Flashcards in 010614 esophageal disorders Deck (70):
initial phase if voluntary but as bolus is pushed backward by tongue to hypopharynx, the involuntary phase of the swallow reflex is triggered
it's coordinated and sequnetial contraction of the esophageal muscle
primary peristalsis occurs with appropriately timed relaxation of the upper and lower esophageal sphincters
esophageal peristalsis subtypes
primary peristalsis: triggered by swallow (pharyngeal contraction and UES relaxation)
secondary peristalsis: triggered by esophageal distension
peristalsis is generated by what nerves?
intrinsic (enteric neural plexus)
extrinsic (vagus nerve)
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.
difficulty eating during swallow
swallowing takes how long?
just 10 seconds, so if it's longer, it's not dysphagia
lump in the throat
what to ask for hx in dysphagia pt
what kind of food (solid, liquid)
intermittent or progressive
other symptoms? (heartburn, regurgitation, odynophagia, chest pain)
effortless return of gastric contents moving upward into the throat (sometimes associated with sour and bitter taste)
burning feeling rising to the chest
pain during swallow and bolus transit
differential of dysphagia
esophageal (sticks or hangs up after swallow, may have chest pain)
pharyngeal (difficulting initating swallow. coughing, choking and nasal regurgitation)
common causes of dysphagia
mechanical (peptic stricture, esophageal ring, cancer)
neuromuscular (achalasia, esophageal spasm, dysmotility)
eosinophilic esophagitis can be mechanical or neuromuscular
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
if the dysphagia occurs with solid or liquid food, what should you think of?
if it's progressive with heartburn/regurgitation, think scleroderma or achalasia
if it's intermittent and there's chest pain, think spasm
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)
what is the gold standard for diagnosis of esophageal motor disorders?
what is an esophageal spasm
top and bottom of esophagus are contracted at the same time
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)
bird peak appearance
pathophysiology of achalasia
abnormal fxn of LES is due to impaired and then loss of inhibitory NO activity
peak incidence of achalasia is at what age?
7th decade and 20-30
what symptoms can you see in pt with achalasia
chest pain, HEARTBURN, regurgitation, weight loss
food stasis, bacterial fermentation and acidity may result in esophagitis and heartburn
slow and stereotypical eating movements
sigmoid shape esophagus
differential diagnosis or secondary achalasia for a pt with achalasia
other infiltrative disorders (amyloidosis, sarcoidosis)
autonomic nerve damage (diabetes, polio, surgical)
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
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.
what increases PAF and PGE2 in the pathophysiology of GERD?
H2O2, which is increased with IL-6
what do PAF and PGE2 do in the pathophysiology of GERD?
they reduce ACh release and LES tone
separation of the diaphragmatic crura and LES, resulting in protrustion of stomach into thorax
sliding hiatal hernia is symptomatic or asymptomatic commonly?
morphology of GERD
basal zone hyperplasia of total epithelial thickness
small number of EOSINOPHILS, followed by neutrophils
endoscopic morphology of GERD/reflux esophagitis
simple hyperemia may be only change
mucosal breaks (erosions)
is hyperemia in endoscopy specific?
the most common cause of esophagitis
reflux of gastric contents
risk factors for reflux esophagitis
classic symptoms of reflux esophagitis
regurgitation (going back up in throat)
also dysphagia (but dysphagia is an alarm symptom--would want to rule out achalasia and eosionphilic esophagitis)
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)
complications of GERD
esophageal stricture (scarring)
esophageal stricture causes
narrowing of esophageal lumen
epithelial infiltration by large numbers of eosinophils
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.
clinical presentation of eosinophilic esophagitis
in children: nausea, burning and food intolerance
personal or family hx of atopia
most common cause of food impaction
diagnosis of eosinophilic esophagitis
histologic confirmation of more than 15 eosinohpils per higher power field in eophageal mucosa
endoscopic features of eosinophilic esophagitis
it's helpful but not required
findings are non specific
tx for eosinophilic esophagitis
causes of esophagitis
skin disorder associated
infectious esophagitis is most frequent in whom?
debilitated or immunosuppressed
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
most common cause of fungal esophagitis?
incidence of bacterial esophagitis
what skin disorders are associated w esophagitis?
desquamative skin disease (bullous pemphigoid, epidermolysis bullosa)
where is the Z line?
at the end of the LES
normal esophageal sq epithelium is replaced by metaplastic columnar mucosa (especially intestinal metaplasia)
what is the defining feature of intestinal metaplasia?
Barrett's esophagus is a complication of
Barrett's esophagus presents how?
Barrett's esophagus can predispose to?
dysplasia and adenocarcinoma
types of esophageal tumors
squamous cell carcinoma
esophageal adenocarcinoma is typically seen in what population?
white middle aged male
risk factors for esophageal adenocarcinoma
dysplasia in Barrett's esophagus
in esophageal adenocarcinoma, what is frequently present near the tumor?
squamous cell carcinoma of esophagustypically occurs in whom
African Am male adults older than 45
risk factors for sq cell carcinoma in esophagus
caustic esophageal injury history
achalasia and Plummer Vinson
hot beverage consumption
is dysphagia common for esophageal tumors?
not very. if it's present, usually at end of disease
symptoms of esophageal sq cell carcinoma
dysphagia (at end of disease)