esophageal disease
TRANSCRIPT
Esophageal disorder
Index
A. Esophageal perforationB. Boerhaave & mallory weiss syndromeC. Diffuse esophageal spasmD. Barett esophagusE. AchalasiaF. Zenker diverticulum G. Plummer vinson syndromeH. Hiatal herniaI. Esophagitis J. Esophageal cancerK. Scleroderma
Dysphagia is the essential feature of the majority of esophageal disorders.
Dysphagia means difficulty swallowing. Odynophagia is the proper term for pain while swallowing. Both dysphagia and odynophagia can lead to weight loss. Hence, weight loss cannot be used to answer the "What is the most likely diagnosis?" question.
When severe, some forms of esophageal disorders will also give anemia and heme-positive stool.
When any of these alarm symptoms are present, endoscopy should be performed to exclude cancer.
Alarm symptoms indicating endoscopy include:• Weight loss• Blood in stool• Anemia
Esophogeal Perforation
is due to the rapid increase in intraesophageal pressure combined with negative intrathoracic pressure caused by vomiting.
Perforation of the esophagus can present with:• Severe and acute onset of excruciating retrosternal chest pain• Odynophagia• Positive Hamman sign, a crunching heard upon palpation of the thorax due to subcutaneous emphysema• Pain that can radiate to the left shoulder
Boerhaave syndrome is a full thickness tear secondary to extreme retching and vomiting.
It is most commonly tested in the setting of an alcoholic. The most common location is at the left posterolateral aspect of the distal esophagus.
Mallory-Weiss syndrome is a mucosal tear and is also due to vomiting.
It is not a perforation. The most common location is at the gastroesophageal junction.
Treatment
Surgical exploration with debridement of the mediastinum and closure of the perforation is an absolute emergency.
Mediastinitis is a complication that carries a very high mortality rate
A 53-year-old obese man presents with sudden onset of abdominal pain that radiates to his right shoulder. The patient also says he has vomited blood earlier in the day. The patient has a full bottle of esomeprazole in his pocket and says he uses those for his heartburn. Physical examination reveals rebound tenderness in the midepigastrum. Upright chest x-ray shows air under the diaphragm.What is the most likely diagnosis?a. Gastric perforationb. Hemorrhagic ulcerc. Cholecystitisd. Ischemic colitis
Answer: A. This is gastric perforation in the setting of peptic ulcer disease. The patient's bottle filled with PPis is due to his history of ulcers. The fact that it is a full bottle implies the patient is noncompliant with his medication. Hemorrhagic ulcers will present with hematemesis, specifically coffee ground emesis. Cholecystitis would have right upper quadrant pain that is colicky in nature. Ischemic colitits would have an abdominal painthat is out of proportion to physical findings.
Pneumomediatinum
Submucosal dissection of the esophagus in patient with endoscopy for ERCP and "difficulty passing scope." Gastrografin swallow demonstrates intramural dissection of the esophagus from submucosal passage of endoscope with appearance similar to aortic dissection and "true and false lumen." Arrows point to "false lumen" created by passage of endoscope.
esophagram depict contrast extravasation from the distal esophagus in a patient with spontaneous perforation of the esophagus
A 20-year-old female presents to the hospital with severe chest pain. She states that the pain started suddenly and is retrosternal in nature. The pain began shortly after lunch and is worse with swallowing. She has no prior medical history except for a brief inpatient stay for what she describes as an "eating disorder." On exam her vitals are as follows: HR 120, RR 22, BP 145/90. She is flushed and taking deep breaths. Which of the following is the best confirmatory test for the most likely cause of this presentation?1. Chest x-ray 2. EKG 3. Gastrografin esophogram 4. Barium esophogram 5. Observation
Answer : 3 DISCUSSION: The patient in this vignette may be suffering from
an esophageal rupture (Boerhaave's syndrome) as a result of repeated induced vomiting. As time is essential in treating esophageal ruptures, the most appropriate step is a water-soluble (gastrografin) esophogram.
