MOD6-IM2-T1-Disorders of the Esophagus-2.pdf

IM2 INTERNAL MEDICINE 2 Disorders of the Esophagus TRANS 1...

IM2 INTERNAL MEDICINE 2 Disorders of the Esophagus TRANS 1 MODULE 6 Dr. Esperanza Grace Santi September 10, 2024 LECTURE OUTLINE Doctor’s Notes I Esophageal Disorders The esophagus is unique with only 4 layers, unlike the other A. Anatomy and Function segments of the GI tract, the esophagus has no serosa or 5th B. Diagnostic tests layer C. Esophageal disorders II Esophageal Inflammatory Disorders B. DIAGNOSTIC TESTS A. GERD These tests aid in the diagnosis for esophageal disorders: B. Eosinophilic Esophagitis ○ Esophagography C. Infectious Esophagitis ○ Upper GI Endoscopy ○ Esophageal Manometry III Esophageal Motility Disorders ○ Reflux Testing A. Achalasia ○ Endoscopic Ultrasound (EUS) IV Structural Esophageal Disorders ○ CT Scan A. Zenver’s Diverticulum B. Esophageal Rings/Webs ESOPHAGOGRAPHY V Trauma and Iatrogenic Injury A. Corrosive Esophagitis B. Pill-induced Esophagitis C. Mallory-Weiss Tear D. Foreign body ingestion VI References VII Case Discussion LECTURE OBJECTIVES 1. Understand the clinical presentation of common esophageal disorders 2. Understand the principles of management of the esophageal disorders Figure 2. Barium Swallow that shows dilated esophagus with typical finding of a 🧠 Must Know 📖 Book 📝 Previous Trans Bird’s Beak appearance seen in patients with Primary Achalasia Source: Handout - Disorders of the Esophagus I. ESOPHAGEAL DISORDERS Doctor’s Notes A radiologic test where you ask the patient to drink barium, a water A. ANATOMY AND FUNCTION soluble contrast, and take x-ray show the contrast retained in the A long and hollow tube that serves as a conduit for transport of esophagus food from the mouth to the stomach Lined by stratified squamous epithelium UPPER GI ENDOSCOPY/EGD Esophageal wall has 4 layers (no serosa) ○ Mucosa ○ Lamina propria ○ Submucosa ○ Muscularis propria 3 areas of anatomic narrowing: ○ Upper Esophageal Sphincter (UES) ○ Mid esophagus/ Indentation of the aortic arch ○ Lower Esophageal Sphincter (LES) Figure 3. Upper GI Endoscopy Source: Handout - Disorders of the Esophagus Doctor’s Notes To look for abnormalities in esophageal mucosa which otherwise cannot be seen in barium swallow Enables to obtain biopsies and do therapeutic procedures, example like the dilation of esophageal strictures Figure 1. Anatomy and Function of Gastrointestinal Tract Source: Handout - Disorders of the Esophagus Group 12A | Disorders of the Esophagus 1 of 12  ESOPHAGEAL MANOMETRY CT SCAN Figure 4. (A) Normal lower esophageal sphincter pressure and esophageal peristalsis. (B) Hypotonic LES and normal peristalsis and (C) Ineffective esophageal motility and hypotonic LES Source: Handout - Disorders of the Esophagus Doctor’s Notes Figure 7. CT Scan. Esophageal cancer invading the surrounding mediastinal structures (yellow arrow) A test to evaluate pressure along the length of the esophagus as Source: Handout - Disorders of the Esophagus the patient swallows It is very helpful in the diagnosis of motility disorders to assess esophageal peristaltic activity Doctor’s Notes To ass the tumor spread into more distant structures in the chest cavity REFLUX TESTING ○ Mediastinum, lungs, chest wall and bony structures C. ESOPHAGEAL DISORDERS Table 1. Esophageal disorders Trauma/ Inflammatory Motility Structural Iatrogenic Corrosive Diverticulum esophagitis GERD Achalasia Figure 5. Reflux Testing Pill-induced Rings/Webs Source: Handout - Disorders of the Esophagus esophagitis Eosinophilic Doctor’s Notes Esophageal Mallory-Weiss tear esophagitis Tumors pH monitoring involves insertion of a pH probe into a patient's spasm nose and this monitors the esophageal pH over time Infectious esophagitis Foreign body ○ Usually 24 hrs Helpful in the diagnosis of GERD where it is unclear Doctor’s Notes This record the amount of time the esophageal pH goes below 4 Motility disorders and if the value exceed 5% is indicative of GERD ○ Achalasia - is the most common Structural disorders ENDOSCOPIC ULTRASOUND (EUS) ○ If there is occlusion in the