Gi Lecture 2

Front 1

What kind of muscle makes up the upper 1/3 of the esophagus?

Back 1

skeletal muscle

Front 2

What kind of muscle makes up the lower 2/3 of the esophagus?

Back 2

smooth muscle

Front 3

What does the upper esophageal sphincter do?

Back 3

Helps prevent aspiration

Front 4

Where is the lower esophageal sphincter?

Back 4

At the level of the diaphragm

Front 5

What are the 3 phases of swallowing?

Back 5

Oral phase (preparatory), pharyngeal, esophageal

Front 6

What are the 3 classifications of dysphagia?

Back 6

Oropharyngeal dysphagia, esophageal, functional

Front 7

What are 3 classifications of esophageal dysphagia?

Back 7

Motility problem, mechanical obstruction, infectious esophagitis

Front 8

What are the intermittent and progressive types of motility problems that can lead to esophageal dysphagia?

Back 8

Intermittent (diffuse esophageal spasm, nonspecific esophageal motility disorder), progressive (scleroderma, achalasia)

Front 9

What are the intermittent and progressive types of mechanical obstructions that can cause esophageal dysphagia?

Back 9

Intermittent (ring) - protrusion of normal esophageal tissue.
Progressive (stricture, malignancy)

Front 10

How might infectious esophagitis cause esophageal dysphagia?

Back 10

Can cause significant inflammation and affect motility

Front 11

What are 7 types of causes of esophageal dysphagia?

Back 11

Esophageal (peptic) stricture - narrowing, esophageal cancer, esophageal rings and webs, scleroderma, spastic motility disorders, achalasia, rare causes

Front 12

What is esophageal (peptic) stricture - narrowing - a complication of?

Back 12

Acid reflux/ exposure (GERD, ZE, Trauma - ng tube, scleroderma),
Infectious, chemical irritant, pill irritation, radiation.
Progressive mechanical dysphagia

Front 13

What type of esophageal dysphagia do you see with esophageal cancer?

Back 13

Progressive mechanical dysphagia. Rapid - first solids then liqueids. See weight loss, anorexia. >55 yo

Front 14

What are Schatzki rings?

Back 14

Mucosal rings in the esophagus. Can cause esophageal dysphagia.

Front 15

What type of esophageal dyphagia disorder is scleroderma?

Back 15

Motility disorder. progressive to both solids and liquids.

Front 16

What type of esophageal dysphagia disorder is spastic motility disorder?

Back 16

Intermittent motility disorder. Diffuse esophageal spasm caused by neural, acid reflux, stress, hot/cold food. Also, nutcracker esophagus, nonspecific esophageal motility disorder.

Front 17

What type of esophageal dysphagia disorder is achalasia?

Back 17

Motility disorder. Solid and liquid difficult. See bird beak on barium swallow.

Front 18

What are 3 rare causes of esophageal dysphagia?

Back 18

Diverticulum, enlarged aorta, mediastinal tumor.

Front 19

What are signs and symptoms of oropharyngeal dysphagia?

Back 19

Difficulty controlling food/saliva in mouth, regurgiation, food gets "stuck" in cervical region.
Common to have aspiration ---> pneumonia

Front 20

What are 11 causes of oropharyngeal dysphagia?

Back 20

Stroke, Parkinsons, Bell's palsy, myasthenia gravis, xerostomia, oral mucosa disruption, mechanical obstruction, radiotherapy, infection, meds (nervous system), zenker's diverticulum.

Front 21

What should be in your differential for oropharyngeal dysphagia?

Back 21

CVA, Parkinsons, MS, Obstructive lesions, Zenkers

Front 22

What should be in your differential for esophageal dysphagia?

Back 22

Achalasia, spasm, scleroderma, Schatzki rings, infection, thyroid tumor, globus hystericus (swallowing difficulty)

Front 23

What is the FIRST thing you should do in evaluation of dysphagia?
Then what?

Back 23

Obtain history!!
Distinguish oropharyngeal from esophageal

Front 24

What should be included in your PE in evaluation of dysphagia?

