S09C80 - Esophageal emergencies, GERD, Swallowed FB Flashcards
How long is the esophagus?
20-25cm
3 constrictions of esophagus:
- cricopharyngeus muscle (C6)
- aortic arch (T4)
- gastroesophageal junction (T10/T11)
(peds eso also contricted at thoracic inlet and tracheal bifurcation)
Dysphagia: 2 types
- transfer: early in swallowing, difficulty initiating
- transport: impaired movement of the bolus down the esophagus and through the lower sphincter, usually felt 2-4s after swallowing
Transfer Dysphagia: causes
Neuromuscular:
- CVA
- polymyositis or dermatomyositis
- scleroderma
- myasthenia
- tetanus
- parkinson’t dz
- botulism
- lead poisoning
- thyroid dz
Localized Dz:
-pharyngitis, ulcer, candida, peritonsiallar/retropharyngeal abscess, carcinoma, zenker diverticulum, cricopharyngeal bar, cervical osteophytes
-scleroderma
Transport Dysphagia: Causes
- FB
- carinoma
- webs/stricutures
- thyroid enlargement
- diverticulum
- large-vessel abnormality
-motor d/o: achalasia, peristaltic dysfxn (nutcracker esophagus), diffuse esophageal spasm, scleroderma
Risk factors for esophageal cancer
- alcohol
- smoking
- achalasia
- ingestion of caustic material with lye
-barretts esophagus predisposes to adenocarcinoma
Esophageal stricture
- often from GERD or inflm
- usually distal eso, may interfere with sphincter fxn
- tx: dilatation
Schatzki ring
- most common cause of intermittent dysphagia with solids
- fibrous diaphragmatic stricture near the GE jxn
- often asymptomatic
- tx: dilation
Esophageal web
- thin mucosa/submucosa in mid eso
- assoc with plummer-vinson syndrome and pemphigoid and epidermolysis bullosa
- tx: dilatation
Diverticula
- zenker diverticulum (pharyngoesophageal) is a progressive out-pouching of pharyngeal mucosa just above the upper sphincter caused by incr pressures during swallowing
- usually >50y
- pt c/o transfer dysphagia, halitosis, neck mass
Neuromuscular dysphagia
-often more difficulty with liquids and often intermittent
Achalasia
- unknown cause
- impaired relaxation of lower sphincter
- absence of esophageal peristalsis
- onset 20-40yo
- assoc with eso spasm and c/o and odynophagia
- eso can dilate enough to impinge on trachea
- tx: meds to relax lower sphincter, botox, surgical myotomy
Diffuse esophageal spasm
- interruption of normal peristalsis by nonperistaltic contraction
- intermittent non-progressive dysphagia
- c/p
- tx: decr acid reflux, smooth msc relaxant, antidepressant
GERD: pathophys
- hiatal hernia
- prolonged gastric emptying (anticholinergics, outlet obstruction, diabetic gastroparesis, fatty food)
- decr lower eso sphincter pressure: fatty food, nicotine, ethanol, caffeine, mitrates, CCB, Pg, Eg, anticholinergics, pregnancy
- decr eso motility: achalasia, scleroderma, DM, presbyesophagus
GERD: complications
- strictures
- dysphagia
- esophagitis
- barrett eso (10% of pts with GERD)
- dental erosions
- worsening of asthma from minute aspirations
- vocal cord ulcers
- laryngitis
- chronic sinusitis
- chronic cough
GERD: tx
- decrease acid: histamine-2 blocker, PPI
- enhance upper tract motility
- eliminate risk factors: ethanol, caffeine, nicotine, chocolate, fatty food
- sleep with head elevated
- avoid eating w/in 3h of bed
Esophagitis
- tx: acid-suppressants, surguery
- causes: NSAIDs, KCl-, Abx (doxy, tetra, clinda)
-acquired causes: HIV (HSV, candida, EBV)
Nutcracker esophagus
-periods of high amplitude, long-duration peristaltic contractions in distal body of esophagus or lower sphincter
Esophageal perforation`
- iatrogenic cause is most common
- boerhaave syndrome causes 10% of cases
- complications: mediastinitis, penumonitis, peritonitis, shock, pleural effusion
- tx: resuscitate, Abx, surgery
Boerhaave syndrome
- full-thickness perf of eso after sudden rise in eso pressure (Often from emesis but also coughing, straining, seizures, childbirth)
- usually distal eso on L side
FB complications
- airway obstruction
- stricture
- perforation
- erosion
- obstruction
FB: children
Sx:
- refusal to eat
- n/v
- gagging
- stridor
- drooling
- high degree of suspicion for
FB: coins
-if in esophagus then will be circular on AP film and if in trachea the circle will be on the lateral film
FB: bones
Indications for urgent endoscopic evaluation for ingestion of FB
- sharp or elongated object
- ingestion of multiple FB
- button batteries
- concern for perforation
- coin at cricopharyngeus muscle in a child
- airway compromise
- presence of a FB >24h
FB: meat bolus
- emergent endoscopy if complete obstruction or contains bony fragments
- otherwise can treat expectantly for
FB: coin ingestion
-tx: IR can remove with a foley
FB: Button battery
- may induce mucosal injury and necrosis
- perforation can occur w/in 6h
- if past eso then manage expectantly with f/u in 24h, rpt films at 48h to ensure battery past pylorus
- most batteries pass though GIT in 48-72h
FB: sharp object
- if in eso they need immediate removal
- remove with endoscopy if in eso, stomach, duo
- if past duo, daily AXR
- surgery if >3d duration and no passage of object or if GI Sx
FB: packers
- rupture of one packet can be fatal
- endoscopy contraindicated b/c of risk of packet rupture
