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143 Cards in this Set

  • Front
  • Back

What muscle represents the upper esophageal sphincter?

Fibers of the cricopharyngeus muscle

Anatomically where does the esophagus lie?

In the thoracic cavity, posterior mediastinum posterior to the trachea

Which structure does the esophagus pass through to attach to the stomach?

Diaphragmatic hiatus

How long is the LES?

3-5 cm long

What is GERD also known as?

Heartburn/Acid reflux/Pyrosis (this is the medical term)

What is one of the Most Common conditions leading to the need for healthcare in the US?

Gastroesophageal Reflux Disease (GERD)

What can GERD feel like?

Burning/warmth/pain that starts in the lower esophagus and rises substernally

True or False


Prevalence of GERD does not increase with age.

False.


Prevalence increases with age


20% of US population affected every week

True or False


Severity of heartburn DOES NOT correlate with the severity of esophageal disorder.

True

When does GERD typically present?

Within 1 hour of large meals

What is the definition of GERD?

An insufficiency of physiologic anti-reflux barriers at the gastroesophageal junction

What is the etiology of GERD?

Impaired LES function

What does Normal function of the LES depend on?

LES pressure


Intrabdominal location of the sphincter


Extrinsic compression of the crural diaphragm

When an individual is bending down why will the contents of the stomach go up towards the LES and not the pyloric sphincter?

The pyloric sphincter is stronger and will hold tight

What is the pathogenesis of GERD?

GERD overwhelms the esophageal mucosal integrity due to dysfunction of the LES

What is the mechanism of esophageal acid clearance?

It is cleared by peristalsis, gravity, neutralization by saliva and alkaline esophageal secretions

What is one way GERD is diagnosed?

GERD diagnosis is established after evaluating response to a 4 week empiric trial of PPI (75% sensitivity/55% specificity)

How is GERD diagnosed in the ambulatory setting?

pH monitoring

What is the Gold Standard for diagnosing GERD?

Bravo Study (requires EGD, sensor, monitor, and food diary as well as compliance by patient)

What are the ALARM symptoms of GERD?

Weight loss, dysphagia, odynophagia, bleeding, anemia, refractory to medical management

If there is no response to 4 week trial empiric treatment, what is the next step?

Perform EGD

What are the symptoms of GERD?

Substernal burning


Radiating to the neck


Reflux of acid

Non typical symptoms of GERD?

Hoarse voice or voice changes

What labs should be ordered for a patient with uncomplicated GERD?

CBC


CMP


TFT


FOBT

What is the treatment for a patient with uncomplicated GERD?

OTC PPI for 4-8 weeks then PRN

What are the H2 receptor antagonists used to treat GERD?

cimetidine (Tagamet)


ranitidine (Zantac)


famotidine (Pepcid)


nitazidine (Axid)

What are the PPIs used to treat GERD?

omeprazole (Prilosec)


esomeprazole (Nexium)


lansoprazole (Prevacid)


pantoprazole (Protonix)


rabeprazole (Aciphex)

What does PPI block?

Histamine, acetylcholine, and parietal cells

Which H2 receptor antagonists are better tolerated?

ranitidine and famotidine

What is the mechanism of action for H2 blockers?

H2 blockers competitively block H2 receptors on Gastric parietal cells so gastric secretion is inhibited

What is the mechanism of action for PPIs?

Acts by irreversibly blocking the gastric proton pump of the parietal cells.

The proton pump is the __________ stage in gastric acid secretion, being directly responsible for secreting H+ ions into the gastric lumen.

Terminal

What is the next step in treatment of GERD is medical management is ineffective?

Esophagogastroduodenoscopy (EGD)

What are the 4 most common reasons to aggravate GERD?

Alcohol


Caffeine


Tobacco


Chocolate

What medications can aggravate GERD?

Anticholinergic agents


ASA & NSAIDS


CCB


Nitrates


Progesterone

What are the extraesophageal manifestations?

Asthma


Non productive chronic cough


Layngitis

Why is asthma an extraesophageal manifestations?

It is due to micro aspiration of refluxate and/or vaguely medicated esophagobronchial reflux

How long does the chronic cough in GERD last and how many patients does it affect?

> 3 weeks and is associated in up to 40% of patients.