Back 24

CN V, VII, IX, X, XI, XII, observe lip closure mastication and salivation, level of alertness, oral mucosa, tongue mobility and strength, soft palate, throat exam, thyroid exam

Front 25

What are 4 complications of dysphagia?

Back 25

Aspiration pneumonia, dehydration, malnutrition, renal failure (due to dehydration)

Front 26

What are 5 special studies that can be done do dx dyphagia?

Back 26

Flexible Endoscopic Eval of Swallowing w/ Sensory Testing (FEEST), Videofluoroscopy (MBST), Endo, Esophageal pH monitoring, Esophageal manomentry

Front 27

What test should you do in acute dysphagia?

Back 27

Endoscopy!

Front 28

What are treatments for dysphagia in terms of nutrition?

Back 28

Food consistency modifications, involve dietition & speech pathologis, enteral feeding, hydration, oral hhgiene to decrease asp of pathogens

Front 29

What are 3 treatment options for dysphagia that are non-surgical? Surgical?

Back 29

Non surgical: Oropharyngeal structure stimulation, behavioral techniques, electrical stimulation.
Surgical: Mass removal, Zenker's removal

Front 30

What is the frequency of hiatal hernia?
What increases the chances of it occuring?

Back 30

Increases > age 40
Weakened muscles of diaphragm and loss of elasticity of diaphragm over time. Increased intraabdominal pressure.

Front 31

What are 7 causes of Hiatal Hernias?

Back 31

Muscle weakening, pregnancy, chronic constipation, obesity, chronic esophagitis, abdominal ascites (increases pressure), straining/ heavy lifting

Front 32

What are 2 types of Hiatal hernias?

Back 32

Sliding - more common.
Paraesophageal - GE junction.

Front 33

What determines if reflux occurs as a result of a hiatal hernia?

Back 33

Angle of HIS. If angle is acute beyond diaphragm, shouldn't have reflux.

Front 34

What are clinical presentations of hiatal hernias?

Back 34

Chest pain, Reflux, Dysphagia

Front 35

If a hiatal hernia is present but asymptomatic, when should you do?

Back 35

No need to treat.

Front 36

What diagnostic imaging is helpful to dx a hiatal hernia?

Back 36

CXR: fluid level behind heart.
UGI***: establishes diagnosis.
Endo: more difficult to tell if hernia is a sliding hernia.

Front 37

What is the best test to establish a diagnosis of a hiatal hernia?

Back 37

UGI

Front 38

What are medical treatments for a hiatal hernia?

Back 38

Lifestyle changes, neutralize/ inhibit acid production, prokinetic meds.

Front 39

What can be done surgically to repair a hiatal hernia?

Back 39

Fundoplication: esophagus wrapped around top part of stomach to form a sphincter.

Front 40

What is achalasia?

Back 40

Primary esophageal motility disorder.
Failure of LES to relax and/or absence of esophageal peristalsis.
Caused by neurotransmission imbalance.

Front 41

What age group most commonly experiences achalasia? What is achalasia a predisposition to?

Back 41

25-60 yo.
Predisposition to esophageal cancer (10%). Exposure of acid because can't peristalse it out.

Front 42

What is the clinical presentation of achalasia?

Back 42

Dysphagia (90%), difficulty belching (85%), weight loss, regurgitation, pyrosis and chest pain in 40-60%.
Vague presentation - can take yrs to dx because progresses slowly.

Front 43

How is diagnosis of achalasia made?

Back 43

UGI: Birds beak
Manometry (eval of pressure)/ pH monitoring studies.

Front 44

What are the treatment goals when treating achalasia?

Back 44

Relieve sx, decrease resting LES pressure.

Front 45

What are medical treatment options for achalasia?

Back 45

Calcium channel blockers, long acting nitrates (10% benefit)

Front 46

What are surgical treatment options for achalasia?

Back 46

Endo (botulinum toxin, pneumatic dilation), Laparascopic (myotomy + partial fundopliaction)

Front 47

What are esophageal spasms?

Back 47

Uncommon motility disorder w/ unknown etiology but possibly due to stress, age, diabetes, GERD, cholinergic stimulation.

