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Gastroenterology > Esophageal Disorders > Flashcards

Esophageal Disorders Flashcards

1
Q

Evaluation of esophagus

A

-heartburn
-dysphagia- difficulty swallowing
-odynophagia- painful swallowing
-rule out heart/pulmonary

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2
Q

oropharyngeal dysphagia

A

-difficulty transferring material from oropharynx to esophagus
-complex process
-more HEENT issue
-cant get food to go down, repetitive swallowing, coughing, food goes down the wrong way
-symptoms:
-sense of bolus in neck, cough, choke, repetitive swallowing
-may have associated dysphonia, dysarthria, or neuro symptoms

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3
Q

oropharyngeal dysphagia causes and dx

A

-neurologic- MS
-muscular and rheum d/o- sjogren’s (not enough saliva)
-metabolic d/o- thrush
-infectious ds
-structural d/o
-video esophagraphy- best test to evaluate oropharyngeal dysphagia -> allows for rapid sequencing

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4
Q

causes of esophageal dysphagia

A

-impaired transport of material down esophagus
-mechanical obstruction- difficulty with solids, progressive, predictable -> as it gets worse and worse lumen gets smaller and smaller (progressive)
-tumor, schatzki’s ring
-motility d/o- difficulty with solids and liquid , episodic unpredictable -> spasms

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5
Q

odynophagia

A

-substernal pain with swallowing that may limit oral intake
-erosive disease
-corrosive injury

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6
Q

dx studies for esophagus

A

-video esophagography
-upper endoscopy (EGD)
-barium esophagram- x-ray
-esophageal manometry- pressure sensitive tube and ask pt to swallow -> sense pressure of esophagus
-esophageal pH recording

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7
Q

gastroesophageal reflux disease (GERD) causes and frequency

A

-20% of adults report weekly heartburn and 10% daily - very common
-causes:
-incompetent LES
-hiatal hernia
-abnormal esophageal clearance- Sjogren’s (bicarbonate helps wash away acid)
-delayed gastric emptying -> gastroparesis obstruction

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8
Q

signs and symptoms of GERD

A

-typical manifestations- heart burn, clearing throat a lot, sour taste, reflux, painful swollowing
-atypical manifestations- cough, chest pain
-physical exam normal limits in uncomplicated disease

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9
Q

GERD differential Dx

A

-pts have difficulty to localize
-esophageal motility d/o
-PUD
-non-ulcer dyspepsia
-angina- cardiac
-spasm- tightness in chest
-pill induced esophagitis
-infectious causes (CMV, herpes candida)

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10
Q

how to rule out cardiac

A

-pain down arm
-pain with activity
-does it happen after you eat?
-how long dose it last?
-sore through or cough?
-in complex scenario refer to cardio bc more risky

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11
Q

dx of GERD

A

-EGD*- best test -> can determine type of extent of tissue damage
-barium esophagram- shows reflux -> dysphagia (strictures, zenkers diverticulum -> oropharyngeal)
-pH monitoring- unnecessary unless tx failure or atypical symptoms

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12
Q

erosive esophagitis

A

-normal
-grade A-D
-Grade C- < 75
-grade D- across the entire span

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13
Q

GERD tx goals

A

-goals:
-symptomatic relief
-heal esophagus
-prevent complications
-often treat empirically if no alarming symptoms present -> wt loss (intentional/unintentional), GI bleed (what does poop look like), dysphagia, odynophagia, anemia (CBC)
-pepto bismol- makes blood dark

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14
Q

GERD tx

A

-dietary and lifestyle changes:
-caffeine- even green tea can cause
-OTC meds
-foods and timing of meals
-smoking
-wt loss- most helpful
-bed position- bed at an angle - elevate
-dont eat 3 hours before bed
-medications:
-antacids
-H2 blockers
-PPI- omeprazole
-promotility agents- move food out of stomach faster -> gastroparesis (can cause diarrhea)
-step up vs step down approach- hit hard and ween off -> or start small taper up
-PPI can effect iron and Ca over long period of time -> dont want pts on forever -> opt for H2 if so

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15
Q

surgical fundoplication

A

-fundus of the stomach is gathered, wrapped, and sutured around the lower end of esophagus and the LES
-increase the pressure at the lower end of the esophagus and thereby reduces acid reflux
-create barrier for acid to come back up -> issue is that it also is a barrier for food going down
-laparoscopically or trans

