DIP Episode 489 - The Clutch Esophagus Podcast

Welcome, my name is Divine, this is episode 489 of the Divine Intervention Podcasts. In today's podcast, we're going to be addressing a topic I like to call the Clutch, I guess I'll call this, the Clutch Asophagus Podcast, the Clutch Asophagus Podcasts. I'm the Asophagus and it's pathologies, those are things that the US Middle East love to test, so I think that something we should hit and hit hard. Again, you can go endlessly specific on this stuff, but you don't need to. Okay, so we're going to hit on what's really important to know for you exams, but again, if you understand what's in this podcast, most of the Asophagus related questions you'll see, you should be able to knock them right out of the park. So what if they give you a question about a 25-year-old male and you're told that he just had an EGD and the Sofa Go gastro-doat andoscopy. And right now, for the past, we had it like maybe a few hours ago, and that for the last like two, three hours, he has been having shortness on breath, fever, chills, severe chest pain, and it tells you that he almost has like this chest pain that is coming in waves, almost every few seconds. And then they tell you that on imaging, you see an increased diameter of the thoracic cavity. They just throw it to you like that. You see something like that, what should you be thinking about? What really will be your same divine? So this guy's asophagus has perforated. Sounds like this guy has an exploded Asophagus.

This is not a good thing, right? This person has an asophageal perforation. And again, this question I just give you has essentially given you some of the key antecedents you miss hearing exams, right? The person may have recently had some kind of instrumentation in the asophagus. So the person may have just gone through some kind of EGD. As Sofa Go gastro-doat andoscopy. Sometimes you can people can get this from a leg and see if they're not the malignancy can eat it into the macosa and then cause a rupture. Some people can get this if they're eating the solar patient. So they can give you like some person that has anorexia, bulimia, binge it in the solar and the retratch, retratch a lot. Although binge it in the solar, they're probably not going to be retras. There's going to be more of the anorexics and the bulimics. But those people, they've for me a ton. Because remember binge it in the solar, they don't really compensate. But the anorexics and the bulimics they absolutely do. So the retratch, retratch, hard, retratch, hard and often literally expose the asophagus. You get in some very, very, very serious trouble. So those are people that can get that kind of issue. You can also get this from just trauma. Get this from being like a nasty accident or anything of that sort. So these are all things that can cause the presence of Sofa Goastro-doat. Now, if you're asking for a diagnostic test, don't you get that? What are you supposed to do?

We want to go ahead and do the gastro-graphy in swallow. You want to do a gastro-graphy in Sofa-graphy. Basically, gastro-graphy, and I think it's spelled as G-E-S-T-R-O-G-R-A-F-I-N. Gastro-graphy. Sometimes on the exam, they call it water soluble contrast, anema, water soluble contrast, anema. Honestly, you want to go with those on the exam. So you don't want to use barren, please. If you're suspect the presence of Sofa Goastro-doat is ruptured, barren is not a good idea. And then, you know, if they basically, and it's just FYI, I know it's something that most people know, but you never can see basic things too often. These people should not get like an EGD, at least in that acute phase, right? Because, again, that kind of worse in their situation, right? So that's the classic, classic big thing to know about is the dual-pephoration. And, you know, many times, they can have like a wide-ing media-stine-um, they can have no more media-stine-um, right? They can have subcutaneous and physema, right? Because air is like dissecting through skin layers, right? So the material that they may have like creptose in the neck, they may have creptose of the chest wall, or they can tell you that the thoracic diameter is increased. When you see any of those things, I really, really want you to think about them. Really, really want you to think of as a Jo-pephoration, right? And, again, bare-half syndrome, right? It's almost like a derivative of as a Jo-pephoration.

It's pretty much like, again, usually it's going to be in the distance of a Gus. And, typically, you can almost always find this, almost exclusively in people that have, you know, like bulimics or anorexics. And then don't forget that also certain pills can certainly cause your syphagosteoreoptera, right? If you have like a really nasty penis of a gydis, right? That can lead to a syphagyroidoptera as well. Well, we'll talk about penis of a gydis in a bit. Okay. So that's the big thing. And obviously, the person that has a syphagyopeporation, they're going to need surgery, as simple as that. If not, they're going to die. Now, what if they give you a question about a 25-year-old female and they tell you that, you know, for the past three months, she's been having this dysphysia to solids and liquids, solids and liquids, right? Solids and liquids, solids and liquids. That's actually pretty ideal to know. Dysphysia solids and liquids, and that's sometimes you know, she regurgitates on digested for the next morning. Well, you see stuff like this. It's going to be a collision. It's going to be a young person. You're going to see them regurgitation on digested for them. You're going to have dysphysia to solids and liquids. That's something many people kind of screw up. They have this feature to solids and liquids, not only solids, not only solids, right? And there are many different things they can test on the exams with regards to this, right?

