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Esophageal Disease


Esoph dx studies Barium esophagram (limited value); Upper endoscopy w/bx; Esophageal Manometry; Ambulatory esophageal pH monitoring
Heartburn (pyrosis) substernal burning, epigastric pain radiating to the neck
Transfer dysphagia etiologies: Oropharyngeal. Neurologic Dysfunction (CVA, ALS). Zenker Diverticulum (most common)
Transport dysphagia: Esophageal: food sticks
Odynophagia: Causes Caustic (corrosive injury); infectious (CMV, Herpes, Candida, HIV)
GERD requires 3 factors: Reflux (dysfn of anti-reflux mechms); reflux of caustic materials; sufficient duration of contact
Chest Pain can be due to: GERD, diffuse esophageal spasm, nutcracker esophagus, achalasia
GERD sx Heartburn (30-60 min after meals, often when supine); Regurgitation; Sour brash; Dysphagia; Relief with antacids
Alarm sx: Dysphagia, wt loss, hematemesis, melena; Sx age > 50
Upper endoscopy: purpose: document type/ extent of tissue damage in GERD; look for erythema, friability, stricture, Barrett’s
Barrett esophagus: pathophys change of squamous epi cells to columnar epi; stomach creeping up into esophagus
Standard procedure for detecting pathologic acid reflux in the esophagus: ambulatory pH monitoring
Manometry tests: function of the esophageal mx contractions & esophageal sphincters; to ensure proper peristalsis, & proper sphincter fn prior to any surg/endoscopic correction for reflux
GERD complications Barrett esophagus; stricture (scarred down)
GERD mgmt: Lifestyle mods (wt loss, low fat diet, avoid food triggers), antacid trial; Rx (H2 antagonists, Reglan, PPI for severe); Surgical (fundo) if med tx fails
Barrett screening EGD Sx > 10 years, age >50, white males
Barrett dx requires: bx-proven presence of specialized intestinal metaplasia in the tubular esophagus
Metaplasia/Dysplasia/Car: poss interventions Medical acid suppression tx; Anti-reflux surg; Endoscopic surveil; Endoscopic ablation tx; Esophagectomy
Infectious esophagitis: common agents: Candida, CMV, HSV (ie, immunosuppressed pts: HIV, organ transplant, leuk/lymphoma)
Infectious esophagitis sx/sx: Odynophagia, dysphagia, retrosternal CP; oral thrush common
Web = a thin infolding of mucosa that narrows/constricts the lumen, typically in proximal esophagus
Plummer Vinson Syndrome Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia; increased risk of cancer
Schatzki ring = a web that occurs in the distal esophagus (at squamocolumnar mucosal junction)
Zenker diverticulum = Outpouching in posterior wall at pharyngoesophageal junction; most common cause of transfer dysphagia; Men >60 yo
Zenker diverticulum sx regurgitation, dysphagia, halitosis; ?palpable neck mass
Eosinophilic esophagitis Rare/idiopathic; food allergies & asthma; food impaction, reflux, strictures; mucosal rings; >15 Intraepithelial Eos/hpf; concern for perf w/dilation
Eosinophilic esophagitis: mgmt PPI; allergy testing & elimination diet; topical corticosteroids (fluticasone); systemic corticosteroids; +/- esoph dilatation
GI bleed 2/2 esophageal dz: 1/3 of all pts with esophageal varices (2/2 portal HTN); Mallory Weiss tear; esophageal ulceration
Achalasia: Sx/Sx Gradual, progressive dysphagia; regurgitation; substernal discomfort/fullness; anorexia
Achalasia: dx gold standard = manometry; see complete absence of peristalsis, with simultaneous, low amplitude waves; very tight LES, lack of contractions in esophagus
Achalasia imaging CXR (air fluid level in enlarged fluid filled esoph); Barium esophagography (birds beak: smooth symmetric tapering; esophageal dilatation "sigmoid esophagus;" loss of peristalsis); upper endoscopy
Achalasia: Mgmt Endoscopic-guided Botox (relief in 2/3 of pts for 6-12 mos); Pharm (nifedipine); Fluoro-guided pneumatic dilation; botox; Myotomy (85% success rate)
Diffuse esophageal spasm: sx/sx anterior nonexertional CP (unrelated to eating); simultaneous, nonperistaltic contractions of esophagus; usually self-limited
Diffuse esophageal spasm dx Barium Esophagography: corkscrew or rosary-bead contraction below aortic arch; manometry: large amplitude intermittent simultaneous contractions
Most common connective tissue disorder involving the esophagus: Scleroderma esophagus (atrophy & fibrosis of esophageal smooth mx)
Scleroderma esophagus: Dx findings: Barium esophagography: patulous LES with free reflux; manometry: low amplitude/absent LES pressure; upper endoscopy detects Barrett or peptic stricture
Esophageal ca: presentation Progressive solid food dysphagia, weight loss
Esophageal ca eval CXR (mediastinal widening, lung or bony mets); barium esophagram (polypoid, infiltrative, or ulcerative lesion); EGD w/ bx (gold standard); Chest CT/EUS for staging
Esoph ca: tx mainstay: surg resection (complete esophagectomy); unresectable: Rtx, Ctx, endoscopic stenting for palliation
GERD pathophysiology: inappropriate relaxation of LES
Drugs, etc that decease LES tone -> GERD: caffeine, nicotine, CCBs, nitrates, theophylline, sedatives
Optimal study to find pathologic reflux (esp in patients with normal endoscopy result) = Ambulatory esophageal pH monitoring
infectious esophagitis workup = EGD with biopsies
Endoscopic findings suggesting candidal esophagitis: linear or diffuse yellow-white plaques
Endoscopic findings suggesting CMV vs HSV esophagitis: CMV: single & multiple superficial ulcers; HSV: deep ulcers
CMV esophagitis tx = IV ganciclovir (if not tolerated: IV foscarnet)
Common causes of pill esophagitis: NSAIDs, iron, Abx, vitamin C, KCl, quinidine, zalcitabine, zidovudine, alendronate
Achalasia pathophysiology: Progressive motor disorder: myenteric plexus & enteric nervous system degeneration; defective LES innervation; loss of esophageal smooth mx peristalsis in distal 2/3; increased tonus of LES
Diffuse esophageal spasm mgmt Sx reduction. SL NTG, nitrates, CCBs may be effective; dilation w/Maloney bougies vs long myotomy if intractable
Scleroderma esophagus is often associated with this syndrome: CREST syndrome
Scleroderma esophagus complications severe erosive esophagitis; peptic stricture; Barrett metaplasia
Scleroderma esophagus mgmt: H2 blocker, PPI, promotility agents; dilation if peptic stricture
esophageal varices tx Tx underlying coagulopathy (if present); endoscopy +/- banding or sclerotherapy; balloon tamponade if big bleed; vasoconstrictive Rx (vasopressin / octreotide); Cipro IV
Scleroderma esophagus pathophysiology Atrophy & fibrosis of esoph smooth mx -> low amplitude peristaltic waves -> aperistalsis. Decreased LES pressures -> free GE reflux & esophagitis
Zenker diverticulum mgmt: Cricopharyngeal myotomy +/- diverticulectomy or excision
Esoph ca: SCC is associated with: smoking and EtOH. AA > white. Most common type worldwide
Esophageal ca: adenocarcinoma is associated with: GERD, increased BMI. White > AA. Barrett esophagus is precursor. Most common type in western world
Esophageal cancer is associated with mets to: LNs, liver, lungs, bone, and brain
Corkscrew esophagus = esophageal spasm
Bird's beak = achalasia
Created by: Abarnard