PANCE Blueprint GI and Nutrition (10%)

Diseases of the Esophagus (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 6 topics under category esophageal disorders

Esophagitis (ReelDx) Non-infectious esophagitis:

  • Reflux esophagitis: mechanical or functional abnormality of the LES
  • Medication induced: think NSAIDS or bisphosphonates
  • Eosinophilic: Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal, barium swallow will show multiple corrugated rings

Infectious esophagitis:

  • Fungal: Infectious Candida: linear yellow-white plaques with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily
  • Viral:
    • HSV: shallow ulcers noted on EGD, treat with acyclovir
    • CMV: deep ulcers on EGD, treat with ganciclovir
  • EBV, Mycobacterium tuberculosis, and Mycobacterium avium intracellulare are additional infectious causes
Motility disorders
  • Achalasia: Decreased peristalsis, increased sphincter tone
    • Presentation: slowly progressive dysphagia, episodic regurgitation
    • Barium swallow: “parrot-beak” - dilated esophagus tapered to distal obstruction
    • Definitive diagnosis: esophageal manometry
  • Diffuse Esophageal Spasm: Corkscrew appearance on barium swallow
  • Neurogenic dysphagia: Dysphagia to liquids and solids caused by injury at brainstem or cranial nerves
  • Zenker diverticulum:  Outpouching of posterior hypopharynx
    • Presentation: Men over 60. Regurgitant symptoms several hours after eating, halitosis
    • Treatment: Excision, myotomy of cricopharyngeus muscle and upper 3 cm of posterior esophageal wall
  • Scleroderma esophagus: Dysphagia to both solids and liquids
  • Esophageal stenosis: Dysphagia to solids but not liquids
Mallory Weiss tear Esophageal mucosal tear

  • Presentation: History of alcohol intake and an episode of vomiting with blood
  • Caused by forceful vomiting. Associated with alcohol use, upper endoscopy showing superficial longitudinal mucosal erosions
  • Treatment: Supportive. May cauterize or inject Epinephrine if needed
Esophageal Neoplasms Progressive dysphagia to solid foods along with weight loss, reflux and hematemesis

  • Squamous cell m/c worldwide and adenocarcinoma common in US

Adenocarcinoma:

  • Complication of Barrett's esophagus (screen barrett's patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of esophagus

Squamous cell:

  • Associated with smoking and alcohol use
  • Affects proximal (upper) 2/3rds of esophagus
  • Progressive dysphagia, weight loss, hoarseness
  • Diagnostic studies: Endoscopy + biopsy
  • Treatment: Resection
Esophageal strictures Solid food dysphagia in a patient with a history of GERD,

  • Esophageal web: thin membranes in the mid-upper esophagus. May be congenital or acquired
  • Plummer-Vinson: esophageal webs + dysphagia + iron deficiency anemia
  • A Schatzki ring is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur

Diagnosed with barium swallow

Treat with endoscopic dilation

Esophageal varices (ReelDx) Dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis

  • Presentation: Often asymptomatic until hematemesis
  • Etiology: Portal hypertension (from cirrhosis), Budd-Chiari syndrome (from occlusion of hepatic veins)
  • Treatment: Therapeutic endoscopy – endoscopic banding and IV octreotide, prevent with nonselective beta blockers
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