Symptoms of esophageal rupture include sudden-onset, severe, retrosternal chest pain, and difficult or painful swallowing. While hematemesis may be present, it is more common in Mallory-Weiss tears. Physical exam may show pleuritic chest pain, hyperventilation, and tachycardia. Evaluation includes a chest CT (may show left-sided hydropneumothorax, pneumomediastinum, or esophageal thickening) or contrast studies (may show leakage from esophageal tear). Of note, water soluble contrasts should be used before barium studies.
incorrect Answers: Answer 1: Chest x-ray is not the best test for
esophageal ruptures. Answer 2: An EKG is not an unreasonable test here
but not the best choice when esophageal rupture must be ruled-out.
Answer 4: Barium esophogram is not the first line choice of contrast agents used in suspected esophageal ruptures to avoid barium associated inflammation of the mediastinum.
Answer 5: Observation would not be appropriate and may have potentially devastating consequences.
Gastrografin esophogram
Boerhaave's Syndrome A 19-year-old female college
freshman presents to the hospital with severe retrosternal chest pain that is aggravated by swallowing. She appears flushed and is taking long ,deep breaths. Her friends report that she got sick after a fraternity party and has not been feeling well ever since
Boerhaave's Syndrome
Spontaneous, full-thickness rupture of the distal thoracic esophagus
Associated with vomiting often following consumption of
large quantities of alcohol in young people
Can occur during endoscopic examinations (75% of adult cases)
Serious complication of bulimia
Boerhaave's Syndrome
Symptoms sudden-onset, severe, retrosternal chest pain difficulty or painful swallowing hematemesis though more common in Mallory-Weiss
tears
Physical exam pleuritic chest pain hyperventilation tachycardia
Chest CT left-sided hydropneumothorax pneumomediastinum esophageal thickening
Contrast studies may show leakage from
esophageal tear use water-soluble contrast agent
(Gastrografin)
Boerhaave's SyndromeMedical management conservative therapy indicated in mild cases with stable patient and
includes intraveous resuscitation nasogastric suction NPO prophylactic antibiotics- usually broad-coverage
to prevent mediastinal infection- imipenim or cilastin
Surgical intervention surgical repair of perforation considered standard of care indicated depending on severity of tear and timing
of diagnosis
Mallory-Weiss is anonpenetratlng tear ofonly the mucosa.
Diagnostic Test
The most accurate test is an esophogram using diatrizoate meglumine and diatrizoate sodium solution (Gastrografin; Bracco Diagnostics, Princeton, New Jersey); it will show leakage of contrast outside of the esophagus.
Barium cannot be used because it is caustic to the tissues.
Mallory-Weiss Tear
Mallory-Weiss tear presents with upper gastrointestinal bleeding after prolonged or severe vomiting or retching.
Repeated retching is followed by hematemesis of bright red blood, or by black stool.
Mallory Weiss does not present with dysphagia. There is no specific therapy, and it will resolve spontaneously.
Severe cases with persistent bleeding are managed with an injection of epinephrine to stop bleeding or the use of electrocautery. Boerhaave syndrome is full penetration of the esophagus.
Diffuse Esophageal Spasm A 47-year-old man presents to the
emergency room saying that he is having a heart attack. He reports that the pain started after he ate some of his favorite soup. It is noted that he also had some difficulty swallowing when the symptoms began
Diffuse Esophageal Spasm
Strong, non-peristaltic contractions of the esophageal body
Often precipitated by by ingestion of hot and cold liquids
Patients have normal sphincter function
Associated with GERD
• Symptoms • symptoms may occur following ingestion of
cold liquids and include • difficulty swallowing• painful swallowing• sudden onset chest pain not related to exertion
• spontaneous and radiated to back, ears, and neck
• Physical exam • symptomatic relief with nitroglycerin
Evaluation•Upper GI/esophageal contrast study
• shows "corkscrew esophagus" •Manometry
• may show high-amplitude, simultaneous contractions (non-peristaltic)
•Endoscopy - normal•EKG - normal•Stress test - normal
Treatment Medical management
symptomatic relief antacids for GERD nitrates for chest pain/spasms calcium channel blockers
Surgical intervention
long esophagomyotomy indicated for severe, incapacitating
symptoms
A 28-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. The medical team next looks to non-cardiac causes for the patient's chest pain. Given the most likely diagnosis, which of the following could be seen on upper GI contrast study?
