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Flashcards in Esophageal disorders Deck (55):
1

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

2

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

3

2 main types of movement?

- peristaltic: moves food forward
- segmental: mixing

4

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?

- achalasia
- UGI: birds beak (barium swallow study)

5

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

neuromuscular disorders:
- stroke
- myesthenia gravis

6

Distance b/t UES and LES?

- 18-24 cm

7

Normal phases of swallowing? (voluntary, involuntary, and b/t swallows)

voluntary: oropharyngeal phase - bolus is voluntarily moved into pharynx
involuntary:
-UES relaxation
-peristalsis (aboral movement)
-LES relaxation
b/t swallows:
- 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

8

origin of esophageal disorders?

- motility
- anatomic and structural
- reflux
- infectious
- neoplastic
- miscellaneous (perf, burns, bleeding)

9

3 common sxs pt will present with esophageal disorder?

- pain
- obstruction (dysphagia)
- bleeding

10

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:
- stroke
- parkinsons
- poliomyelitis
- ALS
- MS
- diabetes
- myasthenia gravis
- dermatomyositis and polymyositis

upper esophageal sphincter (cricopharyngeal) dysfxn may occur in HTN

11

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

12

Clinical picture of achalasia?

- hx:
dysphagia (MC)
regurgitation
chest pain
heartburn
wt loss
- details:
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
manometry
*** radiologic exam of choice in dx of achalasia is barium swallow study with fluoroscopic guidance

13

When is esophagela manometry used?

- to assess LES pressure and peristalsis

14

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

15

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!!!)

16

What is a nutcracker esophagus?

- high pressure peristaltic contractions

17

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

18

What is a TE fistula?

- most common form of atresia
esophagus fused into trachea
- fluid can accumulate and be regurgitated - into trachea

19

What does gasless abdomen suggest?

- that pt has either atresia w/o a fistula or atresia with a proximal fistula only

20

What is GERD?

- syndrome not a disease
- mucosal damage produced by abnormal reflux of gastric contents into the esophagus

21

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

22

4 major physiologic mechanism that protect against esophageal acid injury?

- clearance mechanisms in upper esophagus
- mucosal integrity
- LES competence
- gastric emptying

23

Classic GERD sxs?

- heartburn (pyrosis): substernal burning discomfort
- regurg: bitter, acidic fluid in the mouth when lying down or bending over***

24

Extraesophageal manifestations of GERD?

- pulm:
asthma (esp at noc)
aspiration pneumonia
chronic bronchitis
pulmonary fibrosis
- ENT:
hoarsenss
laryngitis/pharyngitis
chronic cough
globus sensation
dysphonia
sinusitis
subglottic stenosis
laryngeal cancer

25

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

26

Etiology of GERD?

combo of factors:
- hiatal hernia
- incompetent LES
- decreased esophagus clearance
- decreased gastric emptying
- meds
- anything that results in esophageal irritation and inflammation

27

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
- types:
sliding and paraesophageal/rolling

28

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

- factors:
structural changes
obesity
pregnancy
heavy lifting

29

Complications of hiatal hernia?

- GERD
- hemorrhage (from acid reflux)
- stenosis of esophagus
- ulcerations
- strangulation of hernia
- regurgitation
- increased risk for resp. disease

30

Clinical manifestations of hiatal hernia?

- may be asx
- heartburn
- dysphagia
- reflux with lying down
- pain, burning when bending over

31

Tx goals for GERD?

- eliminate sxs
- manage or prevent complications
- maintain remission

32

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

33

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)
- surgery:
reduce hiatal hernia
repair diaphragm
strengthen GE jxn
strengthen antireflux barrier via gastric wasp
75-90% effective at alleviating sxs of heartburn and regurgitation

34

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

35

Complications of GERD?

- erosive esophagitis
- stricture
- barrett's esophagus

36

What is erosive esophagitis?

-responsible for 40-60% of GERD sxs
-severity of sxs often fail to match severity of the erosive esophagitis

37

What is an esophageal stricture?
What may be needed?

- result of healing of erosive esophagitis - collagen is replacing normal lining - narrowing
- may need dilation

38

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

39

When should you perform dx tests on pt with GERD?

- uncertain dx
- atypical sxs
- sxs assoc with complications
- inadequate response to therapy
- recurrent sxs

40

Dx tests for GERD?

- barium swallow
- endoscopy
- ambulatory pH monitoring
- esophageal manometry

41

When is a barium swallow a first dx test?

- for pts with dysphagia:
stricture (location, length)
mass (location, length)
birds beak
hiatal hernia (size and type)

42

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

43

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

44

What is infection indued esophagitis? Bugs? More common in?

- more common in pts with impaired immunity (HIV)
- fungal: candida
- viruses: herpes and CMV

45

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

46

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

47

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

48

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
sxs:
dysphagia
wt loss
regurg
chronic cough
aspiration
- epiphrenic diverticulum: arises in distal esophagus, just above diaphragm, pulsion diverticulum that probably related to incoordination of esophageal peristalsis and relaxation of LES

49

Tx of esophageal diverticula?

- clients learn to empty esophagus by applying pressure
- limit foods (blenderize - yum!)
- endoscopic surgery

50

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

51

Causes of esophageal perforation?

- iatrogenic: 75% - endoscopy is #1 cause
- boerhaave syndrome: 10-15%: due to ETOH or emesis

52

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

53

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

54

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

55

Common causes of burns in the esophagus?

- lye (goose) vs. acid (stomach)
- risk of perforation
- call someone!!