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66 Cards in this Set
- Front
- Back
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Upper Esophageal Sphincter
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extends 3 to 4 cm in length
comprised of at least 3 groups of striated muscles: - distal portion of the inferior pharyngeal constrictor muscle - cricopharyngeus muscle - muscle of the proximal esophagus separates the pharynx from the esophagus closed in basal state to prevent air from entering GI tract and exit of substances from esophagus |
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Lower Esophageal Sphincter
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circular muscle of the esophagus (internal portion of sphincter)
phernoesophageal ligament the crual part of the diaphragm (external portion of sphincter) there is also a squamocolumnar junction intraluminally |
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Innervation of the esophagus
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Proximal esophagus (striated muscle)
- supplied by the somatic efferent fibers carried in the vagus nerve (nucleus ambiguus, no intermediate neurons) through cholinergic, nicotinic receptors Distal esophagus (smooth muscle) - vagus nerves (dorsal motor nucleus) caries preganglionic fibers that release ACh on 2 types of postganglionic effector neurons within the wall of esophagus 1. effector neuron excites with ACh release 2. effector neuron inhibits with Nitric oxide (NO) and vasoactive intestinal polypeptide (VIP) |
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Pharyngeal Phase of Swallowing
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1. Food reaches the pharynx
2. Swallowing center activated 3. Cranial nerves 5, 7, 9, 10, & 12 4. Tongue raises to hard palate (thrusting food posteriorly) 5. Nasal airway closes (soft palate and posterior pharyngeal wall come together) 6. Epiglottis closes (suprahyoid muscles pull the hyoid bone and .: larynx superiorly and anteriorly; contraction of the thyrohyoid, aryepiglottic and thyroepiglottic muscles) 7. UES relaxes 8. Pharyngeal muscles contract |
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Esophageal Phase of Swallowing
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1. Food reaches the proximal esophagus
2. Vagal afferents are activated 3. Peristalsis begins by activation of the intrinsic esophageal nerves (MYENTERIC plexus) 4. LES relaxes 5. Peristalsis proceeds from proximal to distal esophagus |
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Which nerves activate peristalsis?
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Myenteric Plexus (a.k.a. intrinsic esophageal nerves)
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Esophageal Symptoms
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Dysphagia
Odynophagia Heartburn (“pyrosis”) Regurgitation Chest Pain (noncardiac) |
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Odynophagia
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Painful swallowing
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Regurgitation
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Effortless movement of gastric contents into the back of the throat
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Oropharyngeal Dysphagia
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Transfer problem – inability to initiate the act of swallowing
OR inability to transfer the bolus from the pharynx to the upper esophagus |
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Oropharyngeal Dysphagia
Associated Symptoms |
Food sticking in throat (residual food in pharynx after swallowing)
Repetitive swallows Nasal regurgitation Coughing Aspiration |
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Etiology
Oropharyngeal Dysphagia |
Structural:
Zenker’s diverticulum, cricopharyngeal bar, webs, tumors CNS: Stroke, tumors, trauma Other neurologic: Parkinson’s, multiple sclerosis, amyotrophic lateral sclerosis Myopathy: Myasthenia gravis, polymyositis, mixed connective tissue disease |
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Zenker’s Diverticulum
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Outpouching of top of esophagus
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Esophageal Dysphagia
Symptoms |
The patient feels that the FOOD BOLUS STOPS somewhere IN THE CHEST, from the suprasternal notch to the xiphoid process
If the food bolus is regurgitated, it consists of bland chewed food or swallowed liquids, and does not have a bitter or acidic taste, and does not contain the yellow or green fluid of gastric or biliary secretions. |
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Esophageal Dysphagia
Diagnostic Evaluation |
Barium Esophagram
- modified barium swallow with videofluoroscopy - single or double contrast Esophagoscopy (EGD) Esophageal Manometry |
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2 Categories that cause Esophageal Dysphagia
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Mechanical causes
Motility disorders |
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ESOPHAGEAL DYSPHAGIA
Mechanical Causes - Etiology |
Rings (muscular) and webs
Peptic stricture Tumors Infections Caustic ingestion Iatrogenic: Pill-induced esophagitis, radiation, sclerotherapy, NG tube |
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esophageal web
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a congenital or acquired transverse fold of the mucous membrane and sometimes the deeper layers of the esophagus often causing dysphagia, usually in the lower half of the esophagus
