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Esophageal disorders

This is an overview of disorders of the esophagus. This presentation was created using Google Slides Figures were created or adapted from Wikimedia Commons ADDITIONAL TAGS: Disorders of the esophagus GERD Caustic esophagitis Eosinophilic Pill-induced Infectious Achalasia Esophageal spasm Scleroderma Tear / rupture perforation Cancer Zenker’s diverticulum stricture Plummer-Vinson syndrome Schatzki ring inflammatory disorders motility (functional) structural Gastrointestinal reflux disease Pathophys: Weak lower esophageal sphincter Sx: burning chest/epigastric pain (worse with spicy/acidic foods) supine → nocturnal asthma), cough, sour/metallic taste, nausea, hoarseness Alarm symptoms? Dysphagia, odynophagia, weight loss, anemia, GI bleed, recurrent vomiting, age 50, tobacco use? investigate other etiologies (cancer) endoscopy +/- biopsy Dx: First, try a PPI trial for 6 weeks + lifestyle changes Definitive test is 24-hour pH monitor, to correlate symptoms acidity levels (stop acid suppression 5 days prior) Tx: Lifestyle mod (avoid foods, don’t eat before bed, smaller meals, no smoking/alcohol); PPIs (-prazole), H2R antagonists (-tidine). Definitivet tx: nissen fundoplication (risks achalasia) Complication: metaplasia (Barrett’s: squamous columnar epi); dysplasia adenocarcinoma. Requires resection, chemo, radiation Others: ulcers, strictures (endoscopic markers GERD) Damage tissue via chemical origin: occupational exposures (fumes mix saliva), pica acidic or basic liquid, accident (children), self-harm (adolescents, adults), Tide Pod challenge chest pain, odynophagia (painful swallow) drooling, wheezing, stridoer If low severity (shallow erythema on endo), transition from liquids solids in 1-2 high (deep circumferential burns, necrosis), NPO 3 DO NOT induce vomiting neutralize acid/base Complications: cancer (2-3%, requires screening)), (⅔) Chronic immune mediated inflammation; similar allergic rxn; often comorbid asthma, allergies, atopy Chest epigastric reflux, Difficulty swallowing food worse than liquids; impaction; intermittent (whereas achalasia has difficulty both and progressive) Younger men (20-30 yo); when eating meat Endoscopy (shows furrowing, small whitish educates, multiple stacked ringlike indentations [trachealization]) eosinophils ( 15/hpf]) Start like (dietary modification, PPIs), then aerosolized topical steroids (fluticasone, budesonide). Last option dilation Samir at English-language Wikipedia, 3.0, https://commons.wikimedia.org/w/index... direct effect some medications mucosa not taken sufficient liquid Often middle due compression by aorta left atrium Offending meds: bisphosphonates, KCl (osmotic injury), tetracyclines (acidic effect), NSAIDs (disrupt protection), antibiotics (doxy, clinda, SMX-TMP) Worse cheaper, noncoated pills sudden onset dysphagia, retrosternal pain. patients clinical. Confirm (discrete ulcers normal surrounding mucosa) stop medication; take meds 4oz water while sitting up Infection virus, bacteria, fungus; opportunistic infxns; more likely immunosuppression (HIV w CD4 100, organ transplant, leukemia, lymphoma, (viral painful candida) Clinical: Herpes: oral/labial Candida 60% cases): thrush (white plaques throughout mouth) dx endo+biopsy ulcerative round/ovoid lesions (volcano-like); multinucleated giant cells CMV: large linear distal esophagus; intranuclear inclusions bx val/acyclovir, foscarnet val/gancyclovir, forcarnet Candida: fluconazole, nystatin failure relax tightened LES dysphagia solids, ball knot behind their sternum; heartburn; loss. Progressive (avg years dx). Manometry showing hyperactive contraction (despite activity), peristalsis esophagus. manometry unclear barium swallow (bird’s beak narrowing GE junction) can present similarly (pseudoachalasia), so confirm EGD rule out malignancy reveal absent myenteric plexus must open Surgery (laparoscopic myotomy, pneumatic balloon dilation) Poor surgical candidates get nitrates. Idiopathic (primary) achalasia. impaired inhibitory innervation uncoordinated simultaneous contractions body Sx mimics myocardial infarction: crushing precipitated emotional stress, relieved nitrates ECG, troponins MI (repetitive diffuse erratic spasms middle/lower esophagus, either spontaneously ergonovine stimulation) Esophagram show’s corkscrew pattern, nonperistaltic (diltazem) Atrophy fibrosis smooth muscle decreased abnormal tone Associated CREST systemic sclerosis heartburn, dysphagia; ‘must drink solid food’ shows relaxed pressure (in CREST) sclerosis) PPIs; smoking, hot damage proximal cell carcinoma (Barrett esophagus) adenocarcinoma alcohol, n-nitroso compounds AdenoCa: GERD, obesity solid-food bleeding Fe def; loss Can start avoid Then do EGD+biopsy definitive diagnosis CT stage if positive Weakened cricopharyngeus increased intraluminal herniation (pseudodiverticulum) foul smelling breath (halitosis), (gurgling, coughing, aspiration (sometimes PNA), regurgitation undigested food),