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Name four diseases of the esophagus.
- Aphagia-> Foreign body/food impaction
- Dysphagia-> Difficult swallowing ->(Oropharyngeal dysphagia or Esophageal dysphagia)
- Odynophagia-> Painful swallowing-> (Sharp, substernal pain with swallowing and Reflects severe erosive dz, infectious esophagitis)
What is an upper endoscopy useful for?
- Direct visualization
- Capable of biopsy
- Study of choice for persistent heartburn, odynophagia, and abnormalities noted on barium studies
What study differentiates between mechanical and motility disorders and is the study of choice to evaluate dysphagia?
What does an esophageal pH recording do?
- Records pH
- Correlates to patient's symptoms
What study is:
-Used to assess esophageal motility
-Determines the location of the lower esophageal sphincter for pH probe placement
-Establishes etiology of dysphagia, esp. achalasia (after Barium esophagram)
-Pre-operative prior to Nissen fundoplication
What are the 4 layers of the GI wall?
True or false: The mucosa contains blood vessels, nerves, and lymphatics
False. The submucosa contains blood vessels, nerves, and lymphatics. The mucosa contains epithelium.
True or false: The muscularis is usually two layers of smooth muscle -> the outer longitudinal and inner circular.
What makes up the serosa?
Simple squamous epithelium and connective tissue.
What percentage of adults have weekly symptoms of GERD? What percentage have daily symptoms?
What are the factors contributing to GERD?
- Incompetent lower esophageal sphincter
- Hiatal hernia
- Irritant effects of reflux -> (Acidic gastric fluid w/pH < 4.0) -> Alkaline pancreatic secretions
- Abnormal esophageal clearance: diminished peristalsis-> acid stays in esophagus
- Delayed gastric emptying: Gastroparesis or partial gastric outlet syndrome
Causes of GERD: What are contributing causes to decreased pressure of lower esophageal spincter?
- High fat foods
- Medicines (Nitrates, calcium channel blockers, anticholinergics, progesterone, estrogen
Causes of GERD: What are contributing causes to decreased esophageal motility?
- Medicines (nitrates, calcium channel blockers, anticholinergics, progesterone, estrogen)
Causes of GERD: What are contributing factors to prolonged gastric motility?
- Medicines (nitrates, calcium channel blockers, anticholinergics, progesterone, estrogen)
- Outlet obstruction
- Diabetic gastroparesis
- High fat food
Barrett's esophagus is a complication of GERD. What are some of the features of this complication?
- Squamous epithelium replaced by metaplastic columnar epithelium: Can lead to adenocarcinoma
- Occurs in 10% of patients c chronic reflux
- Diagnosed by endoscopy
- Treatment is long-term PPI
- Recommendation of endoscopy in patients with > 5 yr history of GERD symptoms
- Q 3-5 yrs with known Barrett's
- Dysplasia (low grade -> annual endoscopy) (high grade -> esophagectomy)
Stricture is a complication from GERD. What are some of the features of Stricture?
- Occurs in 10% of patients with esophagitis
- Gradual development of solid food dysphagia
- Must have endoscopy to R/O malignancy
- Treatment: Dilation, then long term PPI
What are the treatment goals for GERD?
- Provide symptomatic relief
- Heal esophagitis
- Prevent complications
- Most patients will have empirical diagnosis and treatment
What lifestyle modifications should be made for patients with GERD?
- Avoid lying down within 3 hours after meals
- Elevate head of bed 6"
- Avoid acidic foods (tomato, citrus, spicy, coffee)
- Avoid pepperment, chocolate, ETOH, smoking
- Lose weight
What is used for the pharmacologic treatment of GERD in patients with mild symptoms?
- Antacids (immediate onset, short duration->2hrs)
- H2 receptor antagonists (delay in onset of action: 30 mins, duration for approx. 8 hrs)
Name four H2-receptor antagonists.
- Cimetidine (Tagamet)
- Ranitidine (Zantac)
- Famotidine (Pepcid)
- Nizatidine (Axid)
What pharmacologic treatment is suggested for patients with moderate (daily) symptoms of GERD?
