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Flashcards in esophageal disorders Deck (46):
1

esophageal symptoms

Dysphagia, odynophagia (painful swallowing), GERD/”heartburn” symptoms almost always indicate a primary esophageal disorder

-Esophageal dysphagia can be caused by mechanical lesions or by motility disorders
Dysphagia can be worse with solids vs. liquids or issues can be the same given solid or liquid boluses
-Dysphagia can be due to the oropharyngeal phase of swallowing or the esophageal phase of swallowing

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Causes of oropharyngeal dysphagia and esophageal dysphageal

-Oropharyngeal dysphagia is caused by a variety of mechanical and neuromuscular conditions:
Drooling, food falling from the mouth, dry mouth, or inability to initiate swallow are hallmarks
-Esophageal dysphagia can be caused by mechanical lesions or by motility disorders
Dysphagia can be worse with solids vs. liquids or issues can be the same given solid or liquid boluses

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Neurologic disorders that can cause oropharyngeal dysphagia

Brainstem mass, stroke
ALS, MS, GBS
Parkinson’s disease, Huntington disease
Tardive dyskinesia

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Autoimmune issues that can cause oropharyngeal dysphagia

Myopathies, polymyositis
Sjogren’s syndrome, sicca

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metabolic disorders that can cause oropharyngeal dysphagia

Thyrotoxicosis, amyloidosis
Cushing disease, Wilson disease

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IDs that can cause oropharyngeal dysphagia

Polio, diphtheria, botulism, Lyme disease, syphilis, candida, HSV, CMV

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Structural disorders that can cause oropharyngeal dysphagia

Zenker diverticulum
Cervical osteophytes, esophageal webs
Oropharyngeal tumors
Radiation changes
Pill ulcer

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motility disorders that can cause oropharyngeal dysphagia

Upper esophageal sphincter dysfunction

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Causes of Esophageal Dysphagia: Mechanical obstruction: Solids worse than liquids

Schatzki ring – intermittent dysphagia, not progressive
Peptic stricture – chronic heartburn, progressively worse
Esophageal cancer – progressively worse, usually age older than 50yo, smoker/drinker
Eosinophilic esophagitis – young adults, strictures, papules

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Causes of Esophageal Dysphagia: Motility disorders:  Solid and liquid foods equally

Achalasia – progressive dysphagia
Diffuse esophageal spasm (DES) – intermittent, presents with chest pain
Scleroderma (AI) – chronic heartburn, substernal discomfort

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slide 6, dx?

Schatzki ring on barium swallow, ring of esophagus gets pinched down, may regurgitate food bolus, then may swallow just fine

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slide 7??

"bird's beak appearance": esophageal achalasia

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case: hx RA, w. painful swallowing worse over 2 wks, some substernal burning
questions?

worse with laying down
has had Raynaud's in past
ask what on for RA (naproxen, steroids can affect esophagus)
dx: odynophagia

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odynophagia is ??

Often due to infectious etiologies such as ??

This should be in the differential for ??


Odynophagia is sharp, substernal pain on swallowing
-esophageal candida, herpes, or CMV
-immunocompromised patients, HIV patients, etc.
tx empirically

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dx studies : Upper Endoscopy (EGD)

Study of choice for evaluating persistent GERD, dysphagia, odynophagia, and structural abnormalities
-Biopsy, cultures, and intervention can be performed if warranted

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Barium esophagography

Dysphagia patients often evaluated via barium swallow first before EGD is performed
If a high suspicion exists for a mechanical lesion, EGD often is done first
(intervention can be done at same time)

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Esophageal manometry

Determines the etiology of dysphagia in patients where there is no obvious mechanical obstruction
Done pre-op as well prior to anti-reflux surgeries (Nissen fundoplication)

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Esophageal pH recording

Provides information regarding esophageal reflux

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case 2: smokes 1 PPD, 2 beers/night, chronic cough

GERD

20

GERD ??

a condition that develops when the reflux of stomach contents causes substernal burning, chronic cough, foul taste, etc.
Affects 20% of adults

Impaired lower esophageal sphincter
This is essentially a barrier to reflux when functioning properly
Normal pressure is 10-30mmHg
Patients with severe erosive GERD often have a sphincter tone of less than 10mmHg
-impaired tone in pregnancy!

21

GERD: irritant effects ??

what is associated with more severe esophagitis??

Mucosal damage, gastric acid often with a pH less than 4.0

Hiatal hernias, esp. associated w. Barrett esophagus

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Symptoms of GERD

Typical symptom is heartburn
Usually 30-60min after eating and while reclining
Relief with antacids, patients will often report taking daily

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Diagnosis of GERD

Occasionally diagnosed with a trial of PPIs
-Essentially a clinical diagnosis and empiric therapy
-The “purple pill” 14 day challenge
EGD or Esophageal pH testing can be considered as well
-Biopsy can help delineate the extend of mucosal damage

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GERD complications: Barrett Esophagus

Condition where the squamous epithelium of the esophagus is replaced by columnar epithelium containing goblet and columnar cells
This is essentially a metaplastic process and can lead to malignancy
Present in up to 10% of those with severe, chronic reflux induced injury
Hallmark is the presence of orange, gastric type epithelium that extends from the stomach into the esophagus in a circumferential manner

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most serious GERD/Barrett Esophagus complication
monitor how??

