esophageal disease

1. Esophageal disorder

2. A. Esophagealperforation
B. Boerhaave & malloryweiss syndrome
C. Diffuse esophagealspasm
D. Barett esophagus
E. Achalasia
F. Zenker diverticulum
G. Plummer vinsonsyndrome
H. Hiatal hernia
I. Esophagitis
J. Esophagealcancer
K. Scleroderma

3. Dysphagia is the essentialfeature of the majority of
esophagealdisorders.
Dysphagia means difficulty swallowing.Odynophagia
is the proper term for pain while swallowing. Both
dysphagia and odynophagia canlead 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.
Whenany of these alarm symptoms are present,
endoscopyshould be performed to excludecancer.

4. Alarm symptoms indicating endoscopy include:
• Weight loss
• Blood instool
• Anemia

5.  is due to the rapid increasein intraesophageal
pressure combined withnegative intrathoracic
pressure causedbyvomiting.
 Perforation of the esophaguscanpresent with:
•Severeand acute onset of excruciating retrosternal
chest pain
• Odynophagia
•PositiveHammansign, acrunching heard upon
palpation of the thorax due to subcutaneous
emphysema
• Painthat canradiate to the left shoulder

6. Boerhaave syndrome is afull thickness tear
secondaryto extreme retching andvomiting.
It is most commonly tested in the setting of
an alcoholic.Themost common location is at
the left posterolateral aspect of the distal
esophagus.
Mallory-Weiss syndromeis amucosal tear
and is also due to vomiting.
It is not aperforation.Themost common
location is at the gastroesophageal junction.

7. Surgical exploration with debridement of the
mediastinum and closure of the perforation is
an absolute emergency.
Mediastinitis isacomplication that carriesa
very high mortalityrate

8. A 53-year-old obese man presents with sudden onset of
abdominal pain that radiates to his right shoulder. The
patient alsosayshe hasvomited blood earlier in the day.
The patient has afull bottle of esomeprazole in his
pocket and sayshe usesthose for his heartburn. Physical
examination reveals rebound tenderness in the
midepigastrum. Upright chest x-ray shows air under the
diaphragm.
What isthe most likely diagnosis?
a.Gastricperforation
b. Hemorrhagic ulcer
c.Cholecystitis
d. Ischemic colitis

9. Answer:A.This is gastric perforation in the setting
of peptic ulcer disease.The patient's bottle filled
with PPisis due to his history of ulcers. The fact
that it is afull 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 pain
that is out of proportion to physical findings.

12. Submucosal dissection of the
esophagus in patient with
endoscopy for ERCPand"difficulty
passing scope." Gastrografin
swallow demonstrates intramural
dissection of the esophagus from
submucosal passage ofendoscope
with appearance similar to aortic
dissection and "true and false
lumen." Arrows point to "false
lumen" created by passage of
endoscope.

13. esophagram depict contrast extravasation
from the distal esophagus in a patient with
spontaneous perforation of the esophagus

15. A 20-year-old female presents to the hospital with severe
chest pain. Shestates that the pain started suddenly and is
retrosternal in nature.The pain began shortly after lunch and
is worse with swallowing. Shehas no prior medical history
except for abrief inpatient stay for what shedescribesasan
"eating disorder." On exam her vitals are asfollows: HR120,
RR22,BP145/90.Sheisflushed and taking deep breaths.
Which of the following is the best confirmatory test for the
most likely causeof this presentation?
1.Chestx-ray
2. EKG
3.Gastrografin esophogram
4. Barium esophogram
5.Observation

16. DISCUSSION:The patient in this vignette may be suffering from
an esophageal rupture (Boerhaave's syndrome) asaresult of
repeated induced vomiting. Astime is essential in treating
esophageal ruptures, the most appropriate step is awater-
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 achestCT
(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 usedbefore barium studies.

17. incorrectAnswers:
Answer 1:Chestx-ray isnot the best test for
esophagealruptures.
Answer 2:An EKGis not an unreasonabletest here but
not the best choicewhen esophagealrupture must be
ruled-out.
Answer 4: Barium esophogram is not the first line
choice of contrast agents used in suspected
esophagealruptures to avoid barium associated
inflammation ofthe mediastinum.
Answer 5:Observation would not be appropriate and
may have potentiallydevastating consequences.

