Term
| what is the difference between dysphagia and odynophagia? |
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Definition
| dysphagia is difficulty swallowing, odynophagia is painful swallowing |
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Term
| if you want to view something in the esophagus, what do you order? |
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Definition
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Term
| when is cinefluoroscopy used? |
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Definition
| cinefluoroscopy is used to check and see if the pt has a lesion causing a motility disorder or spasm |
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Term
| if a pt has a barium swallow performed and you think you see something abnormal what is the next step? |
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Definition
| use an endoscope to confirm the abnormality via bx for cytologic studies, want to r/o CA |
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Term
| what is the acid perfusion/berstein test? |
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Definition
| an in-office procedure to confirm GERD where HCl and saline are squirted near the LES. if no pain is experienced with either solution, this usually means the esophagus is healthy and no irritation is present. if pain is experienced with the acid solution but not the saline solution, this can mean that the heartburn is probably due to acid reflux. |
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Term
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Definition
| the gold standard for diagnosing GERD, where a monitor is placed next to the proximal GE junction and pH/flare-ups are recorded. a pH of around 1.5 confirms GERD |
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Term
| what are motility studies? |
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Definition
| this is used to ID some of the neuromuscular disease by running a catheter through the LES, pumping water through it until peristalsis is achieved and analyzing the level of motility |
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Term
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Definition
| difficulty in swallowing due to a disruption in the physiologic process of esophageal motility -*not painful* |
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Term
| what are pre-esophageal causes of dysphagia? |
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Definition
| pseudobulbar palsy from C-V disease, multiple sclerosis, amytrophic lateral sclerosis, parkinson's disease, brain stem tumors, bulbar poliomyelitis, syringomyelia, myasthenia gravis, muscular dystrophies, dermatomyositis, polymyositis, and misc (rabies, botulism, tetanus) |
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Term
| what are structural causes of dysphagia? |
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Definition
| oropharyngeal tumors, inflam. disorders (mumps, pharnygitis, glossitis, tonsillitis), zenker's diverticulum, plummer-vinson syndrome, extrinsic compression (thyroid, lymph node, cervical spurs - from osteoarthritis), sjogren's syndrome, and macroglossia (amyloid, hypothyroidism) |
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Term
| what is plummer-vinson syndrome? how is it diagnosed? treated? |
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Definition
| also known as *sineropedic dysphagia, this is mostly seen in scandinavian females and 50% will have iron deficient anemia/vit deficiency. a *web develops in the prox esophagus w/squamous epithelium (can be inflammed), there is an *atrophic tongue, lose their teeth, experience choking sensations, odyonophagia, often red-haired, and creases in the lip angles. it can be diagnosed by barium swallow and treated with vitamins and iron therapy. |
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Term
| what are the most common neuromuscular (motility) causes of esophageal dysphagia? |
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Definition
| achalasia, scleroderma, and diffuse spasm |
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Term
| what are intrinsic mechanical lesions that can lead to esophageal dysphagia? |
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Definition
| peptic structure, lower esophageal (schatzki) ring, CA, esophageal webs (plummer-vinson syndrome), and esophageal diverticula |
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Term
| what is a manometric study? |
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Definition
| a test to determine if the normal cycle of relaxation and contraction in the esophagus is normal |
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Term
| what are the 2 kinds of esophageal diverticula? |
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Definition
| true/traction or false/zenker's |
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Term
| what is a true or traction diverticulum? |
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Definition
| this occurs in the mid or distal esophagus if the pt has pneumonia or pleurisy and as it heals - it pulls the esophagus toward itself. a true diverticulum means that all the layers of the esophagus are involved and the sac is above the neck of the diverticulum. generally these drain easily and the pt has few problems |
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Term
| what is a zenker's diverticulum? |
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Definition
| zenker's or false diverticuli occur in the proximal part of the esophagus, usually in pts over 60 and result from pressure increasing in the esophagus which pushes the epithelium through the muscular layer, creating a "false diverticulum" lacking a muscular layer as a sac below the neck. when a pt is eating, food can accumulate here, leading to haliosis |
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Term
| what is a sliding esophageal hernia? what % of pt w/a hernia have this? |
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Definition
| a sliding esophageal hernia is when a hernia of the esophagus is mobile above and below the LES. it doesn't cause vascular insults, though pts will complain of GERD and often will have an incompetent LES. 86% of pts with an esophageal hernia will have this kind |
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Term
| what is a paraesophageal hernia? what % of pt w/a hernia have this? |
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Definition
