Esophageal Disorders Flashcards
what is Dysphagia
subjective feeling for the pt.
- inability to initiate the swallowing process
OR
- the sensation of solids or liquids not being able to pass through the esophagus to somach
can be a result of…
- motlility disorders
- structural disorders
- oropharyngeal issue
- esophageal issue
can be acute or chronic
what is Acute Dysphagia
- etiology
- symptoms
- treatment
Etiology
- a sudden onset on not being able to swallow
- a complete obstruction of the eosphgeal lumen
Symptoms
most commonly after ingesting meat (steakhouse syndrome
- complain of excess saliva: the obstruction stops the saliva from being able to pass -> thus a build up
Treatment (from teh ED)
- initial: IV glucagon (will release the LES and promote passage of the bolus into the stomach)
- if glucagon wont help - may need endoscopic management via grasping tool or something to push it into stomach
Non-Acute Dysphagia
Two Types
how to differentiate
Esophageal Dysphagia
- difficulty swallowing SECONDS LATER after the inititaion
- the sensation of food or drink being stuck in the upper esophagus
- retrostrenal dysphagia (they will point to where they feel it) is corresonding to the issue
- if compliants of supersternal –> ususally referred pain from below
Oropharngeal Dysphagia
- difficulty INITIATING the swallow
- pts. will point to the cervical region where the symptoms are
- nasopharyngeal regurg, aspiration and sense of food in pharynx are common
- oral dysfuncion leading to: food spillage, silaorrhea, piscemenntal swallowing
- coughing, choking and dysphonia can result
Esophageal Dysphagia
- Etiology
- Symptoms
Esophageal Dysphagia
- happening seconds after they swallow
Etiology
- if solids AND liquids: think of a motility disorder
- if solids only : think of a structural disorder
- if intermittent : think of a ring or web impacting the swallowing; or a spams of the muscle
- if progessively worsening: think momtility disorders (achalasia)
- if it began with only luqids, now both: think obstruction (rapid = malignancy, gradual = stricture)
Symptoms (look for associated)
- alarming: r/o malignacncy: weight lodss & anemia
- Heartburn: think GERD
- Hematemesis
- hregurgitation of food: peptic stricutres (narrowing)
these can be a result of other underlying conditions
Oropharyngeal Dysphagia
Etiology
Symptoms
Etiology
- a problem with the initation of the swallowing process
Symptoms
- difficult to transfer food from mouth to pharynx
- obstructions in the neck (cervical area)
- coughin, drooling and regurgitation
- may have to manual force food down, move body
- weight loos
- aspiration pneumonia risk!
think of CNS causes, nerve issues
Globus Sensation
Etiology
Symptoms
Etiology
a functional esophageal disorder: not a structual or motility issue and NOT related to GERD!
Symptoms
- the sensatino of a lump within the throat, related to food and tightness in the throat
usually no cause found & no treatment
Odynophagia
Etiology
Work up
Etiology
- painful swallowing
- refractory GERD
- HSV esophagitis
- candida esophagitis
- pill esophagitis
- pahryngitis (like strep throat)
refractor GERD, HSV & candidia warrent an endoscopy
GERD
Etiology
Symptoms
Gastroesophageal Reflux Disease
(complaint of heartburn: always r/o cardiac causes first!)
Etiology
- when the reflux (because some is normal) from the stomach causes troublesome symptoms and complications
- classificaion based on the apperance of the esophagela mucosa on upper endoscopy to be either…
1. Erosive esophagitis: with VISABLE breaks in teh distal esophageal mucosa
2. Nonerosive esophagitis: the symptoms are there but no visable injury to the mucosa
Symptoms
- heartburn (pyrosis): retrosternal burning, post-meals, troublsome if occurring 2+ days a week
- regurgitation: preception of flow of the contents to the mouth or the hypopharynx (acid + undigested food)
Other symptoms include…
- dysphagia
- chest pain
- odynophagia
- extra-esopha. = cough, hoarsness and wheeze
Severe Cases: Water Brash: hypersalivation causing foaming at the mouth due to the reflux)
GERD
Diagnosis
alarm symptoms that something else is going on
Diagnosis : usually a clincal diagnosis
- classic features and symtoms without alarming symptoms of Barretts esophagus are enough to dx. and give PPI (PPI offering relief is suggestive too)
- if atypical features: always rule out more serious conditions first and workupfirst
upper GI endoscopy: not require to make DX. but can help determined type (erosive or not) and r/o barretts
- if they arent resonding to tx. = endo.
- barretts risk = endo.
- alarm symptoms = endo.
Alarm Symptoms: that you sould look for something else
- new dyspepsia (in older than 60)
- evidence of GI bleeding!!!
