Cram The Pance - S1E12 Esophageal Disorders Part 1 of 2

Episode Date: February 10, 2021

**Update**First line treatment for Eosinophilic Esophagitis now includes a Proton pump inhibitors (PPIs) in addition to topical glucocorticoids (inhaled or swallowed).Esophagitis, GERD, Achalasia, Distal Esophageal Spasm, Hypercontractile Esophagus review for your Pance, Panre, and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so working our way through the GI section for the pants, today we're going to be focusing on esophageal disorders. And I'm going to make this a one of two parts series because there is a lot with the esophagus, so I don't want to pack it all into one podcast. I feel like it would be a little bit too much. So today we'll be focusing on esophagitis, gird, and then some motility disorders, including ecalasia, diffuse esophageal spasm, and then something called hypercontractile or jackhammer esophagus.

So we'll go through those today. These are some of the high-yield topics for the pants. and just one other thing, I know I've mentioned this before, but if you don't mind leaving a review, if you like the podcast, it really does help me out. So thank you for that. So let's start with esophagitis. So this is going to be an inflammation or irritation of the esophagus. So as far as the most common cause, which will be going over next, it's going to be GERD. But there's a few other ones that you need to know in this. Now, there's not a lot you need to know for each one. So I'm going to go through these pretty quickly because there's really only like two to three things

you need to know for these. So esophagitis, you're going to have infectious, eocinophilic, pill-induced and caustic or corrosive causes of esophagitis. So all of these are going to present pretty much the same way. It's going to be a patient presenting with either adenophasia, which is going to be painless swallowing or dysphasia, which is difficulty swallowing. So pretty much across the board, that's how these are going to present. And you're going to diagnose these all pretty much the same way, which is going to be an endoscopy. So that makes it much easier.

There's only a few other things you need to know for each one. So let's start with infectious esophagitis. So this is going to be common in. immunocompromise patients. So normally healthy patients are not going to be presenting with infectious esophagitis. And the other couple things you need to know for this is that the most common cause is going to be candida. And the other causes besides candida are going to be CMV, which is cytomaglov, and then HSV, so herpes simplex virus. So those are your three causes of infectious. Candida, again, is going to be the most common. The way, the other thing you need to know for

this is how they present on endoscopy. So Candida is going to present with yellow white plaques. And the way you treat Candida is flucanazol. CMV or cytomagelovirus is going to appear as these ulcers on endoscopy. And the way you treat CMV is going to be with something called Gensyclovier. His Gensyclovier sounds like gang cyclovier. And what I remember with that with CMV, the letters in cytomagelovirus, gang cyclovirus, gang cyclovir. So gangs cause mostly violence. So gangs cause mostly violence, CMV. And that works for CMV pretty much anywhere because there's other causes of other areas CMV can infect. And if you remember that, you'll always remember the first line treatment for

CMV. So CMV cause mostly violence, gan cyclovir, so gangs cause mostly violence. And then the last one, which is going to be HSV. So herpes simplex virus. And you're going to treat this with a cyclovier. So pretty simple, straightforward. Let's move on to. eocinophilic esophagitis. So this is going to be a chronic allergic condition where there's an accumulation of eosinophiles in the esophagus. And this is going to lead to inflammation, which is ultimately going to cause dysphasia, which again is going to be seen in all of these. It's most common in children with atopi or atopic disease. So kids with asthma, eczema, these are going to be kids predisposed to eocinophilic esophagitis. As far as the endoscopic findings,

You're going to see these. They're called corrugated rings or stacked circular rings on endoscopy. So you'll see this ring of inflammation on endoscopy. And then treatment, it's going to be with inhaled corticosteroids. And normally when you use inhaled corticosteroids for pulmonary disorders, you use a spacer. So it gets into the lungs easier. But when you're using it for the esophagus, you use no spacer.

You actually have the patient swallow this. So it can attack the area where you need it to. And another form of treatment is going to be. remove the offending agents, whether it's food causing it, whatever the cause is that's making these kids have this allergic reaction. So eocynophilic, again, things you need to know, chronic aller allergic condition, endoscopic finding, stacked circular rings or corrugated rings, treatment, inhaled corticoster, no spacer, remove offending agent. Very easy. Now the next one, there's like literally nothing for you to know. This is going to be pill-induced esophagitis.

So this is basically somebody that takes a pill, it kind of gets stuck in their throat, and it can cause irritation of the esophagus. Really the only thing, that you need to know is that the most common meds are going to be nseds and bisphosphonates. Those are going to be your two big time meds. Do not forget those. That will definitely be a question, whether it's your EWRs, your exams, your pants, that's always a question. Pill-induced esophagitis.

