Ulcer of esophagus

Upper GI

Clinicals - History

Fact Explanation
Dysphagia, Odynophagia, Retro-sternal pain Commonest presentation in patients with GERD. Heartburn or retrosternal pain is caused by acid reflux. These symptoms are also seen in patients with esophageal injuries induced by drugs or benign/malignant ulcerations. Dysphagia, Odynophagia, Retro-sternal pain
Commonest presentation in patients with GERD. Heartburn or retrosternal pain is caused by acid reflux. These symptoms are also seen in patients with esophageal injuries induced by drugs or benign/malignant ulcerations.
Hematemesis Erosion of esophageal lesions can present as hematemesis, such as in esophageal tuberculosis. Hematemesis
Erosion of esophageal lesions can present as hematemesis, such as in esophageal tuberculosis.
Weight loss Odynophagia can cause a patient unwilling to eat leading to weight loss. Weight loss
Odynophagia can cause a patient unwilling to eat leading to weight loss.
Personal history Pre-existing oesophageal or swallowing disorders such as GERD and hiatal hernia, dysphagia, achalasia, esophageal strictures can lead to formation of esophageal ulcers.
Irritants such as from cigarette smoking and alcohol can injure the esophageal lining and may be cause ulcers of the esophagus on chronic use.
Eating disorders such as Bulimia (forced vomiting) can also cause ulcers of the esophagus from the acidic effects of the repeated expulsion of acidic stomach contents.
Personal history
Pre-existing oesophageal or swallowing disorders such as GERD and hiatal hernia, dysphagia, achalasia, esophageal strictures can lead to formation of esophageal ulcers.
Irritants such as from cigarette smoking and alcohol can injure the esophageal lining and may be cause ulcers of the esophagus on chronic use.
Eating disorders such as Bulimia (forced vomiting) can also cause ulcers of the esophagus from the acidic effects of the repeated expulsion of acidic stomach contents.
Past history of GERD, infections of the upper GI tract, motility disorders A person with prolonged gastroesophageal reflux disease (GERD) is the most common cause leading to Barretts esophagus and ulceration of the esophagus.

Infections of the esophagus can also lead to ulceration and most common etiological agents are: herpes simplex, cytomegalovirus, human immunodeficiency virus ,tuberculosis and candida species.

Patients with esophageal motility disorders are at risk of pill-induced esophageal ulceration.
Past history of GERD, infections of the upper GI tract, motility disorders
A person with prolonged gastroesophageal reflux disease (GERD) is the most common cause leading to Barretts esophagus and ulceration of the esophagus.

Infections of the esophagus can also lead to ulceration and most common etiological agents are: herpes simplex, cytomegalovirus, human immunodeficiency virus ,tuberculosis and candida species.

Patients with esophageal motility disorders are at risk of pill-induced esophageal ulceration.
Medications Frequent doses of multiple medications and prolonged contact of the drug with the esophageal mucosa due to a esophageal motility disorder or taking the pill with little water, can cause esophageal injury and may even lead to ulceration. The commonest drugs known to induce esophageal injury leading to ulceration are NSAIDS, bisphosphonates, ferrous sulfate, nifedipine, quinidine, potassium chloride, and antibiotics such as doxycycline, tetracyclines, erythromycin, amoxicillin-clavulanate ,alendronate and homeopathic medications. Medications
Frequent doses of multiple medications and prolonged contact of the drug with the esophageal mucosa due to a esophageal motility disorder or taking the pill with little water, can cause esophageal injury and may even lead to ulceration. The commonest drugs known to induce esophageal injury leading to ulceration are NSAIDS, bisphosphonates, ferrous sulfate, nifedipine, quinidine, potassium chloride, and antibiotics such as doxycycline, tetracyclines, erythromycin, amoxicillin-clavulanate ,alendronate and homeopathic medications.