What should be considered after endoscopy, 12 weeks of therapy and lifestyle modification does not alleviate GERD?

Gastrinoma (Zollinger Ellison Syndrome)


Pill induced esophagitis


Medications (NSAIDS, Steroids, Bisphosphonates)


Resistance to PPI


Medical noncompliance

What is a hiatal hernia?

When the a small portion of the stomach is above the diaphragmatic hiatus

What is Zollinger Ellison Syndrome?

Gastric ulcers in absence of H. pylori and duodenal ulcers. Caused by pancreatic tumors that release gastrin in excess.

What is Fundoduplication?

The upper curve of the stomach (the fundus) is wrapped around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle

What percentage of patients is fundoduplication usually effective?

50%

What is dysphagia?

Difficulty swallowing

Dysphagia is most common in which population?

People over 65 and alcohol users

What are ALARM symptoms of dysphagia?

Recurrent


Frequent


Persistent

If a person cannot swallow liquids what is affected?

Esophageal motility

If a person cannot swallow solid foods what type of esophageal dysfunction is this?

Mechanical

When does oropharyngeal dysphagia occur?

Immediately after deglutition, patient will have difficulty initiating a swallow

What type of sensation will a patient with oropharyngeal dysphagia feel and what is it associated with?

Coughing or choking sensation and often associated with structural disorders or neuromuscular disorders

What are structural disorders than can cause orophayngeal dysphagia?

Cervical osteophytes


Cricoid web


Phayrngeal (Zenker) diverticulum


Thyromegaly

What is Zenker diverticulum?

Protrusion of pharyngeal constrictor and the cricophayngeal

What is the etiology of oropharyngeal dysphagia?

Loss of elasticity of the UES resulting in restricted opening during swallowing

What are signs and symptoms of Zenker diverticulum?

Aspiration


Neck mass


Regurgitation


Foul breath


Inability to clear throat

If you suspect Zenker diverticulum what should you do first?

Order a barium swallow

What is the treatment for Zenker diverticulum?

Surgical (Upper esophageal myotomy or diverticulectomy)

What are some Neurologic/Myogenic disorders that can cause oropharyngeal dysphagia?

ALS (will also see Upper and Lower motor neuron sign and fasciculations)


CNS tumor


Muscular dystrophy


Myasthenia gravis


Parkinson's disease

When does esophageal dysphagia occur?

After the initiation of a swallow

What can cause esophageal dysphagia?

Mechanical interference or structural disorders

How does a patient with esophageal dysphagia present?

They will describe it as "food getting stuck" (make sure to ask patient to point where they feel it)

Where is esophageal dysphagia often localized?

Lower sternum (but can be as high as suprasternal notch)

True or False


An individual can rarely have esophageal dysphagia to liquids.

True

What structural disorders can cause esophageal dysphagia?

Dysphagia lusoria


Traction diverticulum


Esophageal strictures


Esophageal webs


Neoplasms

What is dysphagia lusoria?

It is when there is double aortic arch and one wraps around the esophagus

What is traction diverticulum?

A localized distortion, angulation, or funnel-shaped bulging of the esophageal wall, due to adhesions resulting from an external lesion (following lymph node infection and almost always TB)

What are the most common structural disorders of esophageal dysphagia?

Esophageal strictures and webs

What are esophageal strictures?

Build up of scar tissue due to acid exposure and almost always secondary to uncontrolled GERD

What are esophageal webs?

Thin diaphragm like membranes of squamous mucosa typically in the mild or upper esophagus and may be multiple.

What is Schatzki's ring and how is it typically found?

A type of esophageal web and is usually an incidental finding

What may be associated with iron deficiency anemia but is not the cause of it?

Schatzki's Ring

What is Eosinophilic Esophagitis?

Sensitization of the esophagus to respiratory and oral antigens

What does increased incidence of Eosinophilic Esophagitis parallel?

That of allergic disease and asthma

What are important therapeutic difference between EoE and GERD?

EoE can be treated with oral corticosteroids (2 puffs and swallow) and avoidance of dietary allergens

How is EoE diagnosed?

Endoscopic biopsy (> or = to 15 eosinophils per high power microscopy field)

True or False


EoE can cause dysphagia to both food and liquids.

True

What are clues for mechanical obstruction?