So esophagitis is due to prolonged exposure from a meds. But remember, insides, bisphosphonates. Know those two. Those are the ones that most commonly cause it, especially bisphosphinates. and the treatment, just drink more water. So drink a lot of water with the pill, avoid recumbency 30 to 60 minutes, common sense stuff. Endoscopathy is going to be really non-specific, may show varying depths of ulcers and things like that. So really nothing specific there.

Just remember, insides bisphosphonates are going to be your most common cause. Treatment is common sense. Drink more water. Don't lay down after you take the pills for a little while. The last one's going to be caustic or corrosive esophagitis. So this is going to be from ingestion. of basically a poison. So ingestion of a caustic substance, either alkali or acidic. One thing that you should know is that alkalotic agents are actually much more dangerous than

acidic, which kind of seems like the opposite of what you would think. But alcoholotic agents actually are much more likely to perforate the asophagus and can cause deeper injury to the tissue. So acidic agents are generally repelled by the mucosal surface of the esophagus. where certain alkaline agents like sodium hydroxide, which is what's in drain cleaner, can cause transmural esophageal necrosis within matter of seconds. So alkalotic agents are much more dangerous. Sodium hydroxide in particular, drain cleaner is really, really dangerous. So these patients, again, like all the other ones, are going to present with the denophagea,

dysphagia, but they also may have some hematomesis, again, because of all the tissue injury you're having in the esophagus. they may actually have some blood coming up. You're going to do an endoscopy, but it's really just to assess the extent of damage. You don't need it to make the diagnosis. You just want to know how badly these patients were injured. And then treatment is mostly going to be supportive. You're going to give them fluids, pain meds.

And one other thing that you need to know is that even if you diagnose them with endoscopy, everything looks okay. There's actually, you need to monitor these patients for up to 10 days because the injured esophageal mucosal wall. It forms a granulation tissue, which is actually susceptible to perforation up to 10 days out. So these are patients that really need to be watched closely. And that's pretty much all you need to know for the esophagitis. So those are pretty straightforward. There's not much to know really like maybe two or three things for each. And there's not a lot they can ask you on a question. So let's get into something a little bit more high yield that's going to be GERD. So gastroasophageal reflux disease. And this is all this is is a reflux of gastric contents into the esophagus.

due to relaxed or incompetent lower esophageal sphincter. So your LES, your lower esophageal sphincter is weak, meaning the acidic contents of the stomach are able to backflow up into the esophagus. So pretty straightforward. On history exam, you're going to have heartburn, obviously, and this is also known as pyrosis. So a burning sensation in the chest, typically after meals, they may have a sour taste in the mouth. And then some of these patients are actually going to present with a cough or constant clearing

of the throat at night due to all of the acid that's coming up. So those are the normal things. There's really nothing like that stands out on history and exam. But the things that you need to know are going to be your abnormal or your alarm symptoms. So these are some of the things that if a patient presents with, you need to go a little bit further to diagnose and make sure that it's not, you know, a malignancy. So weight loss, adenophagia, bleeding, and then dysphasia as well, especially if the dysphasia is progressive. So they say, well, a few weeks ago, I was eating steak and it felt like it was getting

caught in my throat. But now I'm drinking water and that's getting caught in my throat as well. So that indicates there's some kind of evolving mass getting larger and making even liquids getting stuck in the throat now. So those are your alarm symptoms, things you need to look out for. Otherwise, the diagnosis is pretty straightforward as far as the history and exam, just heartburn, maybe a cough at night, you know, sour taste in the mouth. As far as diagnosis, initially, it's going to be a clinical diagnosis. They're going to come in. They're going to come in with normal heartburn symptoms. And you're going to give them a trial of PPI. So proton pump inhibitors. You do this for about eight weeks. And if their symptoms resolve, you know, it's just standard GERD and you can

treat them with PPI's. If their symptoms don't get better after eight weeks of PPI's, then you need to go a little bit further with a diagnosis. So there's a couple other ways you can do this. One of them is with something called esophage.eomonometry. And this is a small catheter that's inserted in into the nasal cavity. It goes down through the nose into the lower softagel sphincter all the way through the LES into the stomach. And it's pressure sensitive and it can transmit date over 24 hours, which can indicate the strength or lack thereof of of the lower sulfadil sphincter. So it's going through the LES into the stomach. They monitor it for 24 hours. And then they can see how hard the LES is clamping down on this catheter. And a normal range for a person without GERD is about

10 to 45 millimeters of mercury. Anything less than 10 indicates GERD. So all this is is a pressure sensitive tube that goes through the LES and indicates how strong the LES is clamping up against this, this catheter. And again, this is only in refractory patients that don't get better with PPI's and you really want to make the official diagnosis. Now, there's another way to diagnosis at well as well. And this is going to be your gold standard. So if they ask you on a vignette, what is it the best way, the most sensitive, specific way to diagnose GERD, 24-hour pH monitoring. So kind of similar to the esophageal monometry in the sense that you have another catheter going through the nose. But this time the probe, instead of going into the stomach through the LES, is actually going to sit about five centimeters above the lower esophageal sphincter.