Clinicals - Examination

Fact Explanation
Dental erosions Maybe due to chronic exposure of the oral cavity to gastric acid from GERD and also from chronic self-induced vomiting (bulimia). Dental erosions
Maybe due to chronic exposure of the oral cavity to gastric acid from GERD and also from chronic self-induced vomiting (bulimia).
Oral burn lesions Suggestive of ingestion of strong acids /alkalis. Oral burn lesions
Suggestive of ingestion of strong acids /alkalis.

Investigations - Diagnosis

Fact Explanation
Barium swallow Initial assessment of dysphagia. Barium swallow
Initial assessment of dysphagia.
Esophagogastroduodenoscopy (EGD) ,biopsy, histopathology and cytology. Golden standard for causality assessment.
Endoscopy can identify Barrett's esophagus, esophagitis and malignancies causing ulceration. Biopsies are taken and histopathology, cytology and viral cultures will confirm the diagnosis with showing the presence of infectious agents and/or abnormal cell changes.
More that three biopsies must be taken to rule out viral esophagitis.
Esophagogastroduodenoscopy (EGD) ,biopsy, histopathology and cytology.
Golden standard for causality assessment.
Endoscopy can identify Barrett's esophagus, esophagitis and malignancies causing ulceration. Biopsies are taken and histopathology, cytology and viral cultures will confirm the diagnosis with showing the presence of infectious agents and/or abnormal cell changes.
More that three biopsies must be taken to rule out viral esophagitis.
Psychiatric evaluation Deliberate ingestion of corrosive substances to cause self harm have been found in patients with psychiatric illness such as depression or psychotic illnesses that predisposed them to suicidal/para-suicidal tendencies. Psychiatric evaluation
Deliberate ingestion of corrosive substances to cause self harm have been found in patients with psychiatric illness such as depression or psychotic illnesses that predisposed them to suicidal/para-suicidal tendencies.

Investigations - Management

Fact Explanation
Esophagogastroduodenoscopy (EGD) Repeat EGD in 6 months for evaluation. Esophagogastroduodenoscopy (EGD)
Repeat EGD in 6 months for evaluation.

Management - Supportive

Fact Explanation
Total parenteral nutrition (TPN) TPN can be administered in patients with odynophagia until it resolves. Total parenteral nutrition (TPN)
TPN can be administered in patients with odynophagia until it resolves.
Advice GERD patients on lifestyle modifications Make dietary changes and reduce weight. Reduce or eliminate caffeine and alcohol consumption. Stop cigarette smoking. Keep head elevated during sleep. Advice GERD patients on lifestyle modifications
Make dietary changes and reduce weight. Reduce or eliminate caffeine and alcohol consumption. Stop cigarette smoking. Keep head elevated during sleep.
Proper intake of medications Insufficient intake of water predisposes the retention of pill within the esophagus facilitating mucosal injury. Pills taken before going to sleep are more in favour of its retention in the esophagus because in the supine position, effect of the gravity disappears and there is decreased salivation and swallowing during sleep. To prevent esophageal injury from this improper intake of medication, patients must be advised to take pills upright with a full glass of water, and avoid laying down for atleast 30 minutes. Proper intake of medications
Insufficient intake of water predisposes the retention of pill within the esophagus facilitating mucosal injury. Pills taken before going to sleep are more in favour of its retention in the esophagus because in the supine position, effect of the gravity disappears and there is decreased salivation and swallowing during sleep. To prevent esophageal injury from this improper intake of medication, patients must be advised to take pills upright with a full glass of water, and avoid laying down for atleast 30 minutes.