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16
Q

complications of GERD: barrett’s esophagus

A

-arises from chronic acid injury
-approx 10% of pts with GERD
-other risk factors- obesity, smoking, familial predisposition
-increase risk of esophageal adenocarcinoma (small %)
-dx- columnar epithelium lining > or equal to 1cm of the distal esophagus and has intestinal metaplasia
-tx- surveillance program of EGDs and PPI
-if normal for several years -> you can drop down to H2
-controversial endoscopy- 3-5 years:
-low grade dysplasia-endoscopic resection +RFA (dont need to know specific)
-indefinite- optimize PPI, repeat 3 mos
-high grade dysplasia- dysplasia-endoscopic resection +RFA or esophagectomy (dont need to know specific)

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17
Q

complications of GERD- stricture

A

-10% of pts
-often low at GE junction
-progressive dysphagia - as lumen gets smaller and smaller -> dysphagia
-Bx - you have to make sure its not cancer
-tx- dilation and PPI - so food can go down -> balloon
-in the lumen- scar tissue

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18
Q

zankers diverticulum

A

muscles are pushing against scar tissue and dilate

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19
Q

infectious esophagitis

A

-mostly in immunosuppressed pts
-painful
-most common causes:
-candida- difficulty swallowing
-herpes
-CMV- longitudinal ulcers - HIV?
-dx- upper endoscopy with bx

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20
Q

infectious esophagitis treatment

A

-based on underlying disease
-candida- fluconazole
-CMV
-herpes- acyclovir, valcyclovir

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21
Q

eosinophilic esophagitis

A

-MC in children and young adults (M>F)
-genetics-familial
-food allergies
-immune response in genetically susceptible - food or environmental
-clinical findings:
-dysphagia
-heartburn
-vomiting
-chest pain
-failure to thrive- children
-eosinophilia or elevated IgE
-chronic

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22
Q

eosinophilic esophagitis dx

A

-barium esophagram- small caliber esophagus, long tapered strictures or multiple concentric rings* -> specific
-EGD: necessary for dx and bx:
-fine concentric rings
-vertical furrowing
-whitish papules
-bx- multiple eosinophils in mucosa in proximal esophagus- 15/hpf

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23
Q

eosinophilic esophagitis tx

A

-3 main modes
-1.diet- allergist vs empiric food elimination-6 main food types -> milk, eggs, wheat, soy, fish, nuts
-rule at allergen
-meds- inhaled steroids -> swallow it (fluticasone and PPI) and dupixent (dupilumab) for failures
-dilation of strictures- gradual dilate due to risk of perforation (risk of perforation and bleeding is much higher bc its stiff)
-can be chronic- difficult to treat

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24
Q

inhaled steroids

A

-asthma -> dont swallow
-if swallowed can cause candida- esophagus thrush
-eosinophilic esophagitis- swallow it so it reaches esophagus

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25
Q

pill induced esophagitis

A

-directed prolonged mucosal contact
-pills without water
-dont take pills and laying down before bed
-most common:
-NSAIDs
-KCL
-quinidine
-bisphosphonates
-iron, vit c
-antibiotics (doxycycline, bactrim, tetracycline, clindamycin)
-symptoms- several hrs after
-complications with chronic injury -> severe esophagitis, stricture, perforation

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26
Q

pill induced esophagitis tx

A

-rapid healing when offending agent eliminated
-lifestyle
-PPI- if actual injury

27
Q

caustic injury esophagitis

A

-accidental vs deliberate
-ingestion of alkali (drain cleaners) or acid
-symptoms - immediate severe burning
-vomiting
-perforation

28
Q

caustic injury esophagitis dx and tx

A

-CXR and abdominal xray- pneumonitis, free air under diaphragm if perforation
-initial tx supportive:
-fluids
-no NG lavage or oral antidotes
-pain meds
-NPO
-endoscopy usually within 25hrs to assess extent of injury (may have none) -> mile and severe injury
-mild- quick recovery, few complications, advance diet over 24-48 hrs
-severe injury- high risk of perf, TE fistula, bleeding, stricture, +/- surgery, feeding tube after 24hrs

29
Q

caustic injury complications

A

-stricture of esophagus- recurrent dilation, steroid injection to decrease recurrence
-squamous cell carcinoma (2-3%)- surveillance 15-20 years after caustic ingestion -> watch

