Gastroenterology
Esophageal Disorders
Gastroenterology

Esophageal Disorders

GERD, Barrett, Zenker, achalasia, infectious, pill esophagitis.

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◆GERD

  • •Substernal burning + regurgitation + worse after meals/lying down
  • •Without alarm features → empiric PPI 8 weeks + lifestyle
  • •Alarm features (weight loss, GI bleed, anemia, persistent vomiting, dysphagia, age >60) → endoscopy
  • •Risk factors for Barrett: chronic GERD + male + >50 + white + obesity + smoking + FH
  • •PPI doesn't eliminate Barrett cancer risk; surveillance still needed

◆Barrett surveillance

  • •No dysplasia: EGD q3–5 years
  • •Low-grade dysplasia: EGD q6 months
  • •High-grade dysplasia: endoscopic eradication (RFA or EMR)
  • •Surgery (Nissen fundoplication) treats reflux but NOT cancer risk

◆Dysphagia differential

  • •Oropharyngeal: cough, choke, nasal regurgitation; stroke/PD/ALS/MG → video swallow study (modified barium swallow)
  • •Esophageal mechanical (solids → liquids progression): EGD; cancer, stricture, ring
  • •Esophageal motility (solids + liquids together): achalasia, scleroderma, DES → barium swallow + manometry

◆Achalasia

  • •Solids + liquids dysphagia at onset
  • •Degeneration of myenteric (Auerbach) plexus
  • •Impaired LES relaxation + absent peristalsis
  • •Barium: 'bird's beak'; manometry confirms; EGD to exclude pseudoachalasia
  • •Treatment: Heller myotomy, POEM, or pneumatic dilation; botox/CCB/nitrates if not surgical

◆Zenker diverticulum

  • •Elderly + dysphagia + halitosis + regurg undigested food hours later + gurgling neck mass
  • •Outpouching at Killian triangle (cricopharyngeal)
  • •Barium swallow FIRST (do NOT scope first — perforation risk)
  • •Cricopharyngeal myotomy + diverticulectomy or endoscopic stapling

◆Infectious esophagitis (HIV)

  • •Mild + thrush → empiric fluconazole
  • •Severe or no thrush → EGD with biopsy
  • •Candida: white plaques → fluconazole
  • •CMV: large linear distal ulcers → ganciclovir; owl's eye inclusions
  • •HSV: small punched-out (volcano) ulcers → acyclovir; multinucleated giant cells
  • •Aphthous: idiopathic → symptomatic

◆Pill esophagitis

  • •Culprits: bisphosphonates, NSAIDs, tetracyclines, KCl, iron
  • •Take with full glass of water + upright 30 min
  • •Stop offending drug + PPI

◆Caustic ingestion

  • •Alkali (drain cleaner): liquefactive necrosis → deep penetration
  • •Acid: coagulative; more stomach injury
  • •Never induce vomiting or give charcoal
  • •Emergent EGD within 12–24 hr to grade injury
  • •Long-term: stricture, squamous cell carcinoma years later

◆Mallory-Weiss vs Boerhaave

  • •Mallory-Weiss: mucosal tear at GE junction from retching → often self-limits
  • •Boerhaave: transmural rupture → pneumomediastinum + subcutaneous emphysema → emergent surgery
  • •Confirm Boerhaave with water-soluble (gastrografin) contrast, NOT barium
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