GI E1- Esophageal disorders

Retrosternal burning sensation is known as ______

heartburn / pyrosis

Difficulty swallowing is known as _____

dysphagia

A sharp, substernal pain with swallowing that reflects erosive or infectious esophagitis is known as _____

odynophagia

The persistent, non painful sensation of a lump in the throat caused by the cricopharyngeal muscle becoming too tight is known as _____

globus pharyngeus / hystericus

What muscle acts as a sphincter to prevent reflux after swallowing and is responsible for globus pharyngeus?

cricopharyngeal muscle

What test allows direct visualization and biopsy and is the study of choice for persistent heartburn, odynophagia, & abnormalities noted on barium studies?

upper endoscopy / EGD

What test differentiates between mechanical and motility disorders, evaluates strictures, and is NOT used to diagnose GERD?

barium esophagography (BA swallow, UGI series)

What test is catheter based or wireless systems and is used to correlate acid reflux to a patients symptoms?

Esophageal pH recording

Ambulatory esophageal pH monitoring, typically wireless capsule, is used for ____

pre-operative evaluation

what is the gold standard for assessing motility disorders?

esophageal manometry (high resolution esophageal pressure topography)

What is the cardinal symptom of GERD?

heartburn sensation that may originate in the epigastrium and radiate upward into chest

What foods exacerbate GERD sx?

chocolate, onions, peppermint, coffee/caffeine, high fat foods, spicy foods

Which kind of hiatal hernia is usually asymptomatic, can cause heartburn, and is caused by weakened muscle tissue surrounding the hiatus?

sliding

What kind of hiatal hernia is uncommon, includes peritoneal layer that forms true hernia sac, and requires surgery only when reflux sx fail to resolve or emergent conditions?

paraesophageal

What clinical findings are associated with GERD?

heartburn that occurs 30-60 min after meals and is immediately relieved w/ antacids for ~2 hours

How is GERD dx?

clinical- H&P, studies not necessary and rx can be started empirically

What can be a co-factor of asthma, chronic cough, laryngitis, or CP causing atypical symptoms & requiring further cardio/pulm evaluation?

GERD

What pH would gastric fluid cause esophagitis and strictures?

< 4.0

Barium radiographs, manometry, and screening for H. pylori are ______ for GERD

NOT recommended

What is the first non pharmacological recommended treatment for GERD?

lifestyle modifications: wt loss, avoid lying down 2-3 hrs after meals, avoid meals 2-3 hrs before HS, elevated head of bed 6”, diet, d/c alcohol & stoking

What is the pharmacological treatment for GERD?

tx empirically: PPIs (most effective, 1st line), H2RAs (w/o erosive dz)

refer if unresponsive or alarm sx

What medication?

• onset of action: 30 min - 2.5 hr

• duration: 4-10 hrs

• MOA: inhibit histamine at H2 receptors of gastric parietal cells to reduce gastric acid secretion

• ex: ranitidine, cimetidine, famotidine, nizatidine

H2RAs

What medication?

• onset of action: w/in 30 min

• duration: 12-24 hrs, can last 3-5 days

• MOA: activated in parietal cell and irreversibly bind to H+/K+ATPase pump, inactivating it & stopping HCl secretion

• first line tx for- mod-severe GERD, erosive esophagitis, NSAID ulcers, H. pylori ulcers

• ex: omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole, dexlansoprazole

PPIs

How are PPIs administered?

QD before the first meal of the day- must be taken 30-60 min before meals

What are adverse reactions of PPIs?

inc risk of PNA, MI, CV mortality, C diff, bone fractures, hypomag, hypocal, low B12 and iron

*can be used w/ clopidogrel to prevent risk of CV events

What condition consists of squamous epithelium at the distal esophagus and is replaced by metaplastic columnar epithelium, increasing the risk of progression to adenocarcinoma?

Barrett’s esophagus

What are the only agents that heal ulcers and erosions?

PPIs

How is Barrett’s Esophagus diagnosed and treated?

EGD & long term PPI

What is the management for Barrett’s with NO dysplasia?

EGD q 3-5 years

What is the management for Barrett’s with low grade dysplasia?

surveillance vs eradication

What is the management for Barrett’s with high grade dysplasia?

esophagectomy, laser ablation, photodynamic tx

What condition is a reflux induced ulceration that causes fibrous tissue production and collagen deposition in the esophagus, leading to the gradual development of solid food dysphagia?

stricture

How are strictures diagnosed and treated?

EGD (r/o malignancy), dilation (fixed size dilators or balloons), & long term PPIs

What are possible complications of GERD?

Barrett’s Esophagus and Strictures

What is the treatment for severe GERD?

surgery: Nissen Fundoplication or Belsey Mark IV Fundoplication

What pathogens cause infectious esophagitis?