18. Gastrografin
esophogram

19. A 19-year-old female college freshman
presents to the hospital with severe
retrosternal chest pain that is aggravated by
swallowing.Sheappearsflushed andis taking
long ,deep breaths. Her friends report that
shegot sick after afraternity party and has
not beenfeeling well eversince

20. Spontaneous, full-thickness rupture of the
distal thoracicesophagus
Associated with vomiting
often following consumption of large
quantities of alcohol in young people
Canoccur during endoscopicexaminations
(75%of adultcases)
Serious complication ofbulimia

21. Symptoms
sudden-onset, severe, retrosternalchest pain
difficulty orpainful swallowing
hematemesis
though more common in Mallory-Weiss
tears
Physical exam
pleuritic chestpain
hyperventilation
tachycardia

22. ChestCT
left-sided hydropneumothorax
pneumomediastinum
esophagealthickening
Contrast studies
may showleakagefrom esophagealtear
usewater-soluble contrastagent
(Gastrografin)

23. Medical management
conservativetherapy
indicated in mild caseswith 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 ofperforation
considered standard ofcare
indicated depending on severity of tear and timing of
diagnosis

30. The most accurate test is an esophogram
using diatrizoate meglumine anddiatrizoate
sodium solution (Gastrografin; Bracco
Diagnostics, Princeton, New Jersey); it will
show leakage of contrast outside of the
esophagus.
Barium cannot be usedbecauseit is caustic
to thetissues.

31. Mallory-Weiss tear presents with upper
gastrointestinal bleedingafter prolonged or severe
vomiting orretching.
Repeated retching is followed by hematemesisof
bright red blood, or by black stool.
MalloryWeissdoesnot present with dysphagia.There
is no specific therapy, and it will resolve
spontaneously.
Severecaseswith persistent bleeding are managed
with an injection of epinephrine to stop bleeding or
the useof electrocautery. Boerhaave syndrome is full
penetration of the esophagus.

32. A 47-year-old man presents to the
emergency room saying that he is having a
heart attack. Hereports 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

34. Strong, non-peristaltic contractions of the
esophagealbody
Often precipitated by by ingestion of hot
and coldliquids
Patients havenormal sphincter function
Associated withGERD

35. • Symptoms
• symptoms may occur following ingestion of cold
liquids andinclude
• difficulty swallowing
• painful swallowing
• sudden onset chest pain not related to exertion
• spontaneousandradiated to back,ears,andneck
• Physicalexam
• symptomatic relief withnitroglycerin

36. Evaluation
•Upper GI/esophageal contraststudy
• shows "corkscrewesophagus"
•Manometry
• may show high-amplitude,
simultaneous contractions (non-
peristaltic)
•Endoscopy - normal
•EKG- normal
•Stress test -normal

37. Medical management
symptomatic relief
antacids forGERD
nitrates forchest pain/spasms
calcium channelblockers
Surgical intervention
long esophagomyotomy
indicated for severe,incapacitating
symptoms

38. 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 EMSand was given
325mg aspirin, sublingual nitroglycerine,and supplemental
oxygen in the field resulting in near resolution of his
symptoms. In the ED,his examis completely unremarkable
except for aheart rate of 110bpm. EKGshows sinus
tachycardia, troponin and CK-MB are within normal limits,
and stress test is normal. The medical team next looks to
non-cardiac causesfor the patient's chest pain. Given the
most likely diagnosis, which of the following could be seen
on upperGIcontrast study?

39. A
B
C

40. D
E

41. Sudden chest pain following ingestion of cold water and relieved with
nitroglycerin is classic of diffuse esophageal spasm. If performed during
an episode, upperGIcontrast study will show the "corkscrew" esophagus
shown in FigureE.
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 ahistory 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
GIstudy 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.

