Esophagus Disorders Flashcards by Katie Keller

Progressive solid food dysphagia

Patients enhance esophageal emptying by lifting the neck or throwing shoulders back

Regurgitation of undigested food

Achalasia

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Aperistalsis in distal 2/3 of esophagus

Failure/incomplete relaxation of
the LES

Denervation of the esophagus

Achalasia

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What is the cause of primary achalasia?

Result from a defect in inhibitory vagal innervation

Unknown if infectious, autoimmune, or environment is the source

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What is the cause of secondary achalasia?

Chagas disease
Cancer
Lymphoma

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How is achalasia diagnosed?

Barium esophagram
Endoscopy
Usually confirmed by manometry

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If you see the characteristic “Bird’s beak” tapering of the esophagus on a Barium esophagram, what diagnosis is it?

Achalasia

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What are some treatment options for achalasia?

Calcium channel blockers
Botulism toxin injection - Inject the LES (temporary relief (1-6 months))
Pneumatic dilation of LES
Surgical esophagomyotomy of LES

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Characterized by uncoordinated, nonpropulsive contractions of the
esophagus - Uncoordinated motility

Simultaneous distal esophageal contractions with normal peristalsis (Lower esophageal sphincter normal)

Diffuse Esophageal Spasm

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3-5% of patients with diffuse esophageal spasms are likely to progress to what disorder?

achalasia

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What are some signs/symtpoms of esophageal spasms?

Progressive dysphagia
Odynophagia
Intermittent substernal pain
Worsen after ingesting cold fluids, large meals, or emotional stress

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What are the diagnostic measures for esophageal spasms?

Barium esophagram
Esophageal manometry

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If you see a “corkscrew” appearance” tapering of the esophagus on a Barium esophagram, what diagnosis is it?

esophageal spasms

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What are some treatment options for esophageal spasms?

Small meals
Avoiding cold foods
Antacids
Calcium channel blockers
NTG

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Inflammation of the esophagus

Three types

Esophagitis

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Any patient who has trouble swallowing and hurts in their chest, what needs to be ruled out?

rule out a foreign body

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What are the three types of esophagitis?

Infectious esophagitis

Pill-induced esophagitis

Caustic esophageal injury esophagitis

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Infectious esophagitis will mainly be seen in what patient demographic?

Mainly in immunosuppressed patients

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What are the common pathogens that cause infectious esophagitis?

Candida albicans
HSV
CMV

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This endoscopic finding on EGD suggests what diagnosis?

Diffuse linear yellow-white plaques adherent to mucosa

Candida albicans

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This endoscopic finding on EGD suggests what diagnosis?

Multiple small, deep ulcerations

HSV

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What are some common agents that result in pill-induced esophagitis?

NSAIDs
KCl
Bisphosphonates
Iron
Vitamin C
Antibiotics (Doxycycline most common)

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What is the evaluation/treatment of caustic esophageal injury esophagitis?

Admit to ICU

ENT/GI consult

Circulatory status along with airway patency and oropharyngeal mucosa should be priority

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Swallowing medication causes inflammation

Occurs most commonly if swallowed without water or while supine

Self limited – no intervention

Pill-Induced Esophagitis

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Accidental (children) or intentional (suicide)

Less likely to have serious gastric injury of no major symptoms

Esophageal Injury Esophagitis

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Chronic immune/antigen mediated disease Causing esophageal dysfunction and eosinophil-predominant inflammation Most common in Caucasian men Characterized by concentric esophageal rings Seen in patients with established GERD

Eosinophilic Esophagitis

What is the treatment for eosinophilic esophagitis?

Treat dysphagia with EGD/dilation PPI Topical glucocorticoids (swallowed fluticasone) Food allergy evaluation

Heartburn is the cardinal symptom Firstly, rule out cardiac origin Very common: 20% of adults have weekly symptoms of this (10% have daily symptoms) 50% develop reflux esophagitis

Gastroesophageal Reflux Disease

What are some alarm symptoms of gastroesophageal reflux disease?

difficulty or pain with swallowing - Odynophagia is NOT common in GERD and warrants further investigation

What are some contributing factors of GERD?

