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Gastroenterology > Esophageal Disorders > Flashcards

Esophageal Disorders Flashcards

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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
pill induced esophagitis
-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
26
pill induced esophagitis tx
-rapid healing when offending agent eliminated -lifestyle -PPI- if actual injury
27
caustic injury esophagitis
-accidental vs deliberate -ingestion of alkali (drain cleaners) or acid -symptoms - immediate severe burning -vomiting -perforation
28
caustic injury esophagitis dx and tx
-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
caustic injury complications
-stricture of esophagus- recurrent dilation, steroid injection to decrease recurrence -squamous cell carcinoma (2-3%)- surveillance 15-20 years after caustic ingestion -> watch
30
benign esophageal lesions
-mallory-weiss syndrome -webs, rings -diverticula -benign tumor
31
mallory-weiss syndrome
-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
mallory-weiss syndrome tx
-most self-limiting nothing needed -fluids, blood if needed -endoscopic tx- cautery, inject epi, endoclip or band -surgery (treatment failure)- very rare
33
esophageal webs
-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
schatzki rings
-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
esophageal diverticula
-mid or distal esophagus -secondary to motility disorders or strictures -seldon symptomatic -usually asymptomatic
36
zenker's diverticulum
-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
zenkers diverticulum
-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
benign esophageal tumors
-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
esophageal varices
-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
risk of bleeding from varices
-size -appearance at endoscopy (red color signs) -severity of liver disease -active alcohol use
41
esophageal varices signs and symptoms
-hematemesis -melena -hematochezia (10%) -hypovolemia and shock -fainting, vomiting blood, pooping blood
42
management of esophageal varices
-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
esophageal varices tx
-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
balloon tamponade: tx for esophageal varices
-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
portal decompressive procedures (TIPS and surgery): esophageal varices tx
-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
esophageal varices rebleeding
-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
prevention of first blood: esophageal varices
-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
esophageal cancer epidemiology
-50-70 yo -men>women -increased incidence in China and Southeast Asia -lower socioeconomic status
49
esophageal cancer: squamous cell epidemiology
-> 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
esophageal cancer: adenocarcinoma
->whites -barrett's -most in distal 1/3 -associated with obesity, ?smoking -more prevalent in US and Europe
51
symptoms of esophageal cancer
-progressive dysphagia -wt loss -+/- odynophagia -+/- TE fistula - esophagus - trachea -+/- chest or back pain, hoarseness
52
disease course: esophageal cancer
-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
diagnosis esophageal cancer
-barium esophagram- polypoid, infiltrative or ulcerative lesion seen -upper endoscopy EGD- allows for bx
54
staging of esophageal cancer
-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
esophageal cancer treatment and prognosis (dont really need to know)
-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
motility disorders of esophagus
-achalasia -diffuse esophageal spasm
57
achalasia
-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
achalasia differential dx
-chagas (trypanasoma cruzi) -cancer- small cell lung cancer -DES- spasm -scleroderma with stricture
59
dx of achalasia
-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
treatment of achalasia
-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
botulinum toxin injection
-reduces LES pressure -> must be repeated -reserved for pts that cant tolerate invasive procedures -treatment of achalasia
62
diffuse esophageal spasm
-non-propulsive contractions -hyperdynamic contractions -chest pain, dysphagia (solids and liquids) -triggers: -very hot or cold liquids -eating fast -stress
63
DES dx and tx
-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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