010614 esophageal disorders Flashcards Preview

Gastrointes > 010614 esophageal disorders > Flashcards

Flashcards in 010614 esophageal disorders Deck (70):
1

swallowing mechanism

initial phase if voluntary but as bolus is pushed backward by tongue to hypopharynx, the involuntary phase of the swallow reflex is triggered

2

antegrade transit

peristalsis
it's coordinated and sequnetial contraction of the esophageal muscle

primary peristalsis occurs with appropriately timed relaxation of the upper and lower esophageal sphincters

3

esophageal peristalsis subtypes

primary peristalsis: triggered by swallow (pharyngeal contraction and UES relaxation)

secondary peristalsis: triggered by esophageal distension

4

peristalsis is generated by what nerves?

intrinsic (enteric neural plexus)
extrinsic (vagus nerve)

5

how is peristalsis generated differently in the proximal and distal esophagus?

proximal: striated muscle peristalsis. involves motor end plate. action potential causes Ca release mostly from SR via T tubules. sequence of peristalsis is generated by the swallowing central generator of the brainstem

distal: sm musc peristalsis. varicose nerve endings and gap jxns. Ca influx is from outside. Dual innervation (both inhibitory wave and excitatory wave). peristalsis goes in waves of inhibition and excitation.

6

dysphagia

difficulty eating during swallow

7

swallowing takes how long?

just 10 seconds, so if it's longer, it's not dysphagia

8

globus sensation

lump in the throat

9

what to ask for hx in dysphagia pt

what kind of food (solid, liquid)

intermittent or progressive

other symptoms? (heartburn, regurgitation, odynophagia, chest pain)

10

regurgitation

effortless return of gastric contents moving upward into the throat (sometimes associated with sour and bitter taste)

11

heartburn

burning feeling rising to the chest

12

odynophagia

pain during swallow and bolus transit

13

differential of dysphagia

esophageal (sticks or hangs up after swallow, may have chest pain)

pharyngeal (difficulting initating swallow. coughing, choking and nasal regurgitation)

14

common causes of dysphagia

mechanical (peptic stricture, esophageal ring, cancer)

neuromuscular (achalasia, esophageal spasm, dysmotility)

eosinophilic esophagitis can be mechanical or neuromuscular

15

if the dysphagia occurs with solid food only, what should you think of?

think mechanical obstruction

if it's progressive and over 50 yrs old, think cancer

if pt has chronic heartburn, think peptic stricture

if it's intermittent, think esophageal ring

16

if the dysphagia occurs with solid or liquid food, what should you think of?

NEUROMUSCULAR

if it's progressive with heartburn/regurgitation, think scleroderma or achalasia

if it's intermittent and there's chest pain, think spasm

17

diagnostic approaches to esophageal disorders

upper GI endoscopy (to look at structure)

esophageal manometry (looks at muscle and sphincters by measuring esophageal intra luminal pressure)

radiography/esophagram (gives info on both structure and fxn)

18

what is the gold standard for diagnosis of esophageal motor disorders?

esophageal manometry

19

what is an esophageal spasm

top and bottom of esophagus are contracted at the same time

20

achalasia

poor relaxation of LES, increased LES tone

in the body of the esophagus, there's lack of peristalsis (instead, there is disorganized nonperistaltic contractions of the esophageal body)

21

bird peak appearance

achalasia

22

pathophysiology of achalasia

abnormal fxn of LES is due to impaired and then loss of inhibitory NO activity

23

peak incidence of achalasia is at what age?

7th decade and 20-30

24

what symptoms can you see in pt with achalasia

DYSPHAGIA

chest pain, HEARTBURN, regurgitation, weight loss

food stasis, bacterial fermentation and acidity may result in esophagitis and heartburn

slow and stereotypical eating movements

25

sigmoid shape esophagus

achalasia

26

differential diagnosis or secondary achalasia for a pt with achalasia

malignancy
other infiltrative disorders (amyloidosis, sarcoidosis)
Chagas disease
paraneoplastic syndromes
autonomic nerve damage (diabetes, polio, surgical)

27

corkscrew radiography

esophageal spasm

28

how is complete aperistalsis/scleroderm esophagus different from achalasia?

in complete aperistalsis, it's not a nerve problem. the muscle is unable to contract. and there's no LES obstruction

29

pathophysiology of GERD

most important barrier against reflux is the constant LES tone.

incompetent LES causes reflux, which causes prolonged acid contact in esophagus, which causes esophagitis, causing decreased peristalsis and also decreased LES pressure. it's a vicious circle.

