Flashcards in Esophageal disorders Deck (55):
2 parts of the GI tract that are made up of squamous epithelium? What is rest of bowel made up of?
- esophagus and anus: made up of squamous epi
- rest of bowel: columnar and cuboidal
Parts of esophagus, fxn?
- muscular tube that conveys food from pharynx to stomach
- inner circular muscle
- no serosa (infection and cancer can spread quickly)
- unforgiving organ
- food passes through quickly because of peristalsis
2 main types of movement?
- peristaltic: moves food forward
- segmental: mixing
27 yo male, presents with prog. increasing difficulty in swallowing over one month period
- dysphagia started with solid food, now trouble with liquids
- wt loss, no previous swallowing problem
- PE unremarkable findings
- what is dx? How do we dx?
- UGI: birds beak (barium swallow study)
Causes of dysphagia?
in the lumen: tumor
in the wall:
- achalasia, tumor, GERD
- plummer vinson syndrome
- scleroderma (CT disorder)
- chagas' disease
outside of wall:
-pressure of enlarged lymph nodes
- Thoracic aortic aneurysm
- bronchial carcinoma
- retrosternal goiter
- myesthenia gravis
Distance b/t UES and LES?
- 18-24 cm
Normal phases of swallowing? (voluntary, involuntary, and b/t swallows)
voluntary: oropharyngeal phase - bolus is voluntarily moved into pharynx
-peristalsis (aboral movement)
- UES prevents air entering the esophagus during inspiration and prevents esophagopharyneal reflux
- LES prevents gastroesoph reflux
- persistaltic and non-peristaltic contractions in response to stimuli
- capacity for retrograde movement (belch, vomiting) and decompression
origin of esophageal disorders?
- anatomic and structural
- miscellaneous (perf, burns, bleeding)
3 common sxs pt will present with esophageal disorder?
- obstruction (dysphagia)
Upper esophageal motility disorders are due to what?
oropharyngeal dysphagia (transfer dysphagia):
-pts complain of difficulty swallowing
- tracheal aspiration may cause sxs
pharyngoesophageal neuromuscular disorders:
- myasthenia gravis
- dermatomyositis and polymyositis
upper esophageal sphincter (cricopharyngeal) dysfxn may occur in HTN
What is achalasia?
- incomplete relaxation of LES during swallowing leading to fxnl obstruction and proximal dilation
- aperistalsis, incomplete relaxation, increased resting tone
- ganglion cells of myenteric plexus are diminished or absent
- histology: inflammation in area of M. plexus
- hypotheses: autoimmune, viral infections
- 5% develop squamous cell carcinoma
Clinical picture of achalasia?
25-50% report episodes of retrosternal chest pain
80-90% experience spontaneous regurg
- some pts may present with signs or sxs of pneumonia (aspiration)
- Physical exam - noncontributory
- lab studies: noncontibutory
- imaging studies:
UGI: birds beak
EGD: normal or dilated esophagus
*** radiologic exam of choice in dx of achalasia is barium swallow study with fluoroscopic guidance
When is esophagela manometry used?
- to assess LES pressure and peristalsis
Tx of achalasia?
- goal: relieve sxs by eliminating outflow resistance caused by hypertensive and nonrelaxing LES
- medical and surgical management
- low surgical risk: laraposcopic myotomy, if fail - refer to have repeat myotomy done or pneumatic dilation or esophagectomy done
or can try graded pneumatic dilation - if fail try laparoscopic myotomy
- if high risk for surgery: botox - if fail - nifedipine (CCB)/ isosorbide dinitrate
How does diffuse esophageal spasm (DES) present?
- chest pain
- intermittent dysphagia
- segmental non-peristaltic contractions
- corkscrew esophagus
- muscular hypertrophy
- this can be extremely painful (mistaken for MI - rule this out first!!!)
What is a nutcracker esophagus?
- high pressure peristaltic contractions
What is esophageal atresia?
