Esophageal Disorders

Front 1

Define and tell what initiates primary peristalsis versus secondary peristalsis.

Back 1

Primary peristalsis: peristalsis wave that occurs directly after swallowing
Secondary peristalsis: peristalsis elicited by esophageal distention, executed entirely by a local intramural reflex. Its physiologic role is to clear the esophagus of food residues and refluxed materials by moving them to the stomach.

A swallow initiates primary peristalsis, whereas secondary peristalsis can be initiated at any level of the esophagus in response to local luminal stimuli such as acid or distention.

Front 2

Regarding esophageal symptoms, define each:
A. dysphagia
B. odynophagia
C. pyrosis
D. globus sensation

Back 2

A. dysphagia - difficulty swallowing. 2 types: oropharyngeal dysphagia (transfer dysphagia, inability to initiate swallow or transfer thru pharynx) and esophageal dysphagia (transport dysphagia)
B. odynophagia - pain with swallowing
C. pyrosis - heartburn
D. globus sensation - feeling a lump or tightness in the throat, unrelated to swallowing

Front 3

There are two types of dysphagia. Name em. Which one is the one more commonly seen in older persons and is usually caused by striated muscle dzs or neurological dsorders and various local structural lesions?

Back 3

2 types: oropharyngeal dysphagia or esophageal dysphagia

That description is oropharyngeal dysphagia, commonly seen with neuromuscular dzs like: CVA esp. stroke, multiple sclerosis, ALS, Parkinson's Dz. Mechanical obstruction in oropharyngeal type is mainly Zenker's diverticulum.

Front 4

Name the common causes of oropharyngeal dysphagia and esophageal dysphagia.

Back 4

Oropharyngeal dysphagia:
Neuromuscular cause- CVA (esp stroke), MS, ALS, Parkinson's dz
Mechanical obstruction cause - Zenker's diverticulum

Esophageal dysphagia:
Mechanical - Webs, rings, strictures, diverticula, eosinophilic esophagitis, congenital malformations, cancers, achalasia

Front 5

True or False:
Zenker's diverticulum is a mechanical cause of esophageal dysphagia.

Back 5

FALSE.
Zenker's diverticulum is a mechanical cause of OROPHARYNGEAL dysphagia, one of two types of dysphagia in the esophagus.

Zenker's diverticulum is in the elderly population just above the UES! Food can get stuck here and cause halitosis. Other associated symptoms: aspiration and coughing a lot.

Front 6

Which of the following is FALSE about odynophagia?
A. Odynophagia is usually seen only with immunocompromised patients.
B. Odynophagia can be caused by meds like quinidine, tetracycline, ferrous sulphate, NSAIDs
C. Can manifest as dull retrosternal ache on swallowing to a stabbing pain with radiation to the back
D. All of the above a true.

Back 6

D. All of the above a true.

Front 7

Odynophagia is usually only seen with immunocompromised patients or with certain medicines. What are the common pill induced esophagitis causes (4) and infectious esophagitis causers (4).

Back 7

Causes of odynophagia from pills: Quinidine, Tetracycline, Ferrous Sulphate, NSAIDs.
Causes of odynophagia from infections: HIV< CMV< HSV, Candida

Front 8

True or False:
Esophageal disorders are probably the most common causes of non-cardiac chest pain.

Back 8

True

Front 9

What are hiatal hernias and differentiate between the four types.

Back 9

Hiatal hernia is herniation of gastroesophageal junction and/or stomach through diaphragmatic hiatus.
Type 1: sliding herina (~95% of cases), is where the G junction is above diaphragmatic hiatus and stomach is pulled up
Type 2: paraesophageal hernia, is where G junction is at correct place but a part of fundus pouch is above diaphragmatic hiatus.
Type 3: elements of both Type I and II
Type 4: herniation of other organs like colon, small intestine, etc.

Front 10

What is/are the classic symptom (1) , associated symptoms (5), and extra esophageal manifestations (4) associated with GERD?

Back 10

Classic = heartburn
Ass. sympts = dysphagia, odynophagia, regurg, water brash, belching
Extra-esophageal sympts = hoarseness, laryngitis, asthma, chronic cough

Front 11

WIth GERD and subsequent esophagitis, what is the strongest predictor of the severity of esophagitis?
A. how hypotensive LES is
B. acidic potency of the refluxate
C. size of the hiatal hernia

Back 11

C. size of the hiatal hernia

Front 12

What are complications of long-standing GERD? (3)

Back 12

- Peptic ulceration
- strictures
- development of Barrett's esophagus (metaplastic columnar epithelium replaces the normal squamous epithelium of the distal esophagus)

Front 13

Which of the following IS NOT AN appropriate management options for GERD?
A. Weight loss for overweight or obese patients
B. Avoiding late meals or meals prior to betime
C. Avoiding specific foods (varies by patient)
D. Proton pump inhibitors like Omeprazole
E. Steroids like Fluticasone

Back 13

E. Steroids like Fluticasone

Front 14

In Barrett's esophagus, what histological changes do we see and what are you at higher risk for?

Back 14

With Barrett's esophagus, we see intestinal metaplasia dn goblet cells in the esophagus. Comes with a risk of adenocarcinoma.

