Test: Bleeding from GIT & Diseases of Esophagus- 2 - NEET PG MCQ

Achalasia is a rare motility disorder of the esophagus which results from lack of innervation of the lower esophageal sphincter muscles and leads to dilatation of proximal esophagus. Patients with achalasia presents typically with dysphagia, vomiting of undigested food and failure to thrive. Cough can be present in achalasia patients due to aspiration of food or due to airway compression by the dilated esophagus.

Medications commonly implicated in pill induced esophagitis are doxycycline, tetracycline, quinidine, NSAIDS and bisphosphonates.

• Compression of the oesophagus by the aberrant right subclavian artery is known as dysphagia lusoria
• Barium study of the esophagus may show the indentation on the posterior esophageal wall by the artery.
• Chest x-ray can demonstrate enlargement of the superior mediastinum.
• (CT angiography and MRI thorax are the best diagnostic modalities that could identify the arteria lusoria).
• Most patients with aberrant right subclavian arteries do not have symptoms. Some present with mild dysphagia, while a small minority have a severe enough disturbance in swallowing that leads to inability to swallow and severe nutritional problems.
• In children, the most common presentations are stridor and recurrent chest infections, may be due to their tracheal softening comparing to adult population.
• The diagnosis of dysphagia lusoria is always difficult and late as the symptoms are often nonspecific and in the same time, diagnostic endoscopy is negative in more than 50% cases, and manometry has no diagnostic role.

While it may be asymptomatic, Zenker diverticulum often causes clinical manifestations such as dysphagia (difficulty swallowing), and sense of a lump in the neck; moreover, it may fill up with food, causing regurgitation, cough (as some food may be regurgitated into the airways), halitosis, potential infection of the pharyngeal areas due to food stuck, and involuntary gurgling noises when swallowing. It rarely, if ever, causes any pain.

• The average age of patients with Barrett esophagus is 55-65 years. The condition occurs in a 2:1 male-to-female ratio, with white males making up more than 80% of cases.
• It is causes columnar metaplasia of lower esophagus and does not respond to any treatment.
• It is a premalignant condition diagnosed with UGIE with biopsy. The goal of surveillance is the detection of dysplasia or early cancer. Currently, dysplasia is the best histologic marker for cancer risk. Surveillance involves repeated upper endoscopy with systematic 4-quadrant biopsies at 2 cm intervals along the entire length of the segment of Barrett esophagus, with additional biopsy of any mucosal abnormalities.

Causes of pseudo-achalasia

1. Tumor infiltration, most commonly seen with carcinoma in the gastric fundus or distal esophagus can mimic idiopathic achalasia.
2. Rarely, pseudoachalasta can result from a paraneoplastic syndrome with circulating antineuronal antibodies
   1. Pseudoachalasia presents at young age, abrupt onset of symptoms (<1 year), and weight loss. Hence, endoscopy should be part of the evaluation of achalasia.
   2. When the clinical suspicion for pseudoachalasia is high and endoscopy nondiagnostic, CT scanning or endoscopic ultrasonography may be of value.
   3. Since barium swallow may not be able to differentiate achalasia from pseudoachalasia, UGIE and CT scan must be done for determining the cause as well as for staging.

Radiographically, a “corkscrew esophagus,” “rosary bead esophagus," is indicative of diffuse esophageal spasm.

• Non progressive dysphagia is seen in choice a and b while choice c and d have progressive dysphagia.
• Diffuse esophageal spasm presents with non cardiac chest pain and globus (something stuck in the throat). Pain may be associated with eating quickly or drinking hot, cold, or carbonated beverages. Patients with nutcracker esophagus or high-amplitude peristaltic contractions usually present with chest pain, as only 10% experience dysphagia.
• The hallmark symptom of esophageal rings and webs is dysphagia mainly to solid food usually is greater than dysphagia to liquid food. Since in this question cold drink is worsening and not improving the symptom of dysphagia, oeso-phageal web is a unlikely answer. When lumen diameter is less than 13 mm due to mucosal ring (Schatzk ring) episodic solid food dysphagia is seen

Complications of endoscopic therapy in barret esophagus should be divided into immediate and delayed outcomes. Immediate complications include bleeding and perforation. Delayed complications from ablative therapy include stricture formation.

