PANCE Blueprint GI and Nutrition (9%)

Esophageal Disorders (PEARLS)

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

Esophagitis (ReelDx)

Patient will present as → a 54-year-old female with odynophagia (painful swallowing), dysphagia and retrosternal chest pain

Esophagitis is simply inflammation that may damage tissues of the esophagus. It can be divided into two types:

⇒ Non-infectious

  • 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 epithelium.
  • Radiation: radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin
    • Dysphagia lasting weeks-months after therapy
    • Radiation exposure of 5000 cGy associated with increased risk for stricture
  • Corrosive: Ingestion of alkali or acid from attempted suicide

⇒ Infectious - odynophagia (pain while swallowing food or liquids) is the hallmark sign

This occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia and chest pain

Diagnosis is by endoscopy, biopsy, double-contrast esophagram, and culture

Treat the underlying condition

  • Candida: treat with fluconazole 100 mg PO daily
  • HSV: treat with acyclovir
  • CMV: treat with ganciclovir
  • Corrosive: treat with steroid
  • Eosinophilic: treat by removing foods that incite allergic response, topical steroids via inhaler
  • Medication-induced: to prevent bisphosphonate-related esophagitis treat by drinking pills with at least 4 ounces of water, avoid laying down for at least 30-60 minutes after ingestion
Gastroesophageal reflux disease Retrosternal pain/burning shortly after eating worse with carbonation, greasy foods, spicy foods and laying down

  • Endoscopy with biopsy—the test of choice but not necessary for typical uncomplicated cases. Indicated if refractory to treatment or is accompanied by dysphagia, odynophagia, or GI bleeding.
  • Upper GI series (barium contrast study)—this is only helpful in identifying complications of GERD (strictures/ulcerations)
  • PH Probe is the gold standard for diagnosis (but usually unnecessary)

Treatment: H2 receptor blockers, proton pump inhibitors, diet modification (avoid fatty foods, coffee, alcohol, orange juice, chocolate; avoid large meals before bedtime); sleep with trunk of body elevated; stop smoking

  • Nissen fundoplication: antireflux surgery for severe or resistant cases
  • Complications: Strictures or Barrett’s esophagus
Mallory Weiss tear Tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding.

  • 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

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 the posterior hypopharynx
    • Presentation: Men over 60. Regurgitant symptoms several hours after eating, halitosis
    • Treatment: Excision, myotomy of cricopharyngeus muscle and upper 3 cm of the posterior esophageal wall
  • Scleroderma esophagus: Dysphagia to both solids and liquids
  • Esophageal stenosis: Dysphagia to solids but not liquids
Esophageal strictures
Patient will present with → solid food dysphagia in a patient with a history of GERD

Dysphagia to solids that is only gradually progressive is suggestive of an esophageal stricture. GERD accounts for approximately 70-80% of all cases of esophageal stricture.

  • 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 by upper endoscopy to determine the underlying cause, exclude malignancy, and perform therapy (dilation) if needed

  • Barium contrast esophagram (barium swallow) can be used as the initial test (prior to upper endoscopy) in patients with clinical features of proximal esophageal lesion or known complex (tortuous) stricture

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

  • Serum labs: hemoglobin and hematocrit, platelet count
  • Prevention of rebleeds (70% of rebleeds are within 1 year of initial bleed and 1/3 are fatal)
      • Nonselective beta-blockers - propranolol, nadolol (treatment of choice in primary prophylaxis to prevent rebleeds)

Screening is indicated when cirrhosis or portal hypertension is diagnosed

  • When high-risk varices are diagnosed, prophylaxis should be started, and further screening is not necessary
  • Otherwise, screening should be repeated every 2 to 3 years for patients without varices and every 1 to 2 years for patients with small varices

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