Solids foods worse than liquids

What are clues for Schatzki ring?

Intermitten dysphagia and is not progressive

What are clues for Esophageal stricture/stenosis?

Chronic heartburn, progressive dysphagia

What are clues for Esophageal cancer?

Progressive dysphagia, age > 50 years

What are clues for EoE?

Young adults, small caliber lumen, proximal stricture, corrugates rings or white papules

What is odynophagia?

Painfull swallowing

What is a hallmark sign for odynphagia?

Sharp substernal pain on swallowing

What is Odynophagia most commonly associated with?

Esophageal ulceration

What is the etiology for odynophagia?

Infectious esophagitis (Most common Candida, others Herpes virus and CMV)

What is Achalasia?

Failure of the LES to relax with swallowing (can be functional obstruction or degeneration of the myenteric plexus)

Which population is more susceptible to Achalasia?

Male=Female


30-50 year old

What can you find on a Barium swallow study for Achalsia?

"Birds Beak" finding

What are pharmacologic treatment for Achalasia?

Calcium Channel blockers/nitrates


Botulism toxin injection

What are mechanical treatments for Achalasia?

Balloon dialation


Surgical myotomy

True or False


All patients with Achalasia do not require EGD to rule out cancer relates pseudoachalasia?

False. It is required

What is esophageal spasm?

A hypertonic motility disorder.

What are the different types of esophageal spasm?

Diffuse esophageal spasm


Intermittent non-peristalic contractions


Nutcracker esophagus

What does esophageal spasm look like on a barium study?

Corkscrew esophagus

What is the treatment for esophageal spasm?

Smooth muscle relaxants (CCB/nitrates)


Antidepressants (Trazadone, Imipramine)

What does esophageal spasm feel like?

Pain just all the time

True or False


Hypotonic motility disorders is more common than hypertonic motility.

False. It is far less common

What is 50% of hypotonic motility disorder diagnosed with?

Scleroderma

How do you treat hypotonic motility disorder?

Control GERD

What are the three disorders of esophageal odynophagia?

Achalasia


Diffuse esophageal spasm


Scleroderma

What are the clues for achalasia?

Solids and liquids foods

What are the clues for diffuse esophageal spasm?

Intermitten, not progressive, may have chest pain

What are the clues for scleroderma?

Chronic heartburn, Raynaud phenomena

What is hiatal hernia?

Protrusion of the upper portion of the stomach through an abnormal opening in the hiatus of the diaphragm

What leads to higher amounts of acid reflux and delayed esophageal acid clearance?

Hiatal hernia

True or False


Hiatal hernia is associated with moderate to severe esophagitis.

True

True or False


75% patients with Barrett's esophagus have a hiatal hernia.

False.


90% patients with Barrett's esophagus have a hiatal hernia

What is Barrett's esophagus?

Intestinal metaplasia-basically starts growing duodenal tissue in the esophagus, sign of chronic uncontrolled said reflux

True or False


If the GERD is controlled then the Barrett's esophagus can change back into normal tissue

True

True or False


Barrett's esophagus is considered a "pre-cancerous" condition and a complication of GERD

True

True or False


Barrett's esophagus is not the most common in patients with large hiatal hernias, low LES pressures and abnormal esophageal motility.

False


Most common in patient with large hiatal hernias, low LES pressures and abnormal esophageal motility

How do you diagnose Barrett's esophagus?

Endoscopy and pathology

What is the next step is Barrett esophagus is confirmed?

Long term treatment with PPI


Repeat endoscopy 6 mo after initial diagnosis then every 2 yrs until intestinal metaplasia and macroscopic findings are resolved

What is the next step is Peptic Stricture is present?

After dilatation (long term treatment with PPI and mechanical soft diet)


Address underlying pathology (such as Scleroderma)


If non Barrett repeat endoscopy PRN

What is paraesophageal hernia?

An uncommon type of gastric hernia that includes a peritoneal layer that forms a true hernia sac (Hernia next to the esophagus)

What are the clinical Hx findings for paraesophageal hernia?

Heartburn (30-60 minutes after meals)


Upon reclining


Atypical symptoms (dry cough, asthma)

What are some general considerations with infectious esophagitis?

Most common in immunosuppressed patients


HIV/AIDS


Solid organ transplants


Leukemia


Lymphoma


Immunosuppressive drugs

What are the clinical findings hx for infectious esophagitis?