30

what increases PAF and PGE2 in the pathophysiology of GERD?

H2O2, which is increased with IL-6

31

what do PAF and PGE2 do in the pathophysiology of GERD?

they reduce ACh release and LES tone

32

hiatal hernia

separation of the diaphragmatic crura and LES, resulting in protrustion of stomach into thorax

33

sliding hiatal hernia is symptomatic or asymptomatic commonly?

asymptomatic

34

morphology of GERD

basal zone hyperplasia of total epithelial thickness
small number of EOSINOPHILS, followed by neutrophils

35

endoscopic morphology of GERD/reflux esophagitis

simple hyperemia may be only change
mucosal breaks (erosions)

36

is hyperemia in endoscopy specific?

no

37

the most common cause of esophagitis

reflux of gastric contents

38

risk factors for reflux esophagitis

obesity

39

classic symptoms of reflux esophagitis

heartburn
regurgitation (going back up in throat)

also dysphagia (but dysphagia is an alarm symptom--would want to rule out achalasia and eosionphilic esophagitis)

40

how to manage GERD

lifestyle modifications (weight loss, elevation of bed, avoiding late meals, avoiding trigger foods)

pharmacologic therapy (anti secretory drugs for esophagitis, proton pump inhibitors)

operative management (fundoplication surgery, etc)

41

complications of GERD

esophageal ulcer
esophageal stricture (scarring)
bleeding
Barrett's esophagus

42

esophageal stricture causes

narrowing of esophageal lumen

43

eosinophilic esophagitis

epithelial infiltration by large numbers of eosinophils

44

what differentiates eosinophilic esophagitis from GERD

in eosinophilic esophagitis, there's an ABUNDANCE of eosinophils as opposed to a few in GERD. also, eosinophils can be found far from the gastroesophageal jxn.

45

clinical presentation of eosinophilic esophagitis

adults: dysphagia

in children: nausea, burning and food intolerance

personal or family hx of atopia

46

most common cause of food impaction

eosinophilic esophagitis

47

diagnosis of eosinophilic esophagitis

histologic confirmation of more than 15 eosinohpils per higher power field in eophageal mucosa

48

endoscopic features of eosinophilic esophagitis

it's helpful but not required

corrugated esophagus
longitudinal furrows

findings are non specific

49

tx for eosinophilic esophagitis

elimination diet
topical steroids
systemic steroids
endoscopic dilation

50

causes of esophagitis

GERD
eosinophilic
chemical
infectious
iatrogenic
skin disorder associated

51

infectious esophagitis is most frequent in whom?

debilitated or immunosuppressed

52

how to differentiate types of viral esophagitis?

HSV-NUCLEAR inclusions within rim of degenerating epithelial cells at the ulcer edge

CMV-CYTOPLASMIC AND NUCLEAR inclusions within capillary endothelium and stroma

53

most common cause of fungal esophagitis?

candida

54

incidence of bacterial esophagitis

very rare

55

what skin disorders are associated w esophagitis?

desquamative skin disease (bullous pemphigoid, epidermolysis bullosa)

lichen planus
Crohn's disease

56

where is the Z line?

at the end of the LES

57

Barrett's esophagus

normal esophageal sq epithelium is replaced by metaplastic columnar mucosa (especially intestinal metaplasia)

58

what is the defining feature of intestinal metaplasia?

Goblet cells

59

Barrett's esophagus is a complication of

chronic GERD

60

Barrett's esophagus presents how?

often asymptomatic

61

Barrett's esophagus can predispose to?

dysplasia and adenocarcinoma

62

types of esophageal tumors

squamous cell carcinoma
adenocarcinoma

63

esophageal adenocarcinoma is typically seen in what population?

white middle aged male

64

risk factors for esophageal adenocarcinoma

dysplasia in Barrett's esophagus
tobacco use
obesity
radiation therapy

65

in esophageal adenocarcinoma, what is frequently present near the tumor?

Barrett's esophagus

66

squamous cell carcinoma of esophagustypically occurs in whom

African Am male adults older than 45

67

risk factors for sq cell carcinoma in esophagus

alcohol, tobacco
poverty
caustic esophageal injury history
achalasia and Plummer Vinson
hot beverage consumption
previous radiation

68

is dysphagia common for esophageal tumors?

not very. if it's present, usually at end of disease

69

symptoms of esophageal sq cell carcinoma

dysphagia (at end of disease)
odynophagia
obstruction
weight loss
vomiting

70

overall five yr survival rate for esophageal sq cell carcinoma

poor (usually it's in advanced stage already at diagnosis)