- H2-receptor antagonists BID
- Proton Pump Inhibitors (PPI) QD
- Discontinue treatment after 8-12 weeks; Treat relapses with either intermittent or daily therapy
Proton Pump Inhibitors should be taken with a snack or milk 30 minutes before a meal. What are some examples of PPIs?
- Omeprazole (Prilosec)
- Esomeprazole (Nexium): s-isomer of omeprazole
- Lansoprazole (Prevacid)
- Rabeprazole (Aciphex)
What pharmacologic treatment is recommended for patients with severe symptoms of GERD?
- PPI QD: 80% will have symptom relief and healing of esophagitis
- PPI BID: 95% will have symptom relief and healing of esophagitis
- If unresponsive to PPI, endoscopy to rule out Zollinger-Ellison, esophagitis
- Surgical Treatment: Fundoplication -> 85% will have symptom relief and healing of esophagitis (medical costs > surgical costs p 10 years)
What are some features of Infectious Esophagitis?
- Occurs mainly in immunocompromised patients
- Candida albicans, Odynophagia and dysphagia (oral thrush seen in only 75% of candida esophagitis)
What is used for treatment of infectious esophagitis?
- Candida: Systemic fluconazole
- If no response, endoscopy to rule out viral cause (CMV: Antiretroviral therapy) (HSV: Acyclovir)
What are some features of pill-induced esophagitis?
- Caused by NSAIDs, KCL, bisphosphonates (especially if not taken with liquids)
- Symptoms: Odynophagia and dysphagia
- Prevention: 1) Instruct patients to take meds with water. 2) Remain upright for 30 minutes p taking meds. 3) Don't Rx known offending agents to patients with esophageal dysmotility or strictures.
What are some features of caustic esophageal injury?
- Accidental or Intentional (suicidal)
- Sx: Severe burning, chest pain, gagging, dysphagia, drooling
- Wheezing/stridor if aspiration
What is the treatment for caustic esophageal injury?
- Airway (laryngoscopy)
- CXR, Abd X-ray (R/O pneumonitis, free air)
- NO NG tube or oral antidotes
- Endoscopy to determine extent of damage
- Mild damage: Good prognosis (psych referral)
- Moderate to severe damage: -> High risk for complications such as bleeding, strictures, esophageal-tracheal fistulas. -> May require esophagectomy
Benign esophageal lesions: -> What is Mallory Weiss Syndrome?
- Mucosal tear at gastroesophageal junction (nonpenetrating) -> Can be caused by vomiting. Alcoholism is predisposing factor. Accounts for 5% of upper GI bleeds
- Signs/symptoms: Hematemesis + History of vomiting or retching
- Diagnosis: endoscopy
- Treatment: -> Fluids, blood if necessary -> Most stop bleeding spontaneously -> Otherwise, endoscopic hemostatic therapy (Epinephrine injection, cautery, mechanical compression)
Benign esophageal lesions: Describe Webs and Rings.
- Esophageal webs -> Mid or upper esophagus -> Congenital or acquired
- Schatzki rings -> Distal esophagus -> Pathogenesis is controversial
What are the symptoms, diagnosis, and treatment for Webs and Rings (Benign Esophageal Lesions)?
- Symptoms: Dysphagia, especially in poorly chewed foods (steak)
- Diagnosis: Barium esophagram
- Treatment: Bougie dilator > 16mm (may require repeat dilations)
What is Zenker's diverticulum (esophageal diverticula)?
Pharyngeal mucosa protrusion at pharyngoesophogeal junction
What are the symptoms, diagnosis, and treatment for Zenker's diverticulum (esophageal diverticula)?
- Symptoms: Dysphagia and regurgitation. Later, halitosis, choking, gurgling, neck protrusion.
- Diagnosis: Barium esophagram
- Treatment: Surgical diverticulectomy
What are some characteristics of esophageal varices?
- Most are secondary to portal hypertension
- 50% of patients with cirrhosis have esophageal varices (1/3 of these will bleed + higher mortality and morbidity than any other upper GI bleed -> 20% with treatment)
True or false: Acute GI bleed (hypovolemia) and Hematemesis are not signs and symptoms of esophageal varices.
False, they are signs and symptoms.
What treatments are recommended for esophageal varices?