And what it does is it just monitors the pH above the LES in the esophagus, where normally the pH should be about 4 to 7. and it shouldn't be very acidic. And if anything's less than 4 pH, this indicates there's some acid in the esophagus and would indicate a lower esophageal sphincter insufficiency. So all this is, again, is it's going to be a probe, goes into the esophagus, sits above the LES, and monitors the pH for about 24 hours. Anytime they see anything less than 4, this is indicating some acid is coming up and you have some GERD going on.

So that's going to be your gold standard way. And then in refractory patients or patients, with alarm symptoms, you can do an endoscopy just to rule out more serious causes like cancer and things like that. So endoscopy isn't going to be your first line. It's really going to be down the line. These patients are refractory, not getting better. So how do you treat these patients? Well, initially you want to try lifestyle modifications. There's a few different lifestyle modifications that you can attempt. First big one is going to be weight loss. That's a huge one. The other thing that you can try with these patients is to elevate the head of the bed.

make sure that they're not eating two to three hours prior to bedtime. And then you want to avoid certain foods and certain dietary triggers, caffeine, chocolate, spicier high fat foods, peppermints, all of these foods can delay gastric emptying. And interestingly enough, peppermint can actually relax the lower esophageal sphincter. And the reason why, like a lot of restaurants and places like that give you peppermint after you eat is because in addition to relaxing the LES, it also relaxes almost the entire digestive symptom. It relieves spasms in the gut. It decreases per stalsis, which generally makes you feel more comfortable after a large meal, but it also decreases pressure of the LES, so it can actually lead to GERD. So that's one of the many foods that you want to

avoid in these patients. And then also smoking in alcohol because both of these can decrease LES sphincter pressure. So those are the things you want to try when you're initially treating these patients. But most of the time these patients come in, they're not going to want you to tell them don't eat spicy foods or fatty foods. They want medications. So the medications that you're going to use initially in mild intermittent cases. So this is going to be less than two episodes per week. You have your in acids they can use as needed. You have your H2 receptor antagonists like Fomodidine or anidididine.

I went over a way to remember that before in the previous podcast. So they all end in tidine or tidine. And I think about two dine, dine. like you're dining. That's why you get heartburned. So Tidine or Tudine, that's how I remember the H2 receptor antagonists. But something about these H2 receptor antagonists that make them not the best medications is normally about after two to six weeks, many patients experience called tachyphylaxis. And this is basically when a medication decreases in efficacy. And after about two to six weeks, these H2 receptor antagonists don't work as well. So it's something you can try temporarily, but

not for long term and ad acids as well. In severe or frequent symptoms, patients having two or more episodes a week, you want to go to your PPI's. That's going to be your best medication. That's going to block the hydrogen potassium ATP-Pase pump. It's going to completely shut down acid production for the most part. And these are going to be for patients who fail lifestyle treatment, fail H2 receptor antagonists. That didn't work for any of the other things. PPI's are going to be really your best medication. And as far, as pharmacological treatment, it's going to be the best treatment that you have. It's the most potent pharmacological treatment.

And after about eight weeks, 86% of patients have a resolution of symptoms. If they fail PPI therapy, you're actually going to want to refer them to GI to see what else is going on. And refractory patients that don't respond to PPI's, H2 receptor antagonist, lifestyle changes. In addition to referring them to GI, another treatment that you can use is, something called a nissen or a nisen fund duplication. And this is where the fundus, which is the upper part of the stomach, is wrapped around the lower esophageal sphincter, sutured close, and it kind of tightens the LES. So you take the top of the stomach, wrap it around the lower part of the esophagus, the lower esophageal sphincter, and you tighten it closed, you suture it closed, and this

prevents the backflow of acid. So that's going to be your last line treatment for patients who don't respond to all of the medications and lifestyle treatments. So that's GERD. Those are things you need to know for GERD, let's go on to motility disorders. There's a few here. These are going to be Ackylasia, as well as, I'm trying to remember what the other ones are, hypercontractile, jackhammer, esophagus, and distal esophageal spasms. So these are all going to be motility disorders, not anything that's blocking, but actually a problem with the spasms of the esophagus. So let's start with Achalasia, which is going to be the, the, most important, I would say, for the boards, the one that seems the most, that come up most frequently.

