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Esophageal Dz
CM GI Esophageal Dz
| Question | Answer |
|---|---|
| How is normal esophageal motility studied? | A catheter with multiple pressure-sensing strictures is introduced through the nose or mouth into the esophagus |
| Transfer dysphagia | Oropharyngeal: obstruction. Most common cause of transfer dysphagia: Zenker's Diverticulum. Men over 60, posterior wall of the pharynx, outpouching of the upper esophagus |
| Transport Dysphagia | Esophageal - food "sticks" |
| Odynophagia | painful swallowing - reflects erosive esophageal disease |
| 3 factors required to have GERD | Reflux: dysfunction of anti-reflux mechanisms, Reflux of caustic materials: acid, pepsin, bile, pancreatic enzymes, Sufficient duration of contact of these caustic materials; inadequate clearance mechanisms |
| Sx of GERD | Heart burn 30-60 min after meals, regurgitation, Sour brash (nasty taste in mouth), dysphagia, relief with antacids |
| Tx of uncomplicated GERD | PPI empirically, nothing further unless long duration (>10years), dysphagia, weight loss, hematemesis, melena. Sx onset in age >50 warrants further investigation |
| Ambulatory pH monitoring used to | detect pathologic acid reflux in the esophagus. Measures frequency, duration of acid and correlates acid contact with sx |
| Who gets an Ambulatory pH monitor? | Refractory symptoms and normal EGD,Atypical Symptoms,Failure to respond to pharmacologic therapy,Patients considered for antireflux surgery. If the diagnosis of GERD is in question owing to atypical sx or comorbidities |
| ________ tests the function of the esophageal muscle contractions and esophageal sphincters | Manometry; Role in GERD is to ensure proper peristalsis, and proper sphincter function prior to any surgical or endoscopic correction for reflux |
| Change from squamous to columnar epithelium in esophagus | Barrett's Esophagus; 10-20% of GERD pts. Predisposition to adenocarcinoma of the esophagus (30 times increased risk, although low overall incidence of adenoCA) |
| Lifestyle Modifications in GERD | Elevate head of bead, lose weight, eliminate:tobacco, late meals, ETOH, fatty foods, chocolate, caffeine. Acid Suppression, Motility Agents. Surgical: Nissen Fundoplication |
| When is Barrett's Screening performed? | Sx>10 years, age>50, white males |
| After surgery, how many patients end up back on meds? | 15-60% are back on meds within 3-9 years |
| Tx Options for Barrett's | Medical acid suppression therapy,Anti-reflux surgery,Chemoprevention,Endoscopic surveillance,Endoscopic ablation therapy,Esophagectomy |
| Radiofrequency ablation | Burns off mucosal layer of esophagus. Grows back squamous |
| Complications of GERD | Barrett's Esophagus, Subsequent cancer, peptic stricture |
| Infectious Esophagitis Causes | Candida, CMV, Herpes Simplex, HIV idiopathic ulceration. Often immunosuppressed patients. Sx: Odynophagia, dysphagia, Chest pain |
| How is candida Esophagitis Treated? | Fluconazole |
| Tx of HIV ulceration | make sure they are taking their HIV meds and check CD4 count |
| Who is predisposed to getting eosinophilic esophagitis? | People with allergies, asthma, atopic dermatitis. |
| What does eosinophilic esophagitis look like? | Strictures, mucosal rings "feline" esophagus, and eosinophilic abscesses |
| Tx for Eosinophilic Esophagitis | First try PPI. Allergy testing and elimination diet, Topical corticosteroids: swalled fluticasone, Systemic Corticosteroids (preferrably avoid b/c of AEs), IL-5 agonist |
| Esophageal varices occur secondary to | portal hypertension (i.e. patients with cirrhosis). Treatment: banding, shunt procedure, meds |
| Mallory Weiss Tear occurs secondary to | repeated retching, although 25% without any clear hx of retching |
| thin infolding of mucosa that narrows the lumen | web (can be found anywhere in the esophagus), tend to occur in proximal esophagus |
