Esophageal and Stomach Disorders

"difficulty swallowing"

dysphagia

oropharyngeal dysphagia

this type of dysphagia occurs in the structure preceding the esophagus (oral cavity, pharynx)

- coughing/choking with swallowing

- difficulty initiating swallowing

- drooling (sialorrhea)

- change in voice/speech (wet voice)

- nasal regurgitation (aspiration risk)

What type of sxs can be expected from someone experiencing oropharyngeal dysphagia?

oropharyngeal

Are neurologic etiologies more common for oropharyngeal or esophageal dysphagia?

- sensation of food sticking in chest after swallowing

- oral/pharyngeal regurgitation

What type of sxs can be expected from someone experiencing esophageal dysphagia?

videofluoroscopic swallow study

What is the gold standard in diagnosing oropharyngeal dysphagia?

upper endoscopy

but barium swallows and manometry tests are helpful too

What is the gold standard in diagnosing esophageal dysphagia?

dyspepsia / "indigestion" / "heartburn"

acute, chronic, or recurrent epigastric pain, burning, or discomfort, early satiety, or postprandial fullness

functional

--> also PUD, GERD, chronic gastric H. pylori infxn

--> also NSAIDs

What is the most common cause of dyspepsia?

< 60: noninvasive test for H. pylori to test for PUD (urea breath test, fecal antigen test)

> 60: may need to do upper endoscopy to look for upper gastric or esophageal malignancy

How is dyspepsia diagnosed in patients above and below 60?

PPI x 4 weeks

Your patient presents with dyspepsia. She tests (-) for H. pylori, so you diagnose her with functional dyspepsia. How should you treat her?

1) increased gastric acid secretion

2) incompetent lower esophageal sphincter

What are the 2 main etiologies of GERD?

heartburn!!!!! (usually retrosternal and postprandial), regurg, dysphagia, cough at night

atypical: chronic hoarseness, aspiration pneumonia, "asthma," weight loss

What sxs can be expected in a patient presenting with GERD?

1) dysphagia

2) odynophagia

3) weight loss

4) bleeding

What are the alarm sxs associated with GERD?

usually clinically (based on sxs)

need to do upper endoscopy if alarm sxs

pH monitoring is gold standard

How is GERD diagnosed?

lifestyle and diet modifications

What is 1st line therapy for GERD?

Barrett's esophagus

replacement of normal squamous epithelium of the distal esophagus with precancerous metaplastic columnar cells from the cardia of the stomach (specialized intestinal metaplasia (SIM))

GERD -->

esophagitis -->

metaplastic change of esophageal lining

How does one develop Barrett's esophagus?

endoscopy (to detect) &

bx (to confirm)

What test is essential for the accurate dx of Barrett's esophagus?

periodic endoscopy

if bx (-) for dysplasia, f/u endo @1yr then q3y

if bx (+) for dysplasia, low-grade dysplasia endoscopy 6-12 months

treat for GERD! (PPIs and lifestyle changes)

How do you treat Barrett's esophagus when there is no or low-grade dysplasia?

endoscopic resection, radiofrequency ablation, cryotherapy, photodynamic therapy, surgery

How do you treat Barrett's esophagus when there is high-grade dysplasia?

1) candida

2) CMV (aka human herpes virus-5)

3) HSV

What are the 3 MCC of infectious esophagitis?

odynophagia

What is the hallmark sx of candida infectious esophagitis?

candida infectious esophagitis

What type of infectious esophagitis?:

- etiology: immunosuppression (HIV, steroids)

- s/sx: odynophagia, linear yellow-white plaques that DO NOT wash off, hyperemia

- tx: fluconazole

CMV infectious esophagitis

What type of infectious esophagitis?:

- etiology: immunocompromised (HIV/AIDS)

- s/sx: 1(+) LARGE superficial, shallow ulcerations; avoid or elongated ulcers may extend for several cms

- tx: ganciclovir

HSV infectious esophagitis

What type of infectious esophagitis?:

- etiology: immunosuppression, reactivation

- s/sx: small, DEEP ulcers with raised margins, surrounding erythematous and edematous

- tx: acyclovir

Mallory-Weiss Syndrome/Tear

longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia

upper GI bleeding 2° to longitudinal mucosal lacerations at the GE junction or gastric cardia

excessive alcohol intake that leads to a SUDDEN rise in intragastric pressure (vomiting, retching, coughing, etc)

What is the main cause of a Mallory-Weiss Tear?

hiatal hernia

What predisposing factor is found in 35-100% of patients with a Mallory-Weiss Tear?

NOT painful

How painful is the hematemesis that comes along with a Mallory-Weiss Tear?

early upper endoscopy

Patients with a suspected Mallory-Weiss Tear should NOT undergo barium or gastrografin studies. If this has not resolved spontaneously, how can it be diagnosed?

True

True or false:

- Patients with a Mallory-Weiss Tear should be treated with supportive tx if there is NO bleed, but those with bleeding should receive medication and surgical methods to stop the bleed.

epinephrine injection (to vasoconstrict) and gentle tamponade with several 1 sec pulses of bipolar heater probe

How can you prevent further n/v or esophageal trauma for a patient with a Mallory-Weiss Tear?

