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Clinical Medicine II > Esophagus > Flashcards

Esophagus Flashcards

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1
Q

Heartburn/pyrosis 30-60 minutes after meals + upon reclining
Relief from antacids
Regurgitation (sour taste)

Dyspepsia, dysphagia, belching, chest pain, cough, hoarseness, sore throat, sleep disturbances, asthma

→ can develop esophageal mucosal damage (reflux esophagitis)

A

GERD

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2
Q

What are alarm symptoms of GERD?

A

Alarm features: dysphagia, odynophagia, anorexia, unexplained weight loss or evidence of GI bleeding – occult blood in stool, melena, hematemesis, hematochezia

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3
Q

What are some RF for GERD?

A

> 50
Obesity
White
Male
Tobacco use
Family Hx

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4
Q

Reflux of stomach contents
Dysfunction of GE junction (LES pressure <10mmHg), hiatal hernia, truncal obesity
Irritant effects of refluxate
Abnormal esophageal clearance
Delayed gastric emptying
Esophageal hypersensitivity

A

GERD

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5
Q

most common cause of noncardiac chest pain with a negative cardiac work up –

A

GERD

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6
Q

Do an upper endoscopy for GERD if

A

→ “alarm” symptoms (dysphagia, odynophagia, iron deficiency anemia, weight loss)
→ risk for Barrett esophagus (chronic >5 years w/ 3+ RF)

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7
Q

Other diagnostic methods for GERD are

A

Barium esophagography - not commonly used but can assess hiatal hernia size or identify stricture

PH monitoring for those who have unsatisfactory response to empiric antisecretory therapy, atypical symptoms

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8
Q

Refer for GERD if

A

Typical GERD whose symptoms do not resolve w/ empiric management with BID PPI

Suspected extraesophageal GERD symptoms that do not resolve w/n 3 months of BID PPI

Significant dysphagia or “alarm” symptoms

Barrett esophagus for endoscopic surveillance

Barrett esophagus with dysplasia or early mucosal cancer

Surgical therapy is considered

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9
Q

Patients w/ unresponsive symptoms or significant symptom correlation with reflux episodes can be diagnosed with —- —– that can be helped with CBT, instruction of breathing, and tx with low dose TCAs (imipramine or nortriptyline)

A

functional heartburn

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10
Q

For mild, intermittent GERD symptoms:

A

Lifestyle modifications → diet, cigarette cessation, weight loss, avoid laying down w/n 3 hours after eating, elevation of head of bed, sleep on left side
Infrequent heartburn (less than once weekly) → PRN antacids, H2 receptor antagonists (cimetidine, famotidine, nizatidine)

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11
Q

For troublesome GERD symptoms:

A

Initial: once daily oral PPI x 4-8 weeks 30 min before breakfast: –prazole
Inadequate response = BID

Long term: discontinue after 4-8 weeks (expect relapse) → can continue PPI at lowest dose possible, intermittently, PRN

Complications/unresponsive → long term PPI at lowest effective dose

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12
Q

For unresponsive GERD:

A

→ need endoscopy to figure out why meds not working
→ consider increase in daily PPIs or vonoprazan
→ should undergo pH monitoring to determine correlation of symptoms (wait 96 hours after PPI)

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13
Q

For uncontrolled GERD w/ medication

A

Surgical fundoplication (new symptoms may develop)
Minimally invasive magnetic artificial sphincter is FDA approved w/ hiatal hernias <3cm

NOT recommended for those controlled with meds
Obese = gastric bypass

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14
Q

Endoscopy = orange, gastric type epithelium extending upward “tongue-like lesions”

> 1cm from GE junction into distal esophagus

A

Barrett’s esophagus

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15
Q

RF for Barrett’s esophagus

A

> 50
Truncal obesity
Hx of smoking
Male
Family hx of esophageal adenocarcinoma

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16
Q

Squamous epithelium → metaplastic columnar epithelium of goblet + columnar cells

A

Barrett’s esophagus

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17
Q

Biopsies obtained at endoscopy confirm diagnosis
Gastric cardiac
Gastric fundic
Specialized intestinal metaplasia

A

Barrett’s esophagus

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18
Q

Endoscopic screening in adults w/ weekly GERD symptoms for — years w/ — risk factors for adenocarcinoma

A

5+, 3+

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19
Q

How do you treat Barrett’s esophagus?