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Causes of Esophagitis
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GERD
Eosinophilic esophagitis (EoE) Infections Medications - tetracycline, KCl, quinidine, alendronate - chemotherapy: 5-FU, daunorubicin, bleo Radiation Caustic ingestion |
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Eosinophilic esophagitis
Clinically |
Clinical symptoms of esophageal dysfunction – usually solid-food dysphagia and food impactions
Normal 24-hour pH monitoring No response to high-dose PPI therapy |
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Eosinophilic esophagitis
Epidemiology |
First case report in 1977
Initially described in children In adults, 75 % are males In adults, mean age = 38 50-80 % are atopic – atopic dermatitis, allergic rhinitis, asthma Most likely food allergens, possibly aeroallergens |
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Eosinophilic esophagitis
Radiographic Appearance |
Proximal Stenosis
OR Corrugated (multiple) rings |
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Eosinophilic esophagitis
Endoscopic Signs |
Concentric rings
Linear furrows White plaques (eosinophilic microabscesses) Food impaction |
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Esophageal Dysphagia
Symptoms |
The patient feels that the FOOD BOLUS STOPS somewhere IN THE CHEST, from the suprasternal notch to the xiphoid process
If the food bolus is regurgitated, it consists of bland chewed food or swallowed liquids, and does not have a bitter or acidic taste, and does not contain the yellow or green fluid of gastric or biliary secretions. |
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Esophageal Dysphagia
Diagnostic Evaluation |
Barium Esophagram
- modified barium swallow with videofluoroscopy - single or double contrast Esophagoscopy (EGD) Esophageal Manometry |
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2 Categories that cause Esophageal Dysphagia
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Mechanical causes
Motility disorders |
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ESOPHAGEAL DYSPHAGIA
Mechanical Causes - Etiology |
Rings (muscular) and webs
Peptic stricture Tumors Infections Caustic ingestion Iatrogenic: Pill-induced esophagitis, radiation, sclerotherapy, NG tube |
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esophageal web
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a congenital or acquired transverse fold of the mucous membrane and sometimes the deeper layers of the esophagus often causing dysphagia, usually in the lower half of the esophagus
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Eosinophilic Esophagitis
Histologic Findings |
> 15 eosinophils/ high-power field
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Eosinophilic Esophagitis
Therapy |
Acid suppression
Diet – elimination, elemental Topical steroids – swallowed fluticasone or budesonide (be careful... you can get yeast) Systemic steroids Cromolyn, Montelukast Biologics |
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Etiology of Odynophagia
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Infectious esophagitis
- Fungal (Candida) - Viral – CMV, HSV - Idiopathic Corrosive esophagitis Pill-induced esophagitis |
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Candida Esophagitis
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Yeast Pseudohyphae and Budding Yeast
typically these patients are immunosuppressed or have an immune disorder this is an AIDs defining disease |
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Esophageal Dysphagia
Motility Disorders |
Achalasia
Other spastic motor disorders - Diffuse esophageal spasm - Nutcracker esophagus - Hypertensive LES Scleroderma Other hypocontractile motor disorders |
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Achalasia
Epidemiology |
Age range: 25 – 60 years
Gender: Male = Female Incidence: 0.4 – 0.6/100,000/year Prevalence: 8/100,000 |
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Achalasia
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“Does not relax”
Failure of LES relaxation + loss of peristalsis in distal esophagus |
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Typical Symptoms of Achalasia
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Dysphagia (90%)
Regurgitation (70%) Chest Pain (60 %) - b/c dilated esophagus Weight Loss (60 %) |
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Atypical Symptoms of Achalasia
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Heartburn (40 %)
Difficulty belching Globus Hiccups |
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Globus
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is a sensation of fullness or lump in throat
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Pathophysiology of Achalasia
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Selective loss of Inhibitory neurons (NO and VIP) in the postganglionic myenteric (located b/w longitudinal & circular muscle layers of the esophagus) plexus leads to unopposed cholinergic excitation which then produces hypertonic LES with failure to relax. The etiology of neural damage is unknown.
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Aperistalsis
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is not well understood, but could be due to the loss of latency gradient along the esophageal body mediated by NO.
associated with Achalasia |
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How does Achalasia look radiographically?