Savary-Miller classification of reflux esophagitis. Grades 1, 2, 3, 4 and 5.
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• A reflux episode is defined as esophageal pH drop below four. Esophageal pH monitoring is performed for 24 or 48 hours and at the end of recording, patients tracing is analyzed and the results are expressed using six standard components.
• Of these 6 parameters a pH score called Composite pH Score or DeMeester Score has been calculated, which is a global measure of esophageal acid exposure. A DeMeester score > 14.72 indicates reflux.
• Components of 24-h Esophageal pH Monitoring (DeMeester scoring)
  • Percent total time pH < 4
  • Percent Upright time pH < 4
  • Percent Supine time pH < 4
  • Number of reflux episodes
  • Number of reflux episodes > 5 min
  • Longest reflux episode (minutes)

• Esophageal rupture in Boerhaave syndrome is due to be the result of a sudden rise in intraluminal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax. The syndrome commonly is associated with overindulgcnce in food and/or alcohol.
• The most common anatomical location of the tear in Boerhaave syndrome is at the left posterolateral wall of the lower third of the esophagus, 2-3 cm proximal to the gastro-esophageal junction, along the longitudinal wall of the esophagus
• The second most common site of rupture is in the subdiaphragmatic or upper thoracic area

Complications of esophagitis include the following:

1. Bleeding and stricture formation
2. Barrett esophagus occurs when the normal squamous epithelium of the esophagus is replaced with columnar epithelium; this condition is linked to the development of esophageal cancer; systematic review of patients with Barrett esophagus and colonic cancer also indicated a link between Barrett esophagus and colonic cancer.
3. Perforation with mediastinitis, although rare, is a serious complication
4. Volume depletion and weight loss may occur secondary to inability to swallow
5. Laryngitis, aspiration pneumonitis, and bronchospasm may occur if gastric contents are refluxed to the level of the larynx.
6. In infants, failure to thrive and apnea

• The site of perforation varies depending upon the cause. (Instrumental perforation is common in the pharynx or distal esophagus). Spontaneous rupture may occur just above the diaphragm in the posterolateral wall of the esophagus. Perforations are usually longitudinal with the left side more commonly affected than the right.
• The esophagus lacks a serosal layer and is, therefore, more vulnerable to rupture or perforation. Once a perforation (i.e, full-thickness tear in the wall) occurs, retained gastric contents, saliva, bile, and other substances may enter the mediastinum, resulting in mediastinitis.
• The degree of mediastinal contamination and the location of the tear determine the clinical presentation. Within a few hours, a polymicrobial invasion of bacteria supervenes, which can lead to sepsis and, eventually, death if the patient is not treated with conservative management or surgical intervention. The mediastinal pleura often ruptures, and gastric fluid is drawn into the pleural space by the negative intrathoracic pressure. Even if the mediastinal pleura is not violated, a sympathetic pleural effusion often occurs. This effusion is usually left-sided but can be bilateral.

Plummer-Vinson syndrome or Sideropenic dysphagia, presents in postmenopausal women as a triad of post cricoid dysphagia from:

1. Esophageal webs,
2. Iron deficiency anemia with beefy-red tongue due to atrophic glossitis
3. Koilyonychia

It is a premalignant condition with increased risk of squamous cell carcinoma of esophagus.

• Small lesions are satisfactorily treated with a cricopharyngeus (CP) myotomy with or without an invagination procedure. Intermediate and large diverticula (i.e., 2 - 6 cm) are best managed with open diverticulcctomy with CP myotomy or by endoscopic diverticulotomy. (Very large diverticula (i.e., > 6 cm) are best managed with excision with CP myotomy or a diverticulopexy with CP myotomy, depending on the health of the patient).
• The pathologic process in Zenker diverticulum involves herniation of the esophageal mucosa posteriorly between the cricopharyngeus (CP) muscle and the inferior pharyngeal constric tor muscles. Therefore, by definition, a Zenker diverticulum is a false diverticulum. The retention of food elements and secretions within the lesion's pouch frequently leads to halitosis, regurgitation, aspiration, and dysphagia in patients.