| Ring that occurs in the distal esophagus that can get food caught on it | Schatzki ring/B rings. Leads to "steakhouse syndrome" |
| Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia | Plummer-Vinson Syndrome. Recent associations with Celiac sprue. Correction of iron deficiency in this disorder may result in resolution of the associated dysphagia, as well as the appearance of the web. |
| ______ is an outpouching of upper esophagus that always involves the posterior wall of the pharynx | Zenker's Diverticulum. Food gets stuck there and ferments, so breath stinks. Most common in men over 60 |
| Pathogenesis of Barrett's Esophagus | Chronic Gastroesophageal Reflux --> Reflux Esophagitis--> Squamous Epithelial Injury -->> Gastroesophageal reflux -->Intestinal Metaplasia (Barrett's Esophagus) |
| Etiology of GERD | Incompetent lower esophageal sphincter, transient lower esophageal relaxation (TLESR), irritants, delayed gastric emptying, abnormal esophageal clearance |
| Causes of abnormal esophageal clearance | impaired swallowing, impaired peristalsis (raynaud's, scleroderma), Impaired salivary secretion (Sjogren's), Hiatal Hernia |
| Diagnostic Studies | Barium esophagram, upper endoscopy, esophageal manometry, ambulatory Esophageal pH monitorin |
| Esophageal Motility Disorders | Achalasia, Diffuse Esophageal Spasm, Nutcracker Esophagus, Scleroderma Esophagus |
| _______ means failure to relax. This is a disease of unknown etiology and characterized by the absence of esophageal smooth muscle peristalsis with increased tonus of the lower esophageal sphincter | Achalasia. Chagas is one identifiable cause in Africa. Dysphagia for solids and liquids, regurgitation of undigested food. tonically contracted LES along with dilated, aperistaltic esophagus |
| What do patients complain of with Achalasia | substernal discomfort or fullness after eating. Regurgitation of undigested food. Gradual, progressive dysphagia for solids and liquids, weight loss |
| Gold standard test for Achalasia | manometry (endoscopy may look entirely normal). Manometry shows incomplete relaxation of lower esophageal sphincter, simultaneous peristalsis and LES hypertension |
| How long does it take for a bolus to pass through the esophagus? | 6-10 seconds |
| CXR in Achalasia | shows air fluid level in enlarged fluid filled esophagus |
| Distal Bird beak stricture is seen in what imaging method of Achalasia? | Barium Esophagography. Smooth symmetric tapering. Beak like narrowing at the EG junction |
| Treatment of choice in Achalasia | Surgical Myotomy. 85% success rate. Other options: relax smooth muscles with drugs, pneumatic dilation (balloon inflated within the LES), Botox (must be repeated every 6 months) |
| Simultaneous, nonperistalic contractions of the esophagus with intermittent dysphagia for solids and liquids | Diffuse Esophageal Spasm. Causes anterior chest pain, unrelated to exertion or eating |
| Diffuse Esophageal Spasm may be caused by______, and is a motility disorder | stress, large food boluses, hot or cold liquids. |
| Rosary bead appearance of the esophagus is suggestive of | Diffuse esophageal Spasm |
| Tx for diffuse esophageal spasm | Nitrates, CCBs, Sx are usually self-limited |
| Nutcracker esophagus manometry findings | Characterized by peristaltic waves of abnormally high amplitude. Strong contractions. Symptoms often of chest pain |
| Most common connective tissue disorder involving the esophagus | Scleroderma Esophagus. Atrophy and fibrosis of the esophageal smooth muscle. No contraction at all. Affects distal 2/3 of esophagus. Use PPI's to decrease erosive GERD in scleroderma |
| Causes of Esophageal Stenoses | Rings and webs, reflux esophagitis, tumors, caustic ingestions, infections, iatrogenic (pill-induced, radiation, sclerotherapy, NG tubes) |
| Progressive solid food dysphagia, accompanied by weight loss and anorexia in a 50-70 year old may be | esophageal cancer |
