PANCE Blueprint GI and Nutrition (10%)

Esophageal strictures

Patient will present with → 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

Strictures are often due to scarring from the healing process of ulcerative esophagitis

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. The cause is not clear, but such rings are usually found in older individuals and have been observed in 6% to 15% of patients undergoing a barium swallow study; however, only 0.5% of those being examined have significant symptoms. Symptoms correlate with the size of the lumen of the ring: a lumen of more than 20 mm in diameter provides few if any symptoms; if it is less than 13 mm in diameter, chronic and more severe symptoms occur.

  • Most patients have an intermittent, nonprogressive dysphagia for solid food that occurs while consuming a heavy meal with meat that was “wolfed down,” hence the pseudonym the “steakhouse syndrome.”
  • Sometimes the meal is regurgitated, relieving the block, and eating can be resumed. Patients with a Schatzki ring are also at risk for GERD.
  • A diagnosis is confirmed by radiographic barium swallow or endoscopic means, and if symptoms are sufficiently troublesome, the treatment of choice is rupture of the ring by dilation.

Barium swallow (meal, esophagram) is the diagnostic test of choice for esophageal webs

Endoscopy and dilatation rarely will you need surgery

Esophageal Web thin membranes, partial across lumen occur in pharynx and esophagus often multiple most often from ant. wall of hypopharynx

Esophageal Web thin membranes, partial across lumen occur in pharynx and esophagus often multiple most often from ant. wall of hypopharynx

Question 1
Which of the following is the most common cause of esophageal stricture?
A
Corrosive ingestion
Hint:
Corrosive strictures account for less than 5% of all cases of esophageal stricture.
B
Gastroesophageal reflux disease (GERD)
C
Postoperative scarring
Hint:
Postoperative scarring account for about 10% of all cases of esophageal stricture
D
Esophageal cancer
Hint:
Esophageal cancer is not the most common cause of esophageal stricture.
Question 1 Explanation: 
GERD accounts for approximately 70-80% of all cases of esophageal stricture.
Question 2
Which of the following is not a cause of distal esophageal stricture?
A
GERD
B
Adenocarcinoma
C
Scleroderma
D
Infectious esophagitis
Question 2 Explanation: 
Infectious esophagitis causes stricture mostly at the proximal and mid esophagus
Question 3
A 60-year old man has had GERD for years. For about 13 months now he has noticed an increasing difficulty in swallowing his food. Which of the following is the most likely diagnosis?
A
Achalasia
Hint:
Achalasia is a possible cause, but the history of GERD makes strictures the most likely diagnosis.
B
Diffuse esophageal spasm (DES)
Hint:
DES is also a possible cause, but the history of GERD makes strictures the most possible cause.
C
Pyloric stenosis
Hint:
Pyloric stenosis occurs in neonates/infants.
D
Esophageal stricture
Question 3 Explanation: 
Esophageal strictures cause dysphagia. They are secondary to chronic GERD.
Question 4
Which of the following is not a treatment modality for esophageal stricture?
A
Proton Pump Inhibitor
Hint:
is used in the initial treatment of esophageal stricture
B
Endoscopic dilatation
Hint:
is a definitive treatment
C
Endoscopic intralesional steroid
Hint:
commonly used for refractory strictures.
D
Endoscopic sclerotherapy
Question 4 Explanation: 
Endoscopic sclerotherapy is used in the treatment of bleeding esophageal varices.
Question 5
A Schatzki ring will cause dysphagia to:
A
solids
B
liquids
C
both solids and liquids
Question 5 Explanation: 
A Schatzki ring is a stricture of the mucosa causing a lower esophageal constriction at the squamocolumnar junction. MC associated with a hiatal hernia.
Question 6
A 45 year old Caucasian female presents with dysphagia to solid foods with a CBC indicative of iron deficiency anemia. What finding on endoscopy would lead you to a diagnosis of Plummer-Vinson Syndrome?
A
Esophageal webs
B
Mallory-Weiss tear
C
Barrett's Esophagus
D
Varices
E
A solid tumor
Question 6 Explanation: 
Plummer–Vinson syndrome (PVS), also called Paterson–Brown–Kelly syndrome or sideropenic dysphagia, is a rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome.Plummer-Vinson Syndrome has 3 main findings: 1. dysphagia 2. esophageal webs 3. iron deficiency anemia
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Esophageal Neoplasms (Prev Lesson)
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