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Flashcards in Esophageal Disorders Deck (58)
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1

Symptoms of esophagitis

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

2

Causes of esophageal dysphagia via mechanical obstruction

Solids worse than liquids (in beginning)

3

Schatzki ring

-mechanical
intermittent dysphagia, not progressive; band around esophagus that sometimes spasms in, impinges esophagus, then releases
-know what this looks like on barium swallow
-tiny band of esophagus that pinches esophagus
-may vomit up food because it can’t go down
-next bite of food may go down fine

4

Peptic stricture

-mechanical causes dysphagia
-from chronic heartburn, progressively worse

5

Esophageal cancer

-mechanical causes dysphagia
-progressively worse, usually age >50yo, smoker/drinker (extraluminal mass may impinge)

6

Eosinophilic esophagitis

-mechanical causes dysphagia
-young adults, strictures, papules

7

Motility disorders

Solid and liquid foods equally affected

8

Achalasia

-motility cause of dysphagia
-progressive dysphagia
**Birds beak appearance**

9

Diffuse esophageal spasm

-motility cause of dysphagia
-intermittent, presents with chest pain (swallow something cold, have substernal chest pain; or when vomiting)

10

Scleroderma

-motility cause of dysphagia
-chronic heartburn, substernal discomfort (autoimmune disease)

11

Case: A 68yo woman with a h/o rheumatoid arthritis presents to your office with a c/o painful swallowing which is becoming worse over the past 2 weeks. She also complains of some substernal burning. Raynauds issues in past, worse when laying down, ask if pt is taking meds (naproxen) or steroids (both can effect esophagus)

Think odynophagia

12

Odynophagia is

a sharp, substernal pain on swallowing

13

Usual cause of odynophagia

Often due to infectious etiologies such as esophageal candida, herpes, or cytomegalovirus
*This should be in the differential for immunocompromised patients, HIV patients, etc.

14

______ is the study of choice for evaluating persistent GERD, dysphagia, odynophagia, and structural abnormalities

Upper Endoscopy (EGD)

-Biopsy, cultures, and intervention can be performed if warranted

15

When is Barium esophagography performed?

-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

16

Esophageal manometry is used to

Determine 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)

17

Esophageal pH recording provides information regarding

esophageal reflux

18

Case: A 56yo man who smokes 1PPD and drinks 2 beers/night comes into your office complaining of a chronic cough. His wife reports he sometimes coughs himself awake at night.

Think GERD

This is reflux- tobacco and alcohol make it worse (especially if consumed close to bedtime, meals before med too; pregnancy causes loss of LE tone too)
Aging- lose some lower esophageal tone.

19

GERD is a condition that develops when

the reflux of stomach contents causes substernal burning, chronic cough, foul taste, etc.

20

Cause of GERD is

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

21

Irritants from GERD cause

Mucosal damage, gastric acid often with a pH

22

GERD can also be from __________, associated with more severe esophagitis, especially Barrett esophagus

Hiatal hernias
(stomach is sliding through diaphragm, this causes chronic s/s)

23

S/S of GERD

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

24

Occasionally can diagnose GERD 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

25

One complication of GRED is

**Barrett Esophagus**

26

Barrett Esophagus is a 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 (esophageal cancer)
-Present in up to 10% of those with severe, chronic reflux induced injury

27

Hallmark of Barretts Esophagus is ________

the presence of orange, gastric type epithelium that extends from the stomach into the esophagus in a circumferential manner

KNOW HISTO PIC
(clinical pic too, esophagus appears "orange")

28

With Barretts esophagus diagnosis, EGD every _________

3-5 years recommended to look for changes

29

Barretts esophagus presents with no skip lesions or ulcers, crawls up esophagus homogenously, treated with

2x PPI for life

30

Peptic stricture

-another complication of GERD
-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
-A luminal diameter of ~15mm is needed to relieve dysphagia
-Long term PPI use is required to try and reduce the chance of relapse

31

GERD treatment for mild-intermittent S/S

-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

32

GERD treatment for troublesome S/S

-PPIs become the mainstay of therapy
-Take 30min before breakfast for 4-8 weeks (takes this long to heal ulcers/lacerations; will recur if you don't change your diet or take H2 receptor blockers)
-Some patients may require BID therapy
-Long-term Therapy, many patients experience relapse and begin continuous PPI therapy