- irondefiencey anemia
- anorexia
- unexplained weight loss
- dysphagia/ odynopagia
- vomiting
- cancer in first degree relative
Barret’s Esophagus Risk factors
- GERD for 5-10 years
- men, white
- hital hernia
- obese
- noctural reflux
- tobacco use
- relative with cancer or Barrets
If you do endoscopy…..
- can be normal looking!
- the esophagitis: classified via the LA Criteria- 4 stages
- ulcerations can be seen in the distal esophagus
- stricutres, metaplasis (barrets) or adenocarcinoma all possible findings
other tests….
- barium esophagram: not diagnostic
- esophageal manometry: not diagnostic but can r/o motility issue
- pH monitoring of the esophagus to assess tx. (rare)
GERD
Treatment
Refractory GERD
- Lifestyle Changes First!
- dietary changes to avoid (citrus, spice, tomatoes, carbonated, onions, mint, fatty foods, fried food)
- medication changes (avoid caffeine, b-blockers, CCBs, alpha agonists, theophylline)
- avoid tobacco and alcohol
- elevated HOB 4-8 inches
- avoid laying down after meal
- weight loss
- avoid tight clothing - Drug Therapy
- if mild symptoms: PRN antacids like tums
- PPI is standard of care: takes 2 weeks to work (not PRN med)
watch c diff, QT prolongation, osteoporosis risk
- H2 Blockers (otc) : less effective but can be used prn, watch rebound symptoms (no daily use)
- prokinetic agents: used when PPI not working: or use with PPI (Metoclopramide)
- Sucrulfate: to coat mucosal surface (empty stomach!!)
Refractory GERD
- those who do not respond to meds: endoscopy to r/o other conditions
- use combo PPI and baclofen (reduces LES muscles)
- do NOT use PPI and H2 together — if so, space them out
- surgery
- radioablation of the GE junctions
long term GERD increases risk of strictures, Barret’s & adenocarcinomas
Barret’s Esophagus
a complication of long-term GERD
- a precancerous conditions of lesions whihc increases risk for the development of adenocarcinoma
- the typical squamous epithelium changes via metaplasis to the columar epithelium of the stomach
On Endoscopy
- salmon-colored well demarcated lesions above the GEJ
- Biopsy required to dx
Treament
- PPI treatment
- routine surveillance
Hiatal Hernia
Etiology
two types
Diagnosis
Treatment
Etiology
- a hernial of the abdominal contents through the esophgeal hiatus of the diaphragm (stomach peaks through the esophgeal hole)
Two types
1. Sliding HH: where displacement of the GEJ goes above the diaphragm but not a true hernia becuase it slides back to its place; often ahve GERD symptoms (like like slides up through the pre-exisitng hole)
2. Paraesophgeal: a true hernia with sac, upward disloaction of the gastric fundus through a ture defect in the hole (para-next to; meaning true issue with the hole and the staomch comes up next to the esophagus)
- presenint with mild, vague, intermittenet fullness, nausea, etc.
diagnosis
- if sliding: no findings on barium esophogram (xray with swallowing the radiographic dye)
if paraesophageal
- barium esophogram most reliable
- can be seen on upright xray, CT or MRI
Treatment
surgical
Esophageal Web
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- a THIN ECCENTRIC: meaning not full circumference membrane which protrudes into the lumen of the esophagus; covered in squamous epithelium
- commonly anteriorly located, in the cervical esophagus below cricoid
Causes
- most commonly: unknown why they form
- associated with Zenkers Diverticulum, dermatoligc issues (bullous pemph, pemp vulgaris), graft v host disease, Plummer-Vinson Syndrome (IDA, dysphaiga nad the web)
Symptoms
- esophageal dysphagia
Diagnosis
- Barium swallow (more sensitive) see the filling defect
- Upper GI endoscopy
Treatment
- endoscopic dilation at the area
Esophageal Ring
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- a CONCENTRIC: all the way around ring which narrows the esophageal lumen
“A”- Ring
- caused by normal smooth muccle contraction
- just proximal to the squamocolumnar junction
“B”-Ring
- a mucosal structure
- sitting directly on the squamocolumnar junction
- the mucosa above = squamoud
- the mucosa below = columnar
often associated with a sliding hiatal hernia
Causes
- chronic acid reflux
- hiatl hernia
- eosinophili esophagitis
Symptoms
- dysphagia to solid foods
Diagnosis
- barium Esophagus (sensitve)
- endoscopy (needed if need tobx. for eosinophili esophagitis)
Treatment
- ednscopic dialation
Zenker Divirticulum
etiology
symptoms
diagnosis
treament
Etiology
- an outpouching of the wall (similar to a diverticula) in the upper esophageal sphincter
Symptoms
- Halitosis (bad breath because food gets stuck here)
- regurgitation of saliva, pills, food
- often, associated with other motility disorder
Diagnosis
- barium esophagram (PPP) with video flourscopy to see the collection of the dye in the “divirtucla”
Treatment
- surgical : cricopharyngeal myotomy
- diverticulectomy