• Candida albicans (uncontrolled DM, immunosuppression, systemic corticosteroids)

• HSV

• CMV (AIDS, solid organ transplants)

What condition?

• mainly in mmunocompromised patients

• sx: odynophagia and dysphagia

• Candida tx: fluconazole, itraconazole, or ampthotericin B

• HSV tx: acyclovir, famciclovir, valacyclovir, or EGD w/ bx if no response

• CMV tx: gangciclovir

infectious esophagitis

What condition?

• chronic, inflammatory, immune mediated

• UGI sx assoc w/ dense eosinophilic infiltration of squamous esophageal epithelium or deeper tissue

• allergic inflammation & remodeling → assoc w/ food & environmental ags

• MC in young adult males w/ hx atopic conditions

• common finding → multiple concentric rings

• dx: endoscopy w/ bx

eosinophilic / allergic esophagitis

What are symptoms of eosinophilic esophagitis?

adults → dysphagia & food impaction (MC), heartburn, CP, abd pain, V, can be assoc w/ narrow esophagus and strictures

children → GERD & reflux sx, N, V

What is the long term treatment for eosinophilic esophagitis?

elemental & elimination diets, aerosolized/oral/topical corticosteroids, PPIs, esophageal dilation PRN, refer allergy testing

What pills can cause erosions & esophagitis?

NSAIDs, KCl, bisphosphonates, doxy

How can pill induced esophagitis be prevented?

• swallow meds w/ water

• remain upright for 30 min post taking meds

• dont prescribe offending meds if esophageal dysmotility or strictures

• consider routes other than PO

Which occurs higher in the esophagus-

reflux esophagitis or pill-induced esophagitis?

pill-induced esophagitis

What condition?

• accidental or intentional (suicidal)

• sx: severe burning, CP, gagging, dysphagia, drooling, wheezing/stridor

• mgmt: airway (laryngoscopy), imaging, EGD, esophagectomy, psych referral

• NO NG tube or oral antidotes

Caustic esophageal injury

What condition is a muscle tear at the GE junction (non penetrating) that involves underlying venous/arterial plexus and is usually caused by prolonged vomiting/retching?

Mallory-Weiss Tear

What are symptoms of Mallory Weiss Tears?

hematemesis, hx of vomiting & retching, alcoholism is predisposing factor

what is the treatment for mallory Weiss tear?

most heal uneventfully w/in 24-48 hrs; IV fluids, endoscopic hemostatic therapy (epi injection, cautery, mechanical compression)

A full thickness (transmural) tear in the esophagus that usually occurs with overindulgence _____

Boerhaave syndrome / effort rupture

what condition?

• MC in males age 50-70

• forceful vomiting from overindulgence → transmural tear in esophagus, usually left posterior distal rupture

• chemical then infectious mediastinitis

• Hammans sign → crunchy raspy sounds heard over precordium due to pneumomediastinum

• severe CP, sepsis, shock, pyopneumothorax

• rx: fluids, abx, surgical consult

boerhaave’s syndrome

How is Boerhaave syndrome diagnosed?

CXR: mediastinal air, L pleural effusion, pneumothorax, widened mediastinum

UGI series w/ gastrografin (diatrizoic acid) - water soluble

what condition?

• thin fibrous protrusion of squamous epithelium in upper esophagus

• can be asx or cause dysphagia +/- IDA

• uncommon; increased in women

• dx: EGD, BA xray studies

• rx: endoscopy, esophageal dilation

esophageal webs

what condition is associated with the following?

• Plummer vinson syndrome - in middle aged women w/ IDA, increased incidence SCC

• bullous diseases → pemphigus, pemphigoid

• GVHD

• celiac dz

Esophageal Webs

What condition?

• thin, weblike constriction at/near border of LES (distal esophagus)

• common cause of intermittent solid food dysphagia

• worse with eating quickly and inadequate mastication

• reflux sx (chronic GERD may play role)

• dx: BA esophagram

• rx: esophageal dilation

esophageal / schatski’s rings

Out pouchings in the mid or distal esophageal wall secondary to motility disorders or strictures are known as ______

diverticula

what is the diagnosis and treatment of esophageal diverticula?

dx- barium swallow, endoscopy to r/o other, manometry;

often asx so no treatment

What condition?

• pharyngeal mucosa protrusion at posterior hypopharyngeal wall

  • appears as natural zone of weakness (Killian’s triangle)

• sx: regurgitation of saliva/food consumed several days prior, dysphagia w/ enlargement, severe halitosis, choking, gurgling, neck protrusion

• dx: BA esophagram

• tx: surgery is symptomatic

zenker’s diverticulum

What are enlarged venous collateral channels that dilate as a result of portal HTN, and has highest mortality/morbidity of any UGI bleed?

esophageal varices

The following is the pathogenesis of what condition?

