Gi - Esophageal Disorders

Front 1

what is the order of contraction of the esophagus?

Back 1

(1. pharynx)
2. UES
3. body
4. LES

Front 2

What are symptoms of esophageal dysfunction?

Back 2

- odynopagia - pain on swallowing
- dysphagia - difficulty swallowin/sensation of pain on swallowing
- heartburn - acid reflux
- chest pain

Front 3

What does Odynophagia indicate?
- what are the causes?

Back 3

- indicates severe inflammatory process in esoph - disrupts the mucosa
- causes:

1. infection - candida, HSV, CMV (AIDS patient)
2. pill-induced ulcer - aspirin, doxycycline, KCl, vitamin C, NSAIDs, alendronate

Front 4

What can severe odynophagia lead to?

Back 4

can lead to spasms, achalasia

Front 5

What are the receptors in the esophagus?

Back 5

NO PAIN RECEPTORS!!!
- only stretch and chemo receptors --> thus, can narrow down cause of pain

Front 6

What does dysphagia indicate?
- what are the types of dysphagia?

Back 6

- often the presenting symptom, indicating organic disease --> needs evaluation!'

1. oropharyngeal dysphasia
2. esophageal dysphasia
3. dysph due to mechanical obstruction
4. dysphagia due to neuromuscular (motility) disorders

Front 7

Oropharyngeal Dysphasia
- description?
- causes?
- what makes it worse?

Back 7

Descrip:
- transfer dysphagia - difficulty initiating a swallow --> food, drink may get caught in throat or go up nose, etc.
- coughing or choking due to aspiration on swallow

Causes:
- muscular (polymyocitis)
- neural (MS, muscular dystrophy, myasthenia gravis, CVA)
- local (throat cancer)

**disease often very apparent

- often worse with liquids!!

Front 8

Oropharyngeal Dysphagia
- dx??

Back 8

Radiology: cine-MRI barium swallow
-- retention of barium in valleculae or pyriform sinuses; or barium in respiratory tract

Front 9

What are important signs of an esophageal dysphagia?
- main means of Dx??

Back 9

- no odynophagia
- no globus sensation

Dx: ... DO HX!!!... should give strong suspicion of correct dx in 85% cases!

Front 10

What are the 3 questions you should ask in a history for esophageal dysphagia?

Back 10

1. What foods cause sx?
- solids only = mechanical/obstructive
- both liqs and solids = motor/MOTILITY disorder

2. Where is the pain localized to?
- suprasternal notch = not specific
- along sternum = more specific

3. Are the sx intermittent or progressive?
- progressive = dysphagia to smaller, smaller, smaller solids, then liqs

Front 11

What are important symptoms associated with esoph dysphagia to be aware of?

Back 11

- presence of heart burn
- chest pain
- nighttime cough

Front 12

What type of intake causes problems when you have esoph dysphagia due to mechanical obstruction?

Back 12

- typically solid food only

Front 13

What is the critical means of Dx for mechanical obstruction of esophagus?

Back 13

Upper Endoscopy!!!

Front 14

What are the major causes of esophageal dysphasia due to MECHANICAL OBSTRUCTION?

Back 14

1. Peptic Stricture - scar tissue secondary to chronic esophagitis
2. Lower Esoph (Schatzki's) Ring
3. Carcinoma

Front 15

Peptic Stricture
- what is?
- cause?
- leads to...?
- how diagnosed?

Back 15

= fixed narrow distal esophagus
- due to scarring secondary to chronic esophagitis: long hx of heartburn and antacid use
- leads to mechanical obstructive esoph dysphagia
- dx: seen on barium swallow

Front 16

Lower Esophageal Ring
- aka?
- what is?
- cause?
- leads to...?

Back 16

- aka: Schatzki's Ring
= thin mucosal invagination in distal esoph at GE Junction
- often congenital
- In 10% of normal people, asymptomatic ring is present - only might notice when take a really big bit
- leads to mechanical obstructive esoph dysphagia
- dx: hx of INTERMITTENT dysphagia for solids; or persistent dysphagia
- not usually seen on barium swallow (unless look carefully)

Front 17

Carcinomas of the esophagus
- what major sx can they lead to? another sx?
- causes?
- incidence?