lumen of the esophagus which Visualize the esophageal wall and its relation with adjacent obstructs the passage to the stomach structures like the heart, azygos vein, aorta, mediastinal structures and lymph nodes Determine local extent of the tumor II. ESOPHAGEAL INFLAMMATORY DISORDERS Guide treatment based on tumor stage A. GASTROESOPHAGEAL REFLUX DISEASE Pathophysiology: poorly functioning EG function (LES and crural diaphragm) with impaired esophageal clearance and altered mucosal integrity Doctor’s Notes At distal end of the esophagus is the LES which is usually closed except during swallowing to allow food to enter to the stomach In patients with GERD the LES remains open allowing food, hydrochloric acid and gastric contents to reflux into the esophagus This causes unpleasant symptoms such as heartburn and regurgitation May also present with atypical symptoms like dysphagia and heartburn Typical symptoms: heartburn and regurgitation Atypical symptoms: dysphagia, chest pain, cough Diagnosis ○ Combination of symptoms ○ Endoscopic evaluation ○ Reflux monitoring Figure 6. Endoscopic Ultrasound (EUS) ○ Response to therapeutic intervention Source: Handout - Disorders of the Esophagus Group 12A | Disorders of the Esophagus 2 of 12  Figure 8. Gastroesophageal Reflux Disease Source: Handout - Disorders of the Esophagus COMBINATION OF SYMPTOMS Alarm Symptoms dysphagia odynophagia Figure 11. Clinical Guideline for the Diagnosis and Management of GERD weight loss Source: Handout - Disorders of the Esophagus anemia GI bleeding DISCLAIMER: A larger photo is provided on page 9 as ANNEX A. age >50 hoarseness tobacco use Doctor’s Notes In patients presenting with typical symptoms of GERD withOUT alarming signs → a trial of 8-weeks of PPI as warranted Is complete relief after 8 weeks → discontinue After 8 week NO relief → request for an EGD and patient is off any PPI for at least 2 weeks If patient WITH alarm symptoms → endoscopy immediately TREATMENT weight loss in overweight and obese patients PPI > H2RA for healing of erosive esophagitis, administered 30-60 minutes before meal on an empty stomach Figure 9. Combination of Symptoms in GERD REMARKS: Strongly recommended with moderate to high level of Source: Handout - Disorders of the Esophagus evidence Endoscopic Evaluation (EGD) Endoscopic hallmark: Erosive esophagitis B. EOSINOPHILIC ESOPHAGITIS (EoE) Los Angeles classification for erosive esophagitis is most widely and Pathophysiology:immune-mediated validated tool used for endoscopic grading. ○ In children: association with asthma, rhinitis, eczema: 53%; response to diet restriction or elimination: 98% ○ In adults: atopy 78%, IgE for food allergen 82% Figure 10. Los Angeles Classification for Endoscopic Grading Source: Handout - Disorders of the Esophagus Table 2. Los Angeles Classification for Endoscopic Grading Grade A ≥ 1 mucosal break ≤ 5mm not extending between folds Grade B ≥ 1 mucosal breaks > 5mm not extending between folds ≥ 1 mucosal break continuous between folds but involves Grade C < 75% of the circumference of the esophagus ≥ 1 mucosal break that involves at least 75% of the Grade D circumference of the esophagus Figure 12. Pathophysiology of EoE Source: Handout - Disorders of the Esophagus Doctor’s Notes Only Grades B, C, D are diagnostic of GERD Grade A is NOT sufficient due to interobserver variability Reflux monitoring - done in patient with GERD where EGD shows NO evidence with GERD ○ If pH is < 4 more than 5% of the time measured is indicative of GERD Group 12A | Disorders of the Esophagus 3 of 12 Doctor’s Notes C. INFECTIOUS ESOPHAGITIS Chronic immune mediated disorder of the esophagus associated with esophageal symptoms and intense eosinophils in biopsy (>15 hpf) Should rule our when considering EoE ○ GERD ○ Parasites ○ Fungi ○ IBD ○ Hodgkin’s Disease ○ Scleroderma ○ Drug injury ○ Allergic vasculitis (Figure 12) Allergen can be airborne or food and gets into the esophagus and produces a reaction where the helper T-cells will release cytokines and interleukins that will recruit eosinophils in Figure 14. Infectious Esophagitis