Gastroenterology [ESOPHAGUS]

Solid then Liquid Solid and Liquid

Introduction Dysphagia
Progressive Ø Progressive
The purpose of the esophagus is to carry food from the mouth to
the stomach - AKA swallowing. So it’s no surprise that disorders Mechanical Motility
of the esophagus present as dysphagia (difficulty swallowing) or (Obstructive) (Functional)
odynophagia (pain on swallowing). An important initial step is to
separate the motility/functional dysphagia from the
mechanical/obstructive dysphagia. The former is dysphagia to
everything at once, the latter is dysphagia progressive from foods Rings Stricture Cancer Achalasia Scleroderma Spasm
to liquids.
1st: Barium Swallow 1st: Barium Swallow
MOTILITY Best: EGD w/ Bx Then: Manometry
Achalasia Best: EGD w/ Bx
This is a failure of the LES to relax and presents as dysphagia to
solids and liquids. Food enters the esophagus, moves just fine to Dilated
the stomach, but can’t fit through a tightened LES. Patients Esophagus
describe a knot or ball of food behind their sternum along with Ø Esophageal
Tightened Activity
dysphagia. A diagnosis can be made on barium swallow
LES
demonstrating a bird’s beak. It’s confirmed with a manometry
that shows hyperactive contraction and inactivity of the rest of the Sustained LES
esophagus. An EGD must be done, revealing absent auerbach Contraction
plexus and ruling out cancer. For treatment, the LES has to be Achalasia. Depiction and Manometry studies. LES
opened. You can do Botulinum or Balloon Dilation (risk of contracts as normal but cannot relax, producing sustained
perforation). The preferred treatment is surgery: Heller Myotomy. contraction.

Scleroderma
An autoimmune disorder that presents with a severe and
refractory GERD. Found typically in reproductive aged
females, it can be screened for with Anti Scl-70 Abs. A definitive
Ø Esophageal
diagnosis is made with manometry showing a relaxed esophagus
Activity
(Ø tone) and ↓pressure in the LES. There’s not much we can do
for the scleroderma or the relaxed esophagus so focus on the
relentless GERD that it produces. Prevent esophageal cancer in
Scleroderma. Depiction and Manometry studies. LES is
these patients by giving them high-dose PPIs.
persistently relaxed permitting regurgitation of acid
contents. LES has no activity at all.
Esophageal Spasm
This looks like an MI at first glance. It presents with a crushing,
retrosternal chest pain that’s relieved with nitrates but isn’t an
MI. After the patient spends a good time ruling out myocardial
ischemia, esophageal spasm is diagnosed by manometry showing
erratic, diffuse spasm unrelated to eating, drinking, or position.
While not usually performed, a barium swallow done at the time
of pain may show multiple regions of spasm, the “corkscrew
esophagus.” Treat this with Calcium Channel Blockers or
Nitroglycerin as needed. Esophageal Spasm. Depiction and Manometry. Diffuse,
uncoordinated, painful contractions of the esophagus.
MECHANICAL
Schatzki Ring Ring occludes lumen
A fibrous ring located at the LES causes only large diameter New Lumen is smaller
foods to get stuck. This will be a very episodic (months in
between) dysphagia with odynophagia. Since most food is cut or “Steakhouse Dysphagia”
chewed well most foods get by the ring - hence episodic. A
barium swallow will show a narrowed lumen and an EGD will
yield definitive diagnosis with visualization and biopsy. Breaking
the ring will alleviate symptoms. Schatzki Ring, Depiction. Only once in a while does that
large caliber food get stuck. Thus it is the critical diameter
food that makes this disease

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 Gastroenterology [ESOPHAGUS]

Plummer-Vinson Syndrome New Lumen

Esophageal Rings + Esophageal Webs + Iron Deficiency
Anemia, typically in a woman is Plummer-Vinson. Note that
these patients have a special type of ring located in the upper
Webs
esophagus. They also have an ↑ risk of squamous cell
carcinoma of the esophagus. There’s no treatment but ppx
esophagectomy is not indicated. Recognize the syndrome. Esophageal Webs. Side view and cross-section. Webs can
occur anywhere in the esophagus. They stay within the
Stricture lumen, and can be of any size
Potential consequences of long-standing GERD is Barrett’s and New Lumen
Ingestion
Cancer. Another, considered grade 4 GERD, is a stricture. So Circumferential Scar
much inflammation over such a long period causes scarring.
Another cause of stricture is caustic ingestion (harsh acid or
base). The scarring enters the lumen. This is a progressive GERD
history of GERD or remote history of ingestion followed by
motility dysphagia. There may be weight loss (b/c they can’t eat
as much, distracting you towards cancer) but that’s atypical.
Diagnosis is made first with a barium swallow then confirmed
by EGD with Biopsy for definitive diagnosis. Treatment is the
aggressive management of GERD (high dose PPI) and resection Stricture. Side view and cross-section. GERD causes
of the stricture. stricture at lower esophagus, ingestion can be anywhere,
usually at entrance. Scar is circumferential with a new,
Cancer smaller lumen in the center
Cancer presents as progressive weight loss and progressive
Fungating Mass
dysphagia in an older person with GERD (adenocarcinoma) or
New Lumen
in a smoker/EtOH (sqaumous cell). There’s often an associated
weight loss. Progressive = obstructive, weight loss = cancer,
risk factors = which cancer. A barium swallow is done 1st to
identify the area of the lesion and to rule out cancer high in the
esophagus (which you might perforate if you did an EGD first).
Follow up the swallow with an EGD and Bx. If positive, stage
with a (PET)CT. Resection and chemo is the treatment as most Cancer. Side view and cross-section. GERD causes
of the cancers are invasive at the time of diagnosis. Because acid adenocarcinoma in the distal esophagus. Toxic exposure
refluxed from the stomach into the bottom of the stomach, causes sqaumous cell in the proximal esophagus.
adenocarcinoma is at the ↓1/3 of the esophagus. Because Fungating mass eats into the lumen from a single focus,
smoke and hot drinks enter at the top of the esophagus, new lumen is oddly shaped. This tumor is depicted as
sqaumous cell is at the ↑1/3. having invaded the wall of the esophagus.

Zenker’s Zenker’s. False lumen with an

In a really old guy with bad breath who has trouble eating undigested stick figure in it. This
(coughing + gurgling at the start of eating) suspect a Zenker’s figure will leap out at night onto the
diverticulum. The diagnosis is sealed if the patient regurgitates pillow. It will first make this old man’s
undigested food days after eating it. The diverticulum is a false breath smell terrible and hard from
diverticulum caused by decades of ↑pressure. Do a barium him to eat.
swallow to identify and an EGD if need be. Treat with resection.

Disease Presentation Classic Sxs 1st Test Best Test Treatment

Achalasia Motility Knot or Ball of Food at esophagus Manometry Dilation, Botox, Myotomy
Scleroderma Motility CREST, Female GERD tx, Ø cure
Esophageal Spasm Motility CP better with Nitro, CCB NTG, CCB prn
Schatzki Ring Mechanical Episodic to Large caliber foods Resection
Plummer Vinson Mechanical Iron Def Anemia, Webs, Female Ø, Monitor for Cancer
Barium
Stricture Mechanical GERD with Weight Loss or Resection
Swallow
h/o Caustic Ingestion EGD Bx
Zenker’s Mechanical Old Man, Halitosis, regurgitation Resection
Cancer Mechanical GERD Weight Loss Resection
Or + Chemo
Smoking + EtOH

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