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My DEMS I > Pathophysiology of the Esophagus > Flashcards

Pathophysiology of the Esophagus Flashcards

1
Q

Dysphagia

A

difficulty swallowing

2x2 table:
obstructive & propulsive/motility
x
oropharyngeal & esophageal

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2
Q

oropharynx

A

entrance to gut

  • teeth/lips: biting and grinding
  • mastication/saliva: conversion of bite into small, soft, lubricated bolus
  • tongue: pushes bolus into pharynx
  • pharynx: movement of bolus from mouth to upper esophagus
  • protection of airway and nasal passages
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3
Q

Deglutition (swallowing)

A
  • closure of nasopharynx via elevation of the soft palate
  • elevation of posterior tongue
  • epiglottis and vocal cord closure
  • bolus movemnt and nose/airway closure

normal: 600x/d
oral phase: voluntary
Pharyngeal phase: involuntary (begins with bolus on posterior tongue and upper pharynx)

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4
Q

oropharyngeal dysfunction

A

oropharyngeal dysphagia
inability to initiate a swallow or transfer food bolus to esophagus
-may occur w/ obstruction or neuromuscular disease (leads to dysfunction of oropharyngeal musculature: propulsive/motility disorder)

  • Nasal regurgitation may occur
  • Aspiration= food or liquids passing into airway or lungs (cough after attempted swallows; airway obstruction– choking, stridor, wheezing, cyanosis; aspiration pneumonitis = lung injury from acidic or lipophillic properties of food– SOB or hypoxia; pneumonia if bacterial colonization occurs– SOB, fever, white count, consolidation on CXR)
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5
Q

Neurologic oropharyngeal diseases

A 
stroke
ALS
Parkinson's
MS
Polio
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6
Q

Muscular oropharyngeal diseases

A

Myasthenia gravis
Muscular dystrophy
Muscular injury (surgery, radiation therapy)

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7
Q

Benign structural oropharyngeal diseases

A

Zenker’s diverticulum: outpouching of esophagus leading to food regurgitation or bacterial colonization (halitosis)

  • Crycopharyngeal bar
  • thyromegaly, fibrosis (eg radiation)
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8
Q

Malignant structural oropharyngeal disease

A

squamous cell carcinoma of tongue, oropharynx, soft palate, or upper larynx (Head and neck cancers)

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9
Q

Oropharyngeal Disease dx

A

History
PE
(Modified) barium swallow– XR (video) of mouth and throat under direct observation while pt chews and swallows various consistencies of radio-opaque barium
?neurology consultation for tx

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10
Q

Oropharyngeal disease tx

A
  • mod of diet
  • radiation or surgical resection for tumor, ring, or diverticulum
  • speech/PT– cornerstone of tx for neuromuscular disease
  • percutaneous endoscopic gastrostomy (PEG) tube may be needed for feeding and preventing aspiration
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11
Q

Table: Box 1: obstructive x oropharyngeal

A

Head and neck cancers
Zenker’s diverticulum
radiation therapy

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12
Q

Table: Box 2: propulsive/motility x oropharyngeal

A 
-Neurologic conditions:
stroke
ALS
MS
Parkinsons
-Myasthenia gravis
-muscular dystrophy
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13
Q

Esophagus

A

transport: conduit for food/water from oropharynx to stomach
barrier: protection of mediastinum and lungs from ingested food/water
1 way system: prevention of reflux of gastric contents into pharynx or airway

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14
Q

Motility Disorders of esophagus: sx, etiology, dx

A

Sx: dysphagia to BOTH solids and liquids; chest pain

Etiology: 
achalasia: abnormal peristalsis, failure of LES relaxation
spastic disorders of esophagus
weak peristalsis
scleroderma

Dx:

  • exclude structural lesion (upper endoscopy or barium esophagram)
  • esophageal manometry
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15
Q

Achalasia

A

“no relaxation”

  • most imp motility disorder of esophagus
  • impaired relaxation of lower esophageal sphincter
  • absence of normal peristalsis
  • idiopathic
  • both genders, all races, adults (25-60)
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16
Q

Sx of achalasia

A
  • dysphagia to solids and liquids
  • weight loss
  • regurgitation
  • chest pain
  • difficulty belching
  • heartburn
  • hiccups
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17
Q

Type I Achalasia (manometry)

A 
Type I (Classic)
-swallowing--> no significant change in esophageal pressurization
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18
Q