30
Q

benign esophageal lesions

A

-mallory-weiss syndrome
-webs, rings
-diverticula
-benign tumor

31
Q

mallory-weiss syndrome

A

-nonpenetrating mucosal tear at GE junction
-happens with vomiting a lot- alcoholism
-weight lifting
-minimal bleed
-self limiting
-vomiting blood can occur
-arises from increase in transabdominal pressure
-5% of UGI bleeds
-dx- endoscopy (stable pt) -> .5-4cm linear mucosal tear at GE junction or can be below in gastric mucosa

32
Q

mallory-weiss syndrome tx

A

-most self-limiting nothing needed
-fluids, blood if needed
-endoscopic tx- cautery, inject epi, endoclip or band
-surgery (treatment failure)- very rare

33
Q

esophageal webs

A

-thin membrane of squamous mucosa in mid to upper esophagus
-single vs multiple
-congenital
-associated with blistering skin diseases
-Plummer-Vinson syndrome (PVS)- triad- dysphasia, web, iron deficiency
-graft vs host disease, phemphigoid, epidermolysis bullosa, iron deficiency anemia

34
Q

schatzki rings

A

-at bottom
-thin, circumferential mucosal structures
-distal esophagus at squamo-columnar junction
-associated with hiatal hernia, reflux
-dx and tx:
-barium esophagram is more sensitive test
-endoscopy- evaluate and treat
-dilate- rupture
-PPI- acid

35
Q

esophageal diverticula

A

-mid or distal esophagus
-secondary to motility disorders or strictures
-seldon symptomatic
-usually asymptomatic

36
Q

zenker’s diverticulum

A

-protrusion of pharyngeal mucosa at the pharyngeoesophageal junction
-prevalence < 1%, underreported
-cause- ? due to decrease elasticity of UES, abnormal esophageal motility
-muscles working against tissue that stiff -> dialtion/pouching

37
Q

zenkers diverticulum

A

-symptoms- coughing up food in pouches, waking up to food on pillow, bad breath
-complications- aspiration pneumonia, lung abscess, bronchiectasis
-dx- barium esophagram, EGD to exclude malignancy
-tx-
- < 1cm none if asymptomatic
- > 1cm or symptomatic - surgical or endoscopic

38
Q

benign esophageal tumors

A

-rare, submucosal
-lieomyoma MC (like a fibroid)
-usually asymptomatic- large lesions: dysphagis, ulceration or pain
-dx- endoscopy or barium esophagram -> need EUS to confirm benign
-ultrasound
-usually bx

39
Q

esophageal varices

A

-dilated submucosal veins due to portal hypertension -> can result in major UGI bleed
-MC cause of portal HTN- cirrhosis -> 50% have varices
-30% of 50% with varices will have serious bleed

40
Q

risk of bleeding from varices

A

-size
-appearance at endoscopy (red color signs)
-severity of liver disease
-active alcohol use

41
Q

esophageal varices signs and symptoms

A

-hematemesis
-melena
-hematochezia (10%)
-hypovolemia and shock
-fainting, vomiting blood, pooping blood

42
Q

management of esophageal varices

A

-NG tube confirms UGI bleed
-blood, fluid
-FFP and platelets if coagulopathy
-endoscopy once hemodynamicaly stable (2-12h)
-differential- mallory-weiss, PUD, vascular anomalies

43
Q

esophageal varices tx

A

-tx- banding (preferred) or sclerotherapy
-injection
-meds:
-antibiotics- for peritonitis
-reduce portal pressure
-+/- vitamin K -> if abnormal prothrombin time
-lactulose- if encephalopathic -> decrease ammonia

44
Q

balloon tamponade: tx for esophageal varices

A

-this is acute treatment to stop bleeding
-gastric and esophageal balloons apply pressure
-only if medication and endoscopic tx fails and is temporary
-complications frequent
-compress bleeding
-intubate when you do this

45
Q

portal decompressive procedures (TIPS and surgery): esophageal varices tx

A

-creates a shunt from portal vein to hepatic vein- bypass liver
-can stop acute hemorrhage in 90%
-high mortality rate on actively bleeding pt

46
Q

esophageal varices rebleeding

A

-high risk without further therapy - band
-banding preferred over sclerotherapy
-B-blockers (propanolol, nadolol)
-liver transplant- who -> MELD score > or equal to 14 and hx of bleed
-rebleeders:
-transjugular intrahepatic portosydstemic shunt (TIPS)
-surgical shunt- rare since TIPS