the area. Eosinophils congregate in the esophagus as observed Source: Handout - Disorders of the Esophagus in biopsy as eosinophilic infiltration.Congregations then produce fibrosis and lead to esophageal rings typically seen in EoE during III. ESOPHAGEAL MOTILITY DISORDERS endoscopy Due to esophageal neuromuscular dysfunction Table 3. Esophageal Motility Disorders CLINICAL PRESENTATION Male predominance PRIMARY SECONDARY Symptoms: dysphagia, food impaction Achalasia Chagas disease DIAGNOSTIC TESTS Diffuse esophageal ○ Endemic in South America spasm ○ Transmitted by reduviid bug Esophagogram Jackhammer Scleroderma esophagus ○ This is a connective tissue disorder Doctor’s Notes Pseudoachalasia On barium swallow, you may see ring-like structures along the ○ Caused by a tumor in the stomach body of the esophagus which can cause significant narrowing of the esophagus causing some strictures giving rise to dysphagia and food impaction DIAGNOSTIC TESTS High resolution esophageal manometry UGI endoscopy Doctor’s Notes Show linear furrows that appear trachea like, with whitish plaques Biopsy Doctor’s Notes Numerous intraepithelial eosinophils that meat the diagnostic criteria must be > 15 hpf Figure 15. Esophageal Motility Disorders on High-Resolution Manometry: Chicago Classification Version 4.0© Source: Handout - Disorders of the Esophagus DISCLAIMER: A larger photo is provided on page 9 as ANNEX B. A. ACHALASIA Figure 13. Esophagogram (upper left), Biopsy (upper right) and UGI endoscopy (lower) Source: Handout - Disorders of the Esophagus NOTES: On esophageal mucosal biopsies, eosinophilia is observed at >15/hpf. It is important to rule out other causes of eosinophilia before clinching the diagnosis. TREATMENT PPI Elimination diets Topical glucocorticoids (Fluticasone, Budesonide) - with 50-80% recurrence after short term treatment Esophageal dilation with balloon in symptomatic patients Figure 16. Lower Esophageal Sphincter Source: Handout - Disorders of the Esophagus Group 12A | Disorders of the Esophagus 4 of 12 Doctor’s Notes DIAGNOSTIC TESTS Rare idiopathic disease of esophageal motility Most common among the rare primary esophageal motility High-Resolution Esophageal Manometry (HREM) disorders All esophageal motility disorders are rare but relative to others primary achalasia is a bit more common It is characterized by: ○ Insufficient LES relaxation The LES is normally closed. It is only supposed to open when swallowing food to allow entry of food into the stomach. However, in patients with achalasia, when they swallow the LES contracts instead of opening. ○ Loss of esophageal peristalsis Which results in symptoms such as dysphagia and regurgitation HISTORY Dysphagia - most common ○ to both solids and liquids Regurgitation Figure 18. High resolution esophageal manometry Chest pain Source: Handout - Disorders of the Esophagus Weight loss ○ Patients with achalasia can’t eat properly, hence the weight Doctor’s Notes loss This is the gold standard in the diagnosis of esophageal motility disorders. It is difficult to differentiate one motility from another clinically. X-ray and EGD are only complementary tests to manometry in the diagnosis and management of esophageal motility disorders. Figure 17. Achalasia Source: Handout - Disorders of the Esophagus Doctor’s Notes NATURAL HISTORY OF ACHALASIA Figure 19. Esophageal Motility Disorders on High-Resolution Manometry: Chicago Classification Version 4.0© Early Stages Source: Handout - Disorders of the Esophagus ○ There is a progressive esophageal dilation that occurs with time Doctor’s Notes ○ The prominent symptom is chest pain early on In High-Resolution Manometry, several parameters are Late Stages considered such as integrated relaxation pressure (IRP). ○ As the disease progresses, the esophagus becomes more It is essential to check if there is peristalsis in order to identify the dilated and takes on a more sigmoid shape specific esophageal motility disorder a patient has. ○ The chest pain gradually wane during the disease Abnormal IRP: Disorders of EGJ outflow obstruction progression, dysphagia