They can ask, like, what's the pathophys? Well, the pathophys is because you're lower, so for a geosfinger, just literally cannot relax. So because you cannot relax, then you get in trouble. Why can you not relax? Well, the thing is the neurons that make things that dilute your lower softwares, they kind of degenerate, right? So some of these neurons in your mind, they'reic, your albax plexus, they degenerate. These are neurons that make things like nitric oxide. Remember, nitric oxide is a beautiful visual dilator, right? And it can also just dilute things, right? So if you lose things that make stuff like nitric oxide that can dilute your distal softwares, then you're going to get into a lot of trouble, right? You can get into a lot of trouble. And remember, it's a leisure. It's actually pretty high-yield to know that you can get it because you have a collision. So people can also get ecalasia for the reasons. They can get ecalasia from having shagas disease. So if you see a self-American association, think of trapezoic, trapezoic, or somacruzii, causing shagas disease, that can certainly cause a problem, right? That can certainly cause problems. Or sometimes you can even see people that have ecalasia. And they have like an ecalasia-like presentation. Why? Because they have like some kind of a sodium alignancy. You know, sometimes think about it. It can just work with me here.

If you have like a mastinastias of a joke answer, that's like kind of like on the outside of the esophagus and it's compressing it inward. That can give you an ecalasia-like presentation. That's pretty high-yield to them. And when you see us talk about the, see me talk about the work-op, you understand why oh, wait, gee, maybe we should also get an eGD in the work-op of ecalasia, right? So how do we work-op ecalasia? Well, the first thing you're going to do is you're going to do a barum swallow. That's pretty high-yield to know. You're going to do a barum swallow. What are you going to see? You're going to see the bird's beak sign, right? The USMLE is not going to come out and see bird's beak. That's ridiculous. What they're going to do is they're going to describe it for you. They're going to tell you that, oh, that, you know, the person has this markedly dilated esophagus with a distal area of stenosis. That's how they're going to describe it on your exact markedly dilated esophagus with a distal ear of stenosis. You see that? That's going to be ecalasia straight up, right? And then after you do the barum swallow, you're going to do monometry. That's actually pretty high-yield to know. You're going to do monometry. And what are you going to find on monometry? Limiter or not, they occasionally test monometry findings on the USMLE exams, right? Because these people have an abnormal monometry. Why? Because again, some neurons are literally degenerated.

So neurons are degenerated. So on monometry, you're going to see like a peristolsis, right? Or reduced or diminished peristolsis in their esophagus. Even in the mid-esophagus, believe it or not, even in the mid-esophagus. And you're going to notice that the lower sub-agilist interest in pressure is going to be elevated, right? That means you're taking pressure measurements, right? Monometry, a monometer, natural pressures. And then the final thing you're going to do before treatment is you're going to do an EGD, right? Just to allow cancer. Because again, some people that you think, oh, wow, it's just a ecalasia. No, they have pretty do have straight up cancer. And ecalasia itself increases your risk of esophageal cancer. You're going to see it again. Having ecalasia itself does jack up the risk of having esophageal cancer. So how do we treat a ecalasia on the exams? You're going to do surgery, right? You're going to do like a Miami-Automy. You're going to do a Miami-Automy to treat ecalasia. Although you can also do things like, you know, you can inject Botox. That's fine. You do it every few months. But also another thing you can do, in fact, let me tell you this. In general, you shouldn't do this. But they can do it on the exam because the complication is very high yield, right? So what's the thing? The big thing is a pneumatic dilation. You can do pneumatic dilation, great, great, great stuff. But you can also explore the esophagus and land in the first pathology.

We literally just talked about it. So you probably don't want to do that. But just keep your mind. So your perforation is a very high yield complication of pneumatic dilation that I love to throw on the exams. And I strongly encourage you to make sure that you look up like in those like, uh, uh, barum suano pictures of ecalasia. That's a classic image you love to kind of throw on the USMD exams. That's a pretty classic image I love to throw on the exams, right? And then what if they give you a question about a person that's, you know, they have like this cough that's worse at night, um, really, really bad at night. And it improves when they sit up, you know, so as they go, they won't even see it improves when they sit up. They will just say that, you know, the person kind of goes throughout the day. This that feeling a lot better. When you see that, that's, that's very easy, right? Kurt, Kurt, Kurt, right? Because when you lay supine, right? All that assages, bro, reflux is through. So it's going to retake your throat, your larynx and stuff, your cough up a lot. The meantime is going to be a dry cough, right? They can even have like this thing that just feels like something is like in their, in their truth, almost like a global sensation, believe it or not. So, um, if you see that presentation, that's, that's a good, right? So they've got good, good, and presented many ways, right? You can have heartburn, they can have dysphysia, right?

