GERD... 1. Heartburn. May be exacerbated by meals, bending, or ____? 2. Typical uncomplicated cases do not require _____. 3. Endoscopy demonstrates abnormalities in ____ of patients

1. recumbency. 2. diagnostic studies. 3. one-third (so, MOST patients will NOT have abnormalities)

1. Dysfunction of the LES (usually due to transient relaxations of LES caused by gastric distention) 2. Hiatal hernias 3. Abnormal esophageal clearance 4. Delayed gastric empyting (gastroparesis or obstruction)

Esophagus Flashcards by Cal Schiller

Substernal burning sensation

often radiates to the neck

Pyrosis (heartburn)

Highly specific for GERD

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Difficulty swallowing?

PAINFUL swallowing?

Dysphagia

Odynophagia

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Characterirized by immediate sense of bolus catching in the NECK

Need to swallow repeatedly to clear food from pharynx

Or coughing/chocking

Pharyngeal (oropharyngeal)

Pharyngeal = prompt

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Esophageal dysphagia can be caused, broadly, by what?

Mechicanical obstruction (solids)

Motility disorders (more severe: solids and liquids)

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Study of choice for evaluating heartburn, dysphagia, odynopahgia, structura abnormalities?

Upper endoscopy

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In patients w/ suspected motility disorders (of the esophagus) what study should be performed first?

Barium swallow

barium esophagography

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Mechanical causes of esophageal dysphagia…

Schatzki ring

Stricture (Peptic)

Eisonophilic esophagitis

Cancer (Esophageal )

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Motility-related causes of esophageal dysphagia

Achalasia

ineffective esophageal motility (duh)

Diffuse esophageal spasm

Scleroderma

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Tests function of LES?

esophageal manometry

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A diagnostic study option for esophageal dysphagia but only provides info for acid reflux (no nonacid data provided)

pH testing

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GERD…

Heartburn. May be exacerbated by meals, bending, or ____?
Typical uncomplicated cases do not require _____.
Endoscopy demonstrates abnormalities in ____ of patients

recumbency.
diagnostic studies.
one-third (so, MOST patients will NOT have abnormalities)

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two most common symptoms of GERD?

heartburn and regurgitation

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Etiologies of GERD?

Dysfunction of the LES (usually due to transient relaxations of LES caused by gastric distention)
Hiatal hernias
Abnormal esophageal clearance
Delayed gastric empyting (gastroparesis or obstruction)

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Damage to the mucosa of the esophagus due to acidity of refluxate… gastric fluid is what pH?

4.0, which is caustic to the esophageal mucosal surface

prolonged exposure -> dysplasia

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Number one symptom of GERD? When’s it appear?

Heartburn… 30-60 min pc

Or upon reclining

(relieved w/ antacids)

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GERD pts also typically present w/ waterbrash

regurgitation of sour fluid or almost tasteless saliva into the mouth

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GERD is one of the top three causes of?

Chronic cough

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less common ssx associated w/ GERDth

Cough
Dysphagia (Suggest advacned dz)
Laryngitis
Sore throat
Chest pn
Difficulty w/ sleep (pts might angle their beds)

NOTE: in the absence of heartburn, these atypical unlikley to be related to GERD!!!

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Physical exam for GERD is unremarkable… but what should be in your differential diagnosis?

Esophageal motility d/o
Peptic ulcer
ANGINA PECTORIS
functional d/o
Eosinophilic esophagitis

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Initially no work up for GERD is warranted unless patient presents w/ alarm freatures, which are?

Fever/chills/ns

Wt. loss

Odynophagia

Dysphagia

OR patient who doesn’t respond to (h2, PPI therapy)

They get an EGD

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GERD Pt w/ alarm features OR pts who don’t respond to therapy will get an EGD.

However, a specialist may also order what?

EGD = test of choice

But also consider esophageal pH or LES manometry

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Barrett’s Esophagitis (15% of pts w/ GERD)… what happens to the esophageal tissue?