42. Figure A shows ahiatal hernia. Rugaeof the
stomach canbe seenin the herniated contents.
Figure Bshowsastricture of the esophagusin a
patient with Barrett's esophagus.
FigureCshowsthe classicbird beak and
proximal dilatation of apatient with achalasia.
Figure D showsafilling defect in apatient with
esophagealcarcinoma.
FIgure Eshows the classic corkscrewesophagus
in apatient experiencing an acute episode of
diffuse esophagealspasm.

43. Answer 1:Hiatal hernias canpresent with GERD
and/or chest pain, or they canbe asymptomatic.
They are not associated with sudden pain
relieved bynitroglycerin.
Answer 2: Esophagealstricture 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 weightloss.
Answer 4: Esophageal carcinoma usually
presents withdysphagia and lymphadenopathy.

44. Metaplasia of the squamouscell architecture
of the esophagusto glandular architecture
A complication of chronicGERD

45. Biopsy
glandular metaplasia of distal esophagus
presenceof stomachacid resutls in
conversion of normal squamous cells into
columnar andgoblet cells (normally found in
stomach and smallintestine)

47. Ulceration leading to formation of stricture
Increasedrisk of esophageal adenocarcinoma

48. A 45-year-old man
presents to his primary
care physician
complaining ofdifficulty
swallowing solids and
liquids. He also reports
unintentional weight
loss.

49. Motor disorder of the distal esophaguscaused
by degenerationof Aurbach'splexus
 the most common motility disorder
Pathophysiology
 autoimmune process causesloss of NO-producing
neurons which normally relax the sphincter muscles
▪ association with HLA-DQw1
 leads to failure of the LESto relax during swallowing
 results in loss ofperistalsis

50. Associatedwith
 Chagas'disease
▪ amastigotes destroy ganglioncells
 scleroderma
▪ presents in 70%ofthese patients
Epidemiology
 more common in people under 50years of age

51. Symptoms
 dysphagia forsolids and liquids
▪ usually worse forliquids
 weight loss

52. Barium swallow mayshow
 narrowing of the distal
esophagus
 loss of peristalsis in the distal
two thirds
 dilated proximalesophagus
 classic "bird's beak"tapering
at theesophageal sphincter

53. most accuratetest that may show
increased LESpressure
inability of LESto relax
decreasedperistalsisin the esophageal body
diffuse esophagealspasm

55. useful in excluding secondary causesof
achalasia (i.e.malignancy)
useto rule out malignancy
shows normalmucosa

56.  medications to reduceLES tone
▪ nifedipine
▪ nitrates
▪ CCBs
▪ botulinum toxininjections
▪ wears off in approximately 3-6 months
▪ requires reinjection

57.  endoscopic balloon dilation of LES
▪ cures80%
▪ leadsto perforation in <3%of patients
 myotomy withfundoplication
▪ more effective and dangerous than
pneumatic dilation

58. Prognosis
 medical and surgical outcomes are similar
 often require multipletreatments
Prevention
 no preventive measures are available at this time
Complications
 esophageal malignancy secondary toBarrett's
esophagus secondary tochronic GERD

59. A 29-year-old female presents to general medical clinic with
dysphagia. Her symptoms began several months ago. Shehas
trouble swallowing solids and liquids though liquids seem to
makeher choke and sputter the most; therefore, shehasbeen
unable to eat and hasthus experienced significant weight loss.
Shehas no significant past medical history apart from a20-
pack-year smoking history. Shedenies any recent travel. Vital
signs are stable. Physical examination is within normal limits.A
barium esophagram showsthe following (FigureA).
Subsequent esophageal manometry reveals elevated resting
lower esophageal sphincter pressure, incomplete lower
esophageal sphincter relaxation after swallowing, and almost
total absenceof peristalsis in the esophageal body.What is the
next best step in management?

60. 1. Begin acalciumchannel
blocker
2. Begin botulinumtoxin
injections
3. Endoscopic balloondilation
of the lower esophageal
sphincter
4. Upperendoscopy
5. Myotomywith
fundoplication
fIGURES:A

61. DISCUSSION: In diagnosing achalasia, one must first rule out
malignancy with an endoscopic evaluation. After a barium swallowand
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 managementconsisting
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.

