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GI Exam 2 > Disorders of the Esophagus > Flashcards

Disorders of the Esophagus Flashcards

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1
Q

4 Layers of the Esophagus

A

● Stratified Squamous Epithelial Cells
● Inner Circular Muscle
● Myenteric Nerve Plexus- Can Provide local
reflexive control
● Outer longitudinal Muscle

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2
Q

Upper Esophageal Sphincter anatomy

A

thickened area of striated muscle

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3
Q

Lower Esophageal Sphincter anatomy

A

Tonically contracted smooth muscle via vagal cholinergic mechanism. During
swallowing, vagal inhibitory fibers allow sphincter to relax

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4
Q

Swallowing phases

A
  • Pharyngeal Phase
    Touch receptors in the oropharynx
    Epiglottis covers the larynx
  • Esophageal Phase
    Bolus passes past the Upper Esophageal Sphincter
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5
Q

_____: a subjective sensation of difficulty or abnormality of swallowing

A

Dysphagia

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6
Q

_____: pain with swallowing.

A

Odynophagia

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7
Q

_____: a non-painful sensation of a lump, tightness, foreign body or retained food bolus in the pharyngeal or cervical area

A

Globus sensation

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8
Q

_____: painful, difficult, or disturbed digestion, accompanied by symptoms such as nausea, heartburn, bloating, and stomach discomfort

A

Dyspepsia

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9
Q

Esophagitis is ____

A

Inflammation of the esophagus due
to an irritant or reaction of some kind

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10
Q

Most common etiologies of esophagitis

A

○ Reflux esophagitis (most common)
○ Pill-induced esophagitis - Antibiotics, NSAID
○ Infectious esophagitis
○ Eosinophilic esophagitis
○ Radiation/Chemo esophagitis

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11
Q

Inflammation of the esophageal mucosa can (if severe) ultimately lead to _____

A

erosions with hemorrhage

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12
Q

Infectious esophagitis is most common in _____

A

immunocompromised patients (HIV/AIDS, leukemia, Immunosuppressive medications)

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13
Q

Most common infectious etiology of esophagitis is ______.

A

Candida albicans

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14
Q

Medication-induced esophagitis occurs secondary to _____

A

NSAIDs, antibiotics, potassium chloride, vitamin C, Quinidine, Alendronate, etc.

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15
Q

_____ is a little-understood condition that is believed to be related to an allergic, immune reaction (usually to food)

A

Eosinophilic esophagitis

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16
Q

Eosinophilic esophagitis leads to _____ visible on EGD and Barium Swallow

A

concentric mucosal rings due to the esophageal lining becoming densely populated with eosinophils

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17
Q

T/F Radiation Therapy directed over the chest or neck region may lead
to inflammation of the esophagus that is usually self-limited

A

T

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18
Q

_____ occurs with GERD

A

Reflux esophagitis

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19
Q

Characteristic Signs and Symptoms of esophagitis

A

■ Retrosternal chest pain (heartburn) is common
■ Odynophagia or Epigastric abdominal pain/bloating
■ Dysphagia
■ Water brash (acidic regurgitation, “bitter taste in mouth”)

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20
Q

Patients with infectious esophagitis may also experience the following S&S:

A

■ Acute onset of dysphagia (difficulty) and/or odynophagia (pain)
■ Fever
■ Hematemesis (occasionally) or blood tinged sputum
■ Acute Anorexia and weight loss

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21
Q

Diagnosis of Esohpagitis

A

● Barium Swallow studies are ordered first.
● EGD is also usually ordered.
○ The two are complementary of each other.
GI-ESOPH-1
● Barium Swallow Esophagram can reveal
characteristic shapes and findings, including
strictures and concentric rings if Eosinophilic.
● EGD allows for biopsy or sampling of pathology.
● Labs: Test to see if they are Immunocompromised

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22
Q

What test is ordered first for esophagitis?

