Week 3: Esophageal diseases

Question 1

Anatomy of GERD

Answer 1

1. lower esophageal sphincter
   - pressure, length and intraabdominal length. Problems when pressure is low, length is too short
   - Crura -inspiration helps contract sphincter
   - flap valve
   - transient relaxations (TLESRS)
2. Esophagus
   - gravity, primary/secondary peristalsis, saliva and esophageal bicarb, squamous epithelium
3. Stomach
   - gastric emptying: when delay, allows for increased reflux
   - hiatal hernia: LES pressure too low, exposed to intrathoracic pressure, no esophageal pinch from crura

Question 2

Symptoms of GERD

Answer 2

1. esophageal
   - heartburn from regurg
   - dysphagia/odynophagia
   - chest pain
2. Extra esophageal
   - waterbrash
   - asthma
   - cough
   - laryngitis
   - pharyngitis
   - hiccups
   - dental erosive

Question 3

Complications of GERD

Answer 3

• esophageal ulceration and bleeding
• esophageal stricture
• Barett’s esophagus - premalignant condition leading to esophageal adenocarcinoma

Question 4

Workup for GERD

Answer 4

1. H&P
2. Esophagoscopy: not retried but recommended in older patients, persistent or recurring symptoms, unusual symptoms
3. 24 hr pH: recommending in patients with unusual symptoms whose upper endoscopy is negative, not responding to therapy,
4. esophageal manometry and impedence: used when severe dysphagia, endoscopy is negative, prior to surgical interventions

Question 5

Treatment of GERD

Answer 5

1. Lifestyle changes
   - elevating head at night in bed
   - weight loss
   - small frequent meals, no late meals
   - avoid food with high fat, spices chocolate
2. medications
   - Antacids: tums and mylantaa
   - mucosal protective agents: sulcrafate, gavicon
   - H2 blocker: Tagamet
   - PPI: prelosec/prevacid
   - prokinetic agents: metaclopromide, erythromycin
3. surgery: fundoplication -upper curve of stomach wrapped around esophagus and sewn into place

Question 6

Eosinophilic esophagitis

Answer 6

• dysphagia, solid food bolus obstruction, chest pain, heartburn. Contains >15 eosinophils throughout esophagus
• unknown etiology. Hx of allergies and/or asthma.
• elimination diet: soy, wheat, peanuts, shell fish, milk, tree nuts
• Rx: PPI to rule out GERD. 6 food elimination diet, short term systemic steroids, leukotriene inhibitors, Il5 inhibitors

Question 7

Caustic injuries

Answer 7

• alkali injuries cause liquefactive necrosis
• acids injuries cause coagulation necrosis
• may be mild, may result in stricture, perforation
• management depends on initial findings: endoscopy is normal, patient goes home. Endoscopy is abnormal, hospitalize and follow up.
• symptoms: drooling, local pain, dysphagia, odynphagia, hoarsness, stridor, aphonia, dyspnia, chest pain, back pain, ab pain, retching, vomiting, peritoneal
• complications: strictures. squamous cell CA.

Question 8

Pill esophagitis

Answer 8

• when pill has direct and prolonged contact with esophageal mucosa
• ulceration often seen. location usually at level of aortic arch where aorta indents the esophagus
• sudden severe chest pain, dysphagia.
• complications: hemorrhage, perforation, stricture,

Question 9

esophageal achalasia: characteristics

Answer 9

• abnormally elevated LES pressure
• partial or complete failure of LES relaxation
• total loss of peristalsis in the esophageal smooth muscle
• etiology is idiopathic

Question 10

esophageal achalasia pathology

Answer 10

• damage to myenteric nervous system
• may be: loss of ganglion cells through esophageal body, vagal nerve degeneration, degeneration of ganglion cells in dorsal motor nucleus of the vagus in brain stem
• decrease amounts of NO/VIP in LES
• secondary: due to chagas, infiltrative disease such as lymphoma

Question 11

Symptoms of esophageal achalasia

Answer 11

20-40 yos

• dysphagia, progressive
• regurgitation of undigested food
• chest pain
• heart burn

Question 12

evaluation of esophageal achalasia

Answer 12

• barium swallow: dilated esophagus with narrowing in the LES: bird beak deformity
• esophagoscopy: to rule of structural abnormality
• manometry: reveals poorly relaxing, elevated LES pressure and lack of peristalsis of esophagus.

Question 13

Spastic motor diseases

Answer 13

1. diffuse esophageal spasm: simultaneous and/or repetitive contractions
2. nut cracker esophagus: contractions are peristaltic but very high amplitude
3. hypertensive LES: elevation of LES pressure which may or may not relax normally
4. ineffective esophageal motility: non peristaltic or of low amplitude contractions
   EVAL: rule out GERD, manometry, pH test
   RX: smooth muscle relaxants, psychotropic drugs, esophageal dilation, surgical myotomy

Question 14

Entities affecting UES

Answer 14

1. neurological: stroke, tumor, parkinsons, ALS, MS
2. Muscle: myesthenia gravis, polymyositis
3. local: UES bar, cervical spurs

Question 15

Systemic diseases affecting the esophagus

Answer 15

1. scleroderma: CT disorder
   - CREST syndrome: calcinosis, raynards, esophageal involvement, sclerodactyl, telangectasia
   - severe GERD. low LES pressure or loss of contractions
2. mixed connected tissue disease (MCTD)
   - collagen vascular disease
3. polymyositis and dermatomyositis
   - inflammatory myopathy, affects proximal esophagus. Striated muscle
4. Lupus and RA