62. IncorrectAnswers:
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 anupper endoscopy.

63. 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. Hehasno significant past medical history.Travel
history reveals arecent trip to South America but no other
travel outside the UnitedStates.Vital signsare stable.
Physical examination is within normal limits. He has no
palpable masses.What is the next step in management?
1.Upper endoscopy
2. Barium esophagram
3.Esophageal manometry
4. CTof thechest
5.Administer nifurtimox

64. DISCUSSION:This patient presents with signsandsymptoms concerning
for achalasia, possibly due to Chagasdisease.A barium esophagram is
the next step in management and shouldprecede endoscopyin patients
with dysphagiaand abroad differential diagnosis.
Recallthat achalasiais amotor disorder of the distal esophagusresulting
from degeneration of Auerbach's plexus where lower esophageal
sphincter fails to relax during swallowing. Asaconsequence, 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 hasbeen associated with Chagasdisease, where the parasitic
amastigotes destroy ganglioncells.
A barium esophogram is helpful in making the diagnosis and should
reveal the classicbird's beak tapering at the esophagealsphincter(see
Illustration A). Diagnosis is eventually confirmed with esophageal
manometry.

65. IncorrectAnswer:
Answer 1: Upper endoscopy would be more costly than barium
esophagramand is not the preferred next step in management in
dysphagia.
Answer 3:Esophagealmanometry may be usedto confirm a
diagnosis of achalasiabut should not be the next step in
management.
Answer 4: CTof the chest is not needed in the diagnosis of
achalasiabut could be warranted if malignancy were the causeof
this patient'sdysphagia.
Answer 5: Nifurtimox is successful in treating Chagasdisease
which is caused by Trypanosoma cruzi and transmitted by the
Reduviidbug. However, diagnosis should be made by blood smear
before treating thispatient.

66. A66-year-old woman presents to your outpatient clinic for her
regular checkup. During the visit, shetells you that shefeels "in
great health," with the exception of some recent trouble
swallowing. Further questioning reveals that she hasdifficulty
swallowing solids and liquids. These symptoms have been
worsening slowly for the past 5months. Vital signs are within
normal limits, but her weight hasdecreased by 12pounds since
her last visit 6 months ago. Barium swallow reveals smooth
tapering of the distal esophagus (Figure A). Which of these
choicesis the most appropriate next step in management?
FIGURES:A
1.Nifedipine
2. High-calorie nutritionalsupplementation
3.Botulinum toxininjection
4. Surgical myotomy
5.Upper GIendoscopy

67. 5
DISCUSSION:This patient presents with the classic signs and
symptoms of achalasia. Upper GIendoscopy to rule out
malignancy is indicated prior to treatment in casesof suspected
achalasia.
Achalasia is adisorder of esophagealmotility 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.
Esophagealmanometry and pH monitoring are also usedin the
diagnosis of thiscondition.

68. IncorrectAnswers:
Answer 1: Calcium channel blocker administration may help
decrease lower esophageal sphincter pressure and easethe
symptoms of achalasia;however, malignancy must be ruled out
first throughendoscopy.
Answer 2: High-calorie nutritional supplementation is
inappropriate in this case,asher weight lossis most likely caused
by aGIcondition suchasachalasiaor malignancy.
Answer 3: Botulinum toxin administration may help decrease
lower esophageal sphincter pressure andeasethe symptoms of
achalasia;however, malignancy must be ruled out first through
endoscopy.
Answer 4: Surgical myotomy is indicated for treatment of
achalasiain many patients; however, malignancy must first be
ruled out throughendoscopy

69. 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
unbearableupon arrival to the ED.Sheis also
noted to haveapalpable, fluctuant neck mass
on physicalexamination.

