Flashcards in CM- Approach to Esophageal Disease Deck (43):
What are the 2 main purposes of the tubular gut?
1. provide nutrients to power and rebuild
2. eliminate waste not absorbed by the small intestine
.What are the 2 phases of swallowing? Which CNs are used in each?
1. oral phase- voluntary (5,7.12)
2. pharyngeal phase - involuntary (5,10,11,12)
-nasopharynx closes and soft palate contracts
- larynx elevates to prevent food aspiration
- vocal cord closure/arytenoid tilt to close larynx more
- hyoid raises maximally as cricopharyngeal relaxes
- pharyngeal contraction passes bolus into esophagus
What is oropharyngeal dysphagia? What are the potential causes?
It is when problems with the pharyngeal phase of swallowing return the bolus to the mouth and/or nose.
1. neuromuscular - stroke, ALS
2. cranial nerve disease- diabetes
3. skeletal muscle disease - systemic sclerosis, muscular dystrophy
4. prior x-ray therapy or ENT surgery
What three components make up the upper esophageal sphincter?
1. inferior constrictor
3. proximal esophagus
What is dysphagia for solids? Liquids?
Solids- mechanical obstruction
liquids- motility disorder
What is Zenker's diverticulum?
A defect in the muscular wall of the hypopharynx that allows the hypopharynx mucosa to outpouch between the inf. pharyngeal constrictor and the cricopharyngeus.
If it becomes large or filled with food, it will compress on the esophagus and cause dysphagia
What are 5 structural diseases that present with the symptom of dysphagia?
1. benign - diverticula, webs, rings RARE
2. Zenker's diverticulum (hypopharynx between inf. constrictor and cricopharyngeus) due to increased pressure
3. cervical osteophytes
4. cricopharyngeal dysfunction - failure to relax
What is knowledge of Zenker's diverticulum important before you do endoscopy?
Edoscopy can perforate the diverticulum
What is the treatment of choice for cricopharyngeal dysfunction?
cricopharyngeal myotomy- removing a strip of muscle
Describe the musculature of the esophagus.
The top 1/3 is skeletal muscle innervated by somatic vagal fibers.
The middle 1/3 is skeletal and smooth muscle
the lower 1/3 is just smooth muscle.
Describe the muscularis propria of the esophagus.
It consists of 2 layers:
1. outer longitudinal muscle that shortens the esophagus upon contraction
2. inner circular muscle that propels the food downward via peristalsis
What is the difference between the UES and LES in terms of musculature?
UES = skeletal muscle
LES = smooth muscle
Describe normal manometry.
It is a technique used to study the motility function of the esophagus. A catheter with multiple pressure-sensing structures is place.
1. A pharyngeal contraction and UES relaxation occur at the same time so the bolus can go from the oropharynx to the esophagus
2. Esophagus squeezes the bolus along (peristalsis)
3. As the bolus approaches LES, the LES will relax for 1-2.5 seconds to allow entrance into the stomach.
4. the LES pressure than returns to basal level
What is the dividing line for pain sensation in the GI tract?
The esophagus has sensation and can feel pain. The GEJ is the dividing line for sensation.
The mucosa distal to the esophagus (stomach, small intestines and colon do not have sensation!!)
When the esophagus functions abnormally, what are common symptoms a patient may experience?
2. chest pain
3. GERD symptoms (heartburn, regurg, laryngitis, asthma)
What are two major systemic neuromuscular diseases that affect esophageal function?
2. systemic sclerosis
Diseases that affect __________ present with dysphagia for both solids and liquids at the onset.
Disease that affect ____________ present first with dysphagia for _____ and progress over time to dysphagia for __________________.
Diseases that affect esophageal function (motility disorders) present with dysphagia of solids and liquids.
Diseases that affect esophageal structure present with dysphagia for solids first and then progress to dysphagia for both
What is systemic sclerosis and how does it effect the function of the esophagus?
What can it lead to?
What is the treatment of choice?
It is scleroderma- fibrosis and vascular obliteration of smooth muscles. For this reason, there is:
1. poor esophageal peristalsis in the lower 2/3
2. weak or absent LES
This leads to dysphagia and can progress to GER.
Treat with a PPI for heartburn and to prevent esophageal strictures.
How does manometry look for systemic sclerosis?
The mid to low esophagus pressure sensors show :
3. weak peristalsis
The LES is absent/low
What are the 2 characteristic features of achalasia?