A
B
C
D
E
E Sudden chest pain following ingestion of cold water and relieved
with nitroglycerin is classic of diffuse esophageal spasm. If performed during an episode, upper GI contrast study will show the "corkscrew" esophagus shown in Figure E.
Diffuse esophageal spasm is the painful uncoordinated, non-peristatlic contraction of the esophagus with normal lower esophageal sphincter tone. It is often precipitated by the ingestion of hot or cold liquids as seen in this vignette and is associated with a history of gastric-esophageal reflux disease (GERD). Associated symptoms include dysphagia, odynophagia, and chest pain radiating to the back, neck, and jaw which is unrelated to exertion, but revealed with nitroglycerin. Upper GI study will show corkscrew esophagus; manometry will show high-amplitude, simultaneous contractions; endoscopy will be normal. Medical treatment includes symptomatic relief with nitrates or calcium-channel blockers, and long esophagomyotomy may be indicated in refractory cases.
Figure A shows a hiatal hernia. Rugae of the stomach can be seen in the herniated contents.
Figure B shows a stricture of the esophagus in a patient with Barrett's esophagus.
Figure C shows the classic bird beak and proximal dilatation of a patient with achalasia.
Figure D shows a filling defect in a patient with esophageal carcinoma.
FIgure E shows the classic corkscrew esophagus in a patient experiencing an acute episode of diffuse esophageal spasm.
Incorrect Answers:
Answer 1: Hiatal hernias can present with GERD and/or chest pain, or they can be asymptomatic. They are not associated with sudden pain relieved by nitroglycerin.
Answer 2: Esophageal stricture would have more chronic symptoms of GERD, dysphasia, and weight loss.
Answer 3: Achalasia would more likely present with chronic dysphagia for liquids greater than solids and weight loss.
Answer 4: Esophageal carcinoma usually presents with dysphagia and lymphadenopathy.
Barrett's Esophagus
Metaplasia of the squamous cell architecture of the esophagus to glandular architecture
A complication of chronic GERD
Evaluation
Biopsy glandular metaplasia of distal
esophagus presence of stomach acid
resutls in conversion of normal squamous cells into columnar and goblet cells (normally found in stomach and small intestine)
Prognosis, Prevention, and Complications Ulceration leading to formation of
stricture Increased risk of esophageal
adenocarcinoma
Achalasia
A 45-year-old man presents to his primary care physician complaining of difficulty swallowing solids and liquids. He also reports unintentional weight loss.