- vascular markings (edema)

- multiple esophageal rings (diffuse irritation)

- longitudinally oriented furrows

- whitish exudate

Eosinophilic esophagitis if commonly caused by food allergens and aeroallergens. What are the main findings on endoscopy for a patient with eosinophilic esophagiti?

esophageal web

thin mucosal membrane in the esophagus, causing intermittent dysphagia; associated with Plummer-Vinson syndrome

part of lumen, mucosal, proximal esophagus (ONLY PARTIAL)

esophageal ring (aka Schatzki ring)

narrowing at the lower esophagus often d/t GERD; causes intermittent solid food dysphagia

circumferential (goes all the way around), muscle or mucosa, at distal esophagus

esophageal stricture

narrowing of the esophagus from chronic inflammation (e.g., GERD, radiation, caustic ingestion)

zenker diverticulum (aka hypopharyngeal diverticulum)

outpouching of the pharyngeal mucosa through weakened muscle, causing regurgitation of undigested food

outpouching in esophagus; "false diverticula;" involves mucosa AND submucosa; benign cause to dysphagia; usually tx by symptomatic therapy and monitoring

portal vein HTN

RF: cirrhosis

Esophageal varices are a complication of...?

What is a major RF to esophageal varices?

esophageal varices

S/sx of this include...

- upper GI bleed

- hematemesis

- coffee-ground emesis

- melena

- hematochezia

- shock and hypovolemia if severe

non-selective BBs (propranolol, nadolol)

esophageal variceal ligation

How do you manage a pt with NON-BLEEDING esophageal varices?

endoscopic variceal ligation

octreotide

balloon tamponade

vit K (esp if you're worried abt clotting)

How do you manage a pt with BLEEDING esophageal varices?

achalasia

idiopathic proximal loss of Auerbach's plexus --> causes increased LES pressure

distal esophageal peristalsis lost, LES fails to relax

loss of ganglion cells in LES

dysphagia to both solids and liquids, weight loss, regurg of undigested foods

What are the main s/sx of achalasia?

esophageal manometry (inc LES pressure > 40 mmHg, decreased peristalsis)

How is achalasia dx?

bird's beak appearance of LES d/t pressure buildup from surrounding muscles

A double contrast esophagram will show what for a patient with suspected achalasia?

diffuse esophageal spasm /

corkscrew esophagus /

distal esophageal spasm

irregular, uncoordinated squeezing of the muscles of the esophagus

pts will complain of "squeezing pain in the chest"

diffuse esophageal spasm /

corkscrew esophagus /

distal esophageal spasm

What disorder?:

- s/sx: noncardiac CP that is retrosternal and radiates to the back; globus (sensation that object is trapped in throat)

- dx: esophagram, manometry (showing simultaneous contraction), or endoscopy

- tx: CCBs, nitrates

nutcracker esophagus /

hypercontractile esophagus

What disorder?:

excessive contractions during peristalsis

- s/sx: painfully strong contraction / chest pain; dysphagia

- dx: manometry (inc pressure during peristalsis)

- tx: CCBs, nitrates, sildenafil, botox

erosive

- MCC is NSAIDs

nonerosive

- MCC is H. pylori

What are the mcc of erosive and nonerosive gastritis?

upper GI bleeding (presents as hematemesis, "coffee grounds" emesis, or blood aspirate in pt receiving NG suction, OR as melena)

What is the m/c clinical manifestation of erosive gastritis?

upper endoscopy (may show subepithelial hemorrhages, petechiae, erosions)

How is erosive gastritis diagnosed?

urease

What enzyme produced by H. pylori helps it adapt to hostile gastric environments?

gold standard: endoscopy with bx -> rapid urease test

other options:

- urea breath test

- H. pylori stool antigen (HpSA)

- serological antibodies

What is the gold standard for diagnosing H. pylori gastritis?

triple "CAP" therapy

clarithromycin + amoxicillin + PPI x 2 wks

*if PCN allergy (CMP), metronidazole

*if recurrent/resistant (LAP), levofloxacin for clarithromycin

What is the current ToC for H. pylori gastritis?

1) NSAIDs

2) chronic H. pylori infxn

What are the 2 main causes of PUD?

dyspepsia (epigastric pain)

"gnawing, dull, aching, 'hunger-like'"

RUQ pain = duodenal ulcer

LUQ pain = gastric ulcer

What is the hallmark sx of PUD?

endoscopy (can do bx to r/o malignancy)

What is the gold standard dx of PUD?

zollinger-ellison syndrome

tumor of the pancreas (gastrinoma - gastrin secreting tumor often in the pancreas, duodenum then lymph nodes)

most arise in the gastrinoma triangle bounded by the porta hepatis, neck of the pancreas, and 3rd portion of duodenum

fasting serum gastrin concentration (>150)

How can we test for zollinger-ellison syndrome?