1. LES fails to relax
2. poor peristalsis of the esophageal body
This is due to degeneration of neurons in the esophageal wall (specifically inhibitory neurons that allow LES relaxation)
What is a known causes of achalasia?
In Central and South America, Chagas disease is the most common cause of achalasia.
Chagas is due to an infection by Trypanosoma Cruzi caused by the Reduvid bug
What is therapy for achalasia?
1. oral nitrates and calcium channel blockers to relax LES
2. Botox - decreases LES pressure for 6 months in 2/3 of patients
3. balloon esophageal dilation ("forceful")
4. surgical myotomy "Heller"
What is a complication of Heller myotomy?
GERD because part of the LES was removed so this allows room for reflux
What does manometry look like for achalasia?
The esophagus will have aperistalsis so waves will be:
3. spontaneous simultaneus
The LES will have a constant raised pressure (60) where normal is about 20
What is the technical definition of GER?
An abnormally long proportion of the day (2-3%) where the esophagus has a pH of 4 or less.
What are two situations where GER can occur?
1. LES is too weak - systemic sclerosis
2. LES relaxes inappropriately and too often -transient LES relaxation (TLESR)
What is the "cardinal symptom" of GERD? How does it present?
The cardinal symptom is heartburn. It is radiating pain from beneath the sternum up the midline to the chest.
The patient will present it with a wave of the open hand
What is the usual treatment to reduce the symptom of heartburn?
1. antacids- to neutralize acid that was already made
2. PPI or H2 blockers to prevent acid formation from parietal cells
What is a surgical treatment for GER in patients who respond well to PPIs but who still have gastric contents encroach on the upper airway?
Fundoplication - surgeons wrap the fundus around the esophagus to tighten the area of the LES
What is the relationship between hiatal hernas and GER?
Hiatal hernia is one factor that can make GER worse, but it is not a primary cause of GER/
What does manometry look like for GER?
It will show no pressure in the esophagus (because food is not coming down).
The LES will show a transient decrease in pressure.
What 4 things can benign GER lead to?
2. Barrett's esophagus
3. stricture formation
4. mucosal (Schatzki's) ring
In what percent of patients getting endoscopic examination for heartburn will have inflammatory changes from refluxed acid?
What is Barrett's espophagus?
When esophagitis heals with intestinal columnar epithelium instead of the normal stratified squamous (metaplasia). There will be Goblet cells present to protect from acid insult.
0.5% per year progress to adenocarcinoma
What is the gastroenterologist recommendations for barrett's esophagus?
1. biopsy surveillance every 3 years
2. surveillance for dysplasia periodically (surgery if it gets severe)
3. suppression of gastric acid
4. Obliteration of the mucosa (RFA, mucosal resection) in hopes that it returns as squamous
What is a stricture? What is treatment?
Who will we be likely to see it in?
Stricture is a fibrous "peptic" ring in the distal esophagus that causes dysphagia for solids.
Treatment is recurrent esophageal dilation.
Some patients have GERD w/o heartburn because their line of sensation is really high. These are the most likely patients to get strictures because they will not present until late in the course.
Strictures can be prevented with H2 blockers and PPIs
Where does a mucousal ring form?
How is it best seen?
What is it associated with?
Schatzki's ring forms at the lower boundary of the LES and becomes symptomatic when the lumen decreases to 13mm
It is best seen on a barium swallow with tablet.
It is seen above hiatal hernia so is associated with GER.
What populations are SCC more common in? What are 4 predisposing factors?
What part of the esophagus is the cancer found? What are the symptoms?
What is treatment?
Blacks and Asians
3. spiced/salted foods
4. nutritional deficiencies
It is found in the upper 2/3 of the esophagus
dysphagia and weight loss
Curative - resection
What is the population where adenocarcinoma of the esophagus is most common?
What is the predisposing factor?
What is treatment?
Overweight white men with GER
It stems from Barrett's esophagus and it is believed that it progresses through low and high grade dysplasia to get to cancer so surveillance is done.
What are the techniques used for evaluation of the esophagus?
1. Barium swallow can assess structure/function of the esophagus
2. EGD can evaluate dysphagia, GERD, bleeding, odynophagia
3. Dysphagiagrams are done by speech pathologists to see if the swallowing problem is oropharyngeal
What are 2 major situations when esophageal manometry is done?
1. systemic sclerosis
How does EE usually present in children? Adults?
Children - chest pain with muscle infiltration of eosinophils