Most serious potential complication is esophageal CA
EGD every 3-5 years recommended to look for changes

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more GERD complications: peptic stricture

Stricture formation occurs in about 5% of those with chronic esophagitis
Usually presents with gradual solid food dysphagia over months to years
Usually located at the GE junction
-Patients usually require, and benefit from, dilation with gradual catheters inserted over guide wires or balloon procedures (be careful not to perf)
-A luminal diameter of ~15mm is needed to relieve dysphagia
-Long term PPI use is required to try and reduce the chance of relapse (but almost always relapse)

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GERD tx: Mild Intermittent Symptoms

Lifestyle modifications
Avoid bothersome foods (citrus, tomatoes, coffee, spicy foods, chocolate, fatty foods, peppermint, alcohol)
Antacids are the mainstay of therapy for rapid relief
OTC oral H2-receptor blockers – cimetidine, ranitidine, famotidine

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GERD tx: Troublesome Symptoms

PPIs become the mainstay of therapy
Take 30min before breakfast for 4-8 weeks
Some patients may require BID therapy

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GERD tx: Long-term Therapy

Many patients experience relapse and begin continuous PPI therapy

30

GERD sx tx

Nissen fundoplication has an 85% success rate in controlling symptoms and ultimately healing esophagitis
SEs however, including dysphagia, bloating, flatulence, dyspepsia and diarrhea happen in over 30% of patients
Not recommended in patient currently well controlled with PPIs (only refractory cases)

-grab on fundus of stomach and wrap around LES creating more pressure, limits reflux but changes anatomy (slide 21)

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Infectious Esophagitis

*Most common cause of odynophagia and dysphagia*
-Often present with substernal chest pain or discomfort
-Oral thrush is a poor indicator, however should be assessed for possible clues (but may imply yeast in oropharynx)
-Also look for oral ulcers or consideration for CMV infection in other sites (retina, colon) esp. in HIV pts
-Serologic testing: HSV, CMV ("CMV colitis")

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case 3: tick bite, erythema migrans (Lyme disease) -typically where bite occurred, may have satellite lesions
man being tx, presents halfway w. c/o sev. retrosternal CP, dysphages after meds, feels like he is swallowing over a lump

dx? what is the tx he is on?

pill ulcer: Pill induced esophagitis

doxycycline (for Lyme): ulcer inducing

get EGD, may find pill, ulcer may feel like a lump

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Pill-Induced Esophagitis

Caused by numerous medications, classically NSAIDs, potassium, iron, Vitamin C, and antibiotics (especially tetracycline and doxycline
-More likely to occur if pills are swallowed without water or with minimal water
-May occur suddenly and persist for days
-Chronic injury can result in severe esophagitis, hemorrhage, or even perforation

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Pill-Induced Esophagitis: other caustic injuries caused by toxic ingestions

Suicide attempts or accidental consumption by children
Burning, pain, gagging, dysphagia, drooling
-dishwater pods look like gummies

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Mallory-Weiss Syndrome

A non-penetrating mucosal tear at the G-E junction that generally results from increased transabdominal pressure
What patient population might you classically see this in? alcoholics, bulimics
-Sometimes can present with hematemesis or melena too (typ. blood tinged vomit)

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Mallory-Weiss Syndrome tx

Treated with injection of epinephrine or cautery if there is active bleeding that does not spontaneously resolve

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Zenker Diverticulum

protrusion of pharyngeal mucosa at the pharyngoesophageal junction
-Symptoms include dysphagia, halitosis (bad breath), and regurgitation of undigested food
-Often occurs in the elderly and complications can include aspiration pneumonia and lung abscesses as well
-Curative treatment is a surgical diverticulectomy

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case 4: known chronic etOH dependence, ER w. substernal pain, hematemesis, waning mental status, hypotensive, projectile vomiting

Esophageal Varices

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Esophageal Varices

Dilated submucosal veins that develop in patients with serious portal hypertension
-Severe upper GIB may occur
-Bleeding varices can present with severe hematemesis and shock
-50% of all cirrhotics have esophageal varices, and 30% of them will experience bleeding at some point
-Tx can be multifactorial depending on the severity of the varices and the severity of the underlying disease

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Esophageal Varices tx options

-Antibiotic prophylaxis: High risk of SBP (spont. bac. peritonitis) or pneumonia
-Vasoactive drugs: Somatostatin and octreotide – reduce splanchnic and hepatic blood flow
-Vitamin K
-Lactulose for encephalopathy which can complicate an acute variceal bleeding episode
-Emergent endoscopy: Banding or balloon tamponade

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Portal Decompressive Procedures : TIPS – Transvenous Intrahepatic Portosystemic Shunt

Over a wire that is passed through the jugular vein, a mesh stent is passed through the liver parenchyma crating a shunt from the portal vein to the hepatic vein
Can control acute hemorrhage 90% of the time.
Also a strategy for the prevention of re-bleeding in those with severe bleeds
slide 29 pic

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Portal Decompressive Procedures: Portosystemic shunt

When TIPS procedure is unavailable, shunt surgery can be performed to create similar shunting from the portal vein to the hepatic vein
40-60% mortality when done in emergency situations

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Esophageal Achalasia

Gradual, progressive dysphagia for solids and liquids
-Loss of peristalsis in the distal 2/3rds (smooth muscle) of the esophagus
-50% experience substernal chest pain
-Regurgitation of undigested food
-Patients may lift their chins or throw their shoulders back to get food to move through
-Barium esophagram with “bird’s beak” appearance to the distal esophagus (also looks like esophageal ca, but w. less systemic symps)
-Diagnosis confirmed with esophageal manometry

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Esophageal Achalasia tx: Botulinum toxin injection

Results in marked reduction in LES pressure with initial improvement in symptoms in the majority of patients
Relapse reoccurs almost universally by 2 years

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Esophageal Achalasia tx: Pneumatic dilation

Less effective in younger patients, but the majority get a long lasting response
Relapse common around the 10 year mark

46

Esophageal Achalasia tx: Surgical myotomy

Excellent improvement in 90% of patients however GERD is a common side effect of the procedure
Fundoplication often performed at the same time