71. 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
suggestedthe causesto be related to structural or
physiological abnormalities of the cricopharyngeus
Epidemiology
 incidence unknown
 most often occursin agegroup (>70yearsold)

72. Symptoms
dysphagia
regurgitation
choking
chronic cough
bad breath(halitosis)
Physical exam
palpable, fluctuant neckmassmay be
appreciable

73. Diagnosis is basedhighly on clinical
observations and patienthistory
Avoid upper endoscopy if known or highly
suspiciousdue to risk of rupture
Barium swallow
- confirms diagnosis by visualizing pharyngeal
outpouch

74. myotomy ofcricopharyngeus muscle
-with diverticularesection
- endoscopichasbetter successrates compared
to externalapproach

75. Complications surgery canlead to significant
complications including death given location
of lesion and age/health of average patient
population with this pathology
-may developcarcinomawithin the pouch if not
resected

76. A 78-year-old male presents to clinic with achief
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
diagnosis
2.Upper endoscopy
3.Chestradiograph
4. Barium swallow
5.Manometry

77. 4
DISCUSSION:This patient is experiencing aZenker's diverticulum
(ZD).Clinical observations, history, and abarium swallow study are
the keysneeded to make this diagnosis.
Zenker's diverticulum is acondition characterized by afalse
diverticula of the esophagus. The pathophysiology of this
condition includes apulsion 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 aneck mass, but will often include halitosis secondary to
trapped foodparticles.

78. 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 usedin the diagnosis of
Zenker's diverticula.
Answer 3:Although achest radiograph would be used in
the overall workup, in order to diagnosis Zenker's
diverticula, abarium swallow study must be performed.
Answer 5: Manometry would be the appropriate choice for
ayounger patient experiencing dysphagia that also
perhaps some regurgitation but less fetid breath in the
caseof achalasia.The demographics of this casebetter fit
ZD

79. llustrationA is a lateral view of a barium
study showing aZenker's diverticulum.
Illustration Bisan artists rendition of a
diverticulectomy.

80. Illustration Cis an artists rendition of a
diverticulopexy.

81. A 63-year-old woman with chronic anemia
presents to her primary care physician
complaining of difficulty swallowing. An
upper endoscopy isordered.

82. Small, thin web-like tissue growth partially
obstruct theupper esophagus
Characterized by atrophic glossitis, esophageal
webs, andanemia
Etiology unknown
Epidemiology
 most commonly observed in elderly woman
 associatedwith chronic iron-deficiency anemia
Patients at increased risk of developing
squamouscell carcinoma of the esophagus

83. Symptoms
difficulty swallowing
chronic cough
weakness/malaise
nail changes
Physicalexam
atrophic glossitis
esophageal webs
anemia
spoon naildeformitie

86. Diagnosis canbe aided by clinical observations,
including skin and nailchanges
Upper endoscopy
- may identify esophagealwebs
CBC
- may indicated chronic anemia
Festudies
- show Fedeficiency

87. Fesupplementation
 indicated to treat chronic anemia state
esophageal dilation
 canbeperformed concurrently with upper
GIendoscopy ormanometry
 most commonly donewith radial expansion
balloon method

88. Prognosis
 most patients respond to treatment
Prevention
 Fesupplementation in patients with known anemia may
prevent webdevelopment
Complications
 bleeding may occur secondary to esophageal tear during
dilation
 esophagealcarcinoma

90. A 45-year-old man presents to the emergency
room with chest pain, difficulty swallowing, and
heartburn after meals, especially when
reclining.

91. Herniation of the stomach through the diaphragm into the chest cavity
TypeI
 sliding hiatalhernia
most common type(>95%)
occurs at theGEjunction
stomach slides into the mediastinum
TypeII
 paraesophageal hiatal hernia(<5%)
herniation of stomach fundus through diaphragm
GEjunction remains belowdiaphragm
parallel tothe esophagus
Associatedwith GERDin 80%of sliding hiatal hernia cases

93. Symptoms
may be asymptomatic,usually identified
incidentally onradiography
chest pain
heart burn
GERD
Physical exam
usually no significantfindings

94. Barium swallow
- may observe stomach in chestcavity
Usually an incidentalfinding

96. Medical management
symptom management andlifestyle
modifications
indicated in type I (sliding hiatal hernias) to
relieve GERDsymptoms
antacids
weight loss


 dieting
Surgical intervention -surgicalrepair
 indicated in type II (paraesophageal cases)due
to risk of strangulation