Front 15

___________ is an inflammatory disorder of the esophagus characterized by symptoms of esophageal dysfunction in association with histologic evidence of eosinophilic infiltration of the esophageal mucosa.

Back 15

Eosinophilic esophagitis, aka asthma of the esophagus

Diagnosis is based on seeing 15 eosinophils per high power field in absence of GERD. (Unlike the rest of the GI tract, normally the esophagus does NOT have any resident eosinophils.) Diagnosis is also supported by a family history of EE and other allergy-based disorders like asthma, seasonal allergies.

Front 16

What condition is depicted and what is the treatment?

Back 16

Eosinophilic esophagitis, "asthma of the esophagus". Classic endoscopy appearance is that of a corrugated or ringed narrow caliber esophagus, commonly associated with multiple strictures.

Appropriate treatment is typically with steroid fluticasone (22 mcg/puff, without spacer).

Front 17

___________ is a primary esophageal motor disorder of unknown etiology characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis.

Back 17

Achalasia!!

Radiographically there is aperistalsis, esophageal dilation, minimal LES opening with a birdbeak appearance and poor esophageal emptying of barium.

Symptoms are: dysphagia for solid and liquid, regurgitation, heartburn

Diagnosed via esophageal manometry.

Front 18

Which of the following is FALSE regarding achalasia?
A. Upon barium esophagram study, there is smooth tapering of the lowerr esophagus leading to the closed LES, resemblinga "bird's beak"
B. There is esophageal aperistalsis upon esophageal manometry
C. Golden test for diagnosis is endoscopy
D. there is no cure but goal of treatment should be relief of patient symptoms and improved esophageal emptying.

Back 18

FALSE is: C. Golden test for diagnosis is endoscopy

The diagnosis is established by B. There is esophageal aperistalsis upon esophageal manometry.

Front 19

What are the appropriate treatments for each?
A. GERD
B. Eosinophilic esophagitis
C. Achalasia
D. Zenker's diverticulum

Back 19

A. GERD: PPIs
B. Eosinophilic esophagitis: Steroid Fluticasone
C. Achalasia: no cure, but goal is relief of patient symptoms and improved esophageal emptying. Two most effective treatments are: graded pneumatic dilation and surgical myotomy.
D. Zenker's diverticulum: resection of diverticulum and myotomy of cricopharyngeus muscle

Front 20

What is depicted and what is its treatment?

Back 20

Zenker's diverticulum! Treatment is resection of diverticulum and myotomy of cricopharyngeus muscle.

Front 21

1. A 79 year old male is admitted to the hospital with aspiration pneumonia. He gives a significant history of dysphagia and regurgitation of undigested food material. His wife of 55years complains of severe bad breath. Below is the endoscopic appearance, Pick the most likely anatomical location for this condition.

A. Between the oblique fibers of the inferior pharyngeal constrictor and transverse fibers of the cricopharyngeus muscle
B. Between the cricopharygeus and the cervical esophagus.
C. Between the oblique and the transverse fibers of the cricopharyngeus muscle
D. Between the middle and inferior pharyngeal constrictors

Back 21

A. Between the oblique fibers of the inferior pharyngeal constrictor and transverse fibers of the cricopharyngeus muscle

Front 22

Select the mechanism that best describes the
contribution of hiatal hernia to GERD.

A. Loss of augmentation of the antireflux barrier by the crural diaphragm
B. Impaired esophageal acid clearance.
C. Transient lower esophageal sphincter relaxation (TLESR) may be elicited more easily.
D. Trapping of gastric content that may reflux during TLESR
E. All the above.

Back 22

E. ALL OF THE ABOVE!!

The size of the hiatal hernia is the strongest predictor of the severity of esophagitis. However the mechanistic causes are multi-factorial.

Front 23

Which of the following are considered to be the gold standard for the diagnosis of GERD?

A. Upper Endoscopy
B. 24-hour pH monitoring
C. Barium Esophagram
D. Esophageal impedance testing
E. None of the above

Back 23

E. None of the above

Despite being a common problem, there is no gold standard for this disease. 25-30% of patients with GERD have no increase in acid exposure. 50% of endoscopies are negative in symptomatic people. Barium radiograph is has a sensitivity of 25-75% and is false positive in 20%. Impedance, promising not yet established.

Front 24

A 22 year old medical student presents with significant history of atopy and asthma, presents with history of gradually worsening solid food dysphagia. He had been a slow eater most of his life. Over thanksgiving he had acute impaction of turkey in his esophagus that required Endoscopic disimpaction. What diagnosis best fits this description?

a) Nutcracker esophagus.
b) Eosinophilic Esophagitis
c) LA grade D esophagitis
d) Congenital esophageal stenosis
e) Schatzki’s ring

Back 24

b) Eosinophilic Esophagitis

Front 25

If the dysphagia occurs more with solids rather than liquids, the problem is likely [ motility / obstructive ] related; If the dysphagia occurs equally with solids and liquids, then the problem is likely [ motility / obstructive ] related.

Back 25

Solids > liquids = likely obstructive problem
Solids = liquids = likely motility problem