Clinical: Dysphagia, Odynophagia, Heartburn, Chest Pain

Front 1

This was seen on endoscopy of a patient with reflux symptoms.

What is this an example of?

What are the complications/ risks of this disorder?

Back 1

Esophageal Erosions

Complications:

• Esophageal Ulcerations & Bleeding
• Esophageal Stricture
• Barrett's Esophagus
• Adenocarcinoma

Front 2

What factors (esophageal and gastric) contribute to GERD?

Back 2

• Gravity
• Peristalsis (ability to clear reflex)
• Glandular Secretions (saliva and esophagus secrete bicarb to neutralize acid)
• Gastroduodenal Secretions (how acidic and caustic secretions are)
• Acid Pocket (acid sitting on top of food)
• Gastric emptying (if delayed increased opportunity for reflux)
• Hiatal Hernia

Front 3

What medications are used for the treatment of GERD?

Back 3

• Antacids
• Mucosal Protective Agents
• H2 blockers
• Proton Pump Inhibitors
• Prokinetic Agents

Front 4

What lifestyle changes are recommended for the treatment of GERD?

Back 4

• Elevating head of the bed at night
• Weight loss
• Small, frequent meals
• No late meals
• Avoid food with high fat content
• Avoid food known to promote symptoms (chocolate, spice food, tomato paste)

Front 5

What surgical treatments are used for the treatment of GERD?

Back 5

Fundoplication (aka. "wrap")

• repairs abdominal hernia
• strengthens Lower Esophageal Sphincter by wrapping fundus of stomach around lower esophagus

Linx Bracelet

• reinforces Lower Esophageal Sphincter

Front 6

What are the symptoms of Eosinophilic Esophagitis?

Back 6

• Dysphagia
• Obstruction with solid food
• Chest Pain
• Heart Burn

Front 7

What endoscopic findings are features of Eosinophilic Esophagitis?

Back 7

• concentric rings
• linear furrows
• white plaques
• may appear normal

Front 8

How is Eosinophilic Esophagitis diagnosed?

Back 8

Biopsy

• large number of eosinophils
• hypertrophy of basal layer of esophagus

Front 9

What endoscopic findings can be seen in these images?

What disease/ disorder are these findings consistent with?

Back 9

Left: white plaques (shiny raised bumps)

Right: concentric rings

Consistent with Eosinophilic Esophagitis

Front 10

What site is most commonly injured by ingestion of a strong acid?

What type of damage (necrosis) results?

Back 10

Stomach injured more than esophagus

Coagulative Necrosis

Front 11

What site is most commonly injured by ingestion of a strong alkalis (base)?

What type of damage (necrosis) results?

Back 11

Esophagus injured more than stomach

Liquifactive Necrosis

Front 12

What complications are associated with the ingestion of caustic substances (acids or bases)?

Back 12

• Strictures of esophagus
• Strictures of stomach
• Squamous cell carcinoa of the esophagus

Front 13

What is achalasia?

Back 13

• abormally elevated Lower Esophageal Sphincter pressure
• complete or partial failure of the LES to relax
• total loss of peristalsis of esophageal smooth muscle

Front 14

What age range(s) does achalasia typically present?

Back 14

20-40 yo

Front 15

What symptoms are most commonly associated with achalasia?

Back 15

• Dysphagia
• Regurgitation
• Chest Pain
• Heartburn

Front 16

What is a "bird beak deformity" on barium swallow practically pathogneumonic for?

Back 16

Achalasia

Front 17

How is achalasia diagnosed?

Back 17

• Barium swallow- dilated esophagus with narrowing ("bird beak deformity") at LES
• Esophagoscopy- rules out other causes of symptoms
• Esophageal Manometry- measures coordination of muscles and force of muscles

Front 18

What disease present with achalasia (cause secondary achalasia)?

Back 18

• Chagas Disease
• Carcinoma
• Lymphoma
• Amyloidosis

Front 19

How is achalasia treated?

Back 19

• Botox injection into LES
• Balloon dilation
• Surgical myotomy

Front 20

A patient presents with chest pain and dysphagia. Examination via endoscopy with biopsy, pH test, and barium swallow are normal allowing you to eliminate GERD, eosinophillic esophagitis, and achalasia. What types of disorders (category and specific disorders) should be at the top of your differential?

Back 20

Spastic Motor Disorders

• Diffuse esophageal spasm
• Nut cracker esophagus
• Hypertensive LES
• Ineffective esophageal motility

Upper Esophageal Sphincter Disorder

Front 21

How do you differentiate between the different Spastic Motor Disorders (what would you do to generate a specific diagnosis)?

Back 21

Esophageal Manometry

Front 22

What findings on manometry would you expect to see in a patient with Diffuse Esophageal Spasm?

Back 22

• simultaneous and/ or repetitive esophageal contractions more (10%< of the time < 100%)
• some normal peristalsis
• contractions may be of increased amplitude
• contractions may be of prolonged duration
• abnormalities relaxing the LES

Front 23

What findings on manometry would you expect to see in a patient with Nut Cracker Esophagus?

Back 23

• Peristaltic contractions of the esophagus
• Contractions of very high amplitude (> 2 SD above normal)

Front 24

What findings on manometry would you expect to see in a patient with Hypertensive LES?

Back 24

• Elevated LES pressure
• LES may or may not relax normally

Front 25

What findings on manometry would you expect to see in a patient with Ineffective Esophageal Motility?

Back 25

30% of contractions are non-peristaltic or low amplitude

Front 26

How are patients with Spastic Motor Disorders treated?

Back 26

• Muscle relaxants (nitrates, anticholinergics, Ca channel blockers)
• Psychotropic drugs (antidepressants, anxiolytics)
• Esophageal dilation
• Esophageal balloons
• Surgical myotomy

Front 27

What systemic diseases can affect the esophagus?

Back 27

• Scleroderma- GERD, strictures, dysphagia
• CREST- GERD, strictures, dysphagia
• Mixed CT Disease- GERD, strictures, dysphagia
• Dermatomyositis- GERD & aspiration
• Polymyositis- GERD & aspiration
• Lupus- esophageal motor dysfunction
• RA- esophageal motor dysfunction

Front 28

What factor predisposes an individual to infectious esophagitis?

Back 28

Immunocompromised State:

• AIDS
• Chenmotherapy
• Diabetes
• Elderly
• Immunosuppressive drugs

Front 29

When biopsying a patient with infectious esophagitis what is the most important area to biopsy?

Why?

Back 29

The leading edge of the ulcer

• if HSV is the cause, the viral inclusions are found in the leading edge

Front 30

How does Squamous Cell Carcinoma of the esophagus typically present?

Back 30

• Dysphagia
• Weight loss
• Pain