Front 48

What are two types of esophageal spasm?

Back 48

DES: diffuse esophageal spasm which is uncoordinated.
Nutcracker esophagus: coordinated but high pressure.

Front 49

What are the clinical presentations of esophageal spasm?

Back 49

Non-cardiac chest pain, globus (difficulty swallowing), dysphagia, regurgitation, pyrosis (heart burn)

Front 50

What should be in your differential diagnosis of an esophageal spasm?

Back 50

Ischemic heart disease. GERD

Front 51

How is a dx made for esophageal spasm?

Back 51

UGI: simultaneous contractions --> cork screw or rosary bead appearance if DES.
Manometry --> DES and nutcracker.

Front 52

How would you treat an esophageal spasm medically?

Back 52

Calcium channel blockers, nitrates, TCAs, botulinum toxin, PPI (if GERD)

Front 53

What is the function of PPIs (proton pump inhibitors)?

Back 53

Long lasting reduction of gastric acid production

Front 54

How would you treat an esophageal spasm surgically?

Back 54

Myotomy w/ fundoplication, esophagectomy of portion of portion of esophagus involved.
Balloon dilation.

Front 55

What is globus hystericus?

Back 55

Persistent or intermittent non-painful sensation of a lump or foreign body in the throat. Unknown etiology.
Absence of dysphagia and odynophagia (painful swallowing)

Front 56

What are associations/ triggers of globus hystericus?

Back 56

GERD, upper esophageal sphincter, psychiatric disorders, stress, fear, anger

Front 57

What would you see on imaging in globus hystericus?

Back 57

Everything would appear normal

Front 58

How is dx made of globus hystericus? And what is treatment?

Back 58

Dx: exclusion of organic esophageal disease.
Tx: Reassurance, counseling, psychiatric referral

Front 59

What are esophageal webs?

Back 59

Web-like constrictions of esophagus. Normal esophageal tissue. Most common in cervical esophagus. Can be congenital or acquired.

Front 60

What is the clinical presentation of esophageal web?

Back 60

Solid food dysphagia

Front 61

What is the treatment of esophageal web?

Back 61

Endo rupture of web.

Front 62

What are associated conditions of esophageal web?

Back 62

Plummer-vinson syndrome (triad of dysphagia, glossitis, iron def anemia in women).
Bullous dermatologic disorders.
Graft-vs Host disease.

Front 63

What are esophageal rings?

Back 63

Web-like constrictions of the esophagus. Most commonly at the GE junction.

Front 64

What are the two types of esophageal rings?

Back 64

"A" ring: Muscular (contractile)
"B" ring: Mucosal (Schatzki)

Front 65

What are "A" ring esophageal rings?

Back 65

Proximal to mucosal ring; changes in size and shape. Rarely symptomatic.

Front 66

What are "B" ring esophageal rings?

Back 66

Normal esophageal tissue (actually is a web). Squamo-columnar junction of LES. Causes dysphagia.

Front 67

What is the treatment for esophageal rings?

Back 67

Esophageal dilation, endo sphincterotomy

Front 68

What is Mallory-Weiss Syndrome?

Back 68

UGI bleed due to longitudinal mucosal laceration at GE junction. Caused by sudden increase of intra-gastric pressure (vomiting).

Front 69

What are predisposing factors of Mallory-Weiss syndrome?

Back 69

ETOH, Hiatal hernia

Front 70

What is the presentation of Mallory-Weiss Syndrome?

Back 70

Hematemesis in 85%, melena (tarry stools), hematochezia (fresh blood passed through anus), syncope

Front 71

How is a dx of Mallory-Weiss syndrome made?

Back 71

Endoscopy

Front 72

What are the treatments for Mallory-Weiss Syndrome?

Back 72

Usually self-limited w/ minimal management

Front 73

What is Boerhaave's Syndrome?

Back 73

Esophageal perf. **Transmural** unlike Mallory-Weiss. Specifically usually due to vomiting.

Front 74

What is the most common location of Boerhaave's syndrome?