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Dilated proximal esophagus, might see air-fluid level
extremely constricted distal esophagus |
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Achalasia
Definition |
Aperistalsis: 100% of cases
Abnormal LES relaxation (absent, incomplete, insufficient duration): 100 % of cases Elevated LES pressure: 50 % of cases |
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Treatment for Achalasia
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1. Myotomy... cut the esophagus... best option
2. Nitrates, Calcium Channel Blockers, Botulinum toxin injection 3. Pneumatic Dilation ... insert ballon... risk of perforation |
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GER
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gastroesophageal reflux, which is the effortless movement of stomach contents into the esophagus
GER occurs in almost all people |
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GERD
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GER disease, which is when reflux results in symptoms and/or injury to the esophagus
Key event is reflux of gastroduodenal contents (acid, pepsin, bile) into the esophagus Acid is the primary mediator of symptoms and damage Mucosal defenses are overwhelmed |
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GERD Symptoms
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Heartburn (pyrosis) 83 %
Regurgitation 70 % Dysphagia (from esophagitis or restriction) 37 % Respiratory symptoms 30 % Chest pain 10 % Abdominal pain 10 % Nausea 8 % Belching 7 % |
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Mechanisms of Reflux
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Transient lower esophageal sphincter relaxations (TLESRs) ... occurs in everyone
A hypotensive lower esophageal sphincter (LES) Anatomic disruption of the gastroesophageal junction, usually associated with a hiatal hernia (MOST SEVERE) |
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When during breathing does the diaphragm increase the pressure at the lower esophageal sphincter?
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during inspiration
... this is an non-LES anti-reflux mechanism |
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What is the normal pressure at the lower esophageal sphincter?
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25 mmHg
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Lower Esophageal Sphincter Incompetence
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when there is a decline in basal resting pressure of the LES
if there is an increase in abdominal pressure, then the LES will not be enough to stop regurgitation |
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Hiatal Hernia and Reflux
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LES - pressure often low
Gastric pouch - intra-thoracic reservoir ... esophageal sphinter is displaced upward with some of the stomach Diaphragm - no esophageal pinch |
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How do we naturally clear acid from the esophagus?
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Salivation (saliva contains bicarb)
Peristalsis (empties substances into stomach) Gravity (empties substances into stomach, if standing) |
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GERD Diagnosis
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Symptoms
Response to empirical trial of acid suppression therapy (PPI) Endoscopy 24-hour pH monitoring |
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What are complications of GERD?
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Ulcer
Stricture Barrett's esophagus Adenocarcinoma |
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Barrett's Esophagus
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defined as a change in the lining of the esophageal mucosa from normal squamous epithelium to columnar with INTESTINAL METAPLASIA
occurs in 10-15% of patients with chronic GERD a pre-malignant condition which may eventually lead to dysplasia and adenocarcinoma of the esophagus |
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What is the rate of Barrett's Esophagus to cancer?
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The rate of progression is estimated to be 0.5% per year.
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Barrett's Esophagus
Therapy |
No Therapy is proven effective
Consider screening patients over the age of 50 with chronic GERD symptoms Once identified, routine surveillance is indicated Esophagectomy for high grade dysplasia or Cancer |
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What is the progression of Barrett's Esophagus
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Chronic inflammation -->
metaplasia --> dysplasia --> carcinoma |
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GERD Treatment Goals
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Reduce or eliminate symptoms
Heal esophagitis Prevent complications Improve quality of life |
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GERD Treatment Options
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Lifestyle modifications
Antacids H2-receptor antagonists Proton pump inhibitors Antireflux surgery Prokinetic agents New endoscopic therapies |
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What Lifestyle modifications can be made for GERD?
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SLEEP
- Raise head of bed several inches - Avoid meals 3 hours before bedtime DIET - avoid fatty and spicy foods - avoid citrus and tomato-based foods - avoid chocolate, peppermint HABITS - stop smoking - reduce alcohol intake BODY WEIGHT - lose weight |
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Antacids
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Generally contain ingredients such as aluminum hydroxide, magnesium hydroxide, magnesium trisilicate
Neutralize stomach acid Work only on a short-term basis Examples: Maalox, Mylanta, Gaviscon, Gelusil |
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H2 Receptor Antagonists
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Are all over the counter and presciption
Tagamet (cimetidine) Zantac (ranitidine) Axid (nizatidine) Pepcid (famotidine) |
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What works better PPI or H2RA?
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PPIs are better at relieving heart burn and healing esophagus
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Proton Pump Inhibitors
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The only one that is over the counter is Prilosec
Prilosec (omeprazole) Prevacid (lansoprazole) Aciphex (rabeprazole) Protonix (pantoprazole) Nexium (esomeprazol) Zegerid (omeprazole + bicarb)... combination drug |
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Anti-Reflux Surgery
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Reduce Hiatal hernia
Restore Intra-abdominal esophagus Approximate diaphragmatic crurae (tighten diaphragm) Perform Fundoplication - mobilize the fundus, remove blood vessels and attachments, wrap it around the esophagus, suture it together... restores esophageal pressure |