47
Q

prevention of first blood: esophageal varices

A

-endoscopy for all pts with cirrhosis
-small or no varices- 1-3 years f/u
-large or high risk appearing:
-beta blockers if no contraindication
-banding if intolerant to beta blockers

48
Q

esophageal cancer epidemiology

A

-50-70 yo
-men>women
-increased incidence in China and Southeast Asia
-lower socioeconomic status

49
Q

esophageal cancer: squamous cell epidemiology

A

-> blacks
-EtOH and tobacco
-50% in distal 1/3
-tylosis- genetic disorder
-achalasia
-caustic induced stricture
-other head and neck cancer
-increased in China and SE asia

50
Q

esophageal cancer: adenocarcinoma

A

->whites
-barrett’s
-most in distal 1/3
-associated with obesity, ?smoking
-more prevalent in US and Europe

51
Q

symptoms of esophageal cancer

A

-progressive dysphagia
-wt loss
-+/- odynophagia
-+/- TE fistula - esophagus - trachea
-+/- chest or back pain, hoarseness

52
Q

disease course: esophageal cancer

A

-spreads to adjacent and supraclavicular lymph node, liver, lungs and pleura
-tracheoesophageal fistulas (advanced disesase)
-labs:
-anemia if bleeding
-elevated aminotransferase or alkaline phosphatease
-hypoalbuminemia

53
Q

diagnosis esophageal cancer

A

-barium esophagram- polypoid, infiltrative or ulcerative lesion seen
-upper endoscopy EGD- allows for bx

54
Q

staging of esophageal cancer

A

-PET-CT of chest and abdomen/pelvic- pulmonary, hepatic metastasis, lymph node, local and distance spread
-EUS with FNA of lymph node
-TNM (tumor size, nodes, metastasis)- squamous vs adeno

55
Q

esophageal cancer treatment and prognosis (dont really need to know)

A

-stages 0, 1, 2a- surgical resection, +/- preoperative chemo and radiation
-stages 2b, 3a, 3b- surgical resection, preoperative chemo and radiation
-stages 3c and 4- pallative care (radiation, chemo, stents, photodynamic therapy)
-prognosis- 5 year survival rate is less than 20%

56
Q

motility disorders of esophagus

A

-achalasia
-diffuse esophageal spasm

57
Q

achalasia

A

-idiopathic
-loss of peristalsis in distal 2/3 of esophagus- Auerbach’s plexus disfunction
-impaired relaxation of LES
-symptoms:
-gradual onset of dysphagia for solids and liquids
-substernal discomfort lasting hours
-regurgitation of undigested food hours later
-coughing, aspiration
-foods not going down
-wt loss

58
Q

achalasia differential dx

A

-chagas (trypanasoma cruzi)
-cancer- small cell lung cancer
-DES- spasm
-scleroderma with stricture

59
Q

dx of achalasia

A

-barium esophagram:
-absent peristalsis
-dilated esophagus
-smooth symmetric bird beak appearance (tapering)
-EGD- R/O stricture, cancer
-esophageal manometry:
-pressure sensitive tube to detect peristalsis- gauges pressure
-aperistalsis
-incomplete relaxation of LES
-intraesophageal pressure > gastric pressure

60
Q

treatment of achalasia

A

-balloon dilation of LES:
-cut it and make new sphincter
-1-3 sessions
-75-85% good excellent relief
-3% perforation risk
-laproscopic myotomy
-cardiomyotomy of LES
-good excellent results in > 85% pts
-done with fundoplication to prevent GERD

61
Q

botulinum toxin injection

A

-reduces LES pressure -> must be repeated
-reserved for pts that cant tolerate invasive procedures
-treatment of achalasia

62
Q

diffuse esophageal spasm

A

-non-propulsive contractions
-hyperdynamic contractions
-chest pain, dysphagia (solids and liquids)
-triggers:
-very hot or cold liquids
-eating fast
-stress

63
Q

DES dx and tx

A

-barium esophagram- poor progression of bolus, disordered contraction (not coordinated)
-esophageal manometry- simultaneous, prolonged contractions
-tx- lifestyles, anticholinergics, calcium channel blocker, nitrates
-often quick and acute
-sometimes chronic

Gastroenterology (20 decks)

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