33

Surgical treatment for GERD

Nissen fundoplication has an 85% success rate in controlling symptoms and ultimately healing esophagitis
-Side effects are dysphagia, bloating, flatulence, dyspepsia and diarrhea happen in over 30% of patients
-Not recommended in patient currently well controlled with PPIs

34

Nissen fundoplication entails

Grab fundus of stomach, wrap fundus around esophagus and create more pressure around lower esophageal sphincter to make more tone/make the sphincter tighter

35

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 (assume thrush is also in esophagus)
-Also look for oral ulcers or consideration for CMV infection in other sites (retina, colon)

36

For colitis patients with infectious esophagitis, think

think CVM (CMV Colitis, especially HIV patients)

37

Case: A 26yo man is being treated for a condition stemming from a tick bite which an erythema migrants rash. He presents half-way through his treatment with a c/o severe retrosternal chest pain and dysphagia after taking his medication.
**Reports he feels like he is “swallowing over a lump”**

Developing sharp, severe retrosternal pain; Lyme disease tx is doxycycline, VERY acidic, causes ulcers
Feel like food is getting stuck when swallowing, or feel pain


THINK PILL ULCER

38

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
-Think elderly pts (take multiple pills, laying down, small amt of water)

39

Pill induced- Other caustic injuries can be caused by

toxic ingestions

-Suicide attempts or accidental consumption by children (child consuming dish washer pod)
-Burning, pain, gagging, dysphagia, drooling

40

Mallory Weiss Syndrome

A non-penetrating mucosal tear at the G-E junction that generally results from increased transabdominal pressure

-people who vomit a lot (alcoholics, bulimics)

41

Mallory Weiss Syndrome may also present with

hematemesis or melena too

42

Treatment for Mallory Weiss Syndrome

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

43

Esophageal varicies rupture vs mallory weiss

Esophageal varicies rupture- huge amount of frank red blood

Mallory Weiss- bloody tinged vomit, small amount of oozing blood (may be in stools as well)

44

Zenker Diverticulum

a protrusion of pharyngeal mucosa at the pharyngoesophageal junction

-Small sac, when you swallow food particles get stuck in sac

-Symptoms include dysphagia, halitosis, and regurgitation of undigested food (regurgitate food you ate 2-3 days ago)

45

Zenker Diverticulum often occurs in

the elderly and complications can include aspiration pneumonia and lung abscesses as well

-Curative treatment is a surgical diverticulectomy

46

A 46yo man with a known h/o chronic alcohol dependence presents to the emergency room with substernal pain, hematemesis, and waning mental status. He is found to be hypotensive and immediate resuscitation efforts begin with IVF and blood transfusions. His roommate brought him into the ER stating he projectile vomited blood 15 minutes prior.

Think esophageal varices

47

Esophageal varices are

-Dilated submucosal veins that develop in patients with serious portal hypertension

48

What might occur with esophageal varices?

Severe upper GI bleeding

-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

49

Treatment for esophageal varices

Treatment can be multifactorial depending on the severity of the varices and the severity of the underlying disease

50

Vasoactive drugs used to treat esophageal varices

Somatostatin and octreotide – reduce splanchnic and hepatic blood flow
-Vit K

-many need emergent endoscopy, banding or balloon tamponade

51

________ for encephalopathy, which can complicate an acute variceal bleeding episode

Lactulose

52

Antibiotic prophylaxis can be given for tx of varices but

high risk of spontaneous bacterial peritonitis or pneumonia

53

Portal decompressive procedures

TIPS and portosystemic shunt

54

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

(Needle creates bypass to reroute blood around scarred liver; Alleviates pressure)

55

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

56

Esophageal Achalasia

-Gradual, progressive dysphagia for solids and liquids
-Loss of peristalsis in the distal 2/3rds (smooth muscle) of the esophagus

57

S/S of Esophageal Achalasia

-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
-Diagnosis confirmed with esophageal manometry

58

Treatment for Esophageal Achalasia

1. 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)

2. Pneumatic dilation
(Less effective in younger patients, but the majority get a long lasting response
Relapse common around the 10 year mark)

3. Surgical myotomy
(Excellent improvement in 90% of patients; GERD is a common side effect of the procedure; Fundoplication often performed at the same time)