Back 74

Left posterolateral aspect of distal esophagus

Front 75

What are the associations of Boerhaave's Syndrome?

Back 75

>50% of esophageal perf due to instrumentation.
Alcoholic binge drinking and excessive food intake assoc.

Front 76

What are the clinical manifestations and hx assoc w/ Boerhaave's Syndrome?

Back 76

Vomiting followed by sudden pain in chest or abd, increased pain w/ swallowing, pleuritic pain.
Fever, shock, subcu emphysema, mediastinal crunch, rigid abd

Front 77

How is a dx made of Boerhaave's syndrome?

Back 77

Upright chest radiograph: mediastinal widening**, unilateral effusion, pneumothorax, pneumomediastinum, subcu emphysema.
Esophagram confirms diagnosis.w/ gastrografin - water soluble. Don't use barium b/c can cause inflam response if spills out of esophagus.

Front 78

What should be in your differential dx for Boerhaave's syndrome?

Back 78

MI, PE, aortic dissection, pancreatitis

Front 79

What are the treatment options for Boerhaave's syndrome?

Back 79

Aggressive supportive measures, abx, surgical resection.

Front 80

What are esophageal varices?

Back 80

Dilated sub-mucosal veins in lower esophagus. Can be consequence of portal HTN, commonly due to cirrhosis, bleeding most common in distal 5 cm of esophagus.

Front 81

What are the morbidity and mortality of esophageal varices?

Back 81

High morbidity and mortality. Acute bleed mortality rate 30%, Recurrent hemorrhage risk 70% w/in 1 yr. 30-70% w/ cirrhosis have varices.

Front 82

What are the risk factors for developing esophageal varices?

Back 82

Alcoholic cirrhosis (usually hep C), viral cirrhosis, schistosomiasis (parasite)

Front 83

What are the risk factors for variceal hemorrhage?

Back 83

Variceal size*, endo: red wale markings (longitudinal red lines) cherry red spots and hematocystic spots (blood blister), Child-Pugh classification (liver disease severity), ascites, ETOH, age >60, prev bleed, renal failure.

Front 84

What are 5 things that should be in your diff dx for esophageal varices?

Back 84

Duodenal ulcers, schistostomiasis, gastric carcinoma, gastric ulcers, Mallory-Weiss tear.

Front 85

What are the clinical manifestations of Esophageal varices?

Back 85

Hematemesis**- usually massive, hypovolemia, chock, signs of liver disease**

Front 86

How is dx made of esophageal varices?

Back 86

Endo**, labs, imaging (US)

Front 87

What are 3 main considerations when treating esophageal varices?

Back 87

Hemodynamic resuscitation, prevention/ tx of complications, medical management

Front 88

What pharmacotherpy might be used to treat esophageal varices?

Back 88

Abx prophylaxis, somatostatin, Vit K, lactulose, Thiamine

Front 89

What are ways to treat complications of esophageal varices?

Back 89

Endo management: sclerotherapy (med injected into vessel --> shrinks), band ligation, balloon tamponade, shunts, esophageal transection, liver transplant.

Front 90

What is a form of medical management of esophageal varices?

Back 90

Reduce portal pressure

Front 91

What can cause esophagitis?

Back 91

Infectious: Most common: herpes, CMV, Candida. (more common in immunocompromised)
Gerd, pill esophaitis, physical injury

Front 92

What are the clinical presentations of esophagitis?

Back 92

Odynophagia, dysphagia, chest pain

Front 93

How is a dx made of esophagitis?

Back 93

Endo, bx, cytology

Front 94

What is used for treatment of esophagitis?

Back 94

Candida: azoles, echinocandins, amphoteracin B.
CMV: gancyclovir.
Herpes: acyclovir, fam, val

Front 95

What is Zenker's Diverticulum?

Back 95

AKA pharyngoesophageal diverticulum.
Herniation of esophageal mucosa at the pharyngoesophageal junction. Unknown etiology. Insidious onset. Rare.

Front 96

What are the clinical presentations of Zenker's Diverticulum?