Believe it or not, they can have this hoarseness, right? You always clearing the throat, right? Again, because of the acid that's reflux into the larynx and their, and their firings, actually, right? And believe it or not, it, Kurt does have a pretty, pretty strong association with, with asthma. So again, I don't know what, these are so-called superthologies for whatever is our reason. Our friends at the USM at least, boy, they really, really, really love to test pathophys. So what's the pathophys? The pathophys behind, uh, a gird is that these people have like an episodic or a transient decrease in the tone of the lures of a gel sphincter. I'm going to say it again, an episodic or a transient decrease in the tone of the lures of a gel sphincter. That's something they love, love, love to test, right? So how do you treat gird? We're going to treat gird by giving the person like a six week trial of a PPI, a pertinent bumping inhibitor, right? If you give them that trial and bump, you're not improving, then, okay, you need to do an EGD, into the NIS Ovo-Go gastro-doordanoestopic. If you're doing EGD and it's negative, you're like, man, we have these classy girds, same thumbs. What are you going to do? Well, you're going to do a 24 hours or a gel peach monitoring. That's the gold standard study for a gird. Remember, if a person has a gird and you have alarm symptoms, you're not going to be worried about doing the PPI, you're going to go straight to the EGD, right?

What are these alarm symptoms? Let's say they have weight loss, right? You see the person, they have weight loss, right? You just see, like, or you notice that, man, they have like these electrolyte abnormalities, like nasty anemia, right? That can be an indication that this person probably has cancer, right? All those things are just telling you that, mmm, let's go ahead and check this out. Go ahead and do an EGD. Go ahead and do an EGD, so that gold gastro-doordanoestopic. Right? And again, remember that if you have a gird, a gird can certainly progress to barit's asophagus. That's like a metaplesia, right? That's a metaplesia. So one cell type is changed to another, right? Sometimes on exams. Instead of calling it barit's asophagus, they'll call it an intestinal metaplesia. You're like, oh, come on, really? Yeah, yeah, yeah. Why call it barit's? Right? That is in every onky-deck note to mankind. Which makes more sense. How about we call it an intestinal metaplesia, right? So again, what in the world happens? Again, that's why step two instead of getting harder, people don't realize that they are going to be able to do this. But basically, they know that people are living an onky world, right? So they're just very descriptive. It's only a go over a lot in my testing and strategy class and in many of my review classes, I just got to talk people through like, okay, these are the other ways they can test the same material.

But basically, the thing that happens is that the non-caratermized stratified-scremosa epithelium that we find in the distal esophagus is going to be replaced with intestinal epithelium. What's the intestinal epithelium? This is non-seleeded colomni epithelium with goblet cells. There's just no particularly great reason why goblet cells should be in a person's own distal esophagus. You see that? You only be thinking about baritose esophagus in that person, right? And again, people get it from chronic gurk. And again, obviously, your risk of esophageal cancer is going to get jacked up with that, especially esophageal adnobar. And again, remember, obviously, the baritose can proceed all the way to esophageal adnobar. Again, just very high yield stuff to make sure you understand. All right. So, wouldn't they give you a question about a person that has had a long history of gurk and they tell you that, you know, this person now is having like dysphysia to a solid, right? Like with food dysphysia, not a big deal, but solids. Yeah. You see this? That's a classic presentation of esophageal structures. Okay? They love to test structures as a concept on the US Emily Except, right? They love to test structures as a result of geo-structures, they love to test. Right? So, you're going to see this in a person classically of the exams that has, you know, has a history of like a gurk divided for a long time, poorly controlled, and they know they're having dysphysia.

They're having a solid for dysphysia, think of as a result of geo-structures. Although, those people still need to get an EGD because they're worried about cancer. But many times on the exams, they're going to be going after as a result of geo-structures. But what are some other things that can cause esophageal structures? Some other things that can cause esophageal structures on your exams, believe it or not, or if for example, you know, you have like inflammation, like esophageitis, like candidolus esophageitis, or syinvius esophageitis, those things can cause a structure. Right? And also, if you've had a caustic injection, right? Let's say you took a drink of fluid or something like that, and then you notice that man, it's basically a two-driner fluid, months later, they're having like solid for dysphysia. And that person has esophageal structures. That's pretty high up to no for, for example. Now, what if they give you a question about a patient? And they tell you that this patient has a history of asthma, right? And they have dysphysia, right?

But they have like, they really embellish the question of so much asthma, asthma it too, asthma, asthma it too, history of exima, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, bl

ah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah If you don't see Candida as an answer, many times, if they want you to think of something else, then they will give you some clues, right?

Like for example, if you tell her that, wow, you perform an EGD and you see these punched out ulcers in their suffocates, that's gonna be HSV, you're gonna treat that with A cyclone, right? Or the tell her that you see linear ulcers in their suffocates, you wanna think about CMV, right? You wanna think about CMV, but most times, to be honest with you, for the step two step three level, they don't usually bother with these clues, you're just gonna give you this vision of HIV patient, it's gonna be Candida, they start the inspiration swallow, right? Like, or when I start in, or early is all, call it a day, move along, right? Simple as that, right? But if you see these clues, if they throw in these clues, right? EGD showing linear ulcers, that's CMV, CMV is gonna be money with GAN cyclone, remember, you're