Esophageal Disorders and GERD
Cardia of the stomach comes above the diaphragmatic crura into the chest Diagnosis?
Hiatal hernia
•Omeprazole •Esomeprazole •Lansoprazole •Dexlansoprazole •Rabeprazole •Panoprazole Which drug class?
PPIs (Indicated for Erosive GERD)
White Finger-like projections in the esophagus which virus?
Papilloma virus
Part of the stomach is squeezed up into the chest beside the esophagus Diagnosis?
Para-esophageal hernia
Vascular obliteration and fibrosis of smooth muscle that leads to: -Weak LES -Poor esophageal contractility -delayed gastric emptying
Scelorderma
connective tissue disorder primarily effecting the GI tract
Scelorderma
This type of hernia is not usually clinically significant
hiatal hernia
Components of CREST syndrome
•Calcinosis •Raynaud phenomenon •Esophageal dysmotility •Sclerodactyly •Telangiectasia
5 causes of increased exposure of the esophagus to gastric refluxate
•Defective esophageal clearance •LES 'dysfunction' •Hiatal hernia •Increased intra-abdominal pressure •Delayed gastric emptying
Spasm of the esophagus
"A" ring (muscular cause)
What are the three important structures that surround the esophagus that can possibly cause compression?
1. Aorta: Aortic aneurysms can compress the esophagus and can cause clinical difficulty with swallowing (dysphagia) 2. Bronchus 3. Left Atrium: left atrial enlargement can compress the esophagus
Name two common congenital anomalies that can compress the esophagus
1. Double aortic arch 2. Dysphagia lusoria: Right subclavian artery loops around the back of the esophagus ; causes problems with swallowing
History in dysphagia Ask: Do you have problem swallowing solids, liquids, or both? 1. Liquids not solids suggests __________ 2. Solids progressing to liquids suggests _____________
1. a motility disorder 2. a benign or malignant stricture
What is the distance from the beginning to the end of the esophagus? Why is this important to know?
40 centimeters important when you are placing an NG tube
A disorder of the tube that carries food from the mouth to the stomach (esophagus), which affects the ability of the esophagus to move food toward the stomach. •Inability of the low esophageal sphincter to relax •The criteria: inability to have peristalsis in the esophagus and inability to have complete relaxation in the LES Dx?
Achalasia
Loss of peristalsis in the distal esophagus (whose musculature is comprised predominantly of smooth muscle) and a failure of LES relaxation Which motility disorder?
Achalasia
This disorder can be caused by: Degeneration of dorsal motor nucleus Degeneration of vagal fibers Loss of ganglion cells
Achalasia
•The esophagus cannot empty well •When you do a barium swallow, fluid and food contents are in the esophagus •Meniscus in the esophagus •Absence of an air bubble •Bird-beaking of the distal esophagus Dx?
Achalasia
What is mainstay of therapy for GERD?
Acid suppression
Prompt but temporary relief No objective proof or superiority to placebo Which pharmacologic therapy for GERD?
Antacids
Which lifestyle change was proven to improve symptoms of GERD?
Avoid lying down for 3 hours after eating
Abnormal change (metaplasia) in the cells of the inferior portion of the esophagus squamous epithelium-->columnar epithelium Dx?
Barrett's Esophagus
GERD w/ •Presence of nocturnal symptoms •Complications - stricture, ulcer, and bleeding •Middle age white/ men Diagnosis?
Barrett's Esophagus
Spontaneous rupture of the esophagus
Boerhaave syndrome
If a GERD pt. presents with any of these symptoms, it indicates what type of disease? •Dysphagia - difficulty swallowing •Odynophagia - pain on swallowing •Weight loss •Anemia with negative colon •Failure of empirical therapy
Complicated disease
What is the best treatment for Eosinophilic Esophagitis (EOE)?
Corticosteroids significantly improve the clinical symptoms and esophageal history. Best treatment is to use inhaled steroids and swallow them •Adults are typically treated with fluticasone propionate as a swallowed metered aerosol.
