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Julie W: Module 9 - GI > GI Conditions - Esophagus - Prof. Wall > Flashcards

GI Conditions - Esophagus - Prof. Wall Flashcards

1
Q

Esophagus

GERD

A

Return of stomach contents into esophagus (w/ symptoms)

Most Common D/O of Esophagus

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2
Q

Esophagus

GERD

A

Lower esophageal sphincter is weak or relaxes inappropriately

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3
Q

Esophagus

GERD

+

Hiatal Hernia

A

When the LES & Upper Stomach Portion move up into chest wall through small opening in diaphragm

Causes GERD more often

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4
Q

Esophagus

GERD

+

Epidemiology

A
  • Affects 15-20% of population (report weekly heartburn)

​

  • Caucasians & Pregnancy
  • N. America & Europe
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5
Q

Esophagus

GERD

+

Signs & Symptoms

A
  • Heartburn
  • Odynophagia
  • Dysphagia
  • Regurg
  • Bleching
  • Nausea
  • Anorexia/Weight Loss

​

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6
Q

Esophagus

GERD

+

Atypical Signs & Symptoms

A
  • Sore Thorat
  • Dental Caries
  • Chronic Cough
  • Asthma
  • Hoarseness
  • Recurrent Pneumonia
  • Chest Pain

​

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7
Q

Esophagus

GERD

+

Diagnostics

A
  • Empircally
  • Upper endoscopy w/ bx (esophagogastroduodenoscopy)
  • Barium Esophagogram
  • Ambulatory esophageal pH monitoring

​

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8
Q

Esophagus

GERD

+

Complications

A
  • Esophagitis
  • Atypical symptoms
  • Stricture - GE Junction
  • Barret’s Esophagus!
    • ​Neoplastic changes
    • Risk: 40-100x greater than general population

​

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9
Q

Esophagus

GERD

+

Management

A
  • Repeat Endoscopy every 2 years w/ biopsy
  • Surgical resection - if high grade dysplasia >25%
  • Stay on Proton Pump Inhibitors FOREVER!

​

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10
Q

Esophagus

GERD

+

Treatment Goals

A
  • Provide symptom relief
  • Heal damage
  • Prevent complications

Combo of Pharm & Non-Pharm Tmts

​

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11
Q

Esophagus

GERD

+

Non-Pharm Tmts

A
  • Lifestyle!!!
    • Avoid certain foods & drink
    • Decrease portion size
    • Lose weight
    • Elevate head of bed
    • Avoid eating 2-3 hours before bed

​

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12
Q

Esophagus

GERD

+

Pharm Tmts

A
  • Antacids
    • Mg, Ca, Al
    • *May cause constipation in elderly
  • Sialogogues
    • Gum
  • H2 Receptor Agonists
    • 30 min to work & last 8 hours
  • PPIs
    • ​$$$
    • Once daily dosing

​

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13
Q

Esophagus

GERD

+

Pharm Tmts

A
  • Antacids
    • Mg, Ca, Al
    • *May cause constipation in elderly
  • Sialogogues
    • Gum
  • H2 Receptor Agonists
    • 30 min to work & last 8 hours
  • PPIs
    • ​$$$
    • Once daily dosing

​

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14
Q

Esophagus

GERD

+

PPIs for Severe Disease!!!!

A
  • PPIs
    • ​1-2x daily
    • Therapy course: 8-12wks
      • Most pts relapse & continue with tmt

​

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15
Q

Esophagus

Esophageal Spasm

A
  • Motility D/O
  • Assc. w/
    • Chest Pain
    • Dysphagia

​

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16
Q

Esophagus

Esophageal Spasm

Nutcracker Esophagus

A
  • Hypertensive Peristalsis
  • Increased contraction pressure
    • >180mmHg during Peristalsis

​

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17
Q

Esophagus

Esophageal Spasm

Treatment

A
  • Nitrates
  • CCBs
    • Diltiazem

​

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18
Q

Diagnostics

Esophageal Manometry

A

Evaluates Peristalsis ​

Upper & Lower Esophageal Sphincters

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19
Q

Diagnostics

Esophageal Manometry

Examples

A
  • Achalsia
    • No Relaxation at LES
    • Lack of Peristalsis
  • Nutcrack Esophagus
    • Hyper-contractile especially at LES
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20
Q

