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GERD
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Path
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· Decreased tone or excessive transient relaxations of LES
· Anatomic disruption to gastroesophageal junction (hiatal hernia)
· ⤴️ risk with obesity, pregnancy, smoking, alcohol intake
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S/S
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· Regurgitation of acidic material in mouth
· Heartburn
· Odynophagia (often indicates reflux esophagitis)
· Extraesophageal manifestations – cough, hoarseness, wheezing
· Esophageal – erosive esophagitis, Barrett esophagus, strictures
· Extraesophageal – asthma, laryngitis
Alarming Sx 🚨:
· >10 ys of sx
· Dysphagia
· Bleeding (heme ⊕ stool / hemoptysis / anemia)
· Unintentional weight loss
· >50
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Dx
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· when pt presents w/ sx → offer PPI for 6 weeks
· If no improvement –> endoscopy + Bx
· IF RED FLAGS (N&V / Anemia / weight loss / bleeding / >10 ys sx) –> endoscopy + bx
· GOLD STANDARD: 24h PH monitoring
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Tx
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· Mild (<2 Sx/Week): Antacids
· Moderate (>2 Sx/week): PPI
· ❌ Response: surgery
When u do endoscopy and its ⊕:
· If GERD: PPI
· If METAPLASIA/BARRET: PPI ⤴️ dose
· If DYSPLASIA: Local Ablation Tx
· If Adenocarcinoma: Stage (CT) → Resect → Chemo / radio
· When to do nissen fundoplication? when PPI fails, or pt wants surgery.
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Endoscopy – Esophagitis – Findings
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Candida
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⊕ Oral thrush – White plaques
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CMV
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Linear ulcers
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HSV
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Ovoid ulcers – Vesicles
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Pill-induced
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Round ulcers – ⓝ Surrounding
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Medication-induced Esophagitis
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Drugs
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Abx (Tetracycline)
NSAIDs
Bisphosphonates
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Sx
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Odynophagia – Sudden onset
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EGD
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Ulcer w/ NO surrounding erythema
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Tx
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Stop the drug
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Zenker’s Diverticulum
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Features
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· Elderly
· Pouch
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S/S
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· Halitosis
· Dysphagia
· Regurgitation
· ⤴️ Risk for Aspiration pneumonia
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Dx
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· Barium (SE: risk of pneumonitis)
· Use of other methods is contraindicated ~ upper GI endoscopy, b/c it can cause perforation.
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Tx
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Surgical repair
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Eosinophilic esophagitis
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Path
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Chronic, immune-mediated esophageal inflammation
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Clx
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· Dysphagia
· Chest/epigastric pain
· Reflux/vomiting
· Food impaction (steak / chicken)
· Associated atopy
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Dx
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Endoscopy & esophageal bx (≥15 eosinophils)
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Tx
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· Dietary modification
· ± Topical GCS
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Achalasia
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S/S
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· Chronic dysphagia to solids & liquids,
· regurgitation
· Heartbum, weight loss
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Dx
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· Manometry: ⤴️ LES resting pressure, incomplete LES relaxation, peristalsis of distal esophagus
· Barium esophagram: Smooth “bird-beak” narrowing at gastroesophageal junction
 |
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Tx
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Upper endoscopy to exclude malignancy
Laparoscopic myotomy or pneumatic balloon dilation
Botulinum toxin injection, nitrates & CCB
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Diffuse esophageal spasm
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Path
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Uncoordinated, simultaneous contractions of esophageal body
|
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S/S
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· Intermittent chest pain
· Dysphagia for solids & liquids
|
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Dx
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· Manometry: Intermittent peristalsis,
· Multiple Simultaneous Contractions
· Esophagram: “Corkscrew” pattern
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Tx
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· CCB
· Alternates. Nitrates or TCA
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Eosinophilic Esophagitis
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RF
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· ⊕ Allergy (asthma)
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S/S
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· Dysphagia, heartburn,
· Food impaction
|
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Dx
|
· Endoscopy shows RINGs
· Bx: Eosinphils
|
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Tx
|
· 1˚ PPI + eliminate allergic food
· Failed? swallowing steroids inhalers
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Esophageal Cancer
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Types
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Adenocarcinoma
· Distal esophagus,
· Barrett esophagus
Squamous cell carcinoma
· Anywhere in the esophagus
|
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RF
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· Acid reflux, obesity (adenocarcinoma)
· Smoking, alcohol, caustic injury (squamous cell)
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Sx
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· Chest pain
· Weight loss
· Dysphagla (solids)
|
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Dx
|
· Endoscopy w/ bx
· CT (PET/CT) for staging
|
ER:
|
Esophageal Perforation
|
|
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Causes
|
· Instrumentation (eg, endoscopy), trauma
· Effort/vomiting rupture (Boerhaave syndrome)
· Esophagitis (infectious/pills/caustic)
|
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Clx
|
· Chest/back &/or epigastric pain,
· Systemic signs (eg, fever)
· Crepitus, Hamman sign (crunching sound on auscultation)
· Pleural effusion with atypical (eg, green) fluid
|
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Dx
|
CXR: widened mediastinum, pneumomediastinum, P TX, pleural effusion
CT scan: esophageal wall thickening, mediastinal fluid collection
Esophagography with water-soluble contrast: leak from perforation
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Tx
|
· NPO, IV antibiotics & PPI
· Emergency surgical consultation
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Mallory-Weiss
|
Boerhaave
|
|
|
?
|
· Forceful retching
· Mucosal tear
· Submucosal venous or arterial plexus bleeding
|
· Forceful retching
· Transmural tear
· Spillage of esophageal air/fluid into surrounding tissues
|
|
Clx
|
· Epigastric/back pain
· Hematemesis (bright red or coffee-ground)
· hypovolemia
|
· Chest/back/epigastric pain
· Crepitus, crunching sound (Hamman sign)
· Odynophagia, dyspnea, fever, sepsis
|
|
Dx
|
Upper GI endoscopy confirms diagnosis
|
· 1˚ CXR: PTX, pneumomediastinum, pleural effusion
· Esophagography or CT scan with water-soluble contrast confirms dx
|
|
Tx
|
· Acid suppression
· Most heal alone
|
· Acid suppression, Abx, NPO
· Emergency surgery 🚨
|
|
Mallory-Weiss
|
|
|
?
|
· Sudden increase in abdominal pressure (forceful retching)
· Mucosal tear in esophagus or stomach (submucosal arterial or venous plexus bleeding)
|
|
RF
|
Hiatal hernia, alcoholism
|
|
S/S
|
Vomiting, retching
Hematemesis
Epigastric pain
|
|
Dx
|
Endoscopy: Longitudinal laceration
|
|
Tx
|
· Most heal spontaneously
· Endoscopic therapy for persistent bleeding
|
Fast HY Review 