S1 MTA - Esophageal disorders and varix Flashcards
Most common cause of achalasia
- Idiopahtic (most common)
- Secondary: related to cancer (mostly complaints of dysphagia), chagas (central or South America) or GERD
Both primary and secondary achalasia are not curable
False, secondary achalasia is curable
Parasite that causes Chagas
Trypanosoma cruzi
Whats the normal physiology of the esophagus
Muscular tube with a sphincter at each end, UES and LES, innervated by the vagus nerve to control peristalsis
Whats aperistalsis?
Lack of contractions related to myogenic or neurogenic processes
4 histological layers of esophagus
- Mucosa (epithelium, lamina propia, musculares mucosae)
- Submucosa
- Muscular (circular interna, longitudinal externa)
- Adventitia
NT that normally regulate peristalsis and act at LES
- Substance P and ACH are excitatory
- VIP and NO are inhibitory
How do NTs act in achalasia
Degeneration of inhibitory ganglion cells that secrete NO and VIP in the myenteric plexus
Definition of achalasia
Failure of the LES and non peristaltic contractions in the distal 2/3 of the esophagus
Symptoms of achalasia
- Dysphagia to solids and liquids (first solids then liquids)
- Regurgitation of non-digested food
- Retrosternal pain and cramps
- Weight loss
- Halitosis
Failure of the lower esophageal sphincter due to nervous damage; the sphincter can’t relax… accompanied by NO peristalsis
Achalasia
2 main neurotransmitters that are involved in achalasia
- Absence of Nitric Oxide
- Presence of ACH
Pathophysiology of achalasia
Atrophy of Auerbach plexus → less release of inhibitory NT (NO and VIP) → inability to relax LES → dysfunctional peristalsis
Manometry findings on patients with achalasia
- Absent/ uncoordinated peristalsis @ lower 2/3 of esophagus
- Incomplete or absent relaxation of LES
- High resting LES pressure
Characteristic sign of achalasia
Bird-beak sign
Surgical treatment for achalasia
- Heller or LES myotomy
- Pneumatic dilation is a less invasive procedure that can be done
POEM (endoscopic myotomy of the circular muscle layer) - Diltiazem (medication)
Medical treatment for achalasia
- Nitrates
- Diltiazem
- Calcium channel blockers
- Botulinum toxin (every 6 months)
Can you see a motility disorder when doing an endoscopy?
No, motility disorders can’t be seen
Classification of esophageal motility disorders
Primary and secondary
What are the types of dysphagia
- Oropharyngeal
- Esophageal
Difficulty initiating swallowing, piecemeal swallowing, coughing, regurgitation and a sensation of food remaining in the pharynx
Oropharyngeal
Main causes of oropharyngeal dysphagia
- Neurological due to stroke
- Structural due to Zenker’s diverticulum
Difficulty seconds after initiating the swallow, with both solids and liquids; dolor precordial
Esophageal dysphagia
Main causes of esophageal dysphagia
- Mechanical intrinsec (peptic stricture, GERD)
- Extrinsic causes
Hypercontractile and hypertensive peristalsis caused by vigorous esophageal contractions
Jackhammer esophagus
Barium swallow in someone with DES will show the …. sign
Corkscrew or rosary beads
Premature and uncoordinated esophageal contractions when swallowing “so DEScoordinated it can’t even be a considered peristalsis”
DES (diffuse esophageal spasm)
LES relaxation is common in pathologies like DES and jackhammer
Yes
Symptoms of DES and jackhammer include
- Dysphagia to mostly liquids
- Retrosternal pain
- Reflux symptoms
- Globus sensation
- Upper respiratory symptoms
Esophageal manometry findings in JHE and DES
20% of the cases: hypertensive esophageal contractions JHE; premature non propagative contractions for DES
Treatment for DES and JHE
- Small bites with drinks in between
- No very hot/ cold food
- No bread, rice or chunky meat
- NO OPIOIDS
- Nitrates, calcium channel blockers, peppermint oil
- PPI if GERD
IRP and DCI stand for…
Differential diagnosis for motility disorders (achalasia)
DES and JHE
Secondary achalasia
- Chagas
- Amyloidosis
Most common cause of esophageal varicosities
Portal hypertension
The main cause for portal hypertension is…
Cirrosis (alcoholism, hepatitis C and hepatitis B)
Most of the esophageal varices occur at the middle third of the esophagus, due to the transition of smooth to straited muscle
False, it most commonly occurs at lower third of the esophagus
Signs and symptoms of esophageal varices
- Hematemesis and melena
- Hemodynamic instability
- Tachycardia
- Hypotension & orthostatic hypotension
When doing an endoscopy ¿what characteristics do varices have?