Management - Specific

Fact Explanation
Nasogastric tube passage for stenting and for feeding, intravenous fluids, antibiotics; analgesic; H2- receptor blocker and proton pump inhibitors. Initial management in a patient with esophageal injury. Nasogastric tube passage for stenting and for feeding, intravenous fluids, antibiotics; analgesic; H2- receptor blocker and proton pump inhibitors.
Initial management in a patient with esophageal injury.
Proton-pump inhibitors (PPIS) and/or sucralfate for pill-induced esophageal ulcer Discontinue pill causing ulceration. Supportive treatments: Proton-pump inhibitors (PPIS) and/or sucralfate. Rapid clinical recovery occurs in about 3-8 days and mucosal recovery in about 2-5 weeks. Proton-pump inhibitors (PPIS) and/or sucralfate for pill-induced esophageal ulcer
Discontinue pill causing ulceration. Supportive treatments: Proton-pump inhibitors (PPIS) and/or sucralfate. Rapid clinical recovery occurs in about 3-8 days and mucosal recovery in about 2-5 weeks.
GERD medications Over-the-counter (OTC) antacids can give rapid,
short-term relief from GERD symptoms.
Histamine H2-receptor antagonists (ranitidine, famotidine, cimetidine, nizatidine) provides temporary relief.
Prokinetics (cisapride, metoclopramide) causes increased esophageal and gastric peristalsis which helps in resolving the delayed esophageal clearance seen in GERD.
Proton Pump Inhibitors (pantoprazole, lansoprazole, esomeprazole, omeprazole, rabeprazole) are the standard treatment of GERD. PPIs block the gastric acid pump of the parietal cells in the stomach. They provide faster relief than than prokinetics or H2-blocking agents and provide
long-term healing of esophageal erosion (including
Barrett’s esophagus). In case of presence of H.pylori infection, administer triple therapies for 10-14 days. Treatment regimens consist of OAC for 10 days(omeprazole, amoxicillin, and clarithromycin); BMT for 14 days (bismuth subsalicylate, metronidazole, and tetracycline); and LAC either for 10 or 14 days (lansoprazole, amoxicillin, and clarithromycin).
GERD medications
Over-the-counter (OTC) antacids can give rapid,
short-term relief from GERD symptoms.
Histamine H2-receptor antagonists (ranitidine, famotidine, cimetidine, nizatidine) provides temporary relief.
Prokinetics (cisapride, metoclopramide) causes increased esophageal and gastric peristalsis which helps in resolving the delayed esophageal clearance seen in GERD.
Proton Pump Inhibitors (pantoprazole, lansoprazole, esomeprazole, omeprazole, rabeprazole) are the standard treatment of GERD. PPIs block the gastric acid pump of the parietal cells in the stomach. They provide faster relief than than prokinetics or H2-blocking agents and provide
long-term healing of esophageal erosion (including
Barrett’s esophagus). In case of presence of H.pylori infection, administer triple therapies for 10-14 days. Treatment regimens consist of OAC for 10 days(omeprazole, amoxicillin, and clarithromycin); BMT for 14 days (bismuth subsalicylate, metronidazole, and tetracycline); and LAC either for 10 or 14 days (lansoprazole, amoxicillin, and clarithromycin).
Antitubercular therapy Four-drug therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for patients with esophageal tuberculosis is given for 6-9 months. Antitubercular therapy
Four-drug therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for patients with esophageal tuberculosis is given for 6-9 months.
Steroids, anti-retroviral therapy, anti-fungal therapy, anti-HSV therapy Steroids is the standard treatment of idiopathic esophageal ulcers but because of its immunosuppressive effects, opportunistic infections may occur. It has been found that antiretroviral therapy alone without steroids has shown to cause significant improvement in patients with idiopathic oropharyngeal and esophageal ulcers in HIV-infected patients. Antifungal therapy (fluconazole) can be used in the treatment of esophageal candidiasis. Anti-HSV therapy: HSV infection. Antiviral therapy (ganciclovir): cytomegalovirus infection. Steroids, anti-retroviral therapy, anti-fungal therapy, anti-HSV therapy
Steroids is the standard treatment of idiopathic esophageal ulcers but because of its immunosuppressive effects, opportunistic infections may occur. It has been found that antiretroviral therapy alone without steroids has shown to cause significant improvement in patients with idiopathic oropharyngeal and esophageal ulcers in HIV-infected patients. Antifungal therapy (fluconazole) can be used in the treatment of esophageal candidiasis. Anti-HSV therapy: HSV infection. Antiviral therapy (ganciclovir): cytomegalovirus infection.

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