and regurgitation are constant ○ Achalasia falls under this category symptoms Normal IRP: Disorders of Peristalsis The other details on this table is too technical and considered as Table 4. Clinical Scoring System for Achalasia (Eckardt Score)21 consultant level SYMPTOM Upper Gastrointestinal Endoscopy SCORE Weight loss Retrosternal Dysphagia Regurgitation (kg) pain 0 None None None None 1 10 Each meal Each meal Each meal Source: Handout - Disorders of the Esophagus. Doctor’s Notes Eckardt Scoring System Figure 20. Dilated esophagus Used to assess the severity of symptoms Source: Handout - Disorders of the Esophagus A corresponding score is given for a specific symptom such as weight loss, dysphagia, retrosternal chest pain, and regurgitation. Doctor’s Notes The higher the score, the more severe the disease. Patients with achalasia will present with a dilated esophagus with ○ The chest pain gradually wane during the disease progression, retained saliva (bubbles), liquid, or undigested food particles in dysphagia and regurgitation are constant symptoms the absence of a stricture or tumor Group 12A | Disorders of the Esophagus 5 of 12  Esophagography (Barium Swallow Test) Endoscopic Pneumatic Balloon Dilation Doctor’s Notes Figure 22. Balloon Dilatation Source: Handout - Disorders of the Esophagus This is the current standard of treatment for achalasia It is an effective and validated treatment Figure 21. Barium Swallow Test 80-90% effective but usually needs to be repeated every 2 years Source: Handout - Disorders of the Esophagus or so 5% risk of perforation Doctor’s Notes Bird’s beak appearance or rat-tail sign Pros Cons ○ This indicates that the barium fails to go down the esophagus Endoscopic Risk of perforation In long standing cases, there is poor emptying of barium There is esophageal dilation and tortuosity Out-patient ambulatory procedure Less efficacious than myotomy TREATMENT OPTIONS Rarely cause post-dilation reflux Needs to be repeated at least Pharmacotherapy once a year Doctor’s Notes Per Oral Endoscopic Myotomy (POEM) Most common: Doctor’s Notes ○ Ca-channel blockers: Nifedipine ○ Nitrates: Isosorbide dinitrate These are usual medications for hypertension and coronary artery disease. MOA: relaxation of the smooth muscles of the esophagus Pros Cons Cheap Not really effective Non-invasive balloon dilation Surgery Laparoscopic Heller Myotomy Group 12A | Disorders of the Esophagus 6 of 12  Doctor’s Notes This is a sac-like outpouching of the mucosa and the submucosa through the Killian’s triangle. Since there is no muscle in the diverticulum, this is a “false” diverticulum seen in 0.11% of the population. Usually, patients are asymptomatic. It is commonly seen among males, and usually they are in their middle age to 70 years of life. Figure 24. Balloon dilation (Upper) and Laparoscopic Heller Myotomy (lower) Common symptoms are halitosis, gurgling sound in the throat, Source: Handout - Disorders of the Esophagus some would complain of mass in the neck, regurgitation, and sometimes dysphagia. Complications are rare, but you need to watch out for aspiration, Doctor’s Notes ulceration, and bleeding from the diverticulum, and sometimes Cuts the sphincter 80-90% effectively (initially) fistula formation. Durable but not perfect (estimated 65% symptom recurrence The diagnosis is made through x-ray, barium swallow, after 15-20 years) water-soluble contrast, esophagogram, combined with GERD in 40% even with fundoplication fluoroscopy, where you can see an outpouching of the posterior More invasive than endoscopic therapy aspect of the upper esophageal sphincter, and upper GI endoscopy, where you can see two lumina (one opening enters Pros Cons the blind pouch and one is the opening of the esophageal lumen). Effective, one session only In-patient procedure Standard treatment has been surgical cricopharyngeal myotomy or with a flexible septotomy, and recently endoscopic myotomy Considered as a definitive Done under general anesthesia called ZPOEM. treatment Halts disease progression Post-Tx reflux, hence the need B. ESOPHAGEAL