Achalasia -intro Motor disorder of the distal esophagus
caused by degeneration of Aurbach's plexus the most common motility disorder
Pathophysiology autoimmune process causes loss of NO-
producing neurons which normally relax the sphincter muscles ▪ association with HLA-DQw1
leads to failure of the LES to relax during swallowing
results in loss of peristalsis
Achalasia -intro
Associated with Chagas' disease
▪ amastigotes destroy ganglion cells scleroderma
▪ presents in 70% of these patients
Epidemiology more common in people under 50 years
of age
Presentation
Symptoms dysphagia for solids and liquids
▪ usually worse for liquids weight loss
Evaluation Barium swallow may
show narrowing of the distal
esophagus loss of peristalsis in the
distal two thirds dilated proximal
esophagus classic "bird's beak"
tapering at the esophageal sphincter
Manometry
most accurate test that may show increased LES pressure inability of LES to relax decreased peristalsis in the
esophageal body diffuse esophageal spasm
Upper endoscopy
useful in excluding secondary causes of achalasia (i.e. malignancy)
use to rule out malignancy shows normal mucosa
Medical management
medications to reduce LES tone ▪ nifedipine▪ nitrates▪ CCBs▪ botulinum toxin injections
▪ wears off in approximately 3-6 months▪ requires reinjection
Surgical intervention
endoscopic balloon dilation of LES ▪ cures 80%▪ leads to perforation in < 3% of patients
myotomy with fundoplication ▪ more effective and dangerous than pneumatic dilation
Prognosis, Prevention, and Complications Prognosis
medical and surgical outcomes are similar often require multiple treatments
Prevention no preventive measures are available at this
time Complications
esophageal malignancy secondary to Barrett's esophagus secondary to chronic GERD
A 29-year-old female presents to general medical clinic with dysphagia. Her symptoms began several months ago. She has trouble swallowing solids and liquids though liquids seem to make her choke and sputter the most; therefore, she has been unable to eat and has thus experienced significant weight loss. She has no significant past medical history apart from a 20-pack-year smoking history. She denies any recent travel. Vital signs are stable. Physical examination is within normal limits. A barium esophagram shows the following (Figure A). Subsequent esophageal manometry reveals elevated resting lower esophageal sphincter pressure, incomplete lower esophageal sphincter relaxation after swallowing, and almost total absence of peristalsis in the esophageal body. What is the next best step in management?
1. Begin a calcium channel blocker
2. Begin botulinum toxin injections
3. Endoscopic balloon dilation of the lower esophageal sphincter
4. Upper endoscopy 5. Myotomy with
fundoplication
fIGURES: A
4
DISCUSSION: In diagnosing achalasia, one must first rule out malignancy with an endoscopic evaluation. After a barium swallow and esophageal manometry suggest achalasia, one must perform endoscopy prior to beginning medical or surgical management.
Recall that achalasia is a motor disorder of the distal esophagus resulting from degeneration of Aurbach's plexus. It is the most common motility disorder and is often found in patients under 50. The lower esophageal sphincter fails to relax during swallowing. As a consequence, natural peristalsis is disrupted and the patient experiences dysphagia to solids and liquids, with liquids often being most problematic. A barium esophagram is helpful in making the diagnosis and should reveal the classic bird's beak tapering at the esophageal sphincter. This is the first step in management. Subsequently, diagnosis may be confirmed with esophageal manometry. Once endoscopy is completed, palliative treatment may begin. Treatment includes medical management consisting of calcium channel blockers, botulinum toxin injections, and surgical therapy may include endoscopic balloon dilation of the lower esophageal sphincter or a more invasive option, myotomy with fundoplication.
Incorrect Answers: Answers 1, 2, 3, and 5: All of these
are potential treatments for achalasia. However, treatment should not begin until malignancy is ruled out with an upper endoscopy.
A 37-year-old man presents to general medical clinic with dysphagia. He notes that his symptoms began several weeks ago and have worsened over time. He now has trouble swallowing solids and liquids, though liquids have always given him the most trouble. He denies any other symptoms. He has no significant past medical history. Travel history reveals a recent trip to South America but no other travel outside the United States. Vital signs are stable. Physical examination is within normal limits. He has no palpable masses. What is the next step in management? 1. Upper endoscopy2. Barium esophagram3. Esophageal manometry4. CT of the chest5. Administer nifurtimox
2 DISCUSSION: This patient presents with signs and symptoms concerning
for achalasia, possibly due to Chagas disease. A barium esophagram is the next step in management and should precede endoscopy in patients with dysphagia and a broad differential diagnosis.
Recall that achalasia is a motor disorder of the distal esophagus resulting from degeneration of Auerbach's plexus where lower esophageal sphincter fails to relax during swallowing. As a consequence, natural peristalsis is disrupted and the patient experiences dysphagia to solids and liquids, with liquids often being most problematic. It is the most common motility disorder and is often found in patients under 50. The condition has been associated with Chagas disease, where the parasitic amastigotes destroy ganglion cells.