This cause of increased exposure of the esophagus to gastric refluxate: •May result in an increase in the volume of gastric contents available for reflux into the esophagus
Delayed gastric emptying
20 percent or more simultaneous contractions (with amplitude >30 mmHg) Which motility disorder?
Diffuse esophageal spasm
1. Difficulty initiating swallow 2. Nasopharyngeal regurgitation 3. Pulmonary aspiration 4. Residual This describes what type of swallowing?
Disordered Oropharyngeal Swallowing
Radio frequency and endoscopic sewing •Both reduce symptoms but mild disease •Low, but unquestionable rate of complication •Disease needs to be controlled with PPI therapy What type of therapy for GERD?
Endoscopic Therapy
The most common endoscopic finding is linear esophageal "furrow" (41%), which gives a railroad-track-like appearance. Dx?
Eosinophilic Esophagitis (EOE)
This disease may be related to manifestations of an allergic reaction to particular categories of food.
Eosinophilic Esophagitis (EOE)
dense mucosal eosinophilic infiltration of the esophagus. Dx?
Eosinophilic Esophagitis (EOE)
•In adults, the vast majority of patients demonstrate either linear furrows or multiple transient or fixed "corrugated" circumferential rings or narrowed esophagus. •Of particular note is the report of pronounced esophageal mucosal fragility, described as a crepe-paper-like mucosa. Dx?
Eosinophilic Esophagitis (EOE)
•In adults, there is typically a more narrow range of symptoms, which include: -Solid food dysphagia -Chest pain -"refractory heartburn" Dx?
Eosinophilic Esophagitis (EOE)
•In the pediatric group, presenting symptoms vary and include: -Abdominal and chest pain -Failure to thrive -Vomiting -Gastroesophageal-reflux-like symptoms Dx?
Eosinophilic Esophagitis (EOE)
If the lower esophageal sphincter fails to relax this can cause what type of diverticulum?
Epiphrenic diverticulum
Erosion of the esophageal lining; damages the mucosa causing redness, friability, bleeding and ulcers
Erosive esophagitis
Extrinsic Mechanical lesions: •Aberrant subclavian artery (Dysphagia lusoria) •Cervical osteophytes •Enlarged aorta •Enlarged left atrium •Mediastinal mass (lymphadenopathy, lung cancer, etc.) •Post surgery (laryngeal, spinal) Cause of which type of dysphagia?
Esophageal Dysphagia
Intrinsic Mechanical lesions: •Benign tumors •Caustic esophagitis/stricture •Diverticula •Malignancy •Peptic esophagitis/stricture •Eosinophilic esophagitis •Pill esophagitis •Post surgery (laryngeal, esophageal, gastric) •Radiation esophagitis/stricture •Rings and webs Cause of which type of dysphagia?
Esophageal Dysphagia
Motility disorders Achalasia Chagas' disease Diffuse esophageal spasm Hypertensive lower esophageal sphincter Nonspecific esophageal motility disorder Nutcracker esophagus Scleroderma Cause of which type of dysphagia?
Esophageal Dysphagia
This type of dysphagia arises within the body of the esophagus, the lower esophageal sphincter, or cardia, and is most commonly due to mechanical causes or a motility disturbance
Esophageal dysphagia
This type of dysphagia is most commonly due to mechanical causes or a motility disturbance
Esophageal dysphagia
endoscopic or histological demonstration of inflammation of the esophageal mucosa
Esophagitis
If someone ingests a strong alkali where will it tend to attack?
Esophagus
Epithelial cell type above and below the Z line
Esophagus: Squamous epithelium above the Z line Stomach: Columnar tissue, below the Z line
_____________ is a very common presentation of EOE in adults, and is the presenting complaint in more than half of patients
Food impaction
Chest/epigastric pain Worse on lying down or bending Worse after meals Dx?
GERD
Typical symptoms of this disease include: •Heartburn •Acid regurgitation
GERD
What is the most common Gastrointestinal Disease
GERD
•Reflux related symptoms occur predominantly after meals •Reflux-related symptoms are often triggered by -Unusually large meals -Fatty, spicy or acidic foods -Bending, stooping of lying down -Lifting, straining, or other strenuous activities Dx?
