Gastroenterology - Esophageal Disorders

Question 1

Discuss the differential for oropharyngeal dysphagia

Answer 1

- Difficulty initiating swallowing: choking, coughing, nasal regurgitation
Neurological
- Cortical
- Bulbar
- Peripheral
Muscular
- Muscular dystrophy
- Myasthenia gravis
Structural
- Zenker's diverticulum
- Cervical spur

Question 2

Discuss the differential for esophageal dysphagia

Answer 2

• inability to move food down esophagus
  Solid Food Only
• Progressive mechanical obstruction with age >50 and weight loss then carcinoma
• progressive mechanical obstruction with heartburn then peptic stricture
• Intermittent mechanical obstruction then lower esophageal ring
  Solid Foods and Liquids
• intermittent then diffuse esophageal spasm
• Progressive with reflux then scleroderma
• Progressive then achalasia

Question 3

Discuss the pathophysiology, diagnosis and treatment of achalasia

Answer 3

• failure of smooth muscle relaxation at lower esophageal sphincter
• increased lower esophageal sphincter pressure
  Pathophysiology
• Inflammatory degeneration of Auerbach’s plexus
  Diagnosis
• Bird beak on barium study
• Manometry
  Treatment
• Dilatation with balloon
• Botulinum toxin injection

Question 4

Discuss the diagnosis and treatment of diffuse esophageal spasm

Answer 4

- Normal peristalsis with frequent, repetitive high pressure non-peristaltic waves
Diagnosis
- Corkscrew pattern on barium study
- Manometry
Management
- nitrates, CCB
- Long esophageal myotomy

Question 5

Discuss the pathophysiology, presentation and treatment of Zenker’s Diverticulum

Answer 5

Pathophysiology
- Posterior pharyngeal outpouching above cricopharyngeal muscle and below the inferior pharyngeal constrictor muscle
Presentation
- Dysphagia
- Regurgitation
- Halitosis
Management
- Endoscopic surgical myotomy of cricopharyngeal if symptomatic

Question 6

Discuss the web and rings of the esophagus

Answer 6

• web: upper esophagus
  - Plummer-Vinson syndrome when iron deficiency anemia, dysphagia and web
• ring: lower esophagus
  - Schatzki ring is ring at squamo-columnar junction
  Presentation
• asymptomatic until lumen diameter <12mm
• dysphagia with large food bolus
  Management
• Bougie dilatation

Question 7

Discuss eosinophilic esophagitis

Answer 7

- eosinophilic infiltration into the epithelium
Presentation
- dysphagia
- odynophagia
- food bolus impaction
- allergies
- young men
Diagnosis
- endoscopic biopsy
Management
- diet
- corticosteroid nasal spray
- swallowed viscous corticosteroid