PANCE Blueprint GI and Nutrition (9%)

Esophageal Disorders (PEARLS)

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

Esophagitis (ReelDx)
ReelDx Virtual Rounds (Esophagitis)
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:

1. 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 is associated with increased risk for stricture
  • Corrosive: Ingestion of alkali or acid from attempted suicide

2 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

  • Fungal: Infectious Candidalinear yellow-white plaques with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily
  • Viral:
  • EBVMycobacterium tuberculosis, and Mycobacterium avium intracellular are additional infectious causes

DX: Diagnosis is by endoscopy, biopsy, double contrast esophagram, and culture

TX: 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 an 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

Eosinophilic esophagitis-barium swallow

Barium swallow of the esophagus on the left side shows multiple rings associated with eosinophilic esophagitis.

Gastroesophageal reflux disease
Patient will present as → a 55-year-old male with complaints of heartburn, belching, and epigastric pain which is aggravated by drinking coffeeeating fatty foods, and lying down. He says it gets better when he takes antacids.

Retrosternal pain/burning shortly after eating worse with carbonation, greasy foods, spicy foods, and lying down

DX: Patients with typical symptoms of GERD may be given a trial of PPI therapy. Patients who do not improve or have long-standing symptoms or symptoms of complications should be studied:

  • 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 the trunk of body elevated; stop smoking

  • Nissen fundoplication: antireflux surgery for severe or resistant cases
  • Complications: Strictures or Barrett’s esophagus
Mallory Weiss tear
Patient will present as → a 21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight, when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department.

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

DX: Diagnosed with upper endoscopy showing superficial longitudinal mucosal erosions

TX: Supportive. May cauterize or inject epinephrine if needed

Mallory Weiss Tear

Endoscopic image of Mallory-Weiss tear showing superficial longitudinal mucosal erosions

Motility disorders
Patient presents as → a 46-year-old female complaining of difficulty swallowing solids and liquids. She also reports unintentional weight loss. (achalasia)

Achalasia

  • Failure of LES relaxation and increased LES tone (liquids and solids)
  • The most common motility disorder with dysphagia to both liquids and solids caused by idiopathic loss of nerve cells in the esophagus (Auerbach's plexus), causing failure of LES relaxation and increased tone - obstruction, and a lack of peristalsis.
  • Bird/Parrot beak on barium swallow
  • Confirmed by MANOMETRY GOLD STANDARD
  • Treat: decrease LES pressure, botulinum toxin injection for temporary relief
Radiology 0009 Nevit

Upper gastrointestinal series. Barium swallow. Dilated esophagus with retained column of barium and “bird’s beaking” suggestive of achalasia.


Diffuse esophageal spasm

Patient presents as → a 26-year-old male is brought to the emergency department (ED) via ambulance with sudden onset of extreme chest pain. The patient states that he had just finished his morning run and was drinking from his water bottle when the pain began. He states that the pain was like “nothing he had experienced before” and radiated to his back, neck, and ears. He called EMS and was given 325mg aspirin, sublingual nitroglycerine, and supplemental oxygen in the field resulting in near resolution of his symptoms. In the ED, his exam is completely unremarkable except for a heart rate of 110 bpm. EKG shows sinus tachycardia, troponin and CK-MB are within normal limits, and stress test is normal. You order an upper GI contrast study which shows a corkscrew esophagus.
  • Strong non-peristaltic esophageal contractions cause stabbing chest pain that is often precipitated by ingestion of hot and cold liquids and foods
  • Dysphagia to solids and liquids
  • Corkscrew appearance on barium swallow
  • Confirmed by MANOMETRY GOLD STANDARD
  • Treat with nitrates, calcium channel blockers
Korkenzieher-Ösophagus

Corkscrew esophagus as seen in diffuse esophageal spasm


Neurogenic dysphagia

Patient presents as → a 32-year-old female who reports to your office complaining of nasal regurgitation with the ingestion of fluids. Sure enough, when you hand her a glass of water, and she sips the liquid, it regurgitates out her nose. You make an immediate referral to the neurologist. Three months later, when the patient returns to your office, she explains that she has been diagnosed with multiple sclerosis.