And what Achalasia is, is an esophageal motor disorder where due to a degeneration or damage to the Auerbach plexus, which provides motor innervation to the esophagus. This is where all your nerve innervation is for the esophagus. It's damaged or, for whatever reason, it's degenerated. It's not working as well. And this is going to decrease or you're going to lose. perstalysis in the esophagus. So food isn't going to be pushed down the esophagus and it's going to impair relaxation of the lower esophageal sphincter. So foods aren't getting pushed down to the esophagus.

And even once they do reach, they slowly reach the stomach. The LES is clamped shut. It's not letting any food in. So this is going to be acalasia. As far as history and exam, these patients are going to have dysphasia. You're going to see this is going to be common in all of the motility disorders. Disfasia to both solids and liquids. And this is a key to rule out an obstructive cause, like a mass, or in an esophageal sphincter, other causes, because those are normally going to be only dysphasia to solids. Masses, of course, can evolve into liquids later on as they get larger. But typically, most obstructive causes or esophageal strictures and things like that are going to be just as solids,

whereas motilities are motility disorders like acalasia are going to be. dysphasias to both solids and liquids. So remember that. So that's going to be your most common presentation for these patients are going to have trouble swallowing, both solids and liquids. They may have regurgitation, retro sternal pain or pressure. They may have some weight loss. There's some of your more nonspecific things. But remember dysphasia solids and liquids. That's key. As far as diagnosing, esophageal monometry, again, like we went over before, is going to be your best test overall. And this is again, just like I went over before, you're going to have a flexible catheter.

It's going to be placed into one of the nairs and the nasal cavity down to the stomach. And then these patients are going to be given a couple different food products. There's one that's like a jello like substance. They'll give them some crackers. And while this pressure sensitive catheter is in the stomach down into the LES, they're going to have the patient swallow the food. And they're going to slowly pull the catheter up. So the pressure sensitive catheter is testing different areas of the esophagus. And as they pull it up, they're going to grade the muscle contractions at different segments of the esophagus.

So a positive test is just going to indicate that there's going to be esophageal aparstalysis. So they're not going to have these contractions throughout the esophagus. And also it's going to notice an incomplete relaxation of the lower esophageal spinker. So it's just going to be clamped down on this catheter. So that's going to be your best test for acalasia. Now, even though it's your best test, something else that you really need to know for the boards is going to be your barium swallow or your barium esophogram because it has one of those key terms that they love. So this is going to be a fluoroscopic procedure where the patient drinks barium. They visualize it on live x-ray.

And as it's followed down the esophagus, the key finding that you're going to see you need to know this is going to be a dilated esophagus. So nice, wide open and patent esophagus that all of a sudden narrows and tapers off at the lower esophagus. to this beak-like appearance known as a bird beak appearance. Remember that. So a bird beak or tapered off on a barium swallow is key. So remember that the pants isn't really using these key terms anymore. So they're not going to say bird beak appearance, but they're going to say like a tapered off appearance or narrowing at the LES. You need to know that. That's really important. So barium swallow tapered off appearance or a bird beak appearance is going to be key. And that's because of the lower esophageal sphincter not relaxing.

It's clamped down. So the barium's getting through this thin area, this tapered off area. And then endoscopy isn't really used for diagnosis, but it's used just to rule out if you have any suspicion that this may be caused from cancer. So that's what an endoscopy. So not really a big place to diagnosis. Really, it's going to be your esophageal monometry and your barium swallow. But your gold standard, your best one is going to be your sophageal monometry. As far as treatment.

So definitive treatment, I'll go over that in a minute. Initially, you're going to use calcium channel blockers, which is going to relax the smooth muscle, like nipetapine, varapamil, and nitrates can be used as well. And then Botox injections can be used. But those have to be repeated every six to 12 months. Now, that's what you can use initially. And it can also be a bridge to definitive treatment maybe for the few months before these patients have surgery or in patients who are non-surgical candidates.

But your more definitive options, you have a couple different ways. So there's something called a pneumatic dilation. and this is going to be a forceful dilation that uses this pneumatic balloon. They push it down into the esophagus, into the lower esophageal sphincter. They inflate this balloon and it essentially stretches and weakens the lower esophageal sphincter muscle fibers. And it normally needs to be performed multiple times. And it's not always definitive.

