Esophageal Disorders

Esophageal Bleeding

Retching/vomiting with hx of etOHism (MC), hiatal hernia, bulimia ➔ longitudinal mucosal lacerations/erosions
SSX: Upper GI bleed (hematemesis, dark stool) with chest/back pain
DX: EGD (upper endoscopy)
TX: Supportive with PPIs (most heal spontaneously)
- Severe ➔ EDG with epi injected at site (↓ bleeding), or balloon, or band ligation

↑ intrathoracic pressure (retching, prolonged coughing/vomiting, weightlifting, childbirth) ➔ transmural perforation (all the way through)
Iatrogenic perf MC from EDG
SSX: Dyspnea, chest pain, dysphagia ± upper GI bleed
- MC on left side ➔ air in mediastinum ➔ subq air (crepitus)
DX: Esophagram with gastrografin swallow
- CXR/chest-CT shows air - subQ emphysema, pneumo-mediastinum/thorax/peritoneum
TX: Airway, IVF resuscitation, NPO
- PT COMES IN
  - Mild sx and meets criteria ➔ medical management: NPO 7d, parenteral support, broad spectrum ABX, PPIs
    - Contained within neck or mediastinum or between mediastinum and visceral lung pleura
    - Contrast able to flow back into esophagus, perforation IS NOT in neoplastic tissue, IS NOT proximal to obstruction,
    - Institution can get contrast studies and has on-call GI surgeon
  - Sick ➔ surgery

Cirrhosis ➔ portal HTN (↑ splanchnic arteriolar vasodilation with resistance to outflow)
- Varices develop when hepatic and portal vein pressure > 10mmHg (normal <5mmHg) - relieves pressure within portal system
SSX: Upper GI bleed (hematemesis, melena) in etOH/cirrhotic pt
DX & TX with EGD (upper endoscopy) active bleeding ➔ endoscopic variceal ligation or endoscopic sclerotherapy
- Airway, IVF resuscitation, octreotide or vasopressin (↓ portal pressure) and broad spectrum ABX
- Transjugular intrahepatic portosystemic shunt (TIPS) if tx EDG fails
- PPX with propanolol or carvedilol (non-selective β-blockers)
  - Blocking β1 ➔ ↓ HR, blocking β2 ➔ ↓ portal inflow, blocking ⍺1 ➔ intrahepatic vasodilatation

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