Neurogenic dysphagia is a result of the faulty transmission of nerve impulses to the pharyngeal muscles generally caused by an associated neuromuscular disease, such as myasthenia gravis, amyotrophic lateral sclerosis, MS, or stroke

  • This condition is produced by weakness and incoordination of the muscles in the pharynx that propel food into the esophagus
  • Both liquids and solids are difficult to swallow, and aspiration into the windpipe and regurgitation into the nose commonly occur

Zenker diverticulum

Patient presents as → a 68-year-old female who is being seen at the emergency department after having recurrent coughing spells and regurgitation following meals. Her breath is nearly unbearable upon arrival at the ED. She is also noted to have a palpable, fluctuant neck mass on physical examination.

pharyngeal pouch that develops in the proximal esophageal wall

  • Causes regurgitation of undigested food and liquid into the pharynx several hours after eating, foul odor of breath
  • Diagnose with barium esophagram (swallow) showing outpouching of barium-filled sac 
  • Treat with observation if small and asymptomatic, diverticulectomy, cricopharyngeal myotomy
ZenkerSeitlichZiel

Outpouching of barium-filled sac as seen in Zenker diverticulum


Scleroderma esophagus

Patient presents as → a 42-year-old female complaining of acid reflux and difficulty swallowing both solids and liquids. The patient also complains of sore swollen fingers, joint pains, and a dry cough. She reports that this started a year ago and has not improved. She has a past medical history of vitiligo and primary biliary cholangitis. Physical exam reveals tightened, shiny skin with induration over her face and arms, sclerodactyly, and dry rales in the lungs. There are also telangiectasias on her left cheek.
  • Scleroderma causes decreased esophageal sphincter tone and peristalsis
  • The patient will present with dysphagia to both solids and liquids
Peptic stricture

Peptic stricture showing narrowing of the esophagus near the junction with the stomach due to chronic gastroesophageal reflux in the setting of scleroderma.


Esophageal stenosis

An esophageal stricture is a narrowing of the lumen of the esophagus, preventing the passage of food. Typically, it is at the distal end of the tube and is the result of scarring after chronic exposure to gastric juice due to GERD.

  • Scarring and, consequently, stricture formation can also occur in response to other types of trauma, including swallowing of caustic solutions, chronic swallowing of pills without water, or residual scarring after surgery
  • The patient presents with dysphagia to solids
  • The usual treatment is dilation

Esophageal ulcer

Esophageal stenosis (with multiple ulcers) due to chronic reflux esophagitis

Esophageal strictures
Patient will present with → solid food dysphagia in a patient with a history of GERD

An esophageal stricture is an abnormal tightening or narrowing of the esophagus, making it more difficult for food to travel down the tube. People with esophageal strictures may have pain or difficulty swallowing

  • It can be caused by or associated with gastroesophageal reflux disease, esophagitis, a dysfunctional lower esophageal sphincter, disordered motility, or a hiatal hernia
  • Strictures can form after esophageal surgery and other treatments such as laser therapy or photodynamic therapy
  • Dysphagia to solids that is only gradually progressive is suggestive of an esophageal stricture
    • The majority of esophageal strictures result from benign peptic strictures from long-standing gastroesophageal reflux disease (GERD), which accounts for 70 to 80% of adult cases
Obstructive Disorders of the Esophagus

An esophageal web is a thin mucosal membrane that grows across the lumen in the mid-upper esophagus and may cause dysphagia. It may be congenital or acquired

  • Plummer–Vinson syndrome is a rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis, cheilosis, and esophageal webs

A lower esophageal ring (also called a Schatzki ring) is a 2- to 4-mm mucosal stricture that causes a ringlike narrowing of the distal esophagus at the squamocolumnar junction that often causes dysphagia.

  • Most patients have intermittent, gradually progressive dysphagia for solid food that occurs while consuming a heavy meal with meat that was “wolfed down,” hence the pseudonym the “steakhouse syndrome

Esophageal tumors (benign esophageal tumors or esophageal cancer) can also cause dysphagia

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

Web mit Jet-Phaenomen

Esophageal web on barium swallow: The arrowhead points to the incompletely opened upper esophageal sphincter. The arrow points to the jet phenomenon of the barium contrast when passing through the constricted area.

Esophageal varices (ReelDx)
ReelDx Virtual Rounds (Esophageal varices)
Patient will present as → a 64-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic, where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas but no palmar erythema or hepatosplenomegaly are observed on the exam.

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)

DX: Perform emergent upper GI endoscopy (once the patient is stabilized) in all patients with GI bleed ⇒ diagnostic and can be therapeutic

  • Serum labs: hemoglobin and hematocrit, platelet count

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

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)

Toxic megacolon (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: The Esophagus and the Stomach
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