A

Barium Swallow

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23
Q

Esophagitis management includes:

A

○ To treat Reflux Esophagitis, treat the GERD (PPIs, H2 Blockers, etc.)
○ Treatment of Infectious Esophagitis is specific to the pathogen (Candidal- Clotrimazole Troche (immunocompetent) or PO/IV antifungals such as Fluconazole (immunocompromised or severe sx))
○ Eosinophilic Esophagitis - diet changes, PPIs, and glucocorticoids.
○ Med-induced Esophagitis- d/c offending med and PPI therapy.

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24
Q

Mallory-Weiss Syndrome

A

● Mallory-Weiss tears are Longitudinal lacerations in the mucosa near
the gastroesophageal junction or cardia of the stomach.
● It is characterized by upper GI bleeding.
○ Hematemesis (85%)

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25
When do Mallory-Weiss lacerations occur?
Occur when there is a sudden increase in the intragastric pressure. ○ Frequently, this occurs with significant retching, vomiting, or even coughing. ○ Can accompany the retching after binge drinking ETOH.
26
____ account for 8-15% of Upper GI bleeds
Mallory-Weiss Tears
27
Diagnosis of Mallory-Weiss Tears
○ Upper Endoscopy ASAP ○ Barium Swallow study should be avoided
28
How can we treat Mallory-Weiss tears?
○ If necessary, emergency stabilization should occur. ■ Fluid resuscitation if tachycardic and hypotensive ■ STAT EGD for evaluation and cautery or balloon tamponade ○ Reverse anticoagulant if being taken ○ Twice-daily proton pump inhibitors (IV then oral) ○ NPO for first couple days, then introduce soft foods slowly
29
When is Mallory-Weiss Tears emergent?
If they are tachycardic and hypotensive, difficulty breathing, dizzy, LOC, etc.
30
Esophageal Varices
Dilated submucosal esophageal veins, generally located at the distal esophagus Left gastric→Portal System
31
Develops secondary to portal HTN and seen in 50% of cirrhosis patients
Esophageal Varices
32
Up to 1/3 of patients with esohpageal varices may develop an _____
upper GI bleed
33
Characteristic Signs and Symptoms of esphageal varices
■ Usually painless, massive upper GI bleeding ■ Nausea, with bright red blood or “coffee ground” hematemesis likely ■ May present with hematochezia or Melena ■ Dependent on the size of bleed, may develop weakness, postural hypotension, tachycardia, and shock.
34
T/F Varices are usually asymptomatic until they bleed
T
35
Esophageal Varices Diagnosis
Upper Endoscopy (EGD) is the standard for visualizing the pathology and assessing the risk of hemorrhage ○ Barium esophagrams may reveal varices.
36
If “red wale mark” is present then_____
Esophageal varices are considered “high risk for bleeding.”
37
What other imaging is helpful for visualizing esophageal varices?
CT and MRI are also very useful in assessing the severity and size of the varices, visualizing the “extraluminal” varices EGD cannot see
38
What is prophylactic care for esophageal varices, specifically in patients with cirrhosis?
Patients with cirrhosis should undergo a screening EGD ○ If patient has varices present, treat prophylactically ■ Small to medium - Non Selective B-Blocker (such as nadolol) ■ If large, Esophageal variceal ligation
39
Emergency management for variceal bleeding
○ Emergency stabilization of the patient may be necessary, including fluid and blood transfusion ○ Immediate control of bleeding is necessary (at same time as fluids) ○ Endoscopic evaluation with banding or sclerotherapy to stop the bleeding ○ If these treatments are failing, balloon tamponade may be required.
40
Mortality of variceal bleeds
■ 30% mortality with 1st bleed; 50% within 6 weeks.
41
If the endoscopic treatments are not working to stop the variceal)bleed, there is a procedure of last resort, and what does this do for the patient?
■ Transjugular Intrahepatic Portosystemic Shunt (TIPS) ○ Partially shunts blood away from liver, decreasing portal HTN.
42
Esophageal Dysmotility Disorders include:
○ Neurogenic Dysphagia ○ Achalasia ○ Diffuse Esophageal Spasm ○ Scleroderma Dysphagia ○ Zenker’s Diverticulum ○ Esophageal Stricture/Stenosis
43
Neurogenic Dysphagia
● Any neurological or muscular condition that affects the oral or pharyngeal motor function, leading to dysphagia.
44
Common causes of neurogenic dysphagia:
○ Stroke (CVA) ○ Traumatic brain injury ○ Amyotrophic Lateral Sclerosis (ALS) ○ Cervical Spine surgery (ACDF)
45
Patients with this disorder commonly presents with difficulty swallowing both liquids and solids
Neurogenic Dysphagia
46
Treatment of Neurogenic dysphagia disorder is focused on ______
underlying cause, but prognosis may not be great
47
Achalasia
Esophageal neuromuscular disorder, likely due to a progressive degeneration of ganglion cells in the myenteric plexus, although etiology is usually unknown
48
Results in loss of peristalsis and loss of relaxation of the lower esophageal sphincter.
Achalasia
49
Achalasia S&S:
○ Slowly progressing dysphagia (solids->liquids) with episodic regurgitation and occasional pain. ○ Weight loss can occur secondary to significant difficulty with eating. ○ Average age of diagnosis is between 30 and 60 years of age. ○ Heartburn that is unresponsive to PPIs
50
Diagnosis of Achalasia
○ Barium Swallow study can reveal structural and motor abnormalities: Classic to Achalasia is the “Parrot-Beak” or “Bird-Beak” appearance ○ EGD should be gently attempted to rule out other pathology, such as cancer. ○ Esophageal Manometry (Required for diagnosis) will reveal loss of peristalsis waves within stenosis, as well as incomplete LES relaxation with swallowing
51
Achalasia Treatment
Medical management may include ■ Pneumatic Endoscopic balloon dilation ■ Surgical Myotomy or Peroral endoscopic myotomy (POEM) - the LES is weakened by cutting its muscle fibers ■ Botulism injections into the lower esophageal sphincter
52
T/F If lAchalasia is left untreated, the dilated portion of the esophagus will continue to enlarge
T
53
T/F recurrence of achalasia is uncommon
F
54
Diffuse Esophageal Spasm
An abnormality in the coordination and strength of peristaltic contractions. ○ High-amplitude muscle spasms
55
Characteristic Signs and Symptoms of Diffuse Esophageal Spasm
○ Dysphagia or intermittent chest pain that may or may not be associated with eating or drinking. ○ Symptoms may be triggered by stress, large food boluses, or extreme temperature foods
56
Diagnosis of Diffuse esophageal spasm
○ Barium Esophagram reveals the classic “corkscrew” appearance of uncoordinated simultaneous contractions (AKA “Rosary Beads”). ○ Esophageal Manometry will also be abnormal.
57
Management of Diffuse esophageal spasm
○ Goal- Reduce symptoms and reassure patient. ○ Calcium Channel Blockers or Sublingual Nitroglycerin may stop esophageal spasms for some patients. ○ Endoscopic dilation or surgery reserved for severe.
58
Scleroderma Dysphagia
● Scleroderma (AKA Systemic Sclerosis) is an autoimmune disease characterized by progressive hardening of the skin. ● Atrophy and fibrosis of the esophagus smooth muscle leads to eventual lack of esophageal peristalsis. Present in over 50% of patients with scleroderma ○ The Lower Esophageal Sphincter loses its tone and GERD develops with reflux esophagitis
59
Diagnosis of Scleroderma Dysphagia
Usually based on clinic signs/symptoms ○ Upper Endoscopy - Screen for Barrett’s Esophagus ○ Esophageal Manometry reveals low LES pressure and seemingly paralyzed esophagus with time. ○ Barium Esophagram may reveal loss of peristalsis waves and loss of full Lower Esophageal Sphincter tone
60
In what disorder will you see a "bird beak" appearance on Barium swallow?
Achalasia
61
Management of scleroderma dysphagia
○ This is difficult to treat. ○ The focus is on treating the GERD (PPIs, etc) and working to prevent reflux complications, like esophagitis and Barrett’s
62
Esophageal Strictures
● Luminal narrowing of the esophagus that is most commonly secondary to inflammation or scarring of the lower esophagus (Esophagitis) caused by GERD
63