A

Long term PPIs once or twice daily (reduces risk of cancer)

Nondysplastic Barrett esophagus – surveillance endoscopy q3-5 years

Dysplastic Barrett esophagus – surgery, endoscopic reduction, laser treatments

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20
Q

What are the 5 types of esophagitis?

A

reflux, pill-induced, causatic, eosinophilic, infectious

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21
Q

GERD, heartburn, regurgitation, irritation of respiratory tract → coughing, voice changes, feeling of a lump in throat

A

reflux esophagitis

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22
Q

if meds swallowed w/o water or whip supine with severe retrosternal CP, odynophagia, dysphagia, several hours after taking a medication – suddenly + persist for days

A

pill induced esophagitis

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23
Q

immediately following ingestion → retrosternal CP, odynophagia, oral burns (pain and drooling), voice changes, aspiration (stridor/wheezing)

A

causatic esophagitis

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24
Q

long history of dysphagia for solid-foods or episode of food impaction, heartburn or chest pain (adults)
Abdominal pain, vomiting, failure to thrive (children)

A

eosinophilic esophagitis

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25
odynophagia + dysphagia Sometimes substernal CP Candida – oral thrush, asymptomatic CMV – infection in colon or retina Herpes – oral ulcers
infectious esophagitis
26
What causes pill induced esophagitis
medications directly injuring the esophagus such as: NSAIDs, potassium chloride, quinidine, zalcitabine, zidovudine, alendronate, risedronate, iron, vitamin C, antibiotics
27
What causes causatic esophagitis
accidental or deliberate ingestion of liquid or crystalline alkali or acid (strong acids like vinegar → superficial coagulation necrosis + eschars or bases like detergents → bases are BAD with liquefaction necrosis, thermal burns)
28
What causes eosinophilic esophagitis
food or environmental antigens → response
29
What causes infectious esophagitis
Candida albicans, herpes simplex, CMV
30
With esophagitis you need a
upper endoscopy w/ biopsy
31
causatic esophagitis dx
need circulatory status + assessment of airway patency w/ mucosa + laryngoscopy to assess respiratory distress Need endoscopy w/n 12-24 hours to assess extent of injury
32
eosinophilic esophagitis dx
: eosinophilia or elevated IgE Barium swallow - tapered strictures, multiple concentric rings EREFS in endoscopy - need multiple Edema Concentric Rings Exudates Furrows Strictures Skin testing for allergies Looks like a trachea
33
EREFs
edema concentric rings exudates furrows strictures
34
brushings needed from endoscopy Candidal: diffuse, linear, yellow-white plaques adhered to mucosa Biopsy = hyphae CMV: one to several shallow, superficial ulcerations Large size, “owl’s eye” Herpes: multiple, small deep ulcerations “Punched out” or “volcano-like” appearance
infectious esophagitis
35
reflux esophagitis tx
Reflux: PPI (omeprazole x 8 weeks) gradual taper down Symptoms return = restart lowest dose Severe = repeat upper endoscopy after 8 weeks of treatment to rule out malignancy or vonoprazan
36
pill induced esophagitis tx
Pill-induced: stop offending agent Prevent! Take meds w/ full glass of water + remain upright after ingestion
37
causatic esophagitis tx
Caustic: NEVER neutralize pH or induce emesis Supportive w/ IV fluids, PPIs, analgesics Mild damage w/ edema, erythema, exudates, analgesics: advance to regular diet over 24-48 hrs Severe injury requires continued fasting + monitoring, NG tube after 24 hours → may need esophagectomy, resume liquids 2-3 days after Steroids + ABX NOT recommended
38
eosinophilic esophagitis tx
Eosinophilic: PPIs orally BID x 2-3 months followed by repeat endoscopy and mucosal biopsy Topical steroids BID 8-12 weeks Food elimination Esophageal dilation Intolerant = Dupilumab SQ Refer!
39
infectous esophagitis tx
