LEC 3: ESOPHAGEAL DISEASES

what is the #1 cause of esophageal varices?

portal HTN

what are esophageal varices?

dilated submucosal veins that develop causing major upper GI bleed which can be life threatening

where are esophageal varices m/c seen?

distal 5cm of the esophagus

what is the m/c/c of portal HTN?

cirrhosis

what is the #1 cause of upper GI tract bleed?

peptic ulcer disease

what has the highest morbidity and mortality from GI bleeding?

bleeding varices

what are the s/sx of esophageal varices?

spontaneous emesis (bright red), melena, hematochezia, dyspepsia, hypovolemia, shock

what are the s/sx of liver disease?

palmar erythema, asterixis, spider angiomas, muscle wasting, gynecomastia, ascites, SM, jaundice

what labs should you obtain in a patient w/ esophageal varices?

CBC (check H/H & plts), PT/PTT (type & cross to give blood), LFTs (no liver fxn), serum albumin (expected to be low)

what is the first step in tx esophageal varices?

stabilize pt: ABCs, 2 large bore IVs (in AC fossa), give Ringers until you get blood, then transfuse (each unit elevates Hgb by 1.5-2)

what is the #1 tx and diagnostic modality for esophageal varices?

ENDOSCOPY

what abx prophylaxis can be given to pt's w/ esophageal varices?

quinolone & 3rd gen cephalosporin

what can we give to correct encephalopathy?

lactulose

what can we give to a pt w/ esophageal varices if they have an elevated PT?

vit K

what can be used for temporary tx of uncontrollable bleeding of esophageal varices?

balloon tube tamponade (w/ SB tube or Minnesota tube)

what tx of esophageal varices is used for maintenance after failing medical therapy?

TIPS procedure

what is the biggest AE of the TIPS procedure?

hepatic encephalopathy

what should you do if you see varices in a pt with cirrhosis, what should you start them on as a preventative measure?

beta blockers

what is the order of tx interventions for esophageal varices?

stabilize pt (give ringers)--> drop balloon down & control bleeding

what meds can be used for maintenance of esophageal varices?

BB(nadolol, carvedilol) & nitrates (isosorbide mononitrate) --> dec portal P, which dec bleed

what medication in a patient's chart could be an indication that they have esophageal varices?

nadolol bc it's not really used for cardiac purposes

what meds are used for active bleeding in pt's w/ esophageal varices?

octreotide, vasopressin, terlipressin --> dec blood flow to portal system to dec pressure

what is achalasia?

degeneration of Auerbach's plexus; complete absence of esophageal peristalsis & failure to relax of LES (hypercontracted LES)

what patient populations do we usu see get dx w/ achalasia?

young pt's (20-40s) who suddenly can't swallow & have effortless emesis

what do we see in pt's w/ achalasia?

progressive dysphagia to both solid & liquid foods & regurg of undigested food

what type of pulmonary sx manifest w/ achalasia?

nocutral cough & recurrent aspiration pneumonia

what do we see on CXR of achalasia?

absence of gastric air bubble, retrocardia air-fluid level in dilated esophagus, widened mediastinum

what do we see on an esophagram of achalasia?

bird beak appearance; smooth tapered narrowing of distal esophagus

what is the best way to dx achalasia?

esophageal manometry- shows - peristalsis, - relaxation of LES, + elevated pressure

what should we not get confused w/ achalasia & why?

scleroderma b/c their pressure is low & LES is dilated/relaxed, not hypercontracted

what is the tx of achalasia?

pneumatic dilation (does not fix peristalsis)- can be repeated, but always has a risk of perforation

what tx can provide short term in pt's w achalasia?

botox injections

what is the curative tx of achalasia?

thoracotomy & transection of circular muscle of the LES- (can cause reflux esophagitis, so give PPI therapy)

how should we periodically surveil pt's w/ achalasia?

endoscopy

what is pseudoachalasia?

absent or difficult peristalsis in esophagus due to tumor in fundus of stomach

what is dysphagia & what are the 2 types?

difficulty swallowing; 2 types: oropharyngeal & esophageal

what should you think of if someone has oropharyngeal dysphagia?

THINK NEUROMUSCULAR DISEASE

what are the causes of oropharyngeal dysphagia?

CNS: CVA, Parkinson's, brainstem tumors

Muscle: MG, polymyositis, thyroid disease, SLE

Structural: webs, zenker's, extrinsic compression

where are webs & rings located?

webs- high

rings- low (near GE junction)

what are the s/sx of dysphagia?

nasal regurg, cough, aspiration w/ swallowing, difficulty intiating swallowing

what should you think if a pt has esophageal dysphagia?

THINK CANCER (esp in elderly)

what are the causes of esophageal dysphagia?

carcinoma/stricture, ring/diverticulum, infective esophagitis (2/2 chemo, immunosuppression, chronic disease)

what are the s/sx of esophageal dysphagia?

dysphagia for both solids & liquids (narrowing due to tumor/esophagitis), odynophagia (seen w/ wt loss, carcinoma, achalasia)

what is the most likely cause if acute onset of dysphagia?

inflammatory

what is the most likely cause if gradual onset of dysphagia?

malignancy until proven otherwise

what is the initial study for dysphagia?

barium swallow (dx motility & anatomical disorders)

what is the best, most sensitive/specific test for dysphagia?

endoscopy (EDG)- can obtain bx & cytology under direct visualization, break webs/dilate strictures

what is the best procedure for eval of motility disorders associated w/ dysphagia?

esophageal manometry- measures strength, fxn, coord of upper & lower esophageal strictures and body in response to swallow

what are esophageal webs, where are they m/c found, & what do we see them with?

mucosal stricture that protrudes into lumen; m/c in proximal esophagus, seen w/ Fe def anemia= Plummer Vinson

where are esophageal rings found & what are schatzki rings?

distal esophagus; if above GE junction= schatzki

what are the s/sx of webs & rings?

seen w/ a ring >13 mm in diameter, GERD, intermittent dysphagia w/ solids, PT points to exact site, regurg

what is the tx of webs & rings?

reassurance, chew food well, dilation/removal of ring, tx of anemia

what is globus hystericus?

dysphagia w/ no organic disease (basically, it's all in their head; fear of choking)

what do pt's w/ globus hystericus c/o?

sensation of lump in throat

what should we r/o in pts w/ globus hystericus?