Back 17

**Often lead to PROGRESSIVE mechanical obstructive dysphagia (initially only for solid food)
- also, weight loss!

1. Squamous Cell Carcinoma
- heavy smoking and alcohol
2. Adenocarcinoma
- due to Barrett's Esophagus (chronic GERD)

***Adenocarc incidence increasing = 60-80% in US

Front 18

How do you dx a carcinoma of the esophagus?

Back 18

- esophagoscopy with biopsy and/or cytology
- see irregular narrowing of esoph lumen on barium swallow

Front 19

How could much of esoph carcinoma be prevented?

Back 19

Treating acid reflux!

Front 20

Esophageal Diverticulum
- locations?
- aka?
- symptoms?

Back 20

- Proximal (Zenker's) --> oropharyngeal dysphasia

- Distal --> occasionally causes mechanical obstruction dysphasia

Front 21

What is Plummer Vinson Syndrome?

Back 21

= Iron-deficiency anemia
- associated with dysphagia secondary to an upper esophageal web of tissue

Front 22

Esophageal Monoliasis
- aka?
- cause?
- major sx?
- appearance on x-ray?

Back 22

- aka: candidiasis
- cause: immunocompromised host with candidiasis infection
- major sx: odynophagia
- "cobblestone esoph" on x-ray

Front 23

What are the causes of Dysphagia due to neuromuscular (motility) disorders?

Back 23

1. Achalasia
2. Scleroderma
3. Diffuse Esophogeal Spasm
4. Eosinophilc Esophagitis

Front 24

What is difficult to swallow due to neuromuscular dysphagia?

Back 24

solids and liquids!

Front 25

Achalasia
- what is?
- causes?
- tx?

Back 25

= when the muscle of the LES is super tight, but not a complete stricture

Causes:
- hypertensive LES (often)
- incomplete relaxation of LES
- aperistalsis of esoph body

Tx:
- botulinum toxin
- pneumatic dilation
- surgical myotomy

Front 26

What are clinical features of achalasia?
- how do they present?

Back 26

Slowly progressing sx!

- dysphagia
- nocturnal respiratory symptoms (common)

Front 27

What are the x-ray features of achalasia?

Back 27

- dilated esophagus (BIG)
- smoothly tapered distal end ("bird beak")
- air/fluid level in post mediastinum
- absent gastric air bubble

Front 28

Scleroderma
- what is?
- how often does it involve the esophagus?
- descrip...

Back 28

= connective tissue disease --> sclerosis of skin and organs
- esophagus involved 80% of the time
- weak LES and low amplitude/nonexistent contractions in esoph body

Front 29

Scleroderma of esophagus
- major sx?
- signs on physical exam?
- often associated with?

Back 29

Major sx: heartburn and regurgitation

Physical signs:
- hardened and thickened skin on face
- telangiectasia - blood vessels rupture
- sclerodactyly - tightness of skin on digits
- calcinosis cutis - Ca deposits under skin

Often associated with Raynaud's Syndrome

Front 30

Diffuse Esophageal Spasm
- presentation?
- dx??

Back 30

Presentation:
- severe chest pain - relieved by Nitroglycerin
- intermittent dysphagia

Dx requires:
- dysphagia and/or chest pain
- definite manometric abnormalities (e.g., faulty peristalsis)

Front 31

Manometry

Back 31

measurements of esophageal function

Front 32

Eosinophilic Esophagitis
- definition
- what kind of dysphagia does it present with?
- other sx?
- associations?
- risks?
- tx?

Back 32

- def: >15-20 eosinophils/high power field

- dysphagia for solids and liquids
- in kids, often associated with reflux
- often assoc'd with other allergies - asthma, eczema, etc.

Risks: perforation at dilation

Tx:
- oral systemic steroids
- dietary restrictions

Front 33

Eosiniophilic Esophagitis
- appearance on endoscopy?

Back 33

- "ribbed or feline" on endoscopy - rings loaded with eosinophils

Front 34

What are the most important lab tests for evaluating dysphagia?
- uses?
- most important???

Back 34

1. Barium Swallow (esophagogram) = screening

2. Esophagoscopy (with biopsy) = MOST IMPORTANT for suspected lesions, esp to r/o carcinoma
- must do in achalasia to r/o adenocarcinoma at GEJ (which causes "secondary achalasia"

3. Esophageal Manometry - specific for motility disorders

Front 35

What is a risk the doc must consider for a patient with eosinophilic esophagitis?