Back 96

Dyphagia, regurgitation, throat discomfort, halitosis, nocturnal choking.

Front 97

What are 3 possible complications of Zenker's Diverticulum?

Back 97

Aspiration pneumonia, bronchiectasis, lung abscess

Front 98

How is a dx of Zenker's diverticulum made?

Back 98

Barium swallow

Front 99

What is the treatment for Zenker's Diverticulum?

Back 99

If symptomatic: surgical diverticulectomy and myotomy

Front 100

What causes GERD?

Back 100

Regurgitation of gastric contents into esophagus (physiologic &/or pathologic), Incompetent LES, transient LES relaxation, impaired expulsion of gastric reflux from esophagus.

Front 101

What percentage of GERD will progress to Barrett's? What percentage of Barretts will progress to adenocarcinoma?

Back 101

8-15% develop barretts.
20% of barretts develop adenocarcinoma.

Front 102

What are 4 main sx of GERD?

Back 102

Indigestion or pyrosis, regurgitation (nocturnal), dysphagia, water brash

Front 103

What are the most common causes of GERD?

Back 103

Indigestion and pyrosis (heartburn).
70-85%. Retro-sternal burning. Worse after lying down or bending over.

Front 104

What is water brash?

Back 104

Increased saliva before vomiting - alkanizes the environment. Sialorrhea. Sour or bitter taste in mouth.

Front 105

What percentage of GERD presents w/ atypical symptoms?

Back 105

>30%

Front 106

What does atypical GERD w/ acid pharyngitis present w/?

Back 106

Laryngitis, loarseness, persistant cough, pressure in throat, continually clearing throat.

Front 107

What are the 3 most common causes of chronic cough? (>3 wk duration)

Back 107

GERD (40%), PNDS (38%), Asthma (14%)

Front 108

What is the most common cause of non-cardiac chest pain?

Back 108

GERD. Be sure to r/o caridac causes. Evaluate early w/ pH monitoring and endoscopy.

Front 109

What are 9 alarm symptoms in GERD? These indicate that something is going on w/ the mucosa.

Back 109

Dysphagia (15-20%), odynophagia, weight loss, anorexia, vomiting, anemia, GI bleed, early satiety, sever persistent pain despite therapy.

Front 110

What percent of asthma patients have GERD? What is the correlation?

Back 110

75%
Beta agonists cause LES to relax --> reflux. Also, hyper-inflated lungs --> increased intra abdominal pressure --> GERD
Be aware of patients that present w/ asthma late in life or asthma patients that complain of symptoms indicative of GERD

Front 111

What is the single best test to dx GERD?

Back 111

There isn't a single best test.
Dx w/ endo, 24 hr pH monitoring, manometry, barium swallow, Bernstein test (ng tube used to induce reflux)

Front 112

What test should be performed anytime ALARM symptoms are present in GERD?

Back 112

Endoscopy**

Front 113

What is the gold standard for documenting abnormal acid reflux?

Back 113

24 hour pH monitoring.

Front 114

What are the 5 indications for performing endo in GERD? 50% have normal appearing esophagus.

Back 114

Heartburn not responding to tx, dysphagia**, dx of Barrett's, chronic sx > 5 yrs, ALARM sx***

Front 115

What is esophageal manometry?

Back 115

Assesses esophageal peistaltic fx and defines location of LES. Indicated for pts prior to antireflux surgery. Dtermines peristaltic amp and degree of LES pressure. Can differentiate esophageal spasm, achalasia. Also used in pts w/ recurrent dysphagia.

Front 116

What are 12 complications of GERD?

Back 116

Esophageal strictures, Barretts, Esophageal perf, hoarseness, vocal cord paralysis, laryngitis, pharyngitis, esophagitis, asthma, ear pain, dental etching, globus sensation

Front 117

What are the treatment goals for GERD?

Back 117

Relieve sx, promote healing, prevent complications, prevent recurrences, step-wise approach**

Front 118

What are 7 lifestyle modifications as treatment for GERD?

Back 118

Weight loss, diet modification, raise HOB, avoid laying down after meals, no tight clothes, avoid ETOH and smoking, avoid trigger meds if possible.

