Esophageal Disorders: Esophagitis and Esophageal Cancer

infectious, compromised, endoscopy, friability, fluconazole

Candida Esophagitis

-Most common cause of __________ esophagitis

-Think ____________ host (HIV, diabetes, chronic disease, chemo)

-Need _________ to diagnose. Will see characteristic appearance of linear yellow-white plaques with _________

-Oral ___________ to treat

vesicles, deep, Acyclovir

Herpetic Esophagitis

-HSV type 1 or 2

-________ on nose and lips may coexist

-Endoscopic findings are vesicles and small, ______ ulcerations

-Treatment is __________

immunocompromised, superficial, Ganciclovir

CMV Esophagitis

-Primarily in ______________ patients, particularly organ transplant recipients or AIDS

-Endoscopic findings include large __________ shallow ulcers

-Treatment = ____________

chronic, genetic, asthma, dysphagia, GERD

Eosinophilic Esophagitis: Background

-______, immune/antigen-mediated disease

-Pathogenesis → interplay between _______, environmental, and host immune system factors

-Associated Disorders → food allergies, environmental allergies, _______, and atopic dermatitis

-Symptoms → ___________ (especially solids), food impaction, chest pain, ____, upper abdominal pain

biopsy, ringed, linear, eosinophils, dietary, glucocorticoids

Eosinophilic Esophagitis: Diagnosis and Treatment

-Diagnosis → EGD with _____ makes the diagnosis

• ______ appearance ('“feline” esophagus), strictures, attenuation of subepithelial vascular pattern, _____ furrows, whitish papules

• Biopsy shows increased number of ____________

-Treatment → start with ________ therapy and avoiding known allergens

• Pharmacologic therapy if dietary fails → PPI or topical _____________ (Fluticasone)

• Esophageal dilation

medication, women, fluid, anatomy, tetracycline, bisphosphonates

Pill Esophagitis: Background

-Direct esophageal mucosal injury due to ____________

-Epidemiology → mean age 41.5, higher prevalence in _______

-Risk → position of patient, size of medication, amount of _____ ingested with med, and altered esophageal __________

-Medications include → ___________/doxycycline (antibiotics), _____________ (alendronate), and NSAIDs

medication, barrier, heartburn, swallowing, without

Pill Esophagitis: Pathogenesis and Symptoms

-Pathogenesis → Direct irritant effect from prolonged contact of the ____________ with mucosa, causing a local acid burn or hyperosmolality. Can also cause disruption of cryoprotective _______

-Symptoms → retrosternal pain or _____________, odynophagia, dysphagia, and history of ___________ a pill _________ water (commonly at bedtime)

EGD, discrete, normal, discontinue, water

Pill Esophagitis: Diagnosis and Treatment

-Diagnosis

• Clinical

• ___ → severe sx or sx that persist 1 week after discontinuation of med. Single-multiple, ________ ulcers with ______ surrounding mucosa

• Air contrast barium study → suspect extrinsic compression

-Treatment

• ____________ likely medication (or substitute for liquid form)

• Instruct on how to take medications properly → take with at least 8oz of _____ and stand/sit upright for at least 30 minutes after taking med

acid, stomach, ETOH, erosive, mucosa, GERD, injury

GERD: Background

-Reflux of ____ and pepsin or bile salts from _______ to esophagus, causing inflammation and symptoms

-Risk Factors → obesity, hiatal hernia, ____ use, tobacco use, and pregnancy

-________ esophagitis → visible breaks in the esophageal ______ with or without symptoms

-Nonerosive reflux disease → symptoms of ____ without visible esophageal mucosal ______

relaxation, reflux, smoking, laxity, delayed, lengthens

GERD: Pathogenesis

EGJ Incompetence

-Transient LES ____________ → increased relaxation associated with _____ of acid. Seen in obesity, pregnancy, and gastroparesis

-Hypotensive LES → gastric distention, pregnancy, _______, specific foods and meds

-Anatomic disruption of EGJ (hiatal hernia) → ______ in the LES/diaphragm attachment and increased EGJ distensibility

________ Gastric Emptying

-___________ period during which reflux is possible and increases acid content of chyme, like in gastroparesis

heartburn, gastric, dysphagia, substernally, globus

GERD: Symptoms

-_____________ → retrosternal burning sensation most commonly after eating

-Regurgitation → ______ contents flowing into mouth/throat

-_________

-Chest pain → mimic angina pectoris, squeezing or burning ___________. Usually postprandial, can awaken pt from sleep, can be exacerbated by stress

-______ sensation → perception of constant lump in throat

-Nausea

cough, asthma, respond, necrosis, ulcers, Barrett’s, adenocarcinoma

GERD: Extraesophageal Symptoms and Complications

-_____, hoarseness/laryngitis secondary to mucosal injury from gastric contents, wheezing/exacerbation of ______ due to microaspiration of gastric contents

• Consider GERD in asthma pts whose symptoms don’t _______ well to asthma therapy

-Complications

• Erosive esophagitis → ________ of esophageal mucosa leading to ______

• _______’_ esophagus

• Esophageal stricture → result of healing of erosive esophagitis

• Esophageal ______________ (d/t Barrett’s esophagitis)

dyspepsia, bleeding, loss, vomiting

GERD: Alarm Symptoms for Malignancy

-New onset _________ in > 60 y/o

-GI __________ (hematemesis, melena, hematochezia)

