AGE
BENIGN STRUCTURAL
Zenker’s Diverticulum
(Pres/Diagnx/Treat)
Dysphagia, Halitosis
Detect with EGD
Surgical diverticulotomy
BENIGN STRUCTURAL
Cervical Osteophytes
(Info/Cause)
Osteophytes narrow oropharynx
RARE
BENIGN STRUCTURAL
Cervical Osteophytes
(Pres/Diagnx/Treat)
Often Hx of arthritis or neck surgery
Detect with EGD
Not treatment discussed
BENIGN STRUCTURAL
Cricopharyngeal Ring and HTN
(Info/Cause)
Cricopharyngeal muscle displaced or fails to relax –> UES compression
BENIGN STRUCTURAL
Cricopharyngeal Ring and HTN
(Pres/Diagnx/Treat)
Dysphagia
Detect with EGD
Treat with Cricopharyngeal myotomy
NEUROMUSCULAR
ALS, Parkinson’s, Muscular Dystrophy etc.
(Pres/Diagnx/Treat)
Dysphagia
Diagnx with H&P, neuro exam
Treat - underlying cause, - speech/swallow tx, - PEG tube (eventually)
GERD
info/risks/causes
Reflux of gastric juice into eso
Risk: Obesity, high fat diet, caffeine, EtOH, tobacco
Cause: HCl»_space; enyzmes
Impaired eso peristalsis, hiatal hernias, dysmotility, obstruction, scleroderma
INAPPROPRIATE LES RELAXATION
GERD
presentation
HEARTBURN (substernal or epigastric, rises in chest)
Often after meals, large/fatty, may be worse lying down, acid taste
Rare: wheezing, stridor, hoarseness
GERD
Labs/Diagnx
GOLD STANDARD: 24 hr pH study Barium swallow (10-20% abormal) EGD LES relaxation on manometry INCREASED EOSINOPHILS in DISTAL ESOPHAGUS
GERD
Treatment
Antacids
PPIs, H2 blockers
Change behavior
(5-10% may progress to Barrett’s - risk of cancer)
Achalasia
Info/cause
“No relaxation”
HYPERTONIC LES (vagal input to LES impaired [lack of ganglion cells], secondary to diabetic autonomic neuropath or malignancy)
Age 30-60, progressive, both genders, increased risk of squamous cell carc
Achalasia
Pres
SOLID AND LIQUID dysphagia
Feels like food stuck
Chest pain, regurg, weight loss
Halitosis
Achalasia
Diagnx
Gold Standard: Esophageal Manometry (LES does not relax, no linear peristalsis)
BIRDS BEAK on esophagram (dilated eso, narrow LES)
EGD/CT to rule out cancer
Absence of ganglia in distal eso and LES
Achalasia
Treatment
Dilate LES with BALLOON (1-2% perforation rate)
Surgical myotomy
Oral nitrates, CCBs, Botox into LES
Diffuse Esophageal Spasm (Info/Pres)
Uncoordinated contraction of esophagus body - dysphagia
May be post-prandial, related to swallowing, med side effect
CAN MIMIC ANGINA
Diffuse Esophageal Spasm (Diagnx/treat)
Manometry
Give nitrates/anticholinegics
Nutcracker Esophagus
Unknown cause: high pressure, peristaltic contraction in esophageal body
Intermittent chest pain and dysphagia
Diagnx with manometry
Scleroderma (info/pres)
Multisystem, FIBROSIS OF MANY ORGANS
High incidence of stricture, GERD, dysphagia due to wek peristalsis, heartburn Extra-GI symptoms
Scleroderma (Diagnx/Treat)
Manometry
PRINCIPAL PATH is SM atrophy and gut wall FIBROSIS
Treat with PPIs
Chemical Injury
Corrosive, PILL ESOPHAGITIS ( pill stuck –> inlf, NSAIDs, K supplements), reflux esophagitis
Pres: ODYNOPHAGIA, +/- dysphagia
Diagnx: H&P, +/- endoscopy
Treat: discontinue offending agent (underlying cause)
INFX
Herpes
Usually immunocompromised Pres: PAIN WITH SWALLOWING (odynophagia), dysphagia, GI bleen Diagnx: endoscopy: PUNCHED OUT ULCERS Hist: INTRANUCLEAR VIRAL INCLUSION Treat: Antivirals
INFX
Candida
Most frequent, also immunocompromised
Pres: Odynophagia, +/- dysphagia, or asymptomatic
Diagnx: endoscopy: WHITE PLAQUES, fibrinopurulent exudate
Hist: PSEUDOHYPHAE, budding yeast in tissue (special stains GMS, PAS)
Treat: Antifungals
INFX
CMV
Immunocomprimised, usu in combo with candida
Pres: Odynoophagia, +/- dysphagia, GI bleeding
Diagnx: endoscopy: punched out ulcers in distal eso
Hist: CYTO and NUCLEOMEGALY, intraCYTOPLASMIC inclusions