RINGS AND WEBS for fundoplication Thin structures that partially occlude the esophageal lumen expensive 1. B RING / SCHATZKI RING Located at the distal esophagus Usually asymptomatic CAVEAT “Steakhouse syndrome” No method of preventing or “curing” achalasia is known Treatment is dilation Therapy is directed towards reducing LES pressure LES myotomy > balloon dilation LHM = POEM SUMMARY Esophageal motility disorder characterized by ABSENCE OF PERISTALSIS and NON-RELAXING LES Diagnosis is made thru: Esophagogram, UGIE, and HREM Treatment ○ Nitrates/calcium channel blockers and botulinum toxin injection - not effective ○ Balloon dilation, LHM, and POEM are durable therapies Figure 26. B Ring of Schatzki Ring IV. STRUCTURAL ESOPHAGEAL DISORDERS Source: Handout - Disorders of the Esophagus Diverticulum (Zenker’s) Doctor’s Notes Rings/Webs It is located at the distal esophagus. Tumors Usually, patients are asymptomatic. This can cause the “steakhouse syndrome”, wherein patients A. ZENKER’S DIVERTICULUM would develop a choking sensation after eating a heavy meal. Sac-like outpouching of the mucosa and submucosa through the Patients who are symptomatic are usually treated with Killian’s triangle esophageal dilation. Prevalence 0.01-0.11% If symptomatic M>F, middle age to older adults in 7th/8th decade 2. ESOPHAGEAL WEB of life “False” diverticulum Located proximally Usually asymptomatic Usually asymptomatic Halitosis, gurgling in the throat, mass in the neck, regurgitation, If associated with iron deficiency anemia in a middle-aged female: dysphagia Plummer-Vinson or Paterson-Kelly Syndrome Complications: aspiration, ulceration, bleeding, fistula formation Figure 25. Zenker’s Diverticulum Source: Handout - Disorders of the Esophagus Figure 27. Esophageal Web Source: Handout - Disorders of the Esophagus Group 12A | Disorders of the Esophagus 7 of 12 Doctor’s Notes It is located at the proximal esophagus. Usually, patients are asymptomatic. This condition can be associated with iron deficiency anemia, and IIB Circumferential ulceration if seen in females, this would constitute the Plummer-Vinson or Paterson-Kelly Syndrome. Favorite board exam question Plummer-Vinson or Paterson-Kelly Syndrome ○ Female with iron-deficiency anemia, and on work-up you see an esophageal web. Dr. Santi V. TRAUMA AND IATROGENIC INJURY Multiple deep ulcers with A. CORROSIVE ESOPHAGITIS III brown, black or gray Occurs from ingestion of alkali or acid either by accident or discoloration intention Ingestion of these substances can cause severe injury, not only in esophagus, but in the stomach as well. Nature of injury depends on what was ingested Table 5. Mechanism of Tissue Injury Depending on Substance Ingested No photo for perforation since ALKALI ACID IV Perforation endoscopy is contraindicated. Liquefactive necrosis Superficial coagulative necrosis Source: Delusong, M, et. al. W J Gatroenterol and Pharmacol May 2017 Transmural damage Thrombosis of mucosal vessels and Esophagus > gastric consolidation of connective tissue Ex. sodium/ammonium Gastric > esophagus hydroxide (lye) Pain upon contact Ex. Muriatic acid Doctor’s Notes When a patient ingests alkali, that would result in penetrating injury called liquefaction necrosis, and that extends rapidly along the entire wall of the esophagus towards the mediastinum causing extensive transmural damage. ○ Usually, alkali ingestion would lead to perforation of the esophagus and mediastinitis. Figure 28. Erosions and linear ulcers with exudates in a patient after ingestion of ○ Most common ingested strong alkali: sodium or potassium lye (liquid sosa), Grade IIA hydroxide and ammonium hydroxide, which is common Source: Handout - Disorders of the Esophagus component of household cleaners Acid ingestion causes pain upon contact with oropharynx ○ Patient will vomit. Hence, limiting amount ingested ○ However, upper airway injury is very common ○ Less viscous compared to alkali. Hence, can reach stomach faster compared to alkali and cause superficial coagulation necrosis and thrombosis of mucosal vessels Upper Gastrointestinal Endoscopy ○ Used to grade severity of injury Zargar Classification ○ The more severe the injury, the higher the risks of complications Table 6. Zargar Classification for Endoscopic Grading of Caustic Injury GRADE ENDOSCOPIC FINDINGS Figure 29. Gray discoloration of the esophageal mucosa with linear ulcerations and active bleeding in a patient after ingestion of muriatic acid, Grade III Source: Handout - Disorders of the Esophagus 1. MANAGEMENT I Edema and erythema General measures ○ Initial stabilization of patients with caustic ingestion at the ER includes fluid resuscitation, respiratory support, and pain control ○ Watch out for acute life threatening complications like mediastinitis, peritonitis, respiratory distress and shock ○ Patients should be kept on NPO until the initial evaluation has Hemorrhage, erosions, been performed and done IIA blisters, ulcers with exudate ○ Gastric acid suppression with IV PPI is used to prevent stress ulcers in the stomach ○ Broad spectrum antibiotics are reserved for patients with suspected perforation and should be referred for immediate surgery. Group 12A | Disorders of the Esophagus 8 of 12  AVOID: Doctor’s Notes ○ Insert of NGT because it can induce retching and vomiting Common clinical scenario in the ER: which can compound existing injuries in the esophagus. This ○ Young patient who had a drinking spree the day or night prior may also lead to perforation and is severely hungover. ○ Induce emesis ○ The patient had several retching episodes and vomits with ○ Give neutralizing agents because neutralization releases blood. heat that causes thermal injury to the ongoing chemical destruction of tissues ○ Give steroids because of lack of demonstrable efficacy D. FOREIGN BODY INGESTION Accidental ingestion of a known object History: type object, quantity ingested, and time it occurred B. PILL-INDUCED ESOPHAGITIS Symptoms: odynophagia, chest pain Location: mid-esophagus COMMON SITES OF IMPACTION Causes: inadequate fluid intake with pills or lying immediately after Normal anatomic areas of narrowing: taking a pill ○ Upper esophageal sphincter (UES) Common medications implicated: ○ Indentation of the aortic arch ○ Bisphosphonates (e.g. Alendronate) ○ Lower esophageal sphincter (LES) ○ Antibiotics (e.g. Doxycycline) Areas with anatomic abnormalities: ○ Potassium supplements ○ Webs ○ Ferrous sulfate ○ Rings “Kissing ulcers” - not pathognomonic ○ Eosinophilic esophagitis (EoE) FOREIGN BODY INGESTION WITH HIGH RISK OF COMPLICATIONS Button/disc batteries Multiple magnets Sharp/pointed objects DIAGNOSTICS X-ray ○ Usually the first step in diagnostics ○ Chest (posterior-anterior and lateral views) ○ Neck and abdominal (may be needed) Figure 30. Kissing Ulcers due to Pill-induced Esophagitis CT Scan Source: Handout - Disorders of the Esophagus ○ For radiolucent foreign body not seen on routine X-ray and if NOTE: Prevention is key. complications are suspected ○ High sensitivity for detecting foreign body Doctor’s Notes Occurs when a pill fails to traverse the esophagus and gets stuck within the lumen. Even swallowing of saliva can trigger severe odynophagia and chest pain. Most common locations are the normal anatomical narrowings, especially mid-esophagus wherein indentation of the arch of the aorta is present. Who gets pill-induced esophagitis? ○ Individuals who have poor-taking habits; do not drink sufficient water everytime they take pills. ○ When drinking supplements, drink plenty of water to flush it down the esophagus. Figure 32. X-ray of Ingested Foreign Body Treatment is almost the same as GERD. Source: Handout - Disorders of the Esophagus During endoscopy, ulcers or “kissing ulcers” can be appreciated but these are not pathognomonic. TREATMENT Urgent endoscopic removal IF: ○ Patient is unable to handle oral secretions C. MALLORY-WEISS TEAR ○ The object ingested is high risk of developing complications Longitudinal mucosal lacerations in the distal esophagus ○ Objects > 2.5 cm in size associated with forceful retching ○ Coins in the esophagus Symptoms: hematemesis often preceded by retching ○ Drugs Treatment: ○ Often