- Blue
- Round
- Surrounded by congested mucosa
- Soft and compressible
Common type of pattern found when doing an endoscopy on a patient with esophageal varices
Honeycomb pattern
If a patient is bleeding from the esophageal varices ¿what’s the next step?
Band ligation or sclerotherapy
Prophylactic medications to treat esophageal varices
- beta blockers
- vasopressin, somatostatin, terlipressin…
- antibiotic
Last resource when treating esophageal varicosities. Also used for patients with poor liver function.
TIPS procedure (transjugular intrahepatic protosystemic shunt)
Diagnosis for achalasia
- Endoscopy to discard malignancies or obstruction
- GOLD STANDARD: manometry
- Barium swallow
Liver blood supply comes from…
- 25% hepatic
- 75% portal
Division of portal hypertension
- Acute: acute portal vein thrombosis
- Chronic: chronic thrombosis, cirrhosis, schistosomiasis
Whats portal hypertension
Pathological elevation of portal venous pressure resulting from increase in blood flow or its obstruction
Causes of portal hypertension are divided into
- Prehepatic
- Intraahepatic
- Posthepatic
Causes of posthepatic portal hypertension
- Hepatic vein obstruction
- Budd Chiari syndrome (hepatic vein thrombosis)
- Right sided heart failure
Whats Budd Chiari syndrome
Budd-Chiari syndrome is a rare condition resulting from hepatic vein obstruction that leads to hepatomegaly, ascites, and abdominal discomfort.
Causes of intrahepatic portal hypertension
- Damage to the liver: fibrosis, cirrosis
- Pre, post and sinusoidal causes
Whats the number one cause of portal hypertension
Cirrhosis
Cirrhosis is caused by…
- Alcohol/ non alcoholic in wtf is a kilometer land
- Fatty liver disease in magic Mexico
Clinical manifestations of cirrhosis
- Ascites
- Caput medusae
- Splenomegaly
Most patients with cirrhosis are symptomatic
False, 80 to 90% are asymptomatic
Percentage of patients that develop esophageal varices secondary to portal hypertension
40%
Esophageal varices
- Common @ lower 1/3 of the esophagus
- Only seen @ endoscopy
- Bleed b4 diagnosed
- Platelets are low because they stay in the spleen
Primary prophylaxis for esophageal varices (b4 they bleed)
- 1) patient diagnosed with portal hypertension
- 2) endoscopy search
- 3) non selective beta blockers to small varices
- 4) band ligation of medium/ big varices
- 5) eradicate varices (every 6 to 12 months)
Treatment for acute variceal bleeding
- 1) patient arrives bleeding
- 2) octreotide and antibiotics (ceftriaxona)
- 3) endoscopy and band ligation OR balloon tamponade
- 4) secondary prophylaxis
- 5) rebleed? band ligation or TIPS
Secondary prophylaxis for esophageal varices (patient was bleeding but not anymore)
- 1) patient stabilized
- 2) band ligation and non selective beta blockers
- 3) still bleeding? TIPS
- if TIPS is done there’s no need for band ligation or non selective beta blockers
Non selective beta blockers used to treat esophageal varices
Propanolol or nadolol
Only vasoactive associated to a decrease in mortality due to esophageal varices
Terlipresin
Medication associated with decreasing esophageal varices bleeding with the secretion of glucagon
Octerotide
Vasoactive medications that are associated with hiponatremia as an adverse effect
Terlipresin and vasopressin