Esophageal Dysphagia Algorithm

A
  • Solid Foods -
    • Mechanical Obstruction
  • Solid Food & Liquirds -
    • Neuromsk Obstruction
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21
Q

Esophagitis

A

Inflammation of the Esophagus

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22
Q

Esophagitis

+

GERD

A

50% of those w/ GERD develop Esophagitis

Incidence increases with Age

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23
Q

Esophagitis

+

Risk Factors

A
  • GERD
  • Infectious
    • Viral, fungal, bacterial, parasitic
  • Pill/Med-Induced
    • Abx, KCl, Bisphosphonates
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24
Q

Esophagitis

Signs & Symptoms

A
  • Odynophagia
  • Dysphagia
  • Substernal Chest Pain
  • Oral Thrush
  • Herpes Labialis
  • Retinitis (CMV)
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25
Q

Esophagitis

Herpes Simplex Esophagitis

Signs & Symptoms

A
  • Nausea
  • Vomiting
  • Fever
  • Chills
    • +/- Herpetic Vesicles on Nose & Lips
  • Painful!
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26
Q

Esophagitis

Herpes Simplex Esophagitis

Diagnostics

A
  • Endoscopy:
    • Vesicles
    • Small, discrete superficial ulcerations
  • Culture will show HSV
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27
Q

Esophagitis

Herpes Simplex Esophagitis

Treatment

A
  • Oral or IV Acyclovir
    • 7-21 days
    • IV if complications
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28
Q

Esophagitis

Varicella Zoster Virus

A
  • Kids w/ chickpox or adults w/ zoster
  • Differentiate from HSV via
    • Culture or Cells
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29
Q

Esophagitis

Varicella Zoster Virus

A
  • Vesicles & Confluent Ulcers
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30
Q

Esophagitis

Varicella Zoster Virus

Treatment

A
  • Usually resolve spontaneously
    • BUT may cause Necrotizing esophagitis
  • Acyclovir
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31
Q

Esophagitis

Cytomegalovirus

A

Only occurs in Immunocompromised

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32
Q

Esophagitis

Cytomegalovirus

A
  • Creeping ulcer in otherwise Normal Mucosa
    • May become GIANT
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33
Q

Esophagitis

Cytomegalovirus

Patients present with…

A
  • Odynophagia
  • Persistent chest pain
  • Hematemesis
  • Nausea
  • Vomiting
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34
Q

Esophagitis

Cytomegalovirus

Treatment

A
  • IV Ganciclovir
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35
Q

Esophagitis

Candidia

A
  • Normally in throat
    • Esophagitis form in Immunocompromised
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36
Q

Esophagitis

Candidia

Complicated by:

A
  • Bleeding
  • Perforation
  • Stricture
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37
Q

Esophagitis

Candidia

Endoscopy shows

A
  • Small
  • Yellow-white
  • Raised
    • Plaques
38
Q

Esophagitis

Candidia

Treatment

A
  • Oral or IV Fluconazole
39
Q

Esophageal Lesions

Mallory-Weiss Syndrome

A
  • Intraluminal mucosal tear or distal esophagus or gastric cardia
  • Arterial Bleeding
  • Self-limiting (v. varices)
40
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Caused by:

A
  • Intra-abdominal Pressure
41
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Boerhaave Syndrome

A
  • Esophageal Rupture
42
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Epidemiology

A
  • Alcoholics
  • Hiatal Hernia

Can also occur after:

  • Seizures
  • Childbirth
  • Lifting/Straining/Coughing
  • Blunt Abdominal Trauma
  • Bulimia
43
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Signs & Symptoms

A

Painless

  • ​Multiple bouts of vomiting & retching followed by Hematemesis
    • _​_Arterial bleeding
  • Abdominal pain
44
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Diagnosis

A
  • Endoscopy
  • CBC, PT, PTT
  • BUN/Cr
  • LFTs
  • Type & Cross match
  • +/- CXR and EKG
45
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Stablize!!

A
  • Airway, Breathing, Circulation
  • Transfusion
  • Gastric Lavage to remove blood
46
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Endoscopically control Bleeding!

