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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
Smooth Muscle atrophy and gut wall fibrosis in scleroderma/PSS
Myopathic (predominantly) process - Esophageal Manifestations? - Smooth Muscle Atrophy--> Weak Peristalsis --> Dyspahgia - Smooth Muscle Atrophy --> Weak LES --> GERD - Unrepentant GERD --> Esophagitis -->Stricture - Esophageal manometry
26
Spastic Disorders of the Esophagus
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
Table: Box 4: Propulsive/motility x esophageal
Achalasia - scleroderma - spastic disorders (Jackhammer pattern)
28
Structural disorders of esophagus (sx)
-luminal narrowing/obstruction sx: dysphagia to solids (liquids much LATER) -weight loss (ominous) -heartburn (sometimes)
29
Benign Structural esophageal disorders
strictures - GERD related - Caustic (medication or ingestion) Schatzki's ring Eosinophilic esophagitis (EoE)*** Extrinsic compression
30
Malignant structural esophageal disorders
-Esophageal cancer (can stricture): adenocarcinoma squamous cell cancer ``` -Metastasis (rare) melanoma breast cancer renal cell carcinoma lung cancer ``` -direct invasion
31
esophageal strictures
``` 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
Benign esophageal stricture
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
Malignant esophageal stricture
SCC | adenocarcinoma
34
Eosinophilic Esophagitis (EoE)
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
Demographics of EoE
most common
36
EoE Tx
3 Ds drugs (steroids-- topical >>> 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
Table: Box 3: obstructive x esophageal
esophageal strictures esophageal rings EoE* extrinsic compression
38
GERD
- pathologic reflux of gastric juice (acid) into esophagus - common - causes symptoms, esophageal injury, or increased cancer risk
39
GERD classic sx
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
GERD Pathophysiology
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
GERD RFs
``` Males = females Obesity Caffeine? Not really Alcohol? Minimally if at all Tobacco Medications Pregnancy Other medical illnesses (scleroderma, ZE, gastroparesis) ```
42
GERD complications
normal >80% erosive esophagitis 5-10% Barrett's 5%
43
GERD Dx
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
Barrett's Esophagus
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
Treatment of Barrett's
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
Esophageal cancer
- 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
Squamous cell carcinoma
(esophageal cancer) - RF: older age, alcohol/tobacco use, caustic injuries - can arise anywhere in esophagus - declining incidence in US/Eur
48
Adenocarcinoma
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
Dysphagia Obstructive oropharyngeal
Choking Cough Nasal regurgitation Aspiration Head and Neck Cancers Zenker’s Diverticulum Radiation Therapy Eval: barium swallow
50
dysphagia, causes, eval: propulsive/motility oropharyngeal
Transfer Dysphagia Cough Nasal regurgitation Aspiration ``` Neurologic Conditions Stroke ALS MS Parkinson’s Myasthenis Gravis Muscular Dystrophy ``` eval: barium swallow
51
dysphagia, causes, eval: obstructive esophageal
``` Dysphagia to solids Food impaction (EoE) Weight loss Vomiting Regurgitation ``` ``` Esophageal Strictures Esophageal Rings EoE Extrinsic Compression Esophageal Cancer ``` eval: EGD esophagram
52
Dysphagia causes, eval: propulsive/motility and esophageal
Solid and liquid dysphagia Chest pain Achalasia Esophageal spasm Scleroderma Eval: esophagram EGD (to exclude) esophageal manometry
53
Cases and pics** in ppt
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My DEMS I (26 decks)

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