Approximately 70-80% of all strictures are related _____
to GERD
64
What is this?
Esophageal strictures - Schatzki's ring
65
Slowly progressive dysphagia to solid foods is the most common presenting complaint with _____
Esophageal strictures
66
If the stricture is secondary to an Esophageal Malignancy, the patient can experience ____
rapid onset and development of dysphagia with profound weight loss
67
Diagnosis of Esophageal strictures
○ Barium Swallow Esophagram is the initial test of choice. ○ Endoscopic evaluation (with endoscopic ultrasound and biopsy) is then utilized for further evaluation of Barium Swallow findings. ○ CT scan of the chest can be used to visualize masses.
68
_____ has been shown to be beneficial and safe in benign strictures and Schtazki rings
Endovascular balloon dilation
69
Zenker’s Diverticulum
A rare anatomic abnormality occurring primarily in elderly male patients ● The exact mechanism of development is unknown, but it is believed to develop secondary to a defect in the posterior hypopharynx.
70
What is this called?
Diffuse Esophageal Spasm
71
What is this called?
Achalasia, "bird beak"
72
What is this?
Esophageal strictures
73
Characteristic Signs and Symptoms of Zenker’s Diverticulum
■ Regurgitation of undigested food hours after eating ■ Dysphagia ■ Aspiration of organic material ■ Unexplained weight loss ■ Halitosis
74
Most life-threatening complication of Zenker’s
Aspiration of organic material
75
Diagnosis of Zenker’s Diverticulum
○ Barium Swallow esophagram is still considered the diagnostic study of choice, especially for initial evaluation. ○ Upper Endoscopy (EGD) is often used for further evaluation and pre-operative planning
76
Management of Zenker’s Diverticulum
○ Unless the lesion is large and causing symptoms, treatment may not be recommended ○ Open or Endoscopic surgery can be performed on larger, symptomatic diverticula
77
Esophageal Neoplasm include two disctinct types:
○ Squamous Cell Carcinoma ○ Adenocarcinoma
78
Squamous Cell Carcinoma of the esophagus features:
■ Generally occurring in the proximal (upper) 2/3. ■ Associated with alcohol and tobacco usage. Synergistic
79
Features of Adenocarcinoma of the esophagus
■ Occurring in the distal 1/3. ■ Strongly associated with chronic GERD (Barrett’s)
80
Barrett esophagus (BE)
Stratified squamous epithelium that normally lines the esophagus is replaced by a columnar epithelium
81
Characteristic Signs and Symptoms of Esophageal neoplasms
Progressive dysphagia for solids (and eventually liquids), as well as profound weight loss - The two most characteristic clinical features ○ Other symptoms include: ■ Hoarseness of voice ■ Epigastric or retrosternal pain ■ Odynophagia ■ Hematemesis ■ Cough
82
Diagnosis of esophageal neoplasms
○ Barium Swallow Esophagram may be the good initial test ○ Upper Endoscopy (EGD) allows for detailed intraluminal visualization with ability to biopsy the tumor ○ Endoscopic Ultrasound allows for staging and can measure depth and lymph node involvement
83
a. Bird Beak pattern can be seen, but in places other than the LES with ____
Esophageal neoplasms
84
Management of esophageal neoplasm
○ Treatment generally involves surgery of some sort, as long as the patient is a surgical candidate. ○ Radiation and chemotherapy are generally used to some extent as well, although the effects are less than desirable.
85
Prognosis for esophageal neoplasms?
■ Depends on stage, but is generally pretty poor. ■ The overall 5-year survival rate is approximately 19%. ■ Most patients have metastatic disease upon diagnosis. ■ The 5-year survival of those with Stage 4 disease is < 5%.
86
When speaking of dysphagia, the following are red flags concerning for significant pathology
○ Rapid onset of dysphagia and/or odynophagia ○ Unexpected weight loss with dysphagia ○ Significant worsening of previously controlled GERD These red flags warrant urgent EGD evaluation and/or Barium Swallow.

GI Exam 2 (6 decks)

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