- FFP/platelets (think coagulopathy)
- Spontaneous resolution in 50% (but 1/2 of these will rebleed)
- Emergency endoscopy (within 2-12 hrs) for banding or sclerotherapy
- Pharmacologic treatment
- Baloon tube tamponade if Rx and endoscopy fails
- Portal Decompressive Procedures
What makes up the pharmacologic treatment of esophageal varices?
- Antibiotics for cirrhotic patients
- Octreotide - reduces portal pressures
- Vitamin K if abnormal prothrombin time
- Lactulose to promote defecation in patients with encephalopathy
Why are Portal decompressive procedures utilized for esophageal varices, and what makes up these procedures?
- Used if bleeding can't be stopped with endoscope and medicines
- Transvenous intrahepatic portosystemic shunt (TIPS): Shunts blood from portal vein to hepatic vein
- Emergency portosystemic shunt surgery (40-60% mortality)
What methods are used in prevention of rebleeding for esophageal varices?
- Endoscope: long-term band ligation
- Beta blockers and nitrates -> Nonselective B Blockers (propanolol, nadolol) -> Use in combination with band ligation
- TIPS: reserved for recurrent bleeds -> better than band ligation (20% vs 40%) -> Encephalopathy rates are higher
- Liver transplantation
What age range is the highest risk for esophageal cancer?
Who is more likely to suffer through esophageal cancer, men or women? What ratio of men/women?
Men are more likely to contract at a ratio of 3:1.
What are the two histological types of esophageal cancer?
- Squamous cell carcinoma
What are the general characteristics of Squamous Cell Carcinoma?
- Associated with tobacco use
- Affects African Americans > Caucasian
- Also affects Chinese and SE Asians
- 1/2 occur in distal esophagus
What are the general characteristics of Adenocarcinoma?
- Affects Caucasians > African Americans
- Increasing in incidence
- Develops as cancer of Barrett's
- Most are in distal esophagus
- Also associated with obesity
What are the signs and symptoms of esophageal cancer?
- Most patients have advanced, incurable disease at diagnosis
- Solid food dysphagia in 90%
- Weight loss
- Signs of metastatic disease -> supraclavicular or cervical lymphadenopathy -> hepatomegaly
What is used to diagnose esophageal cancer?
- Barium esophagogram: usually ordered to assess dysphagia
- Upper endoscopy with biopsy
What are the three stages of malignant lesions?
- 1) Resectable with curative intent
- 2) Resectable but not curable
- 3) Not resectable not curable (presence of distant metastases excludes curative resection)
What is the treatment for esophageal cancer?
- "Curative" disease (no T4 or M1): Surgery, with or without chemo ->Esophagectomy ->Combined chemo and radiation may help
- Palliative treatment (T1 or M1 is incurable) ->Radiation or chemo ->Local antitumor therapy (permanent expandable wire stents, endoscopic laser/photodynamic therapy)
What is the prognosis for esophageal cancer?
- Overall 5 year survival rate: <15%
- Spread to lymph node is most important predictor of survival
- If lymph node involvement, survival is <10%
What are the characteristics of the esophageal motility disorder, Achalasia?
- Loss of peristalsis in distal 2/3 of esophagus and impaired relaxation of the lower esophageal sphincter
- Denervation of the esophagus from loss of nitric oxide-producing inhibitory neurons
- Cause of denervation is unknown
What are the signs and symptoms of Achalasia?
- Gradual onset of dysphagia
- Patient may have adopted specific maneuvers to enhance esophageal emptying -> lifting the neck -> throwing the shoulders back
- Regurgitation of undigested food is common
What are the methods of diagnosis for Achalasia?
- Diagnosis is by barium esophagram ->"Bird's beak" tapering of the esophagus -> Dilation of esophagus (late finding)
- Must have endoscopy to rule out neoplasm
- Diagnosis is confirmed by manometry
What exam is used after barium esophagography to exclude a distal stricture or infiltrating carcinoma in diagnosing achalasia?
What is used in the treatment of Achalasia?
- Botulism toxin injection -> Endoscopically into lower esophageal sphincter -> Temporary relief: 6 months - 2 years
- Pneumatic dilation of lower esophageal sphincter: 50-70% of patients achieve long-term relief
- Surgical myotomy of LES (also do Nissen)