GERD

how do we tx globus hystericus?

reassurance

what is Zenker's diverticulum?

outpouching of mucosa @ the junction of thyropharyngeal & cricopharyngeus muscles

where does the diverticula typically protrude?

in the lateral portion of neck

what are the s/sx of Zenker's diverticulum?

dysphagia (m/c), regurg, choking on recently swallowed food, swelling of neck

what is the easiest way to dx Zenker's diverticulum?

barium swallow

how else can we dx Zenker's?

endoscopy (potentially dangerous) & manometry testing

what is the tx of choice for Zenker's?

surgical tx (myotomy & resection of diverticulum)

what is GERD & how does it present?

regurg of acidic gastric contents; substernal CP that radiates upward & is often aggravated by meals & lying down

what do pt's c/o w/ GERD?

hoarseness, cough, wheezing

what is the cause of GERD?

most significant: dec LES pressure

abn gastric emptying, impaired peristalsis, hypersecretion of acid, inadequate salivary flow, outlet obstruction

what medication works quickly for GERD, but is not good long term and can cause tardive dyskinesia?

Reglan

what is the best study for dx GERD?

endoscopy

what is the simplest, least expensive test we can use to dx GERD?

barium swallow

what should we get if an endoscopy comes back normal, but we still suspect GERD?

24 hr pH monitoring

what test provides evidence of sensitivity of the esophagus to acid?

bernstein test (intraesophageal acid perfusion test)

how do we tx GERD?

3 phases: lifestyle mod, pharmacological , surgery

what meds should we give pt's w/ GERD?

start w/ H2 blockers, then can add PPI if it doesn't work after 8 weeks

what can happen if a pt takes omeprazole long term?

c. diff infections & vitamin deficiencies

what are indications for surgery of due to GERD?

strictures unresponsive to tx, hemorrhage 2/2 errosive esophagitis, ulcers unresponsive to tx, aspiration pneumo 2/2 reflux

what are the complications of GERD?

stricture, hemorrhage, ulceration, Barrett's esophagus, esophagitis

what is Barrett's esophagus?

squamous epithelium is replaced by metaplastic columnar epithelium 2/2 chronic reflux induced injury

what part of the esophagus does Barrett's effect?

distal esophagus @ GE junction

what is needed for dx of Barrett's?

endoscopy & biopsy

what is the tx for Barrett's esophagus?

aggressive tx w/ PPI, consider surgical fundoplication, endoscopic ablation of Barrett's w cautery

what is the most serious complication of Barrett's?

adenocarcinoma of the esophagus

what should pt's w/ Barrett's get every 2 years?

endoscopy w/ biopsy

what population does infective esophagitis m/c occur in?

immunosuppressed, chemo pt's, AIDS pts, DM, pt's on long term steroids, cancer

what are the m/c pathogens of infective esophagitis?

candida albicans, herpes simplex, CMV (typically CD4 count <50)

what should we give pt's w/ infective esophagitis to prevent PCP?

bactrim

what are the s/sx of infective esophagitis?

odynophagia, dysphagia, substernal CP, oral thrush (candida), colon/retinal infxns (CMV), oral ulcers (herpes)

"like razor blades in esophagus, malnourished, extremely dehydrated"

what do we see on endoscopy of pt's w/ candida infective esophagitis?

diffuse, linear, yellow-white plaques adherent to mucosa

what do we see on endoscopy of pt's w/ CMV infective esophagitis?

1 to several small or larger ulcers that tend to be linear or longitudinal and shallow

what do we see on endoscopy of pt's w/ herpes infective esophagitis?

multiple, small, deep ulcerations (edges tented up, "volcano like")

what is the tx of candida infective esophagitis?

mild: nystatin swish & swallow, clotrimazole

if pt difficulty swallowing & immunocomp: fluconazole, itraconazole

if immunocomp: admit & start on IV fluconazole (amophotericin B if all other tx fails)

what is the tx of CMV infective esophagitis?

Initial: Ganciclovir

No response: fascarnet

what is the tx of herpes infective esophagitis?

acyclovir, valacyclovir, famciclovir

if no response: fascarnet

what is a hiatal hernia?

herniation of part of the stomach through the diaphragm into the thorax

what populations are effected by hiatal hernias?

F>M, >60

what can a hiatal hernia coexist w/?

esophagitis

what are the s/sx of a type I hiatal hernia?

m/c & sliding; epigastric burning, regurg, effortless emesis, dysphagia (GERD sx)

what are the s/sx of type II, III, & IV hiatal hernias?

postprandial pain, bloating, early satiety, breathlessness w/ meals, dysphagia

what are pt's w/ type II, III, & IV hiatal hernias susceptible to?

volvulus, obstruction, ischemic ulcers w/ frank or occult bleeding, perforation, & gangrene

what is the cause of hiatal hernias?

a lax or defective phrenoesophageal ligament allows protrusion of stomach up through the esophageal hiatus of the diaphragm

what is a type I hiatal hernia (m/c)?

phrenoesophageal ligament intact but lax, GE junction above diaphragm

what is a type II hiatal hernia?

protrusion of peritoneum to herniate upward alongside the esophagus through the esophageal hiatus