A barium esophogram is helpful in making the diagnosis and should reveal the classic bird's beak tapering at the esophageal sphincter (see Illustration A). Diagnosis is eventually confirmed with esophageal manometry.
Incorrect Answer: Answer 1: Upper endoscopy would be more costly than
barium esophagram and is not the preferred next step in management in dysphagia.
Answer 3: Esophageal manometry may be used to confirm a diagnosis of achalasia but should not be the next step in management.
Answer 4: CT of the chest is not needed in the diagnosis of achalasia but could be warranted if malignancy were the cause of this patient's dysphagia.
Answer 5: Nifurtimox is successful in treating Chagas disease which is caused by Trypanosoma cruzi and transmitted by the Reduviid bug. However, diagnosis should be made by blood smear before treating this patient.
A 66-year-old woman presents to your outpatient clinic for her regular checkup. During the visit, she tells you that she feels "in great health," with the exception of some recent trouble swallowing. Further questioning reveals that she has difficulty swallowing solids and liquids. These symptoms have been worsening slowly for the past 5 months. Vital signs are within normal limits, but her weight has decreased by 12 pounds since her last visit 6 months ago. Barium swallow reveals smooth tapering of the distal esophagus (Figure A). Which of these choices is the most appropriate next step in management? FIGURES: A
1. Nifedipine2. High-calorie nutritional supplementation3. Botulinum toxin injection4. Surgical myotomy5. Upper GI endoscopy
5 DISCUSSION: This patient presents with the classic signs and
symptoms of achalasia. Upper GI endoscopy to rule out malignancy is indicated prior to treatment in cases of suspected achalasia.
Achalasia is a disorder of esophageal motility in which esophageal peristalsis is absent and lower esophageal sphincter relaxation after swallowing is impaired. Patients report difficulty swallowing both solids and liquids, and barium swallow shows the classic "bird's beak" appearance. Besides dysphagia, patients frequently report heartburn, chest pain, weight loss, and regurgitation. Esophageal manometry and pH monitoring are also used in the diagnosis of this condition.
Incorrect Answers: Answer 1: Calcium channel blocker administration may help
decrease lower esophageal sphincter pressure and ease the symptoms of achalasia; however, malignancy must be ruled out first through endoscopy.
Answer 2: High-calorie nutritional supplementation is inappropriate in this case, as her weight loss is most likely caused by a GI condition such as achalasia or malignancy.
Answer 3: Botulinum toxin administration may help decrease lower esophageal sphincter pressure and ease the symptoms of achalasia; however, malignancy must be ruled out first through endoscopy.
Answer 4: Surgical myotomy is indicated for treatment of achalasia in many patients; however, malignancy must first be ruled out through endoscopy
Zenker's Diverticulum
A 73-year-old female is being seen at the emergency department after having recurrent coughing spells and regurgitation following meals. Her breath is nearly unbearable upon arrival to 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
Pulsion diverticula involving only the mucosa located between thyropharyngeal and
cricopharyngeus muscle Etiology remains unknown, however, some have
suggested the causes to be related to structural or physiological abnormalities of the cricopharyngeus
Epidemiology incidence unknown most often occurs in age group (>70 years old)
Presentation Symptoms
dysphagia regurgitation choking chronic cough bad breath (halitosis)
Physical exam
palpable, fluctuant neck mass may be appreciable
Diagnosis
Diagnosis is based highly on clinical observations and patient history
Avoid upper endoscopy if known or highly suspicious due to risk of rupture
Barium swallow - confirms diagnosis by visualizing pharyngeal outpouch
Surgical intervention
myotomy of cricopharyngeus muscle
-with diverticula resection- endoscopic has better success rates compared to external approach
Complications surgery can lead to significant complications including death given location of lesion and age/health of average patient population with this pathology
-may develop carcinoma within the pouch if not resected
A 78-year-old male presents to clinic with a chief complain of regurgitation after eating meals. The patients vitals are stable and he is currently in no distress. On exam you note that his breath is particularly foul. Which of the following is the most accurate diagnostic test for this patient's condition? 1. Clinical observations and history are sufficient for diagnosis2. Upper endoscopy3. Chest radiograph4. Barium swallow5. Manometry
4 DISCUSSION: This patient is experiencing a Zenker's
diverticulum (ZD). Clinical observations, history, and a barium swallow study are the keys needed to make this diagnosis.