Type II Achalasia manometry findings

A

Swallowing–> simultaneous pressurization spanning entire esophagus length

-botox injections, pneumatic dilation, surgical myotomy work best

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19
Q

Type III (Spastic) Achalasia manometry findings

A

Swallowing–>abnormal, lumen obliterating contractions/spasms

botox injections, pneumatic dilation, surgical myotomy have POOR outcomes

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20
Q

Pathophysiology of Achalasia

A

-Normal: LES pressure and relaxation regulated by excitatory and inhibitory neurotransmitters

Selective loss of inhibitory neurons in the myenteric plexus resulting in relatively unopposed excitatory (cholinergic) neurons–> hypertensive nonrelaxed esophageal sphincter

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21
Q

Vast majority of achalasias

A

Primary (idiopathic)

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22
Q

Secondary (pseudoachalasia)

A
  • T cells, Ab attacking neurons of myenteric plexus)

Chagas disease

23
Q

Tx for Achalasia

A

-Medical therapy (if contraindications to dilation or surgery):
Nitrates
Calcium channel blockers
Sildenafil

Endoscopic therapy:
GE Junction botox injections

Pneumatic balloon dilation – tear LES fibers (SE: perforation, heartburn); 40-95% remission 12 mo
POEM– per-oral endoscopic myotomy

Surgical (Heller) myotomy
-usually laparscopic
-70 to 85% remission @ 10 y
Complications: reflux, perforation

24
Q

Scleroderma/Progressive Systemic Sclerosis (PSS)

A

Multisystem disorder charac by:

  • Obliterative small vessel vasculitis
  • Connective tissue proliferation with fibrosis of multiple organs

GI manifestations in 80-90%

The principal pathological abnormalities (GI): smooth muscle atrophy and gut wall fibrosis.

25
Q

Smooth Muscle atrophy and gut wall fibrosis in scleroderma/PSS

A

Myopathic (predominantly) process

  • Esophageal Manifestations?
  • Smooth Muscle Atrophy–> Weak Peristalsis –> Dyspahgia
  • Smooth Muscle Atrophy –> Weak LES –> GERD
  • Unrepentant GERD –> Esophagitis –>Stricture
  • Esophageal manometry
26
Q

Spastic Disorders of the Esophagus

A

Conditions of uncertain etiology

Peristalsis preserved

Symptoms usually chest pain and dysphagia

Postulated pathophysiology: overactivity of excitatory nerves or overreactivity of the smooth muscle response

Tx: limited.
meds: CCBs, sildenafil
Botox
?POEM

27
Q

Table: Box 4: Propulsive/motility x esophageal

A

Achalasia

  • scleroderma
  • spastic disorders (Jackhammer pattern)
28
Q

Structural disorders of esophagus (sx)

A

-luminal narrowing/obstruction

sx:
dysphagia to solids (liquids much LATER)
-weight loss (ominous)
-heartburn (sometimes)

29
Q

Benign Structural esophageal disorders

A

strictures

  • GERD related
  • Caustic (medication or ingestion)

Schatzki’s ring

Eosinophilic esophagitis (EoE)***

Extrinsic compression

30
Q

Malignant structural esophageal disorders

A

-Esophageal cancer (can stricture):
adenocarcinoma
squamous cell cancer

-Metastasis (rare)
melanoma
breast cancer
renal cell carcinoma
lung cancer

-direct invasion

31
Q

esophageal strictures

A 
benign or malignant
-cardinal sx: **dysphagia to solids
-characterized by:
Painless
solids
sx usally on regular or daily basis
may be progressive, esp w/ cancer
weight loss (ominous)
32
Q

Benign esophageal stricture

A

Causes: GERD, radiation, caustic ingestion (including medications), congenital

Rule out cancer with biopsy during EGD

Treatment = endoscopic dilation using balloons or sequential commercial dilators

33
Q

Malignant esophageal stricture

A

SCC

adenocarcinoma

34
Q

Eosinophilic Esophagitis (EoE)

A

Chronic immune/antigen-mediated esophageal disease

Clinicopathologic diagnosis:
Symptoms of esophageal dysfunction
Eosinophilic infiltrate in the esophagus
Absence of other potential causes of esophageal eosinophilia

Clinical features:
adults/adolescents: dysphagia (25-100%)
-~50 of cases of acute food impaction
-food avoidance
-maybe heartburn

in children: more non-specific (feeding intolerance, failure to thrive, abdominal pain)

35
Q

Demographics of EoE

A

most common

36
Q

EoE Tx

A

3 Ds
drugs (steroids– topical&raquo_space;> systemic; asthma preparations that are swallowed)
diet (elemental diet– allergen free effective in kids; most practical: 6 food elimination diet SFED– milk, eggs, wheat, soy, seafood, nuts)
dilation