97. Prognosis
treatment relieves mostsymptoms
Prevention
lifestyle modifications canprevent symptoms
Complications
aspirate pneumonia
gastric strangulation
iron-deficiency/malnutrition

98. Schatzki ring is
associated with
intermittent dysphagia
and is treated with
pneumatic dilation inan
endoscopicprocedure
Schatzki ring is often from acid
refluxand is associated with hiatal
hernia.This is a type of scarringor
tightening (also called peptic
stricture) of the distal esophagus.
"Steakhouse syndrome"=
dysphagia from solid food
associated with Schatzki
ring

99. CorrosiveEsophagitis
Causedby ingestion of strongly acidicor basic
chemical
Lye,HCl
Resultsin
esophageal perforation
esophageal strictureformation
Often seenin suicideattempts or in the
pediatricpopulation

100. Infectious Esophagitis
•Commonly seeninAIDSpatients and
the Immunocompromised
•May be viral or fungal
• HSV(punched outlesions on EGD)
• CMV(large solitary ulcersor
erosions onEGD)
• Candida (whitemucosal plaque-
like lesions onEGD)
•Odynophagia is mainsymptom

101. A43-year-old man recently diagnosedwithAIDScomes
tothe emergency department
with pain on swallowing that hasbecome progressively
worse over thelast
severalweeks.There isno pain when not swallowing. His
CD4count is 43mm3•
The patient is not currently taking any medications.
What is the most appropriate next step in management?
a. Esophagram
b. Upper endoscopy
c.Oral nystatin swish andswallow
d. Intravenous amphotericin
e.Oral fluconazole

102. Answer: E.The most commonly asked infectious
esophagitis question is esophagealcandidiasisin aperson
withAIDS.Oral candidiasis (thrush) need not be present in
order to have esophageal candidiasis. One does not
automatically follow from the other.
Although other infections suchasCMVand herpescanalso
causeesophageal infection,over 90% of esophageal
infections in patients withAIDSare causedbyCandida.
Empiric therapy with fluconazole is the best course of
action. If fluconazole does not improve symptoms, then
endoscopyis performed. Intravenous amphotericin is used
for confirmed candidiasisnot responding to fluconazole.
Oral nystatin swishand swallow isnot sufficient to control
esophagealcandidiasis.Nystatin treats oral candidiasis.

103. Thesepills causeesophagitis if in prolonged
contact:
• Doxycycline
• Alendronate
• KCI

104. "What Is the Most Likely Diagnosis?"
Look for:
• Age 50orolder
•Dysphagia first for solids, followed later
(progressing) to dysphagia for liquids
•Associationwith prolonged alcohol and
tobacco use
• More than 5-10yearsof GERDsymptoms

106. 1.Endoscopy isindispensible, sinceonly abiopsy can
diagnose cancer.
2.Barium might be the "best initial test," but no radiologic
test can diagnosecancer.
3.CT and MRI scansare not enough to diagnose esophageal
cancer; they are used to determine the extent of spread into
the surroundingtissues.
4.PET scan isusedto determine the contents of anatomic
lesionsif you are not certain whether they contain cancer.
PETscanis often used to determine whether acancer is
resectable. Local disease is resectable, and widely
metastatic disease isnot.

107. 1.No resection (removal) =no cure.Surgical
resection is alwaysthe thing to try.
2.Chemotherapyandradiation areusedin
addition tosurgical removal.
3.Stent placement isusedfor lesions that
cannot beresected surgically just to
keepthe esophagusopen for palliation and to
improve dysphagia

108. Thesepatients present with symptoms of reflux
and have aclear history of scleroderma, or
progressive systemicsclerosis.
Manometry shows decreased lower esophageal
sphincter pressure from an inability to close the
LES.
Themanagementis with PPisasit would be for
any personwith reflux symptoms.
Thedisorder is simply one of mechanical
immobility of the esophagus.

109. Esophageal smooth muscle
atrophydecreaseŽ•LESpressure and
dysmotility Žacidreflux and dysphagia
stricture,Barrett esophagus, andaspiration.
Part ofCRESTsyndrome.

110. TIP
Manometry is the answerfor:
oAchalasia
o Spasm
o Scleroderma