| in a paraesophageal hernia, a "knuckle" of mucosa goes up above the diaphragm and into the thoracic cavity. paraesophageal hernias can result in vascular and neurologic changes that require sx to amend. 8% of pts with an esophageal hernia will have this kind |
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Term
| how many pts have an hiatal hernia where the entire stomach slips up past the diaphragm? |
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Definition
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Term
| what are the 3 kinds of extrinsic mechanical lesions? |
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Definition
| *vascular compression (in dysphagia dystoria the right subclavian come off the aorta and cross from R->L), *mediastinal abnormalities, and *cervical osteoarthritis |
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Term
| what is the pathogenesis of reflux esophagus? |
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Definition
| an *incompetent LES*, prolonged contact with stomach acid due to an inadequate esophageal clearing of gastric reflux, and the esophageal response: inflammation, stricture, columnar metaplasia |
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Term
| *at what diameter does peptic stricture usually start to produce symptoms?* |
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Definition
| <12 mm - important number |
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Term
| what are peptic strictures usually the result of? |
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Definition
| recurrent mucosal erosions |
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Term
| what tests need to be performed on pts with peptic stricture? |
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Definition
| appropriate diagnostics to ensure benignity |
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Term
| what is the treatment for peptic stricture once it is confirmed? |
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Definition
| intense medical therapy for reflux esophagitis. if this fails - progressive dilation for symptomatic relief. pts who have this procedure done usually can't belch. |
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Term
| what is the risk with GERD? |
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Definition
| unless addressed earl and aggressively, GERD will develop complications requiring more dangerous therapy |
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Term
| does obesity put pressure on the LES? |
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Definition
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Term
| what are the characteristics of barrett's esophagus? |
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Definition
| squamous epithelium in the esophagus is replaced with columnar. usually barrett's esophagus is associated with a hiatal hernia and results in chronic reflux of gastric contents into the esophagus |
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Term
| what is the incidence of barrett's esophagus? |
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Definition
| equal for males/females and comes to medical attention after the fourth decade |
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Term
| how is barrett's esophagus diagnosed? |
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Definition
| via barium esophagram/barium swallow - which if positive will usually (70% of the time) show a palatous GE junction, mid-esophageal stricture |
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Term
| what is the treatment for barrett's esophagus? |
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Definition
| 1) prevent GE reflux with medical therapy 2) surgical correction for intractable complications (stricture, bleeding, CA) CA incidence is 3-9% |
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Term
| what is Symptomatic Diffuse Esophageal Spasm? |
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Definition
| a condition where the pt's esophagus curls up to the point where it resembles pseudo-diverticuli - but only during an attack. |
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Term
| what are the symptoms of symptomatic diffuse esophageal spasm? |
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Definition
| crushing substernal chest pain, dysphagia, and vaso-vagal sycope |
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Term
| what is the pathophysiology of symptomatic diffuse esophageal spasm? |
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Definition
| *hypertrophy of both longitudinal and circular esophageal muscles* and abnormal responses to cholinergic stimuli |
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Term
| how is a symptomatic diffuse esophageal spasm diagnosed radiographically? |
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Definition
| appearance of non-peristaltic, tertiary contractions of the esophagus |
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Term
| how is a symptomatic diffuse esophageal spasm diagnosed via manometry? |
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Definition
| frequent, repetitive simultaneous contractions throughout the esophagus |
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Term
| what is treatment for symptomatic diffuse esophageal spasm? |
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Definition
| analgesics, tranquilizers, sublingual nitroglycerine, anticholinergics, bougienage, and surgery (sx not recommended b/c it opens up other problems) |
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Term
| what are secondary causes of symptomatic diffuse esophageal spasm? |
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Definition
| alcoholic neuropathy, diabetic neuropathy, thyroid abnormalities, lye/caustic agents, and severe esophageal reflux |
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Term
| what is achalasia? what is its pathogenesis? what happens as a result? |
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Definition
| achalasia is an esophageal motility disorder due to *increased LES pressure than in the normal population, *incomplete LES relaxation upon swallowing, and *absence of effective peristalsis along the entire esophageal body. pts w/this will have emesis - but food will only be chewed - not digested |
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Term
| how is achalasia diagnosed? |
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Definition
| pts usually present with dysphagia, regurgitation of undigested food, substernal chest pain with cold food and beverages, **esophageal dilitation with failure of proximal esophageal musculature contraction**, a positive mecholyl test (increases LES pressure for 5-10 min, and manometric studies showing a failure of the esophageal muscle to contract |