Zenker's diverticulum is a condition characterized by a false diverticula of the esophagus. The pathophysiology of this condition includes a pulsion diverticula involving only the mucosa of the esophagus. It is often located at the junction of the pharynx and esophagus where there is an area of weakness involving the cricopharyngeus muscle. Symptoms include dysphagia, regurgitation, and choking. Physical examination can sometimes show a neck mass, but will often include halitosis secondary to trapped food particles.
Incorrect Answers:
Answer 1: Although necessary, clinical observations and history alone are not the appropriate way to diagnose a Zenker's diverticulum. Barium swallow studies are also necessary for confirmation of clinical suspicion.
Answer 2: Upper endoscopy is not used in the diagnosis of Zenker's diverticula.
Answer 3: Although a chest radiograph would be used in the overall workup, in order to diagnosis Zenker's diverticula, a barium swallow study must be performed.
Answer 5: Manometry would be the appropriate choice for a younger patient experiencing dysphagia that also perhaps some regurgitation but less fetid breath in the case of achalasia. The demographics of this case better fit ZD
llustration A is a lateral view of a barium study showing a Zenker's diverticulum.
Illustration B is an artists rendition of a diverticulectomy.
Illustration C is an artists rendition of a diverticulopexy.
Plummer-Vinson Syndrome A 63-year-old woman with chronic
anemia presents to her primary care physician complaining of difficulty swallowing. An upper endoscopy is ordered.
Intro Small, thin web-like tissue growth partially
obstruct the upper esophagus Characterized by atrophic glossitis, esophageal
webs, and anemia Etiology unknown Epidemiology
most commonly observed in elderly woman associated with chronic iron-deficiency anemia
Patients at increased risk of developing squamous cell carcinoma of the esophagus
Presentation Symptoms difficulty swallowing chronic cough weakness/malaise nail changes
Physical exam atrophic glossitis esophageal webs anemia spoon nail deformitie
Evaluation Diagnosis can be aided by clinical
observations, including skin and nail changes
Upper endoscopy- may identify esophageal webs
CBC- may indicated chronic anemia
Fe studies- show Fe deficiency
Medical management
Fe supplementation indicated to treat chronic anemia
state
esophageal dilation can be performed concurrently
with upper GI endoscopy or manometry most commonly done with radial
expansion balloon method
Prognosis,prevention and complication Prognosis
most patients respond to treatment
Prevention
Fe supplementation in patients with known anemia may prevent web development
Complications
bleeding may occur secondary to esophageal tear during dilation
esophageal carcinoma
Hiatal herniaA 45-year-old man presents to the emergency room with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining.
Herniation of the stomach through the diaphragm into the chest cavity
Type I
sliding hiatal hernia most common type (>95%) occurs at the GE junction stomach slides into the mediastinum
Type II
paraesophageal hiatal hernia (<5%) herniation of stomach fundus through diaphragm GE junction remains below diaphragm parallel to the esophagus
Associated with GERD in 80% of sliding hiatal hernia cases
Presentation Symptoms
may be asymptomatic, usually identified incidentally on radiography
chest pain heart burn GERD
Physical exam
usually no significant findings
Evaluation
Barium swallow- may observe stomach in chest cavity
Usually an incidental finding
Management
Medical management symptom management and lifestyle
modifications indicated in type I (sliding hiatal hernias)
to relieve GERD symptoms antacids weight loss dieting Surgical intervention -surgical repair indicated in type II (paraesophageal
cases) due to risk of strangulation
Prognosis
treatment relieves most symptoms
Prevention
lifestyle modifications can prevent symptoms
Complications
aspirate pneumonia gastric strangulation iron-deficiency/malnutrition
Schatzki ring is associated with intermittent dysphagia and is treated withpneumatic dilation in an endoscopic procedure
Schatzki ring is often from acid reflux and is associated with hiatal hernia. This is a type of scarring or tightening (also called peptic stricture) of the distal esophagus.