Sometimes it doesn't work. They need to do it a few times. But essentially, pneumatic dilation is a balloon. They put it into the lower softogel sphincter. they blow it up, stretch out the muscles to weaken them so that you don't have this clamping down. So that's one option. But the better and really definitive treatment, the definitive surgical treatment for acalasia is going to be something known as a cardiomyotomy, also known as a esophagomyomyomyomy. This is a procedure where the strength of the lower esophageal muscle fibers

is weakened by the surgeon cutting through some of the muscle fibers in the lower self-ogeal sphincter. And this is normally performed via a laparoscopic approach. But that's going to be your definitive. It's going to be a cardiomyotomy. And that's just cutting through the LES to weaken the muscles. So this is a couple other options. Remember, calcium channel blockers you can use first, Botox and nitrates as well.

Momatic dilation where your more invasive procedure. And then your best procedure is going to be your cardiomyotomy. That's going to be the cutting of the LES. Now moving on to something else known as a distal esophageal spasm. It was previously known as a diffuse esophageal spasm. And this is going to be due to impaired inhibitory innervation of the esophagus. So it's basically the esophagus, since there's no inhibition of the contractions, it's contracting frequently uncoordinated.

So normally peristosis of the esophagus is the sequential, coordinated, contraction, traveling the length of the esophagus, all the way at the top, all the way down to the distal esophagus into the stomach. But in distal esophagiospasms, it's just squeezing and pumping like crazy. It's just having all these contractions completely uncoordinated. Again, these patients are going to have dysphasia to both solids and liquids, like I said, all motility disorders. Just like in acalasia, they may have retosternal non-cardiac chest pain. They also may have sensation of food being stuck in the esophagus because you're not having this sequential contraction so it may just be stuck somewhere in between. So again, this is just going to be

an uncoordinated spasm of the esophagus. And diagnosing, again, you can do monometry, just like you did in eccalasia. That's going to be your most sensitive and specific test, which is going to show an increase in these premature contractions in the esophagus, primarily in the distal oesophagus, like it says in the name. Now, barium esophagram, not as important as it was in eccalasia, but it does have another one of those key terms that you need to know. So if you do a barium esophogram, there's something called a corkscrew appearance. And this is due to these wild contractions of the esophagus. It's going to show the lumen of the esophagus bending in and out, and it's going to look like a corkscrew on a barium esophagram. So remember that, really you're

going to diagnose them with monometry, but that barium oesophagus. You need to know that key term, corkscrew appearance on imaging. Treatment, just like before, calcium channel blockers are going to be your first line pharmacological treatment. In particular, dilettiasm works really well. And you normally do this for about three months, then you reassess the symptoms. If they're still having symptoms, you may need to move on to other medications. Low dose tricyclic antidepressants like amypramine in patients unresponsive to calcium channel

blockers you can use in these patients as well. And then if these patients are refractory, you can do Botox injections as another option. But typically, unlike Achalasia, these patients, you can normally manage pharmacologically. So calcium channel blockers is going to be your first line. Just remember that. That's the really important one. And then TCA's or Botox injections for refractory patients, but calcium channel blockers for the distal esophageal spasms. Now moving on to the last one, this is known as hypercontractile. It actually has a lot of names. So hypercontractile, esophagus, also known as jackhammer esophagus, also known as nutcracker esophagus. So this is going to be a normal contractions of the esophagus, but they're really high pressure.

So just think of your esophagus on steroids. So it's functioning properly. You're having normal esophageal perastasis running normally, but it's really strong. So high pressure, but normal sequential contractions of the esophagus. history and exam, what do you think is going to happen? Dysphagia to both liquids and solids, and they may have retro-sternal chest pain. So all of these motility disorders present pretty much the same way. Diagnosing, again, what do you think is going to be your most sensitive and specific? I'll give you a second to think about it. Monometry. So what monometry is going to show,

straightforward, it's just going to show an increased strength or pressure of the esophageal contractions. And as far as treatment, again, just like we went over before, calcium channel blockers are going to be your first line. Further down the line, refractory patients, TCA's, nitrates, Botox injections, but calcium channel blockers, first line. So just remember that. Hypercontractal esophagus is really easy and straightforward. Just high pressure contractions.

History and exams are the same as all the other ones, diagnosed monometry, treatment calcium channel blockers. So most of these motility disorders are pretty similar in presentation. Accolation is going to be the only one you take to surgery normally. The other ones you can manage pharmacologic. So that is going to be the first part of the esophagus series that I'm going to do. I'm going to do one more to go over the rest of the stuff we didn't go over today. But that's going to be the stuff I feel like you really need to know.

And then I'll go over part two within the next coming day. So again, thank you so much. Good luck on your pants, your panery or EORs and good luck in PA school.