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Flashcards in Gastro - Online MedEd - esophagus Deck (32):
1

Esophagus purpose

Peristaltic contractions that move food down

2

Dysphagia - approach

Trouble swallowing
Think of 2 separate categories:
1) Motility - functional: not progressive (foods and liquids at same time)
2) Mechanical - obstruction grow into lumen: progressive (first from foods, then liquids)

3

Diagnostic workup of dysphagia

1) Barium swallow - need to know what these look like
2) Endoscopy with biopsy *best test for both cases of dysphagia
3) Manometry - for motility (not mechanical)

4

Motility disorders - types

1) Achalasia/pseudoachalasia:
Absent myenteric plexus --> lower esophageal sphincter cannot relax --> bolus of food sticks at junction (GE junction at mid sternum)
2) Scleroderma - opposite achalasia - collagen deposition disease
3) Diffuse esophageal spasm - random contractions of esophagus
1 and 2 are opposites, both involve the LES

5

Dx of achalasia

Barium - bird's beak
Manometry - will show that lower esophageal sphincter has abnormal tone, whereas the rest of the stomach/esophagus has normal tone
EGD with biopsy * best test - biopsy is to show the absent myenteric plexus - mostly to RULE OUT cancer

6

Myenteric plexus and achalasia - relationship?

Achalasia - missing this plexus
This is an inhibitory plexus
So causes lower esophageal sphincter to be abnormally contracted

7

Treatment of achalasia

Botox injection - doesn't last long (terrible surgical candidate)
Dilation - perforation risk, might need to do several times (don't do this)
Myotomy *best treatment - if take too much muscle, will develop with bad GERD (similarly treating GERD can cause achalasia)

8

Scleroderma - what is it?

Collagen deposition disease
Collagen REPLACES the smooth muscle of the lower esophageal sphincter, so sphincter cannot contract!

9

Scleroderma - presentation

CREST - calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia = systemic sclerosis
also, pulmonary kidney heart involvement
Relentless GERD (no lower esophageal sphincter)

10

Scleroderma - dx

Barium - wide open esophagus
Manometry - no contraction of LES (acid comes up and burns esophagus)
Endoscopy and biopsy

11

Treatment scleroderma

PPI

12

What is the serology associated with scleroderma

CREST = anti-centromere
Systemic GERD = anti-scl-70 (topoisomerase)

13

Diffuse esophageal spasm

Random contractions of the esophagus without swallowing

14

Presentation - esophageal spasm

MI like symptoms
Retrosternal chest pain, crushing in nature, better with nitrates (relax smooth muscle)
-Pain caused by muscle contracting hard
-So need to rule out ACS (trops etc.)

15

Dx of esophageal spasm

Rule out ACS
Then do: barium (cork-screw esophagus/beads on a string)
manometry (contraction at areas that are contracted, in between will be normal)
EGD and biopsy (biopsy not necessary, but get it to rule out cancer)

16

Treatment of esophageal spasm

Not life threatening
CCB
Nitrates as needed

17

Mechanical obstruction types

1) Schatzki's ring

18

Schatzki's ring - what is it

Ring at GE junction - creates a narrowed lumen, only large caliber foods get stuck

19

Presentation of schatzki's ring

Steakhouse dysphagia - big piece of meat, infrequent

20

Dx of schatzki's ring

Barium - narrows at ring
EGD with biopsy - benign, shows ring, no cancer

21

Treatment of schatzki's ring

Lyse it open with EGD

22

Esophageal webs - cause

Plummer-vinson syndrome
-Woman with dysphagia
-Iron deficiency anemia
-Webs
-Eventually esophageal cancer

23

What does esophageal webs look like

Webs in esophagus that get in way of food --> can transform to cancer

24

Dx of esophageal webs

Barium - webs
Do not need to do EGD and biopsy

25

Treatment of eophageal webs

Iron for anemia
EGD and biopsy - to screen for cancer
Esophagectomy if develop cancer (but not just for webs)

26

Zenker's diverticulum - what is it?

Outpouching from esophagus
-Patient with undigested food in zenker's diverticulum

27

Zenker's diverticulum - presentation

Older male
Halithosis - because there is undigested food stuck there
Regurgitation of UNDIGESTED food!

28

Dx of zenker's

Barium will seal diagnosis
EGD and biopsy

29

Treatment of Zenker's

Surgery

30

Need to know difference between stricture and cancer! for obstructive dysphagia

Stricture:
1) Result of GERD (Grade IV esophagitis)
2) Bottom third of esophagus
3) Patient: long standing GERD, dysphagia, has weight loss because can't get food down (decrease food intake)
Cancer:
1) Adenocarcinoma caused by long standing GERD
2) Bottom third of esophagus
But squamous cell (caused by smoking and alcohol is in the upper third)
3) Long standing GERD, dysphagia, also weight loss (cancer stealing nutrients)
-Generally adenocarcinoma will transform to Barrett's esophagus so GERD symptoms will improve
*important thing is cannot use pathology of symptoms to determine strictures and cancer
Main difference is diagnostic tests:
Barium:
1) Stricture - symmetric, circumferential loss of lumen
2) Cancer - asymmetric loss of lumen
EGD and biopsy - for cancer will show cancer, must do barium first to make sure you know where the cancer is

31

Treatment of stricture

High dose PPI
Dilation to open up

32

Treatment of adenocarcinoma

Chemo, radiation, surgery