GERD
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Definition Recurrent reflex of gastric contents into the distal esophagus d/t mechanical or functional abnormality of the lower esophageal sphincter (LES)
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Normal protectant factors of the esophagus Gravity, LES tone, esophageal motility, salivary flow, gastric emptying, tissue resistance
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What can chronic reflux cause? Barrett's esophagitis (replacement of normal squamous epithelium with metaplastic columnar epithelium)
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Barrett's esophagitis can predispose Malignancy
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Clinical Features Heartburn (worse after meals + lying down), hoarseness, halitosis, cough, hiccuping, atypical chest pain
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Sx of more severe GERD Occurs spontaneously when supine, sign of severe impairment of lower esophageal sphincter tone
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Sx of less severe disease Pattern of heartburn following meals, but no PM sx
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Lab Studies Clinical usually, can do endoscopy, EKG r/o MI if needed,
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When is endoscopy indicated? >45 yo w/ new onset of sx, long-standing or frequent sx and failure to respond to therapy, anemia, dysphagia, or recurrent vomiting
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Treatment Lifestyle modifications, antacids, H2-blockers 1st line, PPI most powerful, surgery/endoscopy available last resort
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Mallory-Weiss Tear
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Definition Linear mucosal tear in the esophagus, generally at the gastroesophageal junction, that occurs with forceful vomiting, causing hematemesis
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Most commonly associated with Alcohol use but should be considered in all cases of upper GI bleeding
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Diagnosis Endoscopy
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Treatment Most cases resolve on their own, but may need endoscopic injx of epinephrine or thermal coagulation
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Infectious Esophagitis
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Seen in what patient population? Rare except in immunocompromised
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Etiology Fungal: Candida, Viral: CMV and HSV, other (HIC, M. tuberculosis, EBV)
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Clinical Features Odynophagia (painful swallowing), or dysphagia (difficulty swallowing) in an immunocompromised patient
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Lab Findings Endoscopy shows large deep ulcers (CMV, HIV), or multiple shallow ulcers (HSV), or white plaques (Candida)
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What is needed for definitive dx? Cytology or culture from endoscopic brushings
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Treatment Candida-->fluconazole, HSV-->acyclovir, CMV-->ganciclovir
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Esophageal Varices
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Definition Dilations of the veins of the esophagus, usually at the distal end
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Etiology Underlying portal HTN, most commonly from cirrhosis (EtOH abuse or chronic viral hepatitis); NSAIDs can exacerbate bleeding
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Budd-Chiari Syndrome May cause thrombosis of the portal vein, leading to esophageal varicose
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Diagnosis Patient with signs of cirrhosis + hematemesis (varicose can be asymptomatic until they bleed at which time they can be life-threatening)
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Treatment Hemodynamic support w/ high-volume fluid replacement, vasopressors, immediate control of bleeding! (Bleeding = high mortality). Preferred therapies: endoscopic therapy + pharm. vasoconstriction (i.e. octreotide)
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Esophageal Neoplasms
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Most common types SCC and adenocarcinomas
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Barrett's esophagitis associated with Adenocarcinoma in the distal 1/3 of the esophagus
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Squamous cell lesions associated with Proximal 2/3 of the esophagus
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Why is local spread to the mediastinum common Esophagus has no serosa
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Risk factors esophageal cancer Smoking, EtOH, exposures (HPV, poor dental hygiene)
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Clinical Features Progressive dysphagia for solid foods assoc. w/ weight loss (also heartburn, hoarseness, vomiting)
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Best initial lab test to visualize Biphasic barium esophagram
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Best lab test to diagnose Endoscopy with brushings
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Treatment Surgical
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Esophageal Dysmotility
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Definition Inclues neurogenic dysphagia, Zenker's diverticulum, esophageal stenosis, achalasia, diffuse esophageal spasm, scleroderma
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Etiology Neurologic factors, intrinsic or external blockage, malfunction of esophageal peristalsis
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Clinical features Dysmotility most common
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Lab Findings Barium swallow, can show achalasia (parrot-beak)
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Treatment Benign strictures-->dilation, Malignant strictures-->resection
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