Front 119

What are 5 types of antacids that can be used to treat GERD?

Back 119

Tums CaCO3), Alka-Seltzer (NaHCO3), MOM (Mg(OH)2), pepto (bismuth subsalicylate), Gaviscon (Al (OH)3)

Front 120

What are two types of acid suppression tx for GERD?

Back 120

Histamine H2-receptor antagonists, PPis

Front 121

What are Histamine H2 receptor antagonists?

Back 121

Cimetidine, ranitidine, famotidine. Suppress acid production (only 70%). Short acting. BID dosing usually needed. Good for mild GERD. Rx doses higher than OTC.

Front 122

What are PPIs?

Back 122

Omeprazole, pantoprazole, esomeprazole. Suppress acid secretion. More effective than H2 receptor antagonists. Used to tx GERD, duodenal ulcers, erosive GERD. Dose prior to meals.

Front 123

What are 6 safety issues w/ acid suppression?

Back 123

Pneumonia, hypergastrinemia, enteric infections, vit B12 malabsorption, hip fx and ca absorption, drug-drug interactions.

Front 124

What are Prokinetic agents (metoclopramide)? Used for GERD

Back 124

Used as adjunct to acid suppression. Improve motility, increase LES pressure, enhance gastric emptying.

Front 125

What are two other agents that can be used to treat GERD?

Back 125

Sucralfate (Carafate) - mucosal protectant.
Zegerid: Omeprazole + NaHCO3 combo.

Front 126

What is the only cure for GERD?

Back 126

surgery

Front 127

What are 5 indications for surgery for GERD?

Back 127

Persistant or recurrent sx despite tx, severe esophagitis, persistent esophageal strictures, Barrett's, recurrent pulm sx assoc w/ GERD (aspiration, pneumonia)

Front 128

What is Nissen fundoplication?

Back 128

Surgical tx for GERD. Suture fundus of stomach around esophagus. Last resort. Can be performed laparoscopically.

Front 129

What is Barrett's esophagus?

Back 129

Found in 5-15% of GERD pts. Premalignant condition - adenocarcinoma (mean survival < 1 yr).
Clinical: dyphagia, hematemeis, weight loss.

Front 130

What is the treatment for Barrett's Esophagus?

Back 130

If non-dysplastic: annual obs with endo. Long term tx w/ PPIs. Fundoplication in PPI failures.
Dysplasia: esophagectomy, tissue ablation, endo mucosal resection. Cont med tx.

Front 131

What are the types of esophageal cancer? What is the prognosis?

Back 131

Adenocarcinoma, squamous cell. Poor prog (5 yr survival: 10-13%)
Usually males 50-80 yo. Insidious onset.

Front 132

What are the risks of developing esophageal cancer?

Back 132

Smoking, ETOH, obesity, achalasia, strictures, Plummer-Vinson syndrome (dysphagia, glossitis, iron def anemia)

Front 133

What esophageal cancer is most commonly linked w/ ETOH and tobacco?

Back 133

Squamous

Front 134

What esophageal cancer is most commonly linked with Barretts?

Back 134

Adenocarcinoma

Front 135

What are the signs and sx of esophageal cancer?

Back 135

Progressive solid food dysphagia, weight loss, epigastric pain, regurg of saliva or solid food (in advanced disease), Chronic GI bleed --> iron def anemia, persistant cough/ freq pneumonia, hoarseness --> involvement of recurrent laryngeal nerve

Front 136

What is the most common presenting symptom of esophageal cancer?

Back 136

Dysphagia (90%)

Front 137

What dx tools are used for dx esophageal cancer?

Back 137

Imaging (UGI), Endo - bx***), endo ultrasound, abd and chest CT to look for mets, PET scan

Front 138

What are 4 things that should be in your diff dx for esophageal cancer?

Back 138

Stricture, achalasia, adenocarcinoma, gastric cardia

Front 139

What are the treatments for esophageal cancer?

Back 139

Surgery, RT, chemo, local tumor therapy via endo dilation or laser therapy, stents