"Steakhouse syndrome" =dysphagia from solid foodassociated with Schatzkiring
Esophagitis
Corrosive Esophagitis
Caused by ingestion of strongly acidic or basic chemical Lye, HClResults in esophageal perforation esophageal stricture formation Often seen in suicide attempts or in the pediatric population
Infectious Esophagitis•Commonly seen in AIDS patients and the Immunocompromised•May be viral or fungal
• HSV (punched out lesions on EGD)
• CMV (large solitary ulcers or erosions on EGD)
• Candida (white mucosal plaque-like lesions on EGD)
•Odynophagia is main symptom
A 43-year-old man recently diagnosed with AIDS comes to the emergency departmentwith pain on swallowing that has become progressively worse over the lastseveral weeks. There is no pain when not swallowing. His CD4 count is 43 mm3•The patient is not currently taking any medications.What is the most appropriate next step in management?a. Esophagramb. Upper endoscopyc. Oral nystatin swish and swallowd. Intravenous amphotericine. Oral fluconazole
Answer: E. The most commonly asked infectious esophagitis question is esophageal candidiasis in a person with AIDS. Oral candidiasis (thrush) need not be present in order to have esophageal candidiasis. One does not automatically follow from the other.Although other infections such as CMV and herpes can also cause esophageal infection,over 90% of esophageal infections in patients with AIDS are caused by Candida.Empiric therapy with fluconazole is the best course of action. If fluconazole does not improve symptoms, then endoscopy is performed. Intravenous amphotericin is used for confirmed candidiasis not responding to fluconazole. Oral nystatin swish and swallow is not sufficient to control esophageal candidiasis. Nystatin treats oral candidiasis.
These pills cause esophagitis if in prolonged contact:• Doxycycline• Alendronate• KCI
Esophageal Cancer
"What Is the Most Likely Diagnosis?"Look for:• Age 50 or older• Dysphagia first for solids, followed later (progressing) to dysphagia for liquids• Association with prolonged alcohol and tobacco use• More than 5-10 years of GERD symptoms
Diagnostic Tests
1. Endoscopy is indispensible, since only a biopsy can diagnose cancer.
2. Barium might be the "best initial test," but no radiologic test can diagnose cancer.
3. CT and MRI scans are not enough to diagnose esophageal cancer; they are used to determine the extent of spread into the surrounding tissues.
4. PET scan is used to determine the contents of anatomic lesions if you are not certain whether they contain cancer. PET scan is often used to determine whether a cancer is resectable. Local disease is resectable, and widelymetastatic disease is not.
Treatment
1. No resection (removal) = no cure. Surgical resection is always the thing to try.
2. Chemotherapy and radiation are used in addition to surgical removal.
3. Stent placement is used for lesions that cannot be resected surgically just tokeep the esophagus open for palliation and to improve dysphagia
Scleroderma These patients present with symptoms of
reflux and have a clear history of scleroderma, or progressive systemic sclerosis.
Manometry shows decreased lower esophageal sphincter pressure from an inability to close the LES.
The management is with PPis as it would be for any person with reflux symptoms.
The disorder is simply one of mechanical immobility of the esophagus .
Esophageal smooth muscle atrophydecrease LES pressure and ��dysmotility � acid reflux and dysphagia stricture,Barrett esophagus, and aspiration. Part of CREST syndrome.
TIPManometry is the answer for:o Achalasiao Spasmo Scleroderma