self-limiting ○ If protracted bleeding: endoscopic treatment with adrenaline injection, clipping Figure 33. Ingested Drugs Source: Handout - Disorders of the Esophagus Figure 31. Mallory-Weiss Tear Source: Handout - Disorders of the Esophagus Group 12A | Disorders of the Esophagus 9 of 12 Doctor’s Notes Usually patients have mild symptoms and are usually stable. History is important to determine whether the foreign object needs to be removed urgently or the patient can simply be managed by observation and follow-up. IX. REVIEW QUESTIONS In X-ray, radiopaque items such as food, plastic, wood, and glass are usually not seen; if suspicion of foreign body is still high, CT No. QUESTIONS scan may be indicated. CT scan is helpful in detecting complications such as 1 Which of the following modalities is most sensitive in the perforations. diagnosis of esophageal motility disorders? E. Barium swallow F. HREM VI. APA REFERENCES G. CT Scan Santi, E.G. (2025) Disorders of the Esophagus Handout H. UGIE VII. CASE DISCUSSION 2 A 35/F, overweight, complains of intermittent heartburn and regurgitation in the past 3 months. She denies other No. QUESTIONS symptoms. Physical examination was unremarkable. What is the diagnosis? 1 A 26/M complains of intermittent dysphagia to solids. No A. Achalasia vomiting, chest pain or weight loss. He has allergic rhinitis B. Candida esophagitis and skin asthma. PE was unremarkable. What is the likely C. Schiatzki ring diagnosis D. GERD A. Achalasia B. Eosinophilic esophagitis 3 A 70/M smoker, complains of intermittent heartburn C. CMV esophagitis associated with weight loss and progressive dysphagia, D. Erosive esophagitis solids > liquids. PE was unremarkable. Which of the following should be the next best step in terms of 2 A 46/M known HIV on anti-removal treatment consulted due management? to odynophagia. What is the diagnosis? A. Schedule for EGD A. Achalasia B. CT Scan of the chest B. Eosinophilic esophagitis C. pH studies C. CMV esophagitis D. Give 8-week trial D. Erosive esophagitis 4 Which of the following inflammatory disorders of the 3 A 22/F, YL3 medical student, complains of intermittent esophagus is associated with an immune mediated heartburn for 6 months associated with regurgitation and pathophysiology and is related to allergy? water brash, more severe during exam week. No weight A. Candida esophagitis loss, overt GI bleeding. PE was unremarkable. What is the B. CMV esophagitis best treatment? C. Eosinophilic esophagitis A. Acyclovir D. GERD B. H2RA C. Myotomy 5 A 23/M arrived at the ER due to one episode of D. PPI hematemesis. He came from a party where he had several drinks. His friends noticed that he was retching earlier in the evening before he vomited blood. He is a non-smoker VIII. RATIONALIZATION but a moderate alcoholic beverage drinker. On PE, vital 1 A 26/M complains of intermittent dysphagia to solids. No signs were normal, palpebral conjunctivae were pink and vomiting, chest pain or weight loss. He has allergic rhinitis the abdominal findings were unremarkable. What is the and skin asthma. PE was unremarkable. What is the likely diagnosis? diagnosis A. Squamous cell carcinoma A. Achalasia - dysphagia is both in solid and liquids B. Pill-esophagitis B. Eosinophilic esophagitis - dysphagia to solids C. Corrosive esophagitis C. CMV esophagitis - common in immunocompromised D. Mallory-Weiss syndrome patient D. Erosive esophagitis - seen in patient with GERD, with X. RATIONALIZATION common symptom of heartburn No. RATIONALIZATION 2 A 46/M known HIV on anti-removal treatment consulted due to odynophagia. What is the diagnosis? 