(GERD complication)

Normal squamous epithelium of esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells

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Development of Barret esophagus may affect ssx of GERD in what way?

Development may actuallY REDUCE ssx

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Barrett esophagus increases risk for what?

esophageal adenocarcinoma

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A less common (5%) complication of GERD? Presents how? How might we treat this complication?

Peptic stricture... presetned w/ progressive food dysphagia (can also result in reduction in heartburn as stricture acts as barrier) (tx is endoscopic dilation)

What is a tx for ALL patients w/ GERD?

Lifestyle modifications Smaller meals, avoidance of acidic foods or those that precipitate reflux and discontinue tobacco use

GERD Lifestyle modificatins in regards to sleep?

Avoid lying down for 3 hours after meals Elevate the head of the bed (also, consider wt loss)

Infrequent heartburn (less than once weekly) can be treated w/ what (in addition to lifetsyle mods)

OTC antacids (tums, rolaids, etc.) [provide rapid relief but short duration] H2 receptor antagonists (-tidines)

Compare antacids w/ H2 receptor antagonists

OTC antacids (quick relief/short duration; contain Mg so caution in pts w/ kidney problems) H2 receptor antagonists (onset is 30 mins, but provide 8 hrs relief)

Patients w/ troublesome ssx and pts w/ known complications of GERD (erusive, esophagitis, Barret, stricture) should be treated w/ what?

Lifestyle mods PPIs (-prazoles) taken before breakfast (superior to H2antagonists)

If ssx persist beyond 4 weeks w/ PPI conisder what?

PPI BID

If ssx persist beyond 4 weeks w/ PPI BID, then what?

Refer for EGD!

Any patient w/ alarm ssx of GERD gets? What are the alarm ssx?

EGD duh Dysphagia Odynophagia Wt. loss Fever/chills/ns

Pts may discontinue use of PPI after how long?

8-12 wks if relief has been achieved. However, 80% will relapse and require PPIs again. can try a lower dose or "on-demand" pharmacotherapy

When should you cosnider a fundoplication for a pt w/ GERD?

In those who are refractory to tx or have serious dz

Three types of esophagitis?

Infectious (candida, CMV, herpes) Pill-induced Eosinophilic

Immunosurpressed pt w/ odynophagia, dysphagia, and chest pn? What you think and how do you diagnose?

Infectious esophagitis Diagnose w/ endoscopy w/ biopsy

What are the common etiological agents of Infectitous esophagitis? How do get a specific diagnosis?

Candidia (#1) CMV Herpes Get a endoscopy w/ biopsy for specific diagnosis

Infectitous esophagitis tx is directed at the specific agent. For fungal, whats the tx?

Empirically, w/ antifungal (fluconazole) If no response in 5 days, schedule an EGD

What are some common offending agents for pill-induced esophagitis? How do we fix?

NSAIDs K-Cl pills quinidine Abx (doxy, tetra, clinda, TMP-SMX) Vitamin C (patients should remain upright for 30 mins to avoid)

Eosinophilic esophagitis ssx? Dx? Tx?

Dysphagia w/ solid foods AND heartburn Dx w/ EGD w/ mucosal biopsy which should show eisinophilic infiltrates.

What should you ask a pt w/ suspected eosinophilic esophagitis?

Ask about a history of ashtma/allergies/atopic dermatitis

Tx for eosinophilic esophagitis?

1. First line = PPI BID for 2 months 2. Referall to allergist/immunologist 3. Topical corticosteroids (swallowed/inhaled Fluticasone)

Esophageal webs... thin membranes of squamous epithelium. Mosty asymptomatic, but may cause?

intermittent dysphagia

Schtazki/esohageal rings... assocaited w/? Ssx?

Similar to webs, usually asymptomatic, but may cause dysphagia or GERD like symptoms Associated w/ hiatal hernia

Diagnosis and tx for esophgeal webs/rings?