A
  • Coagulation techniques
  • Blood clotthing agents application
47
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Treatment

A
  • Most bleeding resolves spontaneously
    • Benign & Self-limiting
48
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Admit

A
  • Continuous or massive hemorrhage
  • Hemodynamic Instability/Hypovolemic
  • Age extremes
  • Underlying medical condition
49
Q

Esophageal Lesions

Mallory-Weiss Syndrome

Discharge

A
  • History of minimal bleeding that has stopped
  • Hemodyamically stable/Stable H+H
  • Heme negative stool
50
Q

Esophageal Lesions

Esophageal Ring

A
  • Schatzki’s Ring:
    • ​Ring of tissue located at junction of esophagus & stomach
      • Congenital
      • May be result of Chronic GERD
    • Affects 4 our of 10,000
51
Q

Esophageal Lesions

Esophageal Ring

Symptoms

A
  • Dysphagia
    • Esp. w/ poorly chewed food boluses
    • Liquids are generally okay!
      • May help dislodge bolus
52
Q

Esophageal Lesions

Esophageal Web

A

Similar to Esophageal Ring, but in Mid- to Upper- Esophagus

One or more thin membranes of squamous mucosa that can cause intermittent dysphagia to solid food

53
Q

Esophageal Lesions

Esophageal Web

A

“Smooth, circumferential ring of squamous mucosa, often responsible for causing difficulty swallowing, which can be located anywhere along the esophagus. May be asymptomatic”​

54
Q

Esophageal Lesions

Esophageal Web

Etiology

A

Unknown

55
Q

Esophageal Lesions

Esophageal Web

Plummer-Vinson Syndrome

A
  • Webs w/ Iron Deficiency Anemia & Glossitis
    • Treat with Iron!
56
Q

Esophageal Lesions

Esophageal Web & Rings

Diagnosis for both:

A
  • Barium Esophagram
  • EGD

*Endoscopy is less sensitive than barium esophagram

*Esophagram is like an x-ray using contrast dye

57
Q

Esophageal Lesions

Esophageal Web & Rings

Treatment

A
  • Mechanical Dilation w/ Balloon
58
Q

Esophageal Varices

A

Dilated submucosal veins that develop in patients with Portal Hypertension

59
Q

Esophageal Varices

Most common cause…

A

Cirrhosis!!

60
Q

Esophageal Varices

Other causes

A
  • Portal Vein Thrombosis
  • Budd Chiari Syndrome
  • Infiltrative Liver Disease
61
Q

Esophageal Varices

Pathophys

A
  • Blood flow is increases through microscopic blood vessels w/in esophageal awall
    • Blood flow increases
    • Dilation can be profound
  • Dialate, dialate, dilate then…
    • RUPTURE!
62
Q

Esophageal Varices

Mortality Rates

A
  • First time varices rupture = ~40-70%
63
Q

Esophageal Varices

Most common site of Rupture

A
  • Distal Esophagus
  • Varcies at GE Junction most likely to rupture (most superficial)
64
Q

Esophageal Varices

Signs & Symptoms

A
  • Hematemesis
    • >50% stop bleeding spontaneously
  • Melena
  • Weakeness/Fatigue
  • Tachycardia
  • Hypotension
  • Abdominal Pain
  • Syncope
  • Jaundice
65
Q

Esophageal Varices

Labs

A
  • CBC
  • PT/PTT
  • Electrolytes
  • BUN/Cr
  • Type & Cross
66
Q

Esophageal Varices

Treatment

Immediate

A
  • Control bleeding (if doesn’t stop on own)
  • Emergent Endoscopy
  • Variceal Ligation (rubber band)
  • Sclerotherapy
  • Balloon Tamponade
67
Q

Esophageal Varices

Treatment

Long-Term Treatment

A
  • Antibiotics (prevents Peritonitis)
  • Decrease portal hypertension
    • Beta-blockers (propanolol)
    • Nitrates
  • Shunts
    • TIPS
  • Liver Transplant
  • Stop Drinking!!
68
Q

Achalasia

Greek for: “Does not relax”

A

Loss of Peristalsis in distal esophagus & failure of LES to relax

Symptoms mostly occur b/c LES is NOT relaxing

69
Q

Achalasia

A

Results in Functional Obstruction of esophagus that Persists until the pressure of the retained material causes it to move through the LES

Food backs up & ferments in the esophagus….