Incompetent LES Hiatal hernia Irritant effects of reflux Abnormal esophageal clearance Delayed gastric emptying

What are some exacerbating factors of GERD?

Foods Bending or recumbency

What is the clinical presentation of GERD?

Heartburn Regurgitation Nausea Throat irritation Atypical symptoms - asthma, cough (persistent, dry), laryngitis

Most effective agents available for GERD

Proton Pump Inhibitors (PPIs)

What are the treatment goals of GERD?

Provide symptomatic relief Heal esophagitis Prevent complications

What are some treatment options for GERD?

Proton Pump Inhibitors (PPIs) H2 Antagonists Antacids Complicated patient - Gets EGD right away Surgical treatment – Nissen Fundoplication

What are some alarm symptoms for GERD?

GI bleeding/anemia Dysphagia/odynophagia Unintentional weight loss h/o heavy NSAID use

What are some invasive testing for GERD (either for complicated or unresponsive GERD)?

Upper endoscopy Barium swallow Esophageal pH monitoring

What is a complication we worry about with GERD?

Barrett’s Esophagitis

Squamous epithelium at distal esophagus replaced by metaplastic columnar epithelium

Barrett’s Esophagitis

Why are we concerned about Barrett's Esophagitis?

Can lead to adenocarcinoma - presence of dysplasia increases the risk of progression to carcinoma

What is the treatment for Barrett's esophagitis and why?

Treatment: long term PPI PPIs are the only agents that heal ulcers and erosions - may reduce the risk of cancer (keeps risk of changing from metaplastic to dysplasia down)

Recommend EGD for Barrett’s screening in patients with what factors?

chronic GERD symptoms Male White Hiatal hernia Age 50+ years

What are the Barrett's esophagitis screening guidelines?

If low grade dysplasia is found, repeat endoscopy in 6 months If high grade dysplasia is found, repeat EGD with biopsy EGD every 3-5 years with known Barrett’s esophagitis

What are some complications of GERD?

Barrett’s Esophagitis Stricture

What is a common cause of GERD in neonates/infants?

Usually due to immature lower esophageal sphincter

Gastric regurgitation occurs in up to how many infants, but pathological GERD affects only 1 in 300 infants

two thirds

When should you intervene in neonates/infants who had GERD?

Regurgitation but still having weight gain 🡪 monitor (unless concerning symptoms) Regurgitation with poor weight gain 🡪 intervene

What are the complications of GERD in neonates/infants?

Failure to thrive Respiratory - aspiration pneumonia, chronic cough, wheezing

Mucosal tear at the GE junction Usually caused by prolonged vomiting/retching (50% of cases) Binge drinking can be a predisposing factor Accounts for 5% of upper GI bleeds Benign, self-limiting (typically)

Mallory-Weiss Tear

What is the treatment for a Mallory-Weiss tear?

Most heal uneventfully within 24-48 hours Severe bleeds: IV fluid resuscitation, blood transfusion, endoscopic hemostatic therapy

Any ring-like structure along the length of the esophagus Uncommon - Less than 10% of people May be an incidental finding Covered by squamous epithelium

Esophageal Webs and Rings

Esophageal webs and rings are covered by what type of cell?

Covered by squamous epithelium

Which type of esophageal ring/web is described below? Connective tissue effect Triad: IDA, dysphagia, webs Treat IDA = web resolves If problematic, perform EGD for endoscopic dilation

Plummer Vinson Syndrome

Plummer Vinson Syndrome is associated with what?

Iron Deficiency Anemia

Which type of esophageal ring/web is described below? Distal esophagus - Most common ring in distal esophagus Thin, web-like constriction near the border of LES Common, smooth, benign, circumferential structures Common cause of intermittent solid food dysphagia Chronic GERD may cause a role - although pathogenesis is controversial

Schatzki’s Ring

Schatzki’s Ring is associated with what?