1 CORRECT ANSWER: B. HREM A. Achalasia B. Eosinophilic esophagitis HREM is the most sensitive test in the diagnosis of achalasia, C. CMV esophagitis - common in immunocompromised which is also the gold standard in the diagnosis of esophageal patient motility disorder. D. Erosive esophagitis A is incorrect because Barium swallow is crucial in the 3 A 22/F, YL3 medical student, complains of intermittent evaluation of dysphagia to visualize the mucosa, luminal heartburn for 6 months associated with regurgitation and distensibility, motility, and any anatomic abnormalities water brash, more severe during exam week. No weight loss, overt GI bleeding. PE was unremarkable. What is the C is incorrect for CT Scan has a little role for the diagnosis of best treatment? achalasia, as it is only useful for assessing common A. Acyclovir - viral (e.g. esophagitis) complications B. H2RA - second line treatment for GERD C. Myotomy - done in patient with esophageal motility D is incorrect for UGIE is only a complimentary test to disorders manometry in the diagnosis and management of esophageal D. PPI - best treatment for GERD motility disorders such as achalasia Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus Group 12A | Disorders of the Esophagus 10 of 12  2 CORRECT ANSWER: D. GERD 5 CORRECT ANSWER: D. Mallory-Weiss Syndrome Common symptoms of GERD include heartburn and The patient is a young male with a history of binge drinking and regurgitation. retching that preceded hematemesis. This is the most common presenting symptom of Mallory-Weiss syndrome, A is incorrect because achalasia presents with dysphagia where the forceful retching has caused longitudinal mucosal (MOST COMMON), regurgitation, chest pain, vomiting, and lacerations in the distal esophagus. weight loss. A is incorrect since patients in its early stage are B is incorrect because candida esophagitis is diagnosed with asymptomatic while in advanced stage, symptoms such as snow white plaques/exudates that when we try to flush it out dysphagia to solids, weight loss, anemia and hoarseness would reveal friability of mucosa underneath on endoscopy and manifest, indicating that the tumor has spread to adjacent and candida hyphae on biopsy. distant organs. C is incorrect because Schiatzki rings or b-rings are usually B is incorrect since patients usually present with odynophagia asymptomatic but can cause steakhouse syndrome wherein a and chest pain due to pill ingestion that fails to traverse the patient would develop intermittent choking, especially after a esophagus and gets stuck within the esophageal lumen. heavy meal. It is usually located in the distal esophagus. C is incorrect since this results from ingestion of caustic Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders agents like alkali or acid either by accident or attempted of the Esophagus suicide. Patient immediately vomits upon acid ingestion. 3 CORRECT ANSWER: A. Schedule for EGD Reference: Batch 2025 Ratio This is a patient with alarm symptoms (age >50, weight loss and dysphagia). GERD is unlikely hence EGD is the next step. B is incorrect since CT scan is NOT the first step because it is used to assess involvement of distant structures for metastasis. C is incorrect since pH studies are done in patients with symptoms of GERD and AFTER an endoscopy is negative for signs of GERD. D is incorrect since trial of PPI is not indicated because of ALARM signs. Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 4 CORRECT ANSWER: C. Eosinophilic Esophagitis Eosinophilic esophagitis is a chronic immune mediated disorder of the esophagus. Its pathophysiology involves an allergen that triggers the helper T-cell to release cytokines and other ILs that recruit eosinophils in the area. For children, it is associated with asthma, rhinitis, and eczema in 53% of the patients and for adults, it is associated with atopy and IgE for food allergen. A is incorrect because Candida esophagitis is an infectious esophagitis and is common for immunocompromised patients. B is incorrect because CMV esophagitis is an infectious esophagitis which is common for immunocompromised patients. D is incorrect because GERD is associated with the weakness of the sphincter of the Esophagogastric junction. Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus Group 12A | Disorders of the Esophagus 11 of 12 ANNEX A: CLINICAL GUIDELINE FOR THE DIAGNOSIS AND MANAGEMENT OF GERD ANNEX B: ESOPHAGEAL MOTILITY DISORDERS ON HIGH-RESOLUTION MANOMETRY: CHICAGO CLASSIFICATION VERSION 4.0 Group 12A | Disorders of the Esophagus 12 of 12