Odynophagia


Dysphagia

What can be found on physical examination for infectious esophagitis?

Oral Thrush (white cheesy exudate on oral mucosa)


Evidence of CMV Retinopathy


Evidence of herpetic ulcers on oral mucosa

What is the treatment for infectious esophagitis?

Often empiric


Confirm by endoscopy


What is the treatment for Candida Esophagitis?

Fluconazole 200mg PO 1st day then 100 mg PO QD for 14 days


Amphotericin B IV 0.3-0.7 mg/kg/d

What is the treatment for CMV Esophagitis?

Follow highly active antiretroviral therapy (HAART)


Ganciclovir 5 mg/kg IV Q 12h for 3-6 weeks then


Valganciclovir 900 mg qd

What is the treatment for Herpetic Esophagitis?

Acyclovir 400 mg 1 tab po Q 4h for 7-10 days


Vancyclovir 1gm po qd for 7-10 days


True or False


You will always request blood work up to check for HIV with Herpetic esophagitis?

True

What is Mallory-Weiss Syndrome?

Vertical mucosal laceration of GEJ


Non penetrating mucosal tear at the GEJ


What is Mallory-Weiss Syndrome usually associated with?

EtOH use

What are clinical hx findings for Mallory-Wiess Syndrome?

Heavy lifting


Retching


Vomiting


Hematemeis


Melena may or may not be present


What is the Differential Dx for Mallory-Weiss Syndrome?

Peptic ulcer disease


Erosive esophagitis


AV malformation


Portal Hypertension

What tests should be performed if Mallory-Weiss Syndrome is suspected?

Endoscopy

What is the treatment for Mallory-Weiss Syndrome?

Endoscopic hemostatic therapy

What is Boerhaave syndrome?

Full thickness tear of the esophagus


Effort rupture, almost ALWAYS caused by vomiting

True or False


There is high morbidity in the absence of surgery for Boerhaave syndrome.

True

Where is Boerhaave syndrome typically located?

Almost always left, posterolateral aspect of the distal esophagus

What sign can be seen on clinical examination of Boerhaave syndrome?

Herman's sign (rasping sound caused by the heart beating against air filled tissue, has been described as popping of Rice Krispies)

What are esophageal varices?

Dilated submucosal veins that develop in patients with underlying portal hypertension

What percentage of patients with Cirrhosis have esophageal varices?

50%

True or False


Esophageal varices may result in serious upper gastrointestinal bleed

True


Distal 5cm of the esophagus

After an initial bleed the patient has a _____ chance of recurrence.

60%


Usually within 6 weeks of initial incident

What is the mortality rate of in house patients with bleeding varices?

15%

What are the clinical findings of esophageal varices?

Hematemesis (Bright red blood or coffee grounds)


Melena


Severe bleeding


Postural hypotension


Tachycardia


Tachypnea

What labs should be ordered when esophageal varies is suspected?

Start 2 large bore IV lines


CBC


PT/INR


CMP


Blood type and cross match

What is included in the initial management of esophageal varices?

NGT


0.9 NS or lactated Ringer's solution


if Hgb < or =7 mg/dL transfuse 2 units of packed RBCs (may need 4 units)


Is platelet count < or = 50,000 transfuse platelet


If INR > 1.5 transfuse fresh frozen plasma (one unit for ever 5 units of packed RBCs)


If there is uremia 3 doses of Ddvap (desmopression)


Transfer to ICU

What are the pharmacologic therapy for esophageal varices?

  • Antibiotic prophylaxis (GI tract not sterile) (ceftriazone Rocephin 1gm IV qg or levofloxacin Levaquin 750 mg IV qd)
  • Vitamin K 10mg sq daily
  • Lactulose (encephalopathy is 1 of the complications in patients with cirrhosis) 30-45 mL/hr orally unit, evacuation occurs, then reduce to 15-45 mL/hr every 8-12 hours

Tx for esophageal varices

  • Emergent endoscopy (if bleed identified then banding)
  • Sclerotherapy entholamine
  • Ballon Tamponade (NGT on steroids this is not first line)
  • Portal decompression procedures (transvenous intrahepatic portal shunt or emergency portosystemic shunt surgery)