GERD
Pathological frequency of reflux of GI content into the esophagus
GERD: Gastroesophageal Reflux Disease;
•The persistent or intermittent nonpainful sensation of a lump or foreign body in the throat •Occurrence of the sensation between meals •Absence of dysphagia and odynophagia •Absence of evidence that gastroesophageal reflux is the cause of symptoms •Absence of histopathology-based esophageal motility disorders Dx?
Globus
One or more mucosal breaks no longer than 5mm, none of which extends between the tops of two mucosal folds Which grade of erosive esophagitis from GERD?
Grade A
One or more mucosal breaks more than 5mm, none of which extends between the tops of two mucosal folds Which grade of erosive esophagitis from GERD?
Grade B
One or more mucosal breaks that extend between the tops of two or more mucosal folds but together involve less than 75% of the esophageal circumference Which grade of erosive esophagitis from GERD?
Grade C
One or more mucosal breaks that together involve at least 75% of the esophageal circumference Which grade of erosive esophagitis from GERD?
Grade D
Relief of heartburn symptoms in ~50% of patients Indicated for the healing of erosive esophagitis Which pharmacologic therapy for GERD?
H2RAs
•Cimetidine •Ranitidine •Famotidine •Nizatidine Which drug class?
H2RAs
Burning retrosternal pain due to exposure of the esophagus to acid for a prolonged period of time
Heartburn
This cause of increased exposure of the esophagus to gastric refluxate: •May trap a reservoir of gastric contents above the diaphragm, increasing reflux •May compromise LES function
Hiatal hernia
Resting lower esophageal sphincter pressure above 45 mmHg Which motility disorder?
Hypertensive lower esophageal sphincter
When someone has trouble with painful swallowing, what diagnoses should you think about?
Infections; think about something that is happening immune-competently Candida esophagitis CMV
This represents a potentially weak spot where a pharyngoesophageal diverticulum (Zenker's diverticulum) is more likely to occur
Killians dehiscence
What is the most common benign growth in the esophagus found distally?
Leiomyoma
This type of diverticulum has to do with inflammatory processes in the chest (e.g. tuberculosis)
Mid-esophageal diverticulum
Average distal esophageal peristaltic pressures exceeding 220 mmHg during 10 or more 5 mL liquid swallows Which motility disorder?
Nutcracker esophagus
this term refers to pain with swallowing
Odynophagia
1. Obstructing lesions -Tumors -Osteophytes 2. Neurologic Disorders -CNS lesion -Cranial nerve lesions 3. Skeletal muscle disorders -Inflammatory myopathies -Muscular dystrophies 4. Neuromuscular transmission disorders -Myasthenia gravis These cause which type of dysphagia?
Oropharyngeal
This type of dysphagia, arises from disease of the upper esophagus and pharynx, or from upper esophageal sphincter dysfunction
Oropharyngeal dysphagia
These GERD medications provide rapid symptomatic relief and healing of erosive esophagitis in the highest percentage of patients
PPIs
•Significantly more effective than H2RAs for both symptom resolution and healing of erosive esophagitis •Also effective in more severe cases of GERD •Most patients respond well to standard therapy, but some require prolonged and/or high-dose treatment Which GERD therapy?
PPIs
•Antacids and over the counter acid suppressants are appropriate •Recent approval of OTC PPI may increase efficacy of this therapy •Education to Warning Signs Which type of GERD treatment?
Patient Directed Therapy
This condition presents as a triad of dysphagia (due to esophageal webs), esophagitis, and iron deficiency anemia
Plummer vinson syndrome (mucosal cause)
Improvement of symptoms in mild GERD Effective for healing only mild degrees of erosive esophagitis Can be useful in a select patient population Which pharmacologic therapy for GERD?
Prokinetics
•Current available agents (metoclopramide, betanecol) have insufficient efficacy to overcome potential side effects and are not routinely used to treat GERD •Tegaserod - new agent - but not monotherapy for GERD Which type of GERD treatment?
Promotility Therapy
What is a cornerstone of therapy for EOE?
Refer these patients for food-allergy testing to see if specific food groups can be identified and removed.