| Predisposing factors to Squamous cell Carcinoma | ETOH, Tobacco, Achalasia, Caustic injuries, head and neck cancers, plummer-vinson syndrome. More common in AA than whites (6:1), M:F (3:1). Normally Proximal |
| _____ is an esophageal cancer more common in whites than AA. (4:1) | Adenocarcinoma. M:F (7:1). Develops as a complications of Barrett's esophagus. Lower 1/3 of esophagus. |
| What is the role of ETOH and Tobacco in esophageal diseases? | Lowers LES pressure |
| Evaluation for Esophageal Cancer | CXR (may show mediastinal widening, lung or bony mets), Barium esophogram, EGD with biopsy (gold standard), Chest CT, Endoscopic US for staging |
| What is the gold standard evaluation for esophageal cancer? | EGD with biopsy (esophagogastroduodenoscopy) |
| Complications of Esophageal Cancer | Local tumor extension into tracheo-bronchial tree (TE fistula), Chest or back pain, laryngeal nerve involvement - hoarseness, pneumonia, malnutrition |
| Which stage of esophageal cancer goes through the muscularis layer? | Stage III |
| Tx of Esophageal Cancer | Surgical resection, radiation, chemotherapy, Endoscopic (stenting for palliation, photodynamic therapy) |
| The most common symptom of esophageal disease | pyrosis (heart burn) |
| water brash | bitter or sour fluid in the back of the throat caused by a vagal reflex induced by the presence of acid in the esophagus |
| Possible ways to distinguish chest pain caused by angina or esophageal disorders | chest pain that wakes a patient at night is uncommon in true cardiac disaes and may suggest esophageal disorder. Pain relieved by antacids is also likely esophageal |
| Sx that often accompany GERD | chronic cough, asthma, hoarseness, chronic sore throat, and globus sensation (sensation of a lump or mass in the throat) |
| __ % of patients with GERD will have endoscopic evidence of esophagitis | only 15%. Thus Endoscopy is not a sensitive means of diagnosing GERD, but is useful in identifying complications of GERD: ulcers, strictures, Barrett's |
| The pathophysiology underlying GERD is primarily | an abnormlity of LES motility. However, current therapies directed at augmenting motility are rarely successful, so mainstay therapy is antisecretory and acid-neutralizing |
| Most effective drug treatment of GERD | PPI |
| Risk of cancer in Barrett's esophagus | estimated to be 40-100 times that of the general population |
| Neither acid suppression therapy nor fundoplication leads to regression of _______ metaplasia. | Barrett's |
| mechanical obstruction of the esophagus vs abnormality of esophageal motility | Patient with motility disorders (neuromuscular) often describe dysphagia to both solids and liquids; whereas pts with obstruction generally have progressive obstruction only to solids until very late in their dz, then liquid problems |
| intermittent vs progressive dysphagia | intermittent - esophageal ring or web; progressive more likely to be caused by a stricture or mass lesion |
| If radiologic testing or endoscopic examination fail to demonstrate an obstructing lesion, the motility of the esophagus should be evaluated using | esophageal manometry |
| Difficulty initiating swallows suggests | Oropharyngeal dysphagia |
| The most common symptom of esophageal carcinoma | Dysphagia, occurs when the esophageal lumen has been compromised by approximately 75% of its normal diameter |
| 90% of adenocarcinomas develop where? | In the distal esophagus |
| ____ is more accurate than CT for staging tumor depth, local invasion, and regional node involvement | endoscopic ultrasonography. It has the ability to image the esophageal wall as a 5-layer structure that correlates histologic layers. Also permits FNA of suspicious findings |
| Overall 5-year survival rates for patients undergoing curative resection is | only 5-20%. And this is only in patients who qualify for surgery (meaning that the tumor is confined to the wall of the esophagus) |
Created by:
ltm12