Esophageal Disorders (PEARLS) Smarty PANCE
What happens when the disease worsens?
- Narrowing of the esophagus (esophageal stricture) - An open sore in the esophagus (esophageal ulcer) - Precancerous changes to the esophagus (Barrett's esophagus)
What is Plummer-Vinson Syndrome (3 things)
-Esophageal Webs -dysphagia -Iron Deficiency Anemia
Risk factors of esophageal varices?
- Alcoholism - Cirrhosis - ~50% - Hepatitis
What medical treatments are available?
- Antacids - Histamine H2 antagonists - Proton pump inhibitors - Fundoplication (surgery) - Ablation therapy (esophageal cancer prevention)
What are the signs and symptoms of GERD?
- Heartburn, usually after eating, which might be worse at night - Chest pain - Dysphagia (difficulty swallowing) - Regurgitation of food or sour liquid - Sensation of a lump in your throat - Chronic cough - Laryngitis - New or worsening asthma - Disrupted sleep
Treatment of non-bleeding esophageal varices
- Non-selective b-blocker (propranolol) - Endoscopic varicocele ligation (EVL) when pt. is not a candidate for b-blockers - Treat the underlying liver disease
Diagnostic tests for GERD
- Upper endoscopy - Ambulatory acid (pH) probe test - Esophageal manometry - X-ray of the upper digestive system
Provide five extraesophageal manifestations of GERD
1. Asthma 2. Laryngitis/pharyngitis 3. Dental decay 4. Recurrent sinusitis 5. Recurrent otitis media
List five medicines that can lower LES pressures, thus leading to GERD:=
1. Calcium channel blockers 2. Theophylline 3. Diazepam (Valium) 4. Meperidine (Demerol) 5. Morphine
List four atypical symptoms associated with GERD
1. Cough 2. Hiccups 3. Throat clearing 4. Wheezing
What are four dietary examples that can lower LES pressure and worsen symptoms of GERD?
1. Fatty foods 2. Alcohol 3. Caffeine (coffee, tea, chocolate) 4. Peppermint
What is a Mallory Weiss tear?
A Mallory-Weiss tear is a linear superficial mucosal tear (intramural dissection) in the esophagus at the gastroesophageal junction caused by a sudden rise in pressure due to vomiting - Is linked to alcohol
Define Schatzki Ring (esophageal ring)
A diaphragm-like mucosal ring that forms at the esophagogastric junction (B Ring). If the lumen becomes too small, symptoms occur - more symptoms the smaller the lumen gets
Zenker's diverticulum
A patient complains he regurgitates small amounts of food back into his mouth. He also has noted very foul-smelling breath. What do you suspect?
Define Esophageal Web
A thin membrane in the mid-upper esophagus. May be congenital or acquired.
What are the symptoms of an esophageal stricture?
An esophageal constriction may cause: -Burning sensation in the neck or throat -Difficulty swallowing (dysphagia) -Feeling of food getting stuck in your throat -Frequent episodes of choking
What is an esophageal stricture?
An esophageal stricture is an abnormal tightening or narrowing of the esophagus making it more difficult for food to travel down the tube. People with esophageal strictures may have pain or difficulty swallowing.
Classic history of Mallory Weiss tear
Background of excess alcohol Episodes of vomiting, followed by vomiting a small amount of blood Symptom's stop spontaneously + patient is hemodynamically stable
Schatzki Ring diagnosis is confirmed by which 2 diagnostic methods?
Barium swallow and endoscopy
Achalasia
Bird/Parrot beak on barium swallow with dysphagia to solids and liquids
Management of Mallory Weiss tear
Bleeding often stops on its own!! 1st-line: Upper GI endoscopy: diagnostic and therapeutic with: - Clipping +/- adrenaline - Thermal coagulation with adrenaline - Sclerotherapy with adrenaline High-dose IV PPI: to reduce rebleeding - Don't give before endoscopy as may mask bleeding 2nd-line: Surgical repair
What type of blood will be seen in stool?
Bright red blood
What causes esophageal strictures?
Conditions or treatments that cause inflammation or scarring in the esophagus can lead to strictures: Eosinophilic esophagitis: This allergic reaction/immune system problem causes inflammation in the esophagus, possibly leading to strictures. Esophageal cancer: When abnormal cells divide or grow out of control in esophageal tissue, the tumor can cause strictures. Gastroesophageal reflux disease (GERD): With GERD, stomach acid can flow backward. The acid damages the lining of your esophagus. This type of stricture is called a peptic stricture. Radiation therapy: Treatment for cancer in the head, neck or chest can cause strictures up to a year and a half later. Surgery: A procedure in the esophagus can leave inflammation and scarring, causing a stricture. Other causes: Ulcers, some medications (for example, some antibiotics and non-steroidal anti-inflammatory drugs), certain infections and accidentally swallowing chemicals can also cause strictures.