A narrowing of the lower part of the esophagus that can cause difficulty swallowing
Schatzki ring (mucosal cause)
If someone ingests a strong acid where will it tend to attack?
Stomach
The upper esophageal sphincter is closed unless you do what?
Swallow, this protects it from air entering
Para-esophageal hernia treatment?
This becomes a concern; the blood supply of the stomach can become compromised These people should have surgery
This test can be used to: •Identify Barrett's •Diagnose erosive grade •Diagnose complications •If without cost or complication - ideal for GERD
Use of Endoscopy in GERD
Treatment for a leiomyoma of the esophagus?
We don't do a biopsy of this; it is in the wall of the esophagus Make the diagnosis and send them off to surgery
If someone ingests a caustic agent, what things do you need to find out in the history?
What mental state was the patient in? Why did they do it? What type of agent did they ingest? Did they swallow it or did they spit it out?
A diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle Food will rest in pocket; can cause bad breath, gurgling in the neck, if they push on their neck they may be able to regurgitate the food in that pocket
Zenker's diverticulum
Patient presents with sialorrhea (hyper-salivation). What is most likely stuck in their esophagus?
a food bolus
Dysphagia is considered to be an ______ symptom, indicating the need for an immediate evaluation
alarm
History in dysphagia Ask: Do you cough or choke or is food coming back through your nose after swallowing? Coughing or choking suggests which type of dysphagia?
aspiration and oropharyngeal dysphagia
How is hypertensive LES different from Achalasia?
because there is normal peristalsis
How is CMV esophagitis diagnosed?
biopsy (look for inclusion bodies)
It is important to note that EOE is not associated with ____________ eosinophilic infiltrates.
duodenal or gastric
Subjective sensation that suggests the presence of an organic abnormality in the passage of liquids or solids from the oral cavity to the stomach
dysphagia
History in dysphagia Ask: How long have you had problems swallowing and have your symptoms progressed, remained stable, or are they intermittent? Rapidly progressive dysphagia is concerning for _____________.
malignancy
It is important to recognize that eosinophilic infiltration may have a heterogeneous distribution, therefore when considering EOE, it is critical to biopsy from _________, including the distal and proximal esophagus.
multiple areas
Dysphagia in elderly subjects should not be attributed to what?
normal aging
History in dysphagia Ask: Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after swallowing? If the answer is yes, which type?
oropharyngeal dysphagia
Define Odynophagia
painful swallowing
Aging alone causes mild esophageal motility abnormalities, which are rarely symptomatic What is this termed?
presbyesophagus
What are the vertebral levels of the esophagus?
starts about C6 and goes to T11
When is endoscopy used in GERD?
to evaluate patients with symptoms suggestive of complicated disease and to screen Barrett's
GERD is a common disorder, best diagnosed how?
with a well-taken history and an empirical therapy
Aggravating Factors in GERD
• Morbid Obesity • Pregnancy • Drugs: Ca2+ antagonists; Beta adrenergic drugs; Anticholinergic agents; Theophyllines; Nitrates • Hiatal hernia • Fat, coffee, chocolate, orange juice, peppermint • Alcohol, cigarettes
Causes of LES 'dysfunction' which can lead to increased exposure of the esophagus to gastric refluxate
•Inappropriate and prolonged transient relaxations •Reduction in basal LES pressure/tone
Causes of defective esophageal clearance which can lead to increased exposure of the esophagus to gastric refluxate
•Ineffective peristalsis •Reduced salivary secretion •Reduced secretion from esophageal submucosal glands
Causes of Increased intra-abdominal pressure which can lead to increased exposure of the esophagus to gastric refluxate
•Pregnancy •Obesity •Bending •Straining •Coughing •Tight clothes
GERD pharmacologic therapy options
•Prokinetic agents •Antacid •Alginate •Acid suppressing drugs: H2RA, PPI
Lifestyle changes appropriate for treatment of GERD
•Raise the head of the bed, or lie on left side •Decrease fat intake •Avoid certain foods: high fat and greasy foods •Avoid lying down for 3 hours after eating** •Stop smoking •Lose weight if appropriate