• inc portal pressure → collateral venous pathways dilate in attempt to transport blood from splanchnic bed surrounding cirrhotic liver to the heart

  • this venous network is below mucosa at prox stomach & esophagus

• inc portal pressure → massive rupture

• exsanguination occurs 10-15% of time even in hospital setting

Esophageal Varices

What are possible etiologies of esophageal varices?

alcoholism, viral hepatitis, chronic schistosomiasis (particularly in developing tropical countries)

What are sx of esophageal varices?

acute GI bleed (hypovolemia) → hematemesis, melena, hematochezia

what is the treatment for esophageal varices?

• spontaneous resolution in 50% (1/2 of these rebleed in 6-8 wks)

• fluid resuscitation; FFP/plts

• emergent endo (2-12 hrs) → banding, sclerotherapy

• IV Octreotide (somatostatin analog), vasopressin, NTG

• Vit K (abnormal PT)

• chronic BP mgmt: nonselective BB (propranolol, nadolol), long acting nitrates (isosorbide mononitrate)

what invasive treatment options are used for esophageal varices when other methods are unsuccessful?

portal decompressive procedures: TIPS (pts waiting liver transplant), portosystemic shunt surgery

what can be done to prevent rebreeding of esophageal varices?

band litigation +/- BBs and nitrates, TIPS reserved for recurrent bleeds (comps- encephalopathy & CHF), liver transplant

Who is at highest risk for esophageal cancer?

men, age 50-70

Which of the two histological types of esophageal cancer is the most common form- squamous cell carcinoma or adenocarcinoma?

adenocarcinoma

Esophageal adenocarcinoma is more common in ______ ; Esophageal squamous cell carcinoma is more common in ______

white males ; african americans

What are symptoms of esophageal cancer?

• progressive solid food dysphagia

• odynophagia

• anorexia / wt loss

• hoarseness / voice changes

• anemia

• signs of metastatic dz → supraclavicular or cervical LAD, hepatomegaly

What is the workup for esophageal cancer?

BA esophagram, upper endo w/ bx, CXR, stage TNM

Most esophageal cancers arise in the ______ of the esophagus

middle third

What are risk factors for esophageal cancer?

tobacco, alcohol, chronic GERD, Barrett’s esophagus

what are the treatment options for esophageal cancer?

most too advanced for surgery; palliative care - RT, chemo, dilation & ablation, photodynamic therapy, prostheses/stents

The most important predictor of survival of esophageal cancer is if ____

spread to lymph node

what condition?

• aperistalsis in distal 2/3 of esophagus → failure/incomplete relaxation of LES

• progressive loss of inhibitory neurons in esophagus; primary dz → degeneration of Auerbach’s plexus

• unknown eti

achalasia

Primary or secondary achalasia?

• results from defect in inhibitory vagal innervation

• smooth muscle function is affected

primary

Primary or secondary achalasia?

• due to cancer, lymphoma, chagas dz (trympanosomiasis)

secondary

How should a patient positive for Barett’s with NO dysplasia be managed?

EGD q 3-5 yrs

What condition?

• progressive solid food dysphagia, possible liquid dysphagia

• sx due to stasis of food & esophageal dilation → cough, heartburn, wt loss, aspiration

• pts attempt to enhance esophageal emptying by lifting neck, throwing shoulders back, valsalva maneuvers

Achalasia

How is achalasia diagnosed?

BA esophogram → “birds beak tapering” of esophagus; dilation (late finding)

endoscopy to r/o neoplasm

confirm w/ manometry

what are treatment options for achalasia?

Pneumatic dilation of LES

Surgery (better for relieving dysphagia): PEOM, Heller w/ partial nissen

Rx (failed other tx): CCBs (nifedipine), botulinum toxin injection into LES (older, debilitated pts)

What condition?

• hypertensive peristalsis

• esophageal contractions are coordinated but amplitude excessive

• CP > dysphagia

nutcracker esophagus

What condition?

• simultaneous uncoordinated, non propulsive contractions of segments of esophagus

• prevents normal movement of food bolus

• seen in 5% patients w/ unexplained CP

• unknown cause

• corkscrew appearance

• excellent prognosis

diffuse esophageal spasm

what are symptoms of diffuse esophageal spasm?

severe retrosternal CP min-hrs, intermittent dysphagia

sx worse by - hot/cold food, rapid eating, large meals, carbonated drinks, stress/emotion

How are diffuse esophageal spasm diagnosed?

BA esophageal → corkscrew appearance of esophagus

esophageal manometry

What condition is often confused with angina pectoris due to CP relieve w/ NTG?

Diffuse Esophageal Spasm

What is the treatment for diffuse esophageal spasms?

first → acid suppression w/ PPIs

spasm relief: sublingual NTG & CCBs (can inc GERD sx)

alter esophageal perception: antidepressants (trazodone, nortriptyline)

botox into LES & distal esophagus

surgery if refractory