Esophageal Disorders Flashcards Preview

Gen Med: GI > Esophageal Disorders > Flashcards

Flashcards in Esophageal Disorders Deck (67):

What is Dyspepsia?

1. Impaired Digestion
2. Discomfort in upper abdomen or chest described as gas, feeling of fullness, gnawing, or burning
3. Described as Indigestion, heartburn, & Agida


What are the most common causes of dyspepsia?

2. PUD


Name some less common causes of Dyspepsia?

1. Gastritis
2. Esophageal/Gastric Ca
3. Celiac Dz
4. Food allergy
5. Gastroparesis
6. Ischemic bowel Dz


What is Dysphagia?

Difficulty swallowing (generally painless)
A. Pressure sensation or food gets stuck


With Dysphagia what do you want to determine?

Do Solids or Solids & Liquids get stuck?
A. Solids (Obstruction)
B. Solids & Liquids (mechanical abnormality)


Causes for Dysphagia

1. Achalasia
2. Esophageal CA
3. Zenker’s diverticulum
4. Schatzki’s ring
5. Esophageal stenosis/stricture


What is Odynophagia?

Painful swallowing


Causes for Odynophagia

1. Esophageal spasm
2. Esophagitis
3. Mallory-Weiss tear


What are the alarm symptoms of esophageal cancer

Dysphagia with:
Age > 60 yr
Heme (+) stools
Sx’s > 6 mo
Weight loss


Name for Diagnostic Modalities

1. Esophagram (Barium Swallow)
2. Esophagogastroduodenoscopy (EGD/upper endoscopy)
3. Esophageal Manometry (Motility testing)
4. 24 Hour Esophageal pH monitoring


What is GERD?

Recurrent reflux of gastric contents into distal esophagus due to mechanical or functional abnormality of Lower Esophageal Sphincter (LES)


Symptoms of GERD

1. Pressure
2. Heartburn (pyrosis)
3. Dysphagia


Factors promoting GERD

1. ↑ Gastric volume after meals
2. ↑ Gastric pressure
A. Truncal obesity
B. PP recumbency
C. Pregnancy
3. Delayed gastric emptying
A. Gastroparesis


Contributing Factors of GERD

1. Medications
A. Anticholinergics (dyspepsia/constipation), TCA’s (ileus)
B. NSAID’s, ASA, Steroids, Bisphosphanates
2. Foods
A. Caffeine, chocolate, spicy foods, citrus, carbonated liquids
Fats (Slow to digest)
B. Peppermint, ETOH (Relax LES)
3. Lifestyle behaviors
A. Smoking, wt gain, eating late, overeating


Complications of GERD

1. Reflux Esophagitis
A. Visible mucosal damage
B. Erosions or ulcers in distal esophagus at squamocolumnar junction (Z-line)


Causes of esophagitis

1. Inflammation of esophagus
2. Causes in non-immunocompromised pt
A. Candidiasis (Tx with oral fluconazole (Diflucan))
B. Pills
Alendronate (Fosamax), risendronate (Actonel), doxycycline, NSAIDs, iron, Vit C, KCl, quinine
Tx w/ Sucralfate (Carafate) susp., viscous lidocaine


Complications of esophagitis

1. Esophageal Stricture
2. Barrett’s Esophagus


Risk factors for esophageal adenocarcinoma

1. Large HH
2. Duration of GERD
3. Long segment of BE
4. Abnormal mucosa
A. Ulcerations
B. Stricture
C. Nodules


What is the gold standard for diagnosing Barrett's Esophagitis?

Upper Endoscopy (EGD) w/ Bx of distal esophagus


Lifestyle modifications for GERD

1. Small meals
2. Eliminate acidic/caffeinated foods
3. Eliminate factors that relax LES
4. Weight reduction
5. Avoid lying down w/in 3 hr of meals
6. Elevate HOB 6-8”
7. Smoking cessation
8. Chew (non-mint) gum to ↑ saliva


What can someone take for mild intermittent GERD Sx's

1. Antacids
2. Histamine 2 Receptor Antagonists


What can someone take for persistent GERD Sx's

1. Proton Pump Inhibitors (PPI)


Long Term Therapy for GERD

1. PPI Therapy
A. If sx’s relieved, therapy may be d/c’d after 8-12 wk
B. Pt w/complications of GERD, lifelong PPI qd-bid


If the patient is unresponsive to PPI's what is indicated?