Esophageal spasm
Corkscrew appearance on barium swallow
Esophageal stenosis/stricture/web
Dysphagia only to solids
1. Achalasia 2. Diffuse Esophageal Spasms 3. Neurogenic dysphagia 4. Zenker diverticulum 5. Scleroderma esophagus
Dysphagia to liquids and solids
How are esophageal strictures treated?
Endoscopy and dilatation rarely patients will need surgery
Pt with asthma symptoms and GERD not responsive to antacids.
Eosinophilic esophagitis - Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal epithelium.
How is eosinophilic esophagitis treated?
Eosinophilic esophagitis is treated by removing foods that incite allergic response, topical steroids via inhaler
Barrett esophagitis is associated with which type of cancer?
Esophageal adenocarcinoma
Scleroderma esophagus
Esophageal motility disorder involving smooth muscle atrophy and replacement with fibrous tissue?
What are the most serious complications from chronic GERD (gastroesophageal reflux disease)?
Esophageal stricture and Barrett esophagitis.
How common are esophageal stricture?
Esophageal strictures are not common. They can occur at any age but usually affect people older than 40 years.
What are esophageal varices?
Esophageal varices are dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis
What is esophagitis?
Esophagitis is simply inflammation that may damage tissues of the esophagus. It usually causes dysphagia or difficulty in swallowing, odynophagia or painful swallowing, and retrosternal chest pain.
What is the single, best diagnostic study for evaluating a patient with GERD?
Esophagogastroduodenoscopy (EGD)
How often should patients with Barrett esophagitis have routine endoscopic surveillance?
Every 2 to 3 years
How is candida esophagitis treated?
Fluconazole 100 mg PO daily
How should patients with severe erosive esophagitis be managed?
For individuals with severe erosive esophagitis, a repeat upper endoscopy should be done after 8 weeks of treatment to make sure that it's healing and to rule out malignancy
Patients with Schatzki Ring are at risk for WHAT
GERD
What is the most common cause of esophageal stricture?
GERD accounts for approximately 70-80% of all cases of esophageal stricture.
What is GERD? (Gastroesophageal reflux disease)
Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.
An endoscopy for presumed esophagitis shows multiple shallow ulcers. What is the most likely diagnosis?
Herpes simplex virus
What are the two types of esophagitis?
Infectious and non-infectious
Linear yellow-white plaques with odynophagia or pain on swallowing.
Infectious fungal (candida) esophagitis
Describe the dysphagia associated with Schatzki Ring
Intermittent, non-progressive dysphagia for solid foods. Occurs when consuming a heavy meal with meat that was "wolfed down" = "Steakhouse Syndrome"
What lifestyle changes should be implemented in all patients with GERD?
Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (e.g., coffee, alcohol), certain drugs (e.g., anticholinergics), specific foods (e.g., fats, chocolate), and smoking.
Achalasia
Motility disorder caused by degeneration of Auerbach's plexus?
Do all patients with GERD need esophageal function testing?
No, any additional testing beyond an EGD should be reserved for patients who either fail medical therapy and lifestyle modification or in whom the correlation of reflux symptoms is in doubt
Is odynophagia (painful swallowing) a common symptom of GERD?
No, odynophagia rarely results from GERD. It is normally associated with infectious or eosinophilic esophagitis, malignancy, or ingestion of corrosive agents
Esophageal varices - physical findings
Non-invasive physical exam is low yield in directly diagnosing esophageal varices, but can raise clinic suspicion due to findings of liver disease: - Peripheral edema - Ascites - Spleen enlargement - Jaundice - Spider Nevi
Esophagitis caused by NSAIDs or bisphosphonates
Noninfectious - Medication induced esophagitis
Dysphagia lasting weeks-months after radiation therapy
Noninfectious - Radiation-induced esophagitis. Radiation exposure of 5000 cGy associated with increased risk for stricture
How does this differ from Boerhaave syndrome?
Not Boerhaave syndromes! This is a medical emergency! Boerhaave syndrome is a perforation of the esophagus, due to vomiting + ruptures all layers of the esophagus (transmural)
Presentation of esophageal varices?
Often asymptomatic until they start to bleed (pts w/ cirrhosis should be screened) - once bleeding presents with hematemesis (bloody vomiting) with a coffee ground appearance and melena (dark stools) secondary to metabolized RBCs passing into the lower GI tract
What are some symptoms of portal vein congestion or liver disease?