Distention & Dilation

70
Q

Achalasia

Causes

A
  • Damage to nerves of esophagus
  • Infection
    • (Chagas)
  • Hereditary Factors
71
Q

Achalasia

Incidence

A
  • Frequency increase with older age
  • Incidence:
    • 2 out of 10,000 people
72
Q

Achalasia

Signs & Symptoms

A
  • Dysphagia = MOST COMMON SYMPTOM​
  • Chest Pain
  • Regurgitation
  • Difficulty Belching
  • Weight Loss
73
Q

Achalasia

Diagnosis

A
  • Chest XR
  • Barium Swallow
    • “Bird’s Beak”/”Parrot’s Beak” appearance
  • Manometry
    • pressure gradient
  • Endoscopy
74
Q

Achalasia

Treatment

A
  • Nitrates/CCBs
  • Botulinum toxin
  • Pneumatic Dilation
    • Balloon is inflated in LES, reducing pressure
    • 60-90% effective; last 10 years
  • Myotomy
    • Muscular ring around LES cute
    • 95% success rate
75
Q

Hiatal Hernia & GERD Treatment

Nissen Fundoplication

A
  • Surgical procedure
    • can be laproscopic
  • Gastric fundus is wrapped around lower end of esophagus
  • Complications:
    • Gas Bloat Syndrome
    • Dysphagia
    • Dumping Syndrome
76
Q

Have an Elderly Patient who just keeps getting Pneumonia?

Pearl

A
  • Order a Modified Barium Swallow
77
Q

ESOPHAGEAL CANCER

A
  • Most are:
    • Squamous cell*, or
    • Adenocarcinoma**
  • SCC* is decreasing in US, Adeno** is Rising ALOT!!!
78
Q

ESOPHAGEAL CANCER

Prognosis

A
  • Poor
  • 5-year survivial: 10-13%
    • Patients diagnosed w/ early stage may be cured
79
Q

Esophageal Cancer

Squamous Cell

A
  • Middle esophagus
  • More common in MALES
  • More common in BLACKS
  • Common causes: Smoking & Alcohol
80
Q

Esophageal Cancer

Squamous Cell

Causes

A
  • 90% attributable to smoking, alchohol and lack healthy diet
  • Underlying esophageal disease
    • Achalasia (16x increase)
    • Lye exposure
    • Partial gastrectomy
  • Upper aerodigestive tract cancer
81
Q

Esophageal Cancer

Adenocarcinoma

A
  • Distal esophagus
  • Barret’s esophagus
  • More common in MALES
  • More common in WHITE PEOPLE
82
Q

Esophageal Cancer

Adenocarcinoma

Increasing in Frequency & GERD!

A
  • Past 3 decades adenocarcinoma increasing in Frequency!!
  • GERD!!!!!!
    • Most, if not all, esophageal adenocarcinoma is from Barret’s metaplasia!
    • Risk greatest in those w/ long-standing 20+ years w/ severe symptoms
83
Q

Esophageal Cancer

Adenocarcinoma

Other Causes

A
  • Smoking… increases risk
    • Even after cessation… remains high!
  • Obesity!
    • 2.78x greater chance of Adeno if BMI >30
  • H. pylori infection
    • Controversial, but may cause inflammation & metaplasia
84
Q

Esophageal Cancer

Adenocarcinoma

versus

Squamous Cell

A
  • AC = disease of Caucasians & Males
  • Alcohol =
    • Important factor in SCC, not so much in Adeno
  • Obesity
    • Factor in Adeno, not SCC
85
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

Symptoms

A
  • Have similar clinical presentations
    • Progressive solid food dysphagia
    • weight loss
  • Early symptoms = subtle & non-specific
86
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

More Severe/Later Stage Symptoms

A
  • Dysphagia occurs once esophageal lumen diameter is
  • Retro-sternal discomfort, or burning sensation
  • Most early cancers detected by chance, or during screening for Barrett’s
87
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

Late Stage Symptoms

A
  • Chronic gastrointestinal blood loss
    • May result in Fe Deficiency Anemia
  • Upper GI bleed = rare
    • Result of tumor erosion
  • Tracheobroncial fistulas = late complication
    • Direct invasion through esophageal wall into main stem bronchus
    • Intractable coughing & frequent pneumonia
88
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

Life Expectancy

A
  • <4 weeks following development
89
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

Diagnosis

A
  • Barium Studies
  • Endoscopy
90
Q

Esophageal Cancer

Adenocarcinoma

+

Squamous Cell

Pre-Op Staging Evaluation

A
  • CT Scan of chest & upper abdomen
  • Endoscopic US
  • PET scan
  • Bronchoscopy

Julie W: Module 9 - GI (8 decks)

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