Flashcards in Esophageal Diseases Deck (37)
What is transfer dysphagia?
• Same thing as oropharyngeal dysphagia
• Inability to initiate a swallow or transfer food bolus into esophagus
• May occur with obstruction or neuromuscular disease
○ Dysfunction of oropharyngeal musculature
What are the complications of OP?
• Oropharyngeal dysphagia, or transfer dyphagia
○ Into lungs, either food or saliva
• Nasal regurgitation
• Cough after attempted swallows
• Airway obstruction
○ Choking, stridor, wheezing, cyanosis
• Aspiration pneumonitis
○ Lung injury from acidic or lipophilic properties of food
§ Looks like shortness of breath or hypoxia
• Pneumonia if bacterial colonization occurs
○ SOB, fever, white count, consolidation on CXR
What might cause neurological problems with the oropharynx?
• Parkinson's Disease
• Multiple Sclerosis
What might cause muscular problems with the oropharynx?
• Myasthenia gravis
• Muscular dystropy
• Muscle injury
○ Surgery, radiation therapy
What benign obstructions could be found in the oropharynx?
• Zenker's diverticulum
○ Outpouching of esophagus leading to food regurgitation or bacterial colonization
§ Sign = halitosis
• Crycopharyngeal bar
• Fibrosis of neck b/c of radiation or trauma?
What malignant obstructions could be found in the oropharynx?
• (head and neck cancers) Squamous cell carcinoma:
○ Soft palate
○ Upper larynx
What are the symptoms associated with achalasia?
• Dysphagia to solids AND liquids
• Weight loss
• Chest pain
• Difficulty belching
How many types of achalasia are there?
• 3 types
• Type I
○ Swallowing will cause no significant change in esophageal pressurization
• Type II
○ Swallowing leads to simultaneous pressurization spanning the entire esophagus length
○ Botox injections, pneumatic dilation, surgical myotomy work is best
• Type III
○ "spastic". Swallowing leads to abnormal, lumen obliterating contractions/spasms
○ Treated with botox injections, pneumatic dilation, surgical myotomy have poor outcomes
What is the pathophys of achalasia?
• LES pressure and relxation regulated by excitatory and inhibitory NT
• Selective loss of inhibitory neurons in the myenteric plexus resulting in relatively unopposed excitatory neurons
○ Excitatory is cholinergic.
○ Can you use antimuscarinics?
• This leads to hypertensive nonrelaxed esophageal sphincter (LES)
What is meant by PSS?
Progressive systemic sclerosis
• Multisystem disorder
○ Obliterative small vessel vasculitis
○ Connective tissue proliferation with fibrosis of multiple organs
• GI manifestations in 90% of patients
*smooth muscle atrophy might look like weak peristalsis or it might look like flaccid LES and reflux
• Path - smooth muscle atrophy and gut wall fibrosis
How can you treat spastic disorders of the esophagus?
• Calcium channel blockers
• Sildenafil (NO releaser, smooth muscle relaxant)
• Botox injections to paralyze some muscle (reduce spasticity)
What are the benign structural esophageal Disorders?
• Schatzki's ring
○ A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.
• Eosinophilic esophagitis (EoE)
• Extrinsic compression (tumor)
What are the malignant disorders that can cause structural problems in the esophagus?
• Esophageal cancer
○ These can result in strictures
○ Squamous cell cancer
• Mestasis (rare)
○ Breast cancer
○ Renal cell carcinoma
○ Lung cancer
• Direct invasion of a tumor
What is the cardinal symptom of esophageal strictures?
• Dysphagia to solids
• Symptoms usually on a regular or daily basis
• Potentially progressive
• Weight loss and NOT acute history
What are the causes and treatment of esophageal stricture?
○ GERD, radiation, caustic ingestion (including medications), congenital strictures, squamous cell carcinoma, adenocarcinoma
○ EGD, biopsy to rule out cancer
○ Endoscopic dilation using balloons or sequential commercial dilators
What is EoE?
• Eosinophilic esophagitis
• Chronic immune/antigen mediated esophageal disease
• Diagnosed by symptomology and by exclusion
○ Symptoms of esophageal dysfunction
○ Eosinophilic infiltrate in the esophagus
○ Absence of other potential causes of esophageal eosinophilia
What do people with EoE complain of?
• Nearly all have dysphagia
• About 50% of cases have acute food impaction
• Food avoidance
• Heartburn MAYBE
• If children have it the symptoms are more non-specific
○ Feeding intolerance, failure to thrive, abdominal pain
*strong association with other chronic inflammatory conditions or reactions:
*Asthma, atopic dermatitis, seasonal allergies, food allergies
What are the drug treatments for EoE?