Barium swallow... Tx is w/ endoscopic dilation (balloon dialtion)

Ssx of zenker diverticulum? Dx w/?

Progressive dysphagia Sensation of food sticking Halitosis Regurgitation of undigested bolus Diagnose w/ barium swallow

Gradual, progressive dysphagia for solids and liquids. Regurgitation of undigested food. Barium esophagogram with “bird’s beak” distal esophagus. Esophageal manometry confirms diagnosis.

achalasia

Where does the peristalsis of achalasia occur? And what's is impaired?

Peristalsis is in distal 2/3... relaxation of LES is impaired

Progessive dysphagia for solids AND liquids Regurge of undigested food Substernal discomfort after eating Adotoption of emptying manuevers Wt loss

achalasia

PE is unremarkable but a barium swallow will show a birds beak deformity

achalasia

How do you confirm achalasia?

EGD and manometry

A differential that should be considering in idiopathic achalasia?

Chagas dz (consider if recent travel to S/C America) | more rapido in onset

Tx for achalasia?

1. Botulinum toxin (but will likely relapse) 2. Pneumatic dilation 3. Surgery (cardiomyotomy + fundiplication + PPI)

Develop secondary to portal hypertension. Found in 50% of patients with cirrhosis. One-third of patients with _____develop upper gastrointestinal bleeding. Diagnosis established by upper endoscopy.

esophageal varices

Dilated submucosal veins that develop 2* to portal HTN?

esophageal varices

Risk factors for increased risk of esophageal bleed.... (1) the size of the varices (2) the presence at endoscopy of ____ (longitudinal dilated venules on the varix surface) (3) the severity of liver disease (as assessed by Child scoring) (4) active _____

2. red wale markings | 4. alcohol abuse

Tx of an esophageal varice bleed?

Hemostasis/stablization

After stablization of esohageal varices, what's the follow on tx?

Consider prophylatic abx... Reduce portal HTN! (ocreotide) Propanol (beta blockade) Variceal band ligation

Hematemesis; usually self-limited. Prior history of vomiting, retching in 50%. Endoscopy establishes diagnosis.

Mallory weiss tear

Non penetrating mucosal tear a GEJ?

Mallory weiss tear

For MWT, what's the order of tx?

Stablize then upper endoscopy

Tx for MWT also includes?.

Endoscopic hemostatic agents (epi, cautery, endoclip)

Complete rupture of the esophagus Shock, pneumomediastinum

Boerhaave syndrome

Esophageal carcinoma... Relatively form of cancer 3:1 male to female ratio... Maybe ____ or _____

squamous cell or adenocarcinoma

When do esophageal carcinomas present?

Late, w/ advanced disease

Progressive food dysphagia Odynophagia Significant unexplained weight loss May have aches/pains

Esophageal carcinoma | aches/pains from mets

Dx of esopahgeal carcinoma?

Non specific lab findings Barium swallow to asses dysphagia EGD establishes dx...

Tx of esophageal carcinoma?

Depends on staging... usually involves combo of surgery/chemo/rad (poor prognosis)

How do you confirm the Dx of achalasia?

Esophageal Manometry

Barium esophagography discloses characteristic findings, including esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying, and a smooth, symmetric “bird’s beak” tapering of the distal esophagus. What do we do next?

After esophagography, endoscopy is always performed to evaluate the distal esophagus and GEJ to exclude a distal stricture or a submucosal infiltrating carcinoma. The diagnosis is CONFIRMED by esophageal manometry.

what is esophageal manometry? What does it confirm?

Manometry will indicate how well the esophagus can perform peristalsis. Manometry also allows the doctor to examine the muscular valve connecting the esophagus with the stomach, called the lower esophageal sphincter, or LES. Confirms the dx of achalasia

which study would I do on the esophagus to measure pH continuously for 24-48 hours?

Esophageal pH recording and Impedance Testing Great for measuring acid reflux, but not nonacid reflux.

Esophagus Flashcards

(73 cards)