Infectious: treatment is empiric Candidal: fluconazole If no response, within 3-5 days → endoscopy → still suspected - itraconazole or voriconazole Refractory = IV caspofungin CMV: ganciclovir Cannot tolerate = foscarnet Herpes: immunocompetent -> treat symptoms Immunosuppressed → oral or IV acyclovir Unresponsive = foscarnet
40
Hematemesis after episode of violent retching/vomiting, melena, bleeding associated symptoms ceasing in 24-48 hours Epigastric, back pain, signs of hemodynamic instability (tachy, HOTN)
Mallory-Weiss syndrome
41
Alcohol use Bulimia, food poisoning, hiatal hernia, NSAID abuse, hyperemesis gravidarum
Mallory-Weiss syndrome RF
42
History is prevalent for retching, vomiting, straining → Upper endoscopy: done after appropriate resuscitation Lab: Hgb/Hct to assess bleeding
Mallory-Weiss syndrome
43
Mallory-weiss syndrome tx
Fluid resuscitation + blood transfusions – most stop spontaneously + require no therapy Continued active bleeding → epinephrine, cautery, + mechanical compression w/ endoclip or band Failed endoscopic therapy = angiographic arterial embolization or operative intervention
44
Gradual onset of dysphagia for solids and liquids, substernal discomfort/fullness after eating → may eat more slowly/adopt maneuvers such as lifting neck or throwing shoulders back to help emptying → regurgitation of undigested food (nocturnal) Weight loss
Achalasia
45
Motility disorder – idiopathic from loss of peristalsis in distal ⅔ of esophagus + impaired relaxation of LES
Achalasia
46
PE usually benign CXR: air-fluid level enlarged, fluid-filled Barium esophagography: esophageal dilation, loss of peristalsis, poor emptying, “bird’s beak” tapering of distal esophagus → endoscopy performed after High- resolution esophageal manometry confirms diagnosis (showing absence of normal peristalsis + impaired relaxation after swallowing)
achalasia
47
achalasia treatment
Reduce LES pressure → endoscopic injection w/ botulinum toxin First line for patients w/ comorbidities who are poor candidates for invasive procedures → pneumatic balloon dilation Preferred initial treatment for patients w/ inadequate relief from cardiomyotomy → **surgical heller cardiomyotomy** Usually performed w/ fundoplication to reduce GERD risk
48
Extremely hot/cold beverages can trigger disease – Chest pain, dysphagia, and regurgitation
esophageal spasm
49
Motility disorder - repetitive, non-peristaltic, spontaneous contractions of distal esophageal smooth muscle – LES function is normal
esophageal spasm
50
Barium swallow XR → corkscrew appearance is characteristic Endoscopy can exclude others, 24-hour manometry to show uncoordinated esophageal contractions
esophageal spasm
51
esophageal spasm tx
No cure – Medications can help: nitrates, CCBs, and/or botox injections to lower esophageal muscle, antidepressants, anti-anxiety
52
Peptic – gradual development of solid food dysphagia months-years at GE junction
strictures
53
Peptic - endoscopy w/ biopsy is mandatory to differentiate
stricture
54
stricture tx
Peptic - dilation + long term treatment with PPI
55
Acute GI hemorrhage (preceding retching or dyspepsia) - hematemesis, coffee-ground emesis, melena, hematochezia Variceal bleeding can be severe → hypovolemia → postural VS or shock
varices
56
varices are commonly caused from --
portal HTN
57
Dilated submucosal veins which can cause serious upper GI bleeding → cirrhosis
varices
58
patients w/ chronic liver disease + compensated suspected cirrhosis should undergo diagnostic endoscopy to determine of varices are present
prevention for first bleeding -- diagnostic endoscopy None = repeat in 3 years Treat with beta blockers in those with class B or C cirrhosis Prophylactic band ligation
59
Increased risk of bleeding: Size Presence of red wale markings Severity of liver disease (Child scoring) Active alcohol abuse Lab: CBC, prothrombin time w/ INR, Cr, liver enzymes, blood type + screen Upper endoscopy Increased risk with encephalopathy, ascites, high bilirubin, low albumin, and high prothrombin time
varices
60
How do you prevent varices rebleed?
combo beta blockers + variceal band ligation (carvedilol)
