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) Inflammation of the lining of the esophagus

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
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 gold standard for diagnosis (but usually unnecessary)
  • 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 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
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
Toxic megacolon (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: The Esophagus and the Stomach
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