GERD

Outpouchings in the esophageal wall

Esophageal Diverticula

What are the two types of esophageal diverticula?

Zenker’s diverticulum - Pharyngeal mucosa protrusion at the pharyngoesophageal junction Esophageal diverticulum - Mid or distal esophagus, secondary to motility disorders or strictures

Pharyngeal mucosa protrusion at the pharyngoesophageal junction

Zenker’s diverticulum

False diverticulum/outpouching Harbors undigested food

Zenker’s Diverticulum

What are some signs/symptoms of Zenker’s Diverticulum?

Regurgitation of saliva and food particles consumed several days previously (especially in AM) Uncoordinated swallow/occlusive episode Dysphagia Halitosis Choking/gurgling Cough aspiration Neck protrusion

How is Zenker’s Diverticulum diagnosed?

Barium esophagram EGD contrast CT neck

What is the treatment for Zenker’s Diverticulum?

Surgery if symptomatic

What are some complications of Zenker’s Diverticulum?

Aspiration pneumonia Bronchiectasis

Enlarged venous collateral channels that dilate as a result of portal HTN Dilated sub-mucosal veins in lower esophagus Can be a life-threatening emergency

Esophageal Varices

What amount of patients with varices will bleed?

1/3

Highest mortality and morbidity of any upper GI bleed Mortality rate of 30%

Esophageal Varices

Esophageal Varices is associated with what?

History of portal hypertension/cirrhotic liver disease (Present in 50% of patients with cirrhosis)

What are some causes of esophageal varices?

Alcoholism Viral hepatitis

What are the treatment options for esophageal varices?

Fluid resuscitation Blood transfusion/FFP transfusion if needed Antibiotics Octreotide (reduces portal pressure) Emergency endoscopy within 2-12 hours (Variceal banding, Sclerotherapy) Surgical intervention

What measures can help prevent rebleeding of esophageal varices?

ALCOHOL CESSATION Band ligation Beta blockers TIPS surgery Liver transplantation

Esophageal rupture/perforation Secondary to severe retching/vomiting causing increase in intraoresophageal pressure combined with negative intrathoracic pressure Emergent surgical consult

Beorhaave’s Syndrome

What are some signs/symptoms of Beorhaave’s Syndrome?

Hematemesis with SEVERE retrosternal “tearing” pain Subcutaneous emphysema/crepitation

In Beorhaave’s Syndrome, what finding would you expect to see on a CXR?

Mediastinal widening

What imaging do you order for suspected Beorhaave’s Syndrome?

CXR CT chest (confirms rupture of lower esophagus)

What is the most common type of esophageal cancer worldwide?

Squamous cell carcinoma most common worldwide (90%)

What is the most common type of esophageal cancer in the US?

Adenocarcinoma 80% (associated with GERD and Barrett’s esophagitis)

Which type of esophageal cancer is described below? Typically found in lower 1/3 of esophagus Associated with GERD and Barrett’s esophagitis

Adenocarcinoma

Which type of esophageal cancer is described below? Typically found in upper 2/3 of esophagus Associated with tobacco and alcohol

Squamous cell carcinoma

What are some signs/symptoms of esophageal cancer?

Progressive solid food dysphagia - Dysphagia for solids only (90%) – tolerating soft/liquid foods Odynophagia Anorexia/weight loss Voice changes/hoarseness Anemia Signs of metastatic disease

What methods are used to diagnose esophageal cancer?

Barium esophagogram - May only identify large lesions Upper endoscopy with biopsy for diagnosis

What is the overall 5 year survival rate of esophageal cancer?

<15%

Why does esophageal cancer carry such a poor prognosis?

Over 60% of patients are not candidates for surgery - Present with advanced disease, have significant comorbidities

Esophagus Disorders Flashcards

(82 cards)