37
Q

Table: Box 3: obstructive x esophageal

A

esophageal strictures
esophageal rings
EoE*
extrinsic compression

38
Q

GERD

A
  • pathologic reflux of gastric juice (acid) into esophagus
  • common
  • causes symptoms, esophageal injury, or increased cancer risk
39
Q

GERD classic sx

A

Heartburn: often post-prandial, may be positional (lying down/nocturnal)

regurgitation with acidic taste (Also positional)

less classic sx:
water brash, throat clearing, cough
Rare: wheezing, stridor, hoarseness

Relieved by antacids or anti-secretory medications

40
Q

GERD Pathophysiology

A

Acid in the esophagus or airway –> symptoms and/or esophageal damage
Esophagus lacks defenses (mucous secretion, alkalinity) against acid

Inappropriate LES relaxation
Hiatal hernia
Gastric or esophageal surgery, dysmotility, or obstruction
Rare: Zollinger-Ellison, Sjogren’s, Scleroderma

41
Q

GERD RFs

A 
Males = females
Obesity
Caffeine? Not really
Alcohol? Minimally if at all
Tobacco
Medications
Pregnancy
Other medical illnesses (scleroderma, ZE, gastroparesis)
42
Q

GERD complications

A

normal >80%
erosive esophagitis 5-10%
Barrett’s 5%

43
Q

GERD Dx

A

Usually by symptoms (Heartburn +/- Regurgitation)
Response to acid suppressive therapy (proton pump inhibitors)
Endoscopy usually for refractory symptoms but vast majority normal

Can use ambulatory pH testing; transnasal catheter or wireless capsule

rates of healing erosive esophagitis w/ PPIs 80-95%

44
Q

Barrett’s Esophagus

A

consequence of GERD

RFs:

  • male
  • white
  • central adiposity
  • advancing age (plateau in 60s)
  • Chronic GERD
  • *Increased risk of developing esophageal adenocarcinoma (0.1-0.5% per year)
  • endoscopy w/ biopsies every 3-5 years to assess for dysplasia

Look for dysplasia

  • if present: higher cancer risk
  • low grade: close surveillance
  • high grade: treatment
45
Q

Treatment of Barrett’s

A

Esophagectomy: previously for HGD or any cancer
***Endoscopic Treatment (ablation of Barrett’s tissue, endoscopic resection of visible lesions): Now for HGD and early esophageal adenocarcinomas

46
Q

Esophageal cancer

A
  • progressive dysphagia (solids to liquids)
  • weight loss
  • rare: hemoptysis, chest pain, anemia
  • Causes symptoms when ADVANCED
  • Tx:
  • surg resection if caught early
  • most: chemo/rad in advanced cases
  • Metal stent or feeding tube for palliation
47
Q

Squamous cell carcinoma

A

(esophageal cancer)

  • RF: older age, alcohol/tobacco use, caustic injuries
  • can arise anywhere in esophagus
  • declining incidence in US/Eur
48
Q

Adenocarcinoma

A

RFs: older age, smoking, obesity, GERD, and ***Barrett’s esophagus

  • rising incidence in US and Eur
  • nearly always in distal esophagus or gastric cardia
49
Q

Dysphagia Obstructive oropharyngeal

A

Choking
Cough
Nasal regurgitation
Aspiration

Head and Neck Cancers

Zenker’s Diverticulum

Radiation Therapy

Eval:
barium swallow

50
Q

dysphagia, causes, eval: propulsive/motility oropharyngeal

A

Transfer Dysphagia
Cough
Nasal regurgitation
Aspiration

Neurologic Conditions
Stroke
ALS
MS
Parkinson’s
Myasthenis Gravis
Muscular Dystrophy

eval:
barium swallow

51
Q

dysphagia, causes, eval: obstructive esophageal

A 
Dysphagia to solids
Food impaction (EoE)
Weight loss
Vomiting
Regurgitation
Esophageal Strictures
Esophageal Rings
EoE
Extrinsic Compression
Esophageal Cancer

eval:
EGD
esophagram

52
Q

Dysphagia causes, eval: propulsive/motility and esophageal

A

Solid and liquid dysphagia
Chest pain

Achalasia
Esophageal spasm
Scleroderma

Eval:
esophagram
EGD (to exclude)
esophageal manometry

53
Q

Cases and pics** in ppt

A

–

My DEMS I (26 decks)

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