- congenital abnormalitiy in which mid portion of esophagus is absent
- occurence: 1 in 3,570 and 1 in 4,500
- try to introduce NG tube but it just coils back around
What is a TE fistula?
- most common form of atresia
esophagus fused into trachea
- fluid can accumulate and be regurgitated - into trachea
What does gasless abdomen suggest?
- that pt has either atresia w/o a fistula or atresia with a proximal fistula only
What is GERD?
- syndrome not a disease
- mucosal damage produced by abnormal reflux of gastric contents into the esophagus
PP of GERD?
- primary barrier to GER is LES
- LES normally works in conjunction with diaphragm
- if barrier disrupted, acid goes from stomach to esophagus
4 major physiologic mechanism that protect against esophageal acid injury?
- clearance mechanisms in upper esophagus
- mucosal integrity
- LES competence
- gastric emptying
Classic GERD sxs?
- heartburn (pyrosis): substernal burning discomfort
- regurg: bitter, acidic fluid in the mouth when lying down or bending over***
Extraesophageal manifestations of GERD?
asthma (esp at noc)
Potential oral and laryngopharyngeal signs assoc with GERD?
- edema and hyperemia of larynx
- vocal cord erythema, polpys, granulomas, ulcers
- hyperemia and lymphoid hyperplasia of posterior pharynx
- interarytenyoid changes
- dental erosion
- subglottic stenosis
- laryngeal cancer
Etiology of GERD?
combo of factors:
- hiatal hernia
- incompetent LES
- decreased esophagus clearance
- decreased gastric emptying
- anything that results in esophageal irritation and inflammation
What is a hiatal hernia? Types?
- herniation of portion of stomach adjacent to esophagus through opening in diaphragm (slipped valve)
- opening in diaphragm which allows this to happen is called hiatus, these are common, most are harmless but they do promote reflux
sliding and paraesophageal/rolling
Why do hiatial hernias occur? Etiologies?
- food lodges in pouch: inflammation of mucosa, reflux of food up to esophagus, dysphagia
- often incompetent gastro-esophageal sphincter
- contributing factors: shortening of esophagus, weakness of diaphragm (phrenic nerve cut), increased abdominal pressure
Complications of hiatal hernia?
- hemorrhage (from acid reflux)
- stenosis of esophagus
- strangulation of hernia
- increased risk for resp. disease
Clinical manifestations of hiatal hernia?
- may be asx
- reflux with lying down
- pain, burning when bending over
Tx goals for GERD?
- eliminate sxs
- manage or prevent complications
- maintain remission
Lifestyle goals to prevent GERD?
- avoid large meals
- avoid acidic foods (citrus/tomato), ETOH, caffeine, chocolate, oninon,s garlic, peppermint
- decrease fat intake
- avoid lying down w/in 3-4 hrs after a meal
- elevate head of bed 4-8 inches
- avoid meds that may potentiate GERD (alpha agonists, theophylline, sedatives, NSAIDS)
- avoid clothing that it is tight around the waist
- lose wt
- stop smoking
Tx of GERD?
- antacids: OTC suppressants and antacids approp initial therapy (approx 1/3 pts with heartburn sxs use at least twice weekly)
- H2-receptor antagonists (H2RAs): cimetidine (tagamet), Ranitidine (zantac), famotidine (pepcid), nizatidine (axid)
- PPIs: Omeprazole (prilosec), lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium)
(these are safe during preg)
reduce hiatal hernia
strengthen GE jxn
strengthen antireflux barrier via gastric wasp
75-90% effective at alleviating sxs of heartburn and regurgitation
Postsurgery studies of hiatal hernias?
- 10% have solid food dysphagia
- 2-3% have perm. sxs
- 7-10% have gas, bloating, diarrhea, nausea, and early satiety
- w/in 3-5 yrs 52% of pts back on antireflux meds
Complications of GERD?
- erosive esophagitis
- barrett's esophagus
What is erosive esophagitis?
-responsible for 40-60% of GERD sxs
-severity of sxs often fail to match severity of the erosive esophagitis
What is an esophageal stricture?