Other symptoms of portal vein congestion or liver disease: - Lower extremity swelling - Abdominal distention - Skin yellowing and itching (jaundice) - Easy bruising - Hemorrhoids
Diagnosis of esophageal varices
Perform emergent upper GI endoscopy (once the patient is stabilized) in all patients with GI bleed ⇒ diagnostic and can be therapeutic Serum labs: hemoglobin and hematocrit, platelet count
How are rebleeds prevented?
Prevention of rebleeds (70% of rebleeds are within 1 year of initial bleed and one-third are fatal) - Nonselective beta-blockers - propranolol, nadolol (treatment of choice in primary prophylaxis to prevent rebleeds) - Isosorbide: long-acting nitrate
Complications of Mallory Weiss tear
Rebleed Hypovolemic shock: only for life-threatening, persistent bleeds Esophageal perforation: rare
Who is at risk for esophageal strictures?
Risk factors for esophageal strictures include: -Alcohol use -Cancer in the neck area -Gastroesophageal reflux disease (GERD) -Hiatal hernia -Peptic ulcer disease -A history of dysphagia (difficulty swallowing)
When should patients be screened for esophageal varices?
Screening is indicated when cirrhosis or portal hypertension is diagnosed - When high-risk varices are diagnosed, prophylaxis should be started, and further screening is not necessary -Otherwise, screening should be repeated every 2 to 3 years for patients without varices and every 1 to 2 years for patients with small varices
What are the types of esophageal strictures?
Strictures may be simple or complex: Simple strictures are smaller, leaving a wider opening in the esophagus. They are usually straight and symmetrical. Their surfaces and margins (borders) are smooth. Complex strictures are longer and leave a narrower opening. They are not straight or symmetrical and have uneven surfaces and margins.
Diffuse Esophageal Spasm
Strong non peristaltic esophageal contractions cases stabbing chest pain that is worse with hot or cold liquids and food
What is the gold standard for diagnosis of GERD?
The PH Probe study is the gold standard for diagnosis but is rarely performed
What is the most common cause of esophagitis?
The most common cause is gastroesophageal reflux disease or GERD, and in that situation, it's called reflux esophagitis.
How is esophagitis diagnosed?
The usual workup includes an upper endoscopy with a biopsy. And in case of retrosternal chest pain, an electrocardiogram should always be done in order to rule out cardiac ischemia.
What are the tests for esophageal strictures?
These tests can help confirm an esophageal stricture: X-ray with barium Ultrasound can measure how thick the esophageal wall has become, which shows how much it is narrowing the esophagus. Endoscopy with biopsy Esophageal manometry examines the esophageal muscles and sphincter. A small catheter tube is inserted into the nose and into the esophagus. This catheter measures the muscle and valve function of the esophagus during the swallow
Neurogenic dysphagia
This condition is produced by weakness and incoordination of the muscles in the pharynx that propel food into the esophagus. Both liquids and solids are difficult to swallow, and aspiration into the windpipe and regurgitation into the nose commonly occur. It is a result of faulty transmission of nerve impulses to the pharyngeal muscles generally caused by an associated neuromuscular disease, such as myasthenia gravis, amyotrophic lateral sclerosis, or stroke.
Treatment of bleeding esophageal varices
Treatment is primarily with emergent endoscopic banding (definitive treatment but cannot be performed until the patient is stabilized) and IV octreotide (vasoconstrictor) - airway management - hemorrhage control - if pt continues to bleed (balloon tube tamponade) Medications: • antibiotic prophylaxis - ceftriaxone • IV octreotide OR somatostatin - reduce blood flow to the liver • Omeprazole (PPI) - prevents GERD from worsening • Anti-emetic
What is the treatment of reflux esophagitis?
Treatment of reflux esophagitis starts with proton pump inhibitors or PPIs such as omeprazole for 8 weeks. If symptoms disappear, then the dose of PPI is gradually decreased. If PPIs are needed for more than 6 months, then it's replaced by histamine 2 receptor agonists or H2RAs. If the symptoms recur, then the lowest dose of the medication that last controlled the symptoms is restarted.
Diagnosis of Mallory Weiss tear
Upper GI endoscopy: gold-standard CBC: assess for anemia secondary to bleeding Urea and electrolytes: raised urea (RBCs are digested into urea in upper GI bleed) Coagulation profile: assess underlying coagulopathy causing bleeding LFTs: if deranged suggests variceal bleed CXR: to rule out esophageal perforation or perforated peptic ulcer
Risk factors for Mallory Weiss tear
Vomiting e.g., gastroenteritis, bulimia Alcohol: damages gastric mucous membrane and causes vomiting Hiatus hernia GERD Male Aged 40-60 years