Treat: antiviral
Eosinophilic Esophagitis (cause/info/pres)
Caused by eosinophilic infiltrate, diffuse narrowing of esophagus, MALES,
Eosinophilic Esophagitis (diagnx/treat)
Endoscopy: concentric rings, burrows, nodular plaques and exudates
Biopsy: diffuse sheet of eosinophils, frequent degranulated forms (dust, microabscesses), MID-ESOPHAGUS
Treat: TOPICAL STEROIDS (oral spray), dilation may be necessary, endoscopic removal of bolus, no response to anti-reflux tx
Barrett’s Esophagus (cause/risks/pres)
consequence of GERD (F, decreased LES resting pressure, smoking obesity
Increasing in prevalence
Pres: USUALLY ASYMPTOMATIC OR HEARTBURN
Barrett’s Esophagus (Diagnx/treat)
METAPLASIA (squamous–>glandular containing columnar (goblet) epithelium) this is an effort of the esophagus to protect itself rorm acid
Salmon colored patch on endoscopy
Alcian BLUE stain highlights GOBLET cells (no goblet cells in stomach)
Treat: GERD treatment, also increase screening
Benign Strictures
Minority of pts with reflux eso get peptic stricture of distal eso (due to fibrosis from relfux)
PRES: SOLID FOOD DYSPHAGIA
Diagnx: EGD (biopsy to rule out cancer and tx dilation)
Treat: GERD treatment, also with EGD dilation
Mucosal (“Schatzki”) Rings
congenital esophageal rings –> narrow lumen and cause infl (similar to benign stricture)
Pres: dysphagia
Diagnx: EGD
Treat: EGD dilation
Esophageal Perforation
after profound retching/vomiting, esp EtOH or malnourished, can be complication of surgery procedure
Pres: upper GI bleed, high morbidity/mortality
Diagnx: EGD
Treat: urgent stent/surgical intervention
Mallory-Weiss Tear
linear superficial tear esp in alcoholics
Esophageal Cancer
4% of cancer deaths in men (not top 10 in women)
Pres: dysphagia, weight loss, no symptoms until advanced dz, rarer: bloody vomit, chest pain, anemia
Adenocarcinoma
Risk with GERD/Barretts, more than half of all eso cancers, more common in elderly, Caucasian, mean
Pres: solid food dysphagia, weight loss
Diagnx: EGD, DISTAL eso, big bulky tumor with GLANDS
Treat: RESECTION if early, also CHEMO/radiation and metal STENT placement
Squamous Cell Carcinoma
Risks: smoking, EtOH, casutic injury (hot tea), hx of head & neck cancer, mean age 65, poor oral health/poverty
Pres: eso stricture–> dysphagia, weight loss
Diagnx: UPPER/MID eso (50-60%), more ulcerative tumor, NO glands
Treat: RESECTION if early, also CHEMO/radiation and metal STENT placement
Other cancers
Malignant: neuroendocrine (carcinoud), GISTS, lymphomas, metastases
Benign: leiomyomas, hemangiomas, lymphangiomas
Oropharynx (involved in …/phases …)
Swallowing (deglutition) Normal = 600x /day Oral phase (voluntary): biting,licking, chewing, initiation of swallow Pharyngeal phase (involuntary): once bolus gets to posterior 1/3 of tongue, pharnyx contracts and changes shape (hyoid/larynx up and anterior), UES relaxes, soft palate elevates to close nasopharynx and protect airway
Esophagus (upper & lower)
Upper 1/3 is skeletal muscle, lower 1/3 is smooth (middle is mixed)
BUT ENTIRE ACTION OF ESOPHAGUS IS INVOLUNTARY
Work Up Protocol
Dysphagia
coughing, aspiration, sitting up food
suspect neuromuscular dz, benign obstruction or neoplasia
BARIUM SWALLOW
Work Up Protocol
Esophageal Motility Dysfunction
pain and/or dysphagia
suspect GERD, achalasia, diffuse esophageal spasm, nutcracker esophagus
MANOMETRY (and pH study for GERD)
Work Up Protocol
Benign Structural Disorder
painless +/- solid food dysphagia
suspect strictures, eosinophilic esophagitis, prior trauma
ENDOSCOPY (EGD)
Work Up Protocol
Neoplasia
Painless +/- solid food dysphagia + cancer sx
suspect esophageal cancer
ENDOSCOPY and BIOPSY