What may be needed?
- result of healing of erosive esophagitis - collagen is replacing normal lining - narrowing
- may need dilation
What is Barrett's esophagus? What is the pt at risk for now?
- acid damages lining of esophagus and causes chronic esophagitis
- damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells
- this specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma
When should you perform dx tests on pt with GERD?
- uncertain dx
- atypical sxs
- sxs assoc with complications
- inadequate response to therapy
- recurrent sxs
Dx tests for GERD?
- barium swallow
- ambulatory pH monitoring
- esophageal manometry
When is a barium swallow a first dx test?
- for pts with dysphagia:
stricture (location, length)
mass (location, length)
hiatal hernia (size and type)
What is ambulatory 24 hr pH monitoring?
- physiologic study
- quantify reflux in proximal/distal esophagus
- % time pH is less than 4
- consecutively lower than 4: chronic reflux
When is an esophageal manometry used in GERD?
- limited role in GERD
- assess LES pressure, location and relaxation
- assists placement of 24 hr pH catheter
- assess peristalsis: prior to antireflux surgery
What is infection indued esophagitis? Bugs? More common in?
- more common in pts with impaired immunity (HIV)
- fungal: candida
- viruses: herpes and CMV
What is eosinophilic esophagitis? Assoc with? Tx?
- esophageal bx: many intraepithelial eosinophils (80/high power field)
- assoc with food allergies
- tx: oral steroid (fluticasone) therapy, 220 mcg 2 puffs/day
Cause of mallory-weiss tear? Clinical presentation?
- caused by severe retching and vomiting
- longitudinal tear at gastroesophageal jxn
- clincial setting: chronic alcoholics after a bout of severe vomiting
- tear may be superficial or deep affecting all layers
- clinical picture: pain, bleeding, superimposed infection
- hiatal hernia is found in 75% of pts
- most often bleeding stops w/o intervention but life-threatening hematemesis may occur
What are esophageal varices? Secondary to?
- tortuous dilated veins in submucosa of distal esophagus
- etiology: portal HTN secondary to liver cirrhosis, anything that increases pressure: coughing can start massive bleed
- asx until they rupture leading to massive hemorrhage
- 50% subsides spontaneously
- 20-30% die during first episode
- rebleeding occurs in 70% of cases within one year
What is esophageal diverticula? diff types? Sx?
- saclike outpouching of one or more layers of the esophagus
- zenker's diverticulum: most common of esophageal diverticulum, located above UES
- epiphrenic diverticulum: arises in distal esophagus, just above diaphragm, pulsion diverticulum that probably related to incoordination of esophageal peristalsis and relaxation of LES
Tx of esophageal diverticula?
- clients learn to empty esophagus by applying pressure
- limit foods (blenderize - yum!)
- endoscopic surgery
What is scleroderma?
- chronic CT disease
- motility pattern:
proximal 1/3 striated muscle = normal peristalsis
distal 2/3 smooth muscle: impaired motility
(primarily affects smooth muscle)
- patulous GE jxn: GE reflux can cause distal stricture
Causes of esophageal perforation?
- iatrogenic: 75% - endoscopy is #1 cause
- boerhaave syndrome: 10-15%: due to ETOH or emesis
How common is esophageal rupture?
- rare, 300 cases reported per year
- dx is commonly missed/delayed
- mortality is high: most lethal GI perf, mortality falls with early dx/intervention
What can an esophageal perforation lead to?
- esophageal contents - leak and may cuase necrotizing mediastinhtis and polymicrobial infection - this can lead to shock
- pleural/peritoneal space: rapidly progressive infection/ shock
- can lead to empyema
What pops are we worried about with swallowed FBs?
- peds (80%) of all cases
- prisoners, psych, edentulous adults
- adults = meat and bones
- kids = coins, toys, crayons, pen caps
- pysch and prisoners: unlikey objects, spoons, razors
- most pass spontaneously
- 10-20% require some intervention
- 1% surgical
- most are at anatomic narrowings