-Iron deficiency anemia

-Anorexia

-Unexplained weight ____

-Dysphagia

-Odynophagia

-Persistent __________

-GI cancer in 1st degree relative

5-10, male, tobacco

GERD: Risk Factors for Barrett’s Esophagus

-Duration of GERD of at least _-__ years

-Age 50 or older

-____ sex

-White race

-Hiatal hernia

-Obesity

-Nocturnal reflux

-________ use

-1st degree relative with Barrett’s esophagus or adenocarcinoma

PPI, GERD, persistent, catheter

GERD: DIagnosis

-___ trial → classic symptoms without alarm symptoms or risk factors

-EGD (can be 1st line in certain situations) → indicated in pts with suspected ____ and alarm symptoms. Risk for Barrett’s esophagitis, fail PPI therapy

-Ambulatory esophageal pH monitoring → ___________ symptoms despite therapy and/or normal EGD. 24 hour transnasal pH ________ or 96 hour wireless capsule

lifestyle, loss, dietary, antacids, histamine

GERD: Mild and Intermittent Symptoms Treatment

-__________ and dietary modifications are first line → weight ____, elevation of head of bed, avoid late night meals or laying down directly after eating, elimination of _______ triggers, and tobacco/ETOH cessation

-_______ → usually contain combo of magnesium trisilicate, aluminum hydroxide, or calcium carbonate. Ex Tums

-Histamine 2 Receptor Antagonist → decrease the secretion of acid by inhibiting the __________ 2 receptor on the gastric parietal cell

PPI, 8, Nissen Fundoplication

GERD: Severe or Frequent Symptoms or Erosive Esophagitis Treatment

-___ → block proton pumps to prevent release of gastric acid

• Begin with standard dose of PPI once daily for _ weeks + lifestyle changes

-Reserved for refractory cases → surgical and endoscopic therapy

• Laparoscopic _______ ___________

• Thermocoagulation of LES

• Suturing of LES

metaplastic, adenocarcinoma, distal, columnar, asymptomatic, GERD

Barrett’s Esophagus: Background

-________ change d/t chronic GERD, predisposes to ______________

-Epidemiology → more common in white males, mean age at dx is 55

-Pathophysiology → chronic GERD causes a metaplastic change, d/t inflammation, in the ______ esophagus from normal stratified squamous epithelium to a more acid-resistant _______ epithelium

-Symptoms → Barrett’s esophagus itself is ____________, usually found during investigation of ____ symptoms

biopsy, columnar, metaplasia, goblet

Barrett’s Esophagus: Diagnosis

-EGD with ______

-Diagnostic criteria → ________ epithelium lines > 1 cm of distal esophagus. Biopsy reveals intestinal ___________ with ______ cells

GERD, obesity, smoking

Barrett’s Esophagus: Screen for BE

-Men with chronic ____ (>5 yrs) and 2 or more risk factors like age > 50, Caucasian, central _______, hx of _______, and FHx of Barrett’s esophagus or esophageal carcinoma

3-5, 6-12, endoscopic

Barrett’s Esophagus: Surveillance in those with BE

-30 fold increase of developing esophageal cancer

-Barrett’s Esophagus with no dysplasia → EGD with biopsy every _-_ years

-Barrett’s Esophagus with low-grade dysplasia → EGD with biopsy every _-__ months or perform endoscopic eradication

-Barrett’s Esophagus with high-grade dysplasia → no surveillance, __________ eradication therapy

PPI, eradication, ablation

Barrett’s Esophagus: Treatment

-___ → all patients indefinitely, might prevent cancer

-Endoscopic __________ therapy (if dysplasia present)

• ________ therapy

• Radiofrequency ablation, photodynamic therapy, cryotherapy

• Resection

ETOH, tobacco, mid, upper, polyps, early

Esophageal Cancer: Squamous Cell Carcinoma

-Epidemiology → men > women

-Risk Factors → ____, _______, achalasia/strictures, and tylosis

-Pathogenesis → located in ___ to _____ esophagus

• Arise from small ______, denuded epithelium, or plaques

• Advanced lesions → infiltrating and ulcerated mass

• ______ lymph node invasion

• Metastases → liver, bone, lung

GERD, GEJ, Barrett’s, ulcer, early

Esophageal Cancer: Adenocarcinoma

-Epidemiology → men > women, Caucasian

-Risk Factors → ____/Barrett’s metaplasia, tobacco, obesity

-Pathogenesis → located near the ___ and associated with _______’_ esophagus. May present as _____, nodule, altered mucosal pattern. Lymph nodes involved _____

dysphagia, anemia, biopsy, US, PET

Esophageal Cancer: Symptoms and Diagnosis

-Symptoms: progressive _________, weight loss, odynophagia, iron deficiency ______

-Diagnosis: EGD with _______, contrast CT or ___ scan

-Staging Evaluation: endoscopic __ for locoregional staging. Can also do CT with contrast or ___ scan to look for distant metastasis.

fit, submucosa, invasion, chemotherapy, resection, surgery

Esophageal Cancer: Treatment

-Esophagectomy → preferred in ___ patients with involvement down to the ________/muscularis with or without lymphovascular ________. Some patients may need ____________ or chemoradiotherapy before surgery

• If there is full-thickness involvement with or without nodal disease

• Selected patients with full thickness involvement that invades adjacent structures

-Endoscopic __________ → alternative for selected patients

• Cancers limited to the mucosa without lymphovascular invasion

• Poor candidates for _______ (elderly with multiple comorbidities)

metastases, adjacent, cervical, unresectable, undergo

Esophageal Cancer: Treatment of Advanced/Unresectable EC

-Criteria for Unresectability

• Distant __________ (peritoneal, lung, bone, adrenal, brain, liver, lymph nodes)

• Invasion of ________ structures (aorta, trachea, vertebral body)

• _________ esophageal cancer

-Chemotherapy with radiation therapy

• Standard for fit pts with locally advanced, ____________ thoracic/abdominal EC

-Symptomatic treatment in those who can’t ________ other treatment (treat dysphagia)