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34 Cards in this Set

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How does innervation of the upper esophagus differ from innervation of the lower esophagus?
Upper esophagus (striated muscle): receives stimulatory input from nucleus ambiguus via vagus (Ach)

Lower esophagus (smooth muscle): receives stimulatory input from dorsal motos nucleus via vagus (Ach)
ALSO it is inhibited by NO, VIP
Zenker's Diverticulum:
What is it?
Cricopharyngeus becomes stenotic, esophagus forms a diverticulum (pocket)

Food can get stuck in pocket, feel stuck, and rot (bad breath).
Lower Esophageal Sphincter:
Sources of tone
Pressure in relation to stomach body
Period of relaxation after swallowing
LES:
Tone comprised by distal esophageal SM contraction
Striated muscle of diaphgram (increased pressure upon inspiration--diaphragmatic pinching)

Baseline pressure is 10-30 mmHg above stomach body pressure

Relaxes up to 10 seconds after a swallow
GERD:
Risk Factors
Symptoms
Obesity
Hiatal Hernia
Age

Syx:
Heartburn, acid regurg
Laryngitis, cough, asthma
Dental erosions
In patients with GERD, LES resting pressures are ______.
Normal.

Only in severe dz is LES tone low.
GERD:
Pathophys
Diagnostic Criteria
Transient LES Relaxation:
Relaxations not preceded by swallow, lasts 10-45 seconds.

Should be normal response to gas (belching), but also seen in GERD.

Dx based on Hx alone!
>50 years old
syx >5 years
fever, anorexia, weight loss, dysphagia, odynophagia (painful swallowing), bleeding
Why is reflux during sleep most damaging?
Supine position (no assist from gravity to keep acid in stomach)

No salivation (saliva contains bicarb)

No swallowing (peristalsis) to return acid to stomach
When is endoscopy indicated for diagnosis of GERD?
When GERD is thought to be complicated, e.g., Barrett's esophagus, esophagitis

Note: normal EGD does not r/o GERD
Savary-Miller Classification (Grades 1-4)
Grade 1: isolate ulcer
Grade 2: multiple, non-circumferential ulcers above Z line (GE jn)
Grade 3: Circumferential ulcerations
Grade 4: Chronic changes, stricture
Describe normal pH fluctuations in the esophagus.
pH fluctuates in normal individuals, but rarely <4.

Patients with GERD are likely to have pH<4 frequently and for long pds of time.
GERD:
Therapy in pts with and without esophagitis
With esophagitis or severe syx:
Proton pump inhibitor, H2 receptor blocker, sucralfate

If mild or no esophagitis:
Lifestyle mods:
elevate head of bed
weight loss
avoid fatty foods, bedtime snacks, tobacco, EtOH
PPI vs H2RA: which is more effective?
PPI
Effect of hiatal hernia on LES.
Hiatal hernia reduces pressure diaphragm applies to LES, preventing esophageal pinch, and allowing for GERD.
When is Nissen fundoplication inicated?
To correct hiatal hernia

Involves wrapping portion of gastric fundis around distal esophagus to create barrier to reflux

BUT MAJORITY of pts re-develop syx
What is NERD?
Non-Erosive Reflux Disease

Constitutes 70% of reflux
causes
Barrett's Esophagus:
Pathophys
Risks
Symptoms
Specialized intestinal metaplasia (columnar epithelium w/goblet cells) replaces esophageal squamous epithelium damage by GERD

Can result in dysplasia and potential for adenocarcinoma!

Barrett's is risk for carcinoma!

Asyx!

Appears as salmon colored tongues on endoscopy.
Monitoring protocol post-dx of Barrett's.
EGD every 3 years once dx confirmed with repeat EGD and 4 quadrant bx's.

If high-grade dysplasia present, EMR (resection) or ablation considered.
Barrett's Esophagus:
Management
None for Barrett's specifically (that have been proven to prolong life)

Treat GERD, follow surveillance guidelines
Dysphagia for solids vs for liquids:
Etiology
If dysphagia for solids: mechanical obstruction

If dysphagia for liquids: motility disorder
Eosinophilic esophagitis
Often seen in children, but can be seen in adults.

Allergic reaction leads to inflammation-->ringed esophageal strictures
Achalasia:
Pathophys
Syx
BIRD BREAK

Degeneration of ganglion cells in esophagus that produce NO (inhibitory; relaxation).
Cholinergic neurons that keep LES tone tight are spared.

Patients develop dilated esophagus and present with dysphagia for solids and liquids, weight loss, food regurg

SUMMARY: CAN'T RELAX LOWER SPHINCTER; NOT A REFLUX, but is painful
Achalasia:
Dx
Manometric findings
Barium swallow with bird beak appearance of GE jn; dilated esophageal body

Manometric features:
Incomplete relaxation of LES
Aperistalsis of body of esophagus
High resting LES pressure (>45 mmHg)
What is pseudoachalasia?
Presence of tumor/mass growing in esophagus and presenting as achalasia.
Achalasia:
Tx
Pneumatic dilation of LES using balloons; weakens LES by tearing muscle fibers.

2-6% will have perforation!

Can also perform a heller myotomy (cuts LES fibers) but will give pt iatrogenic GERD--must be placed on PPI
Botulinum injections:
MOA
Indications
Inhibits ACh release; use in achalasia to decrease LES pressure.

Only lasts 6 mos.

Indicated for pts w/high surgical risk
Effect of aging on oropharyngeal function.
Xerostomia (dry mouth) affects chewing and swallowing; as does dementia, stroke, PD, myasthenia gravis, ALS

Delayed elevation of larynx and dec'd clearance from pharynx increases risk of aspiration
Gastroparesis:
What is it?
Syx?
Delayed passage of gastric contents into intestine

Syx are variable:
Early satiety
N/V, bloating, upper abdominal discomfort
This disorder affect up to 50% of patients with long-standing diabetes.
Gastroparesis (acute changes in blood sugar affect gastric motility in all pts--healthy and diabetic)
Scintigraphic study
Radioactive scrambled eggs

Dx gastroparesis
Gastroparesis:
Management
Diet modificaiton: small frequent meals
Low fat meals
Reduced fiber meals
Blood glucose control

Meds are tricky

Gastric pacemaker improves symptoms (gets rid of nausea, discomfort), but not gastric emptying
Scleroderma:
Pathophys
Syx
Autoimmune dz causing fibrosis of skin and organs (systemic)

Often seen in esophagus

Syx: GERD-like, low LES tone, low amplitude contractions

May also have gastroparesis, bacterial overgrowth, small bowel diverticula

Food passes through with gravity, but often have reflux bc there's no barrier.
Hirschprung's Disease:
Pathophys
Presentation
Failure of enteric neurons to migrate to end of bowel during embryogenesis

Internal anal sphincter does not relax with rectal distention

Presents with MEGACOLON/MEGARECTUM

Only tx is surgery
Internal anal sphincter does not relax with rectal distention.
Hirschprung's Dz
Transient lower esophageal relaxation.
GERD