Esophagus Flashcards
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)
GERD
What are alarm symptoms of GERD?
Alarm features: dysphagia, odynophagia, anorexia, unexplained weight loss or evidence of GI bleeding – occult blood in stool, melena, hematemesis, hematochezia
What are some RF for GERD?
> 50
Obesity
White
Male
Tobacco use
Family Hx
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
GERD
most common cause of noncardiac chest pain with a negative cardiac work up –
GERD
Do an upper endoscopy for GERD if
→ “alarm” symptoms (dysphagia, odynophagia, iron deficiency anemia, weight loss)
→ risk for Barrett esophagus (chronic >5 years w/ 3+ RF)
Other diagnostic methods for GERD are
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
Refer for GERD if
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
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)
functional heartburn
For mild, intermittent GERD symptoms:
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)
For troublesome GERD symptoms:
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
For unresponsive GERD:
→ 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)
For uncontrolled GERD w/ medication
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
Endoscopy = orange, gastric type epithelium extending upward “tongue-like lesions”
> 1cm from GE junction into distal esophagus
Barrett’s esophagus
RF for Barrett’s esophagus
> 50
Truncal obesity
Hx of smoking
Male
Family hx of esophageal adenocarcinoma
Squamous epithelium → metaplastic columnar epithelium of goblet + columnar cells
Barrett’s esophagus
Biopsies obtained at endoscopy confirm diagnosis
Gastric cardiac
Gastric fundic
Specialized intestinal metaplasia
Barrett’s esophagus
Endoscopic screening in adults w/ weekly GERD symptoms for — years w/ — risk factors for adenocarcinoma
5+, 3+
How do you treat Barrett’s esophagus?
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
What are the 5 types of esophagitis?
reflux, pill-induced, causatic, eosinophilic, infectious
GERD, heartburn, regurgitation, irritation of respiratory tract → coughing, voice changes, feeling of a lump in throat
reflux esophagitis
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
pill induced esophagitis
immediately following ingestion → retrosternal CP, odynophagia, oral burns (pain and drooling), voice changes, aspiration (stridor/wheezing)
causatic esophagitis
long history of dysphagia for solid-foods or episode of food impaction, heartburn or chest pain (adults)
Abdominal pain, vomiting, failure to thrive (children)
eosinophilic esophagitis
odynophagia + dysphagia
Sometimes substernal CP
Candida – oral thrush, asymptomatic
CMV – infection in colon or retina
Herpes – oral ulcers
infectious esophagitis
What causes pill induced esophagitis
medications directly injuring the esophagus such as: NSAIDs, potassium chloride, quinidine, zalcitabine, zidovudine, alendronate, risedronate, iron, vitamin C, antibiotics
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)
What causes eosinophilic esophagitis
food or environmental antigens → response
What causes infectious esophagitis
Candida albicans, herpes simplex, CMV
With esophagitis you need a
upper endoscopy w/ biopsy
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
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
EREFs
edema
concentric rings
exudates
furrows
strictures
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
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
pill induced esophagitis tx
Pill-induced: stop offending agent
Prevent! Take meds w/ full glass of water + remain upright after ingestion
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
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!
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
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
Alcohol use
Bulimia, food poisoning, hiatal hernia, NSAID abuse, hyperemesis gravidarum
Mallory-Weiss syndrome RF
History is prevalent for retching, vomiting, straining
→ Upper endoscopy: done after appropriate resuscitation
Lab: Hgb/Hct to assess bleeding
Mallory-Weiss syndrome
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
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
Motility disorder – idiopathic from loss of peristalsis in distal ⅔ of esophagus + impaired relaxation of LES
Achalasia
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
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
Extremely hot/cold beverages can trigger disease –
Chest pain, dysphagia, and regurgitation
esophageal spasm
Motility disorder - repetitive, non-peristaltic, spontaneous contractions of distal esophageal smooth muscle – LES function is normal
esophageal spasm
Barium swallow XR → corkscrew appearance is characteristic
Endoscopy can exclude others, 24-hour manometry to show uncoordinated esophageal contractions
esophageal spasm
esophageal spasm tx
No cure –
Medications can help: nitrates, CCBs, and/or botox injections to lower esophageal muscle, antidepressants, anti-anxiety
Peptic – gradual development of solid food dysphagia months-years at GE junction
strictures
Peptic - endoscopy w/ biopsy is mandatory to differentiate
stricture
stricture tx
Peptic - dilation + long term treatment with PPI
Acute GI hemorrhage (preceding retching or dyspepsia) - hematemesis, coffee-ground emesis, melena, hematochezia
Variceal bleeding can be severe → hypovolemia → postural VS or shock
varices
varices are commonly caused from –
portal HTN
Dilated submucosal veins which can cause serious upper GI bleeding
→ cirrhosis
varices
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
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
How do you prevent varices rebleed?
combo beta blockers + variceal band ligation (carvedilol)
TIPS – reserved for those in varices with
recurrent 2+ episodes of variceal bleeding that have failed endoscopic or pharmacologic therapies
Liver transplant
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
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
What are RF for webs and rings?
Web = congenital or eosinophilic esophagitis, graft vs host, pemphigoid, bullosa, vulgaris, anemia
Rings = hiatal hernia, GERD
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
dx for webs and rings –
Barium esophagogram
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
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
Protrusion of pharyngeal pouch mucosa from loss of elasticity of upper esophageal sphincter → restricted opening during swallowing
zenker diverticulum
What can help dx zenker diverticulum
Video esophagography
Barium esophagram
zenker diverticulum treatment
Small <1 cm= observation
Symptomatic or >1cm = surgery
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
RF for SCC esophageal cancer
Low socioeconomic status, consumption of alcohol, tobacco, hot beverages, nitrosamines, poor nutritional status
RF for adenocarcinoma esophageal cancer
Age, obesity, smoking, chronic GERD w/ Barrett
Most in North America + europe
Esophageal cancer is common in
50-70
Males > females
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
— guides treatment – need contrast CT of chest, abdomen, pelvis, lymph node biopsies, PET scans, bronchoscopy
staging
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)
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
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