• Exclusively steroids: topical >>>>systemic
• Asthma preparations that are then swallowed
• Some evidence for efficacy
What is the more common/practical diet change for EoE?
• 6 food elimination diet (SFED)
• Milk, eggs, wheat, soy, seafood, nuts
What are the classic symptoms of GERD?
○ Burning sensation, substernal or epigastric, rises in chest
○ Often post prandial (after meals)
○ Often positional (nocturnal, lying down)
○ Acidic taste
○ Often positional
• Less classic
○ Water brash, throat clearing, cough
○ Wheezing, stridor, hoarseness
• Often find relief with antacids or anti-secretory medications
What might cause GERD?
• Inappropriate LES relaxation
• Hiatal hernia
• Gastric or esophageal surgery, dysmotility, obstruction
○ Zollinger-Ellison syndrome
What are the risk factors for GERD?
• Males more than femaile
• Caffeine?????? Not good evidence for this
• Alcohol? Minimal evidence
• Other medial illnesses
○ Scleroderma, ZE, gastroparesis
What is the risk for forming adenocarcinoma in the setting of barretts esophagus?
• Not as much as I though
• 0.1-0.5% per year
• Follow these patients and get biopsies
If you have a patient with worrisome barrett's esophagus, what treatment modalities do you recommend?
• Esophagectomy: previously for HGD or any cancer
○ This isn't the best care anymore
• Endoscopic treatment
○ Now for HGD and early esophageal adenocarcinomas
○ Ablation of barrett's tissue
○ resection of visible lesions
What are the risk factors for squamous cell carcinoma?
• Risk factors
○ older age
○ Alcohol/tobacco use
○ Caustic injuries
• Incidence is declining in US and Europe
this is the cancer more commonly found above the gastroesophageal junction (like mid esophagus)
What are the risk factors for adenocarcinoma?
• Older age, smoking obesity, GERD,
• BARRETT'S ESOPHAGUS
• Rising incidence in US and Europe
• Nearly always in distal esophagus or gastric cardia
What infectious diseases can cause esophagitis?
• Probably in immunocompromised patients
○ Herpes simplex
What buzz word for herpetic esophagitis should you know about?
• Punched out ulcers
○ Endoscopic findings
• Viral inclusions on biopsy
You are given an endoscopic picture of an esophagus with some erythema, and potentially some erosion of the first layer. The esophagus looks RINGED, like a worm. What are you thinking?
• Eosinophilic esophagitis
• If given a histology slide that shows obvious inflammatory cell infiltrate into the mucosa, and there are quite a few pink eosinophils in there, you have your diagnosis
• Usually these patients have signs of being allergic to several things and will have chronic esophagus symptoms as well
How many different types of esophageal diverticular are there?
• Zenker's, which is the most common and most test appropriate
○ Halitosis, regurgitation, aspiration
○ Patients gurgle after they swallow
○ ASSOCIATED with reduced UES compliance, but doesn't cause it
• Mid esophagus
○ Asymptomatic usually
○ In cases of TB, associated with mediastinal inflammation
○ Symptomatic, but only occurs as a consequence of hiatal hernia
Esophageal atresia and tracheoesophageal fistula are examples of what kind of disease?
• Congenital - failure of the foregut to divide into trachea and esophagus during the fourth week of embryonic development
• Clinical features
○ Regurgitation, drooling, aspiration
○ H shape, particular formation of fistula, can be missed and diagnosed later with recurrent childhood pneumonia
What is nutcracker esophagus?
• Example of a motility disorder in the esophagus, not a structural obstruction but a functional obstruction
• Peristaltic high amplitude peristalsis
• "nutcracker esophagus"
• Extensive hypertrophy of the inner muscular layer
You are given a barium swallow study and you see the bird beak sign. What is the problem?
• The LES will not open properly
Severe retching or vomiting, especially in the context of alcohol intoxication makes you think what?
• Mallory-weiss tears
• OR boerhaave syndrome
• Tears in the lining of esophagus and the resultant pain, and bloody vomitus
How likely is low-grade dysplasia in the context of barrett esophagus going to result in adenocarcinoma?
• 2-15% in low grade dysplasia
• Up to 60% in high grade dysplasia
• FOLLOW THESE PATIENTS
A tumor that invades into the muscularis layers of the esophagus is AT LEAST what T stage?
• T2 if in the muscularis layers
• T3 is through that into the fat on the outside
• TV is local invasion of other tissues
○ Separate from the N and M grades which rely on lymph node involvement and evidence of metastasis to other organs