Esophagus Flashcards
(23 cards)
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
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 (with timing)
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, surgical options
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
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
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
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
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
esophageal spasm tx
No cure –
Medications can help: nitrates, CCBs, and/or botox injections to lower esophageal muscle, antidepressants, anti-anxiety
Esophageal stricture tx
dilation + long term treatment with PPI
How do you prevent varices rebleed?
nonselective beta blockers (carvedilol) + variceal band ligation or sclerotherapy
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
Prevent rebleed w nonselective beta blockers (carvedilol)
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
zenker diverticulum treatment
Small <1 cm= observation
Symptomatic or >1cm = surgery
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)
Radiation therapy
Chemo (Carboplatin + paclitaxel)
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