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Term
| what are treatment options for achalasia? |
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Definition
| pneumatic dilatation (intentionally rupture the LES sphincter musculature) and surgical myotomy (if pneumatic dilitation fails) |
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Term
| what are the premalignant lesions of the esophagus? |
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Definition
| achalasia (SCC), lye strictures (SCC), barrett's esophagus (adenocarcinoma), plummer-vinson syndrome (SCC), and alcohol/smoking (higher in whiskey drinkers than beer) |
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Term
| what is a mallory-weiss tear? what is boerhaave syndrome? |
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Definition
| mallory weis is a tear in the esophageal lining at the GE junction and is less lethal and boerhaave syndrome is a distal esophageal rupture, usually the lower 1/3 in the L posterolateral region and can be lethal |
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Term
| does the presence of a hiatal hernia or LES pressure determine whether a pt will have GERD? |
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Definition
| only the level of LES pressure determines whether a pt will have GERD - at pressures less than 15 mm, reflux occurs, regardless of the presence of a hernia. (pts with a hiatial hernia and incompetent LES will have further complications) |
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Term
| is reflux possible in pts w/out GERD? |
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Definition
| yes, there are 3 kinds of reflux not classified as chronic GERD: transient LES relaxation, intra-abdominal pressure transients, and spontaneous free GE reflux |
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Term
| what is transient LES relaxation? |
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Definition
| sporadic LES pressure decreases, leading to reflux |
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Term
| what are intra-abdominal pressure transients? |
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Definition
| increase in LES due to gastric pressure (like in a supine, obese pt) which causes reflux |
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Term
| what is spontaneous free GE reflux? |
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Definition
| reflux w/out changes in LES or gastric pressure |
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Term
| what is the definition of GERD? |
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Definition
| gastroesophageal reflux: retrograde flow of gastric contents, exacerbated by eating and recumbency of which heartburn is the most common symptom |
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Term
| what are the complications of GERD? |
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Definition
| erosive esophagitis/ulceration, hemorrhage, strictures, barrett's esophagus, respiratory tract complications, and noncardiac chest pain |
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Term
| what are respiratory and atypical disoders assciated with GERD? |
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Definition
| nocturnal breathing/wheezing, hoarseness, asthma, chronic bronchitis, laryngitis/pharyngitis, aspiration pneumonitis, pulmonary fibrosis, recurrent emesis in children, and failure to thrive in children |
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Term
| how do bronchodilators affect pts with GERD, who were wrongly prescribed them? |
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Definition
| these pts had decreased LES pressure, greater esophageal acid exposure time, more frequent reflux episodes, and longer clearance times |
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Term
| what is the initial (phase I) approach to treatment of GERD? what % of pts will improve with it? |
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Definition
| dietary modifications, smoking cessation, elevation of the head of the bed, avoiding medications that affect lower esophageal sphincter pressure and antacids. 90% of pts respond well to this level of tx. |
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Term
| what foods should be avoided in anti-reflux therapy because they irritate esophagus lining? |
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Definition
| citrus fruits, tomato-based products, and coffee |
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Term
| what foods should be avoided in anti-reflux therapy because they reduce LES pressure? |
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Definition
| onions, chocolate, peppermint, and food w/high fat content (increases CCK which decreases LES tone, CCK also competes w/gastrin which increases LES tone for receptor sites) |
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Term
| how far up should the head of a GERD pt's bed be elevated for therapeutic benefit? |
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Definition
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|
Term
| what are some meds that reduce LES pressure? |
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Definition
progesterone, theophylline, anticholinergic agents
(antihistamines, tricyclic antidepressants (except pirenzepine)),
beta-adrenergic agonists, alpha-adrenergic antagonists, diazepam, meperidine, calcium channel blockers |
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Term
| what are some meds that cause esophageal injury? |
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Definition
| tetracycline, doxycycline, quinidine, KCI tablets, iron salts, NSAIDs |
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Term
| what is the phase II approach to GERD tx? |
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Definition
| pharmacologic therapy. PPIs are better if the pt's insurance will pay b/c they give relief and lead to healing. H2 receptor blockers are good for relief but don't necessarily help heal. |
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Term
| what is phase IV GERD therapy? |
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Definition
| surgery, which is reserved for the 5-10% of pts who don't respond to standard therapy or who complications develop in. fundoplication is the most common procedure. |
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