61
TIPS – reserved for those in varices with
recurrent 2+ episodes of variceal bleeding that have failed endoscopic or pharmacologic therapies Liver transplant
62
How do you treat varices
Acute resuscitation → fluids + blood products Decompensated cirrhosis + severe bleeding = platelet transfusion if <50,000 IV ceftriaxone, octreotide, band ligation therapy/sclerotherapy Vitamin K for abnormal prothrombin time Lactulose for those w/ encephalopathy Emergent endoscopy after stable (usually within 12-24 hours) → banding or sclerotherapy Balloon tube tamponade for those w/ massive GI bleed Portal decompression procedures - transvenous intrahepatic portosystemic shunts (TIPS) for those w/ acute variceal bleeding that cannot be controlled w/ pharmacologic + endoscopic therapy
63
Solid food dysphagia (intermittent and NOT progressive) obstructing boluses may pass w/ extra liquids or after regurgitation Plummer-Vinson Syndrome: dysphagia, cervical webs, and iron deficiency anemia Can also have atrophic glossitis
webs and rings
64
What are RF for webs and rings?
Web = congenital or eosinophilic esophagitis, graft vs host, pemphigoid, bullosa, vulgaris, anemia Rings = hiatal hernia, GERD
65
Web = thin, diaphragm-like membranes of squamous mucosa that occur in mid or upper esophagus and may be multiple Schatzki rings = smooth, circumferential, thin (<4mm) mucosal structures at distal esophagus at squamocolumnar junction
webs and rings
66
dx for webs and rings --
Barium esophagogram
67
What's the tx for webs and rings
Dilation or incision of ring Minimum lumen diameter of 15-18mm achieves symptom remission PPI long term suppressive therapy
68
Difficulty swallowing, sense of lump in throat, bad breath As diverticulum enlarges → retains food → halitosis (spontaneous regurg of undigested food → nocturnal choking, neck protrusion
zenker diverticulum, common in male >60
69
Protrusion of pharyngeal pouch mucosa from loss of elasticity of upper esophageal sphincter → restricted opening during swallowing
zenker diverticulum
70
What can help dx zenker diverticulum
Video esophagography Barium esophagram
71
zenker diverticulum treatment
Small <1 cm= observation Symptomatic or >1cm = surgery
72
Early symptoms = nonspecific Solid food dysphagia which progresses weeks-months Odynophagia Significant weight loss Coughing on swallowing, pneumonia Chest or back pain Hoarseness (most present with stage IV)
esophageal cancer
73
RF for SCC esophageal cancer
Low socioeconomic status, consumption of alcohol, tobacco, hot beverages, nitrosamines, poor nutritional status
74
RF for adenocarcinoma esophageal cancer
Age, obesity, smoking, chronic GERD w/ Barrett Most in North America + europe
75
Esophageal cancer is common in
50-70 Males > females
76
PE often unrevealing – could have lymphadenopathy (supraclavicular or cervical) or hepatomegaly = metastasis Lab: anemia, occult blood loss, elevated AST or ALT, hypoalbuminemia Barium esophagogram first line to evaluate dysphagia → appearance of polypoid, obstructive, ulcerative lesion → endoscopy to establish diagnosis CXR: adenopathy, widened mediastinum, pulmonary or bony mets, signs of fistula
esophageal cancer
77
--- guides treatment – need contrast CT of chest, abdomen, pelvis, lymph node biopsies, PET scans, bronchoscopy
staging
78
treatment of esophageal cancer depends on
Depends on stage, location, patient preference, functional status,and treatment team Classify patients by: → early stage (curable) → advanced stage (uncurable)
79
How do you treat curable esophageal cancer?
Esophagectomy (high cure but high risk) Endoscopic mucosal resection (less risk) Surgery +/- chemoradiation therapy Carboplatin + paclitaxel Chemo + radiation w/o surgery Supportive
80
How do you treat incurable esophageal cancer?
Surgery not warranted Primary = provide relief Combo radiation/chemo to achieve palliation (but also negative side effects) Radiation alone for more advanced cancer Feeding tube placement

Clinical Medicine II (50 decks)

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