1. Upper endoscopy
2. Want to r/o Reflux esophagitis, ZE syndrome, Barrett’s esophagus, stricture, PUD, eosinophilic esophagitis, tumor


When to get an upper endoscopy for Barrett's Esophagus
A. For no dysplasia
B. Low grade dysplasia
C. High grade dysplasia

A. q 2-3 yr, after 2 yearly (-) results
B. q 6 mo for 1 year, then yearly thereafter
C. : q 3 mo in those being followed


Indications for Surgery

1. Extra-esophageal manifestations of reflux
2. Severe GERD & noncompliant w/ lifelong medical Tx
3. Large HH & persistent regurgitation despite PPI’s


General Characteristics for infectious esophagitis

Most common in immunocompromised
B. Organ transplants
C. Leukemia
D. Lymphoma
E. Chronic steroid therapy


Pathogens involved in infectious esophagitis

1. Candida albicans
A. Immunocompromised
B. Uncontrolled DM
C. Chronic steroid therapy
D. Undergoing radiation treatments
E. Systemic Abx
2. Herpes simplex virus (HSV)
A. Immunocompromised
3. Cytomegalovirus (CMV)
A. Immunocompromised


S&S of infectious esophagitis

1. Odynophagia (most common)
2. Dysphagia (this sx & above are most common in immunocompromised)
3. May also have:
B. Oral thrush (Candida)
C. Oral ulcers (HSV)


When is an endoscopy w/ Bx done for diagnostic certainty?

1. Candida
A. EGD not required if (+) oral thrush-Tx
B. Diffuse linear yellow-white plaques adhering to mucosa
2. CMV
A. Large shallow superficial ulcerations
3. HSV
A. Multiple small deep ulcerations


Treatment for candida esophagitis

1. Fluconazole (Diflucan) 200 mg PO/IV x 1, then 100 mg PO/IV qd x 14-21 d (2 weeks after sx’s resolve)
2. IV Amphotericin B for life threatening infection 0.3mg/kg/day


Treatment for CMV esophagitis

Ganciclovir (Cytovene) 5mg/kg IV q 12 h x 3-6 wk


Treatment for Herpes (HSV) esophagitis

1. Acyclovir (Zovirax) 400 mg po 5 X daily x 7-10 d
2. Acyclovir 5 mg/kg IV q8h x 7-14 d if odynophagia


What is Mallory-Weiss Tear?

1. Non-transmural mucosal tear at lower esophagus
2. May arise from events that suddenly increase trans-abdominal pressure
A. 2° to severe prolonged vomiting (50% cases)


Primary RF for Mallory-Weiss Tear

1. Chronic Alcoholism
2. Bulimia


Signs & Sx’s of Mallory-Weiss Tear

1. Painless hematemesis following severe vomiting
2. +/- melena
3. Abd pain from retching


Diagnostic test for Mallory-Weiss Tear

1. Upper Endoscopy (EGD)
A. Only necessary if (-) Hx
B. Linear tears (0.5 – 4 cm) usually located at GE junction


Differential Dx for Mallory-Weiss Tear

1. PUD
2. Erosive gastritis
3. AV malformations
4. Esophageal varices/Portal HTN
5. ZE syndrome


Treatment for Mallory-Weiss Tear

1. Fluid resuscitation
2. Blood transfusions
3. 80-90% of tear stop bleeding spontaneously w/in few days


Treatment for Pt with continued bleeding in Mallory-Weiss Tear

1. Endoscopic hemostatic therapy
A. Local injection w/ epinephrine (1:10,000)
B. Electrocautery
C. Mechanical compression of artery - Endo-clip (hemoclip) or endoscopic band ligation
D. Operative intervention
(Pts who fail endoscopic therapy)


What is a Schatzki’s Ring?

1. Circumferential ring of esophageal tissue in lower esophagus causing narrowing
A. Squamocolumnar junction
B. Lower esophageal junction
2. Most asymptomatic
3. Dysphagia w/ solid foods


Diagnostic studies for Schatzki’s Ring



Treatment for Schatzki’s Ring

Endoscopic dilatation


What is Eosinophilic Esophagitis ?

1. Eosinophilic inflamm. of esophagus leading to clinical esophageal dysfunction
2. Hallmark is marked tissue eosinophilia of esophagus on Bx obtained via EGD
3. Esophageal dilatation to relieve dysphagia sx’s from strictures
4. Pathogenesis is unknown
5. Allergy testing
6. PPI trial 8-12 wks
7. Fluticasone MDI & swallowed
8. Budesonide (steroid slurry) to coat esophagus


What are Esophageal Varices?

1. Dilated esophageal veins 2° to portal HTN
A. Cirrhosis (50% of pts)
(Alcoholics, Chronic hepatitis)
B. Budd Chiari Syndrome
(Thrombosis of hepatic vein)


1/3 of pts w/ varies develop?

Serious UGI bleed


Signs & Sx’s of Esophageal Varices

1. Acute & severe UGI hemorrhage
2. +/- preceding vomiting
3. Results in:
A. Hypovolemia
B. Shock
C. Death


Esophageal Varices: How do you assess hemodynamic status

1. SBP < 100 mmHg, HR >100 bpm = severe GI bleed
2. SBP > 100 mmHg, HR >100 bpm = moderate GI bleed
3. Normal SBP & HR = minor GI bleed


Hct take how long to show effect of active bleeding? (esophageal varices)

24-72 hrs


Management of esophageal varices

1. 2 large bore (≥ 18 g) IV lines
A. Blood & fluid replacement dependent on hemodynamic status & labs
(STAT CBC, PT/INR, BUN/Cr, LFT’s, Type & X-match)
2. FFP, Plts, Vitamin K
A. Correct coagulopathy
(INR > 1.8 or platelets < 50,000)
3. Antibiotic prophylaxis
A. ↑ Risk for 2° peritonitis, pneumonia, UTI
B. IV antibx (ceftriaxone/Rocephin or quinolone) - Covers gram (-) as well as resistant gram (+) organisms
4. Nasogastric tube (NGT)
A. Use for all suspected UGI bleeds
B. (+) blood, coffee ground emesis, (+) guaiac = UGI bleed
5. Vasoactive drugs, Terlipressin & octreotide 50-µg bolus IV, then 25-50 µg/h IVF for 1-5 d
A. Reduces splanchnic blood flow and portal HTN
B. Effective in initial control of bleeding
6. Lactulose
A. Treats hepatic encephalopathy assoc w/ cirrhosis
7. Emergent Upper Endoscopy
A. Identify source of bleeding -
Varices, PUD, Mallory Weiss tear
B. Renders endoscopic therapy
- Cautery, injection of sclerotic agent, endoclip or banding


Initial management for esophageal varices?

1. Balloon tube tamponade
A. Mechanical tamponade w/ gastric & esophageal balloons
- Provides temporary control of variceal bleeding
- High complication rate (ulcerations, perforation, airway obstruction)


Once initial bleeding controlled, Tx aimed at reducing high risk re-bleeding. How is this done?

Beta Blockers & variceal band ligation

TIPS procedure
- Reserved for pt who fails above management or has recurrent bleeding


What is the TIPS Procedure?

Transjugular intrahepatic portosystemic shunts (TIPS)
1. “Creation of low-resistance channel between hepatic vein & intrahepatic portion of portal vein using angiographic techniques”
A. Placement of wire stent from hepatic vein thru liver to portal vein --> decompresses portal venous system & controls acute varices bleeding


What is Esophageal Dysmotility?

Caused by neurologic factors, intrinsic or external blockage or malfunction of esophageal peristalsis

Neurogenic dysphagia
Zenker’s diverticulum
Esophageal stenosis
Esophageal spasm


What is Neurogenic Dysphagia?

1. Dysphagia of liquids & solids
A. Caused by injury/disease to brainstem or CN IX, X, XI & XII


What is Zenker’s Diverticulum?

1. Posterior outpouching of esophagus thru pharyngeal constrictor muscles
A. Impaired relaxation and spasm o cricopharyngeal muscle
B. “Esophageal herniation”
2. Pouch collects food → regurg & extreme halitosis
3. Dysphagia (high)
4. Globus
5. Older pt


Diagnostic studies for Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?



Treatment of Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?

1. Surgical Cricopharyngotomy
A. Cut stronger muscle to equalize pressure, allowing hernia to retract
2. Botox injection to cricopharyngeal muscle
A. Relaxes


What is Achalasia?

1. Loss of peristalsis in distal 2/3 of esophagus & impaired relaxation of LES
2. Causes gradual dysphagia w/ episodic regurg & chest pain
A. Solids & liquids
B. No alarm sx’s
3. M=F


Pathophysiology of Achalasia?

1. Idiopathic
2. Electroconduction abnormality
3. Loss of inhibitory neurons w/in the wall of esophagus
4. LES sphincter muscle unable to relax


Diagnostic Studies for Achalasia

1. Esophagram (affirms suspicion)
A. 1st step in Dx
B. Dilated esophagus
C. Loss of esophageal peristalsis
D. Poor esophageal emptying of barium
E. Narrow esophago-gastric junction w/ “bird-beak” appearance
- Caused by persistently contracted LES

2. EGD 1st line if achalasia w/alarm sx’s

3. Manometry (confirms diagnosis)
Final and most accurate test


Achalasia Treatment

1. Pneumatic dilatation-1st line
2. Botox injection into LES
A. Blocks acetylcholine & relaxes LES
3. Heller Myotomy
A. Last resort due to risk of GERD
B. Used if refractive to above Tx’s


Esophageal Stenosis/Stricture characteristics

1. Dysphagia for solid foods
2. Slow progression indicates more benign process
3. Rapid process suggests malignancy


What is an Esophageal Spasm?

1. Neural conduction disorder causing intermittent substernal pain
2. May not related to swallowing
A. Triggered by cold drink


Sx's of Esophageal Spasm

1. Substernal crushing CP, often radiates to back, possible dysphagia/regurg
A. EKG & Cardiac enzymes to R/O CAD


Diagnostic Studies for esophageal spasm

1. Manometry-confirms Dx
2. +/- Esophagram


Treatment for esophageal spasm

1. CCB & Nitrates
2. Symptomatic
A. Eat slowly & take smaller bites of food
B. Warm liquids may facilitate swallowing
C. Trial PPI’s since GERD may cause dysphagia
3. Neurogenic dysphagia
A. Treat underlying Dz
4. Esophageal spasm
A. CCB – nifedipine 10 mg po 30-45 mins ac
B. Oral nitrates –SL NTG prn or isosorbide 10-20 mg qid
5. Benign strictures
A. Esophageal dilation x 1-3 sessions
B. Laproscopic myotomy
6. Malignant strictures
A. Surgical resection