Back 35

***These patients are highly susceptible to laceration and transmural perforation during endoscopy, dilation procedures, bolus impaction, vomiting

Front 36

GERD
- definition

Back 36

= burning retrosternal sensation with acid taste
- usually occurs within 1-2 hours after eating or when lying down or bending over
- relieved by upright posture and/or antacids, or even a glass of water

Front 37

GERD
- prevalence
- when is it especially common?

Back 37

- daily in 10% adult population - VERY COMMON
- very common during pregnancy!

Front 38

GERD
- pathogenesis?
(- #1 cause??)

Back 38

- #1 - abnormal and inappropriate TRANSIENT LES relaxations
- defective and LOW LES pressure barrier
- low-ish LES pressure, but increased abdominal pressure (e.g., overweight, too many sit-ups, tight clothing, etc)
- gastric problems - acid, bile, volume
- esophageal clearing defects - e.g., peristalsis, gravity, salivary volume and HCO3 (neutralizes acid)
- delayed gastric emptying!!


due to acidic gastroesophageal reflux disease

Could also be:
- secondary to factors modifying anti-reflux competence of LES (e.g., fat, smoking, alc, drugs, foods - citrus, coffee, tomato)

Front 39

What is the Z-line?

Back 39

= where squamous epithelium turns into columnar epith
**Normally = GEJ! BUT when metaplasia, might change....

Front 40

What are RISK FACTORS for GERD?
- physical
- behavioral

Back 40

Physical:
- obesity
- delayed gastric emptying
- pregnancy (relaxation of sm muscle - esp during 3rd trimester)
- hiatal hernia
- systemic sclerosis
- recumbency

Behavioral:
- smoking --> lowers LES pressure
- alcohol --> increases acid
- medications - CCBs, Nitrates, OCs (progesterone), B-adrenergics, theophyline --> all relax sm muscle
- consuming large meals (esp before bed)
- certain foods - choc, coffee, peppermint, onions, fatty foods

Front 41

GERD
- associated symptoms?

Back 41

- regurgitation
- pulmonary sx - e.g., asthma, cough (esp at nigh)
- hoarseness, laryngitis
- chest pain
- disturbed sleep (due to increased protective arousals or awakenings, which initiate swallows to clear the acid refluxate)

Front 42

What is the gold standard test for GERD?

Back 42

24-hour ambulatory esophageal pH monitoring
- measures pH in prox and disatal esoph and stomach continuously for 24 hours
- most specific test for GERD

Front 43

What is the only test for Barrett's Esoph?
- why should you do this?

Back 43

= Endoscopy
- do this if pt has long-standing hx of heartburn

Front 44

GERD
- treatment?

Back 44

Lifestyle changes
- no eating for 3 hours before lying down
- elevate head of bed
- avoid food or meds that worsen reflux
- stop smoking
- lose weight

Acid Suppression
- his-2 receptor antagonists
- PPIs
- antacids (for immediate relief)

Front 45

Complications of GERD?

Back 45

- esophagitis
- peptic stricture (scarring, healing, scarring, etc. --> narrows stricture)
- esoph hemorrhage
- esoph ulcer
- pulmonary sx
- Barrett's Esophagus

Front 46

Barrett's Esophagus
- what is a "long segment"?
- tx??

Back 46

- "long segment" = extension of columnar mucosa above GEJ > 3 cm

TX:
- severe dysplasia --> esophagectomy
- when appropriate --> endoscopic ablation and photodynamic therapy

Front 47

Etiology of recurring angina-like chest pain?

Back 47

- CAD = 50-70%
- Esophageal abnormality = 20-30%
- Musculoskeletal disorder = 5-10%
- Other = 5-10%

Front 48

What is the proper diagnostic approach for esophageal cause of chest pain?

Back 48

1. History - heartburn, regurg, dysphagia/odynophagia

2. Esophageal Manometry - to look for motility disorders

3. Ambulatory 24-hour Esophageal pH Monitoring - to evaluate GERD

4. Esophagoscopty - to R/O significant pathology, such as esophagitis, ulcer

(Note: barium swallow usually not indicated for chest pain alone)

Front 49

What is it important to remember when evaluating chest pain for an esophageal cause??

Back 49

Esoph defect should never be accepted as THE cause of ches pain until signif coronary disease EXCLUDED

Front 50

What are names of various esophageal motility disorders?

Back 50

- nutcracker esophagus - high amplitude peristaltic contractions
- diffuse esophageal spasms (DES)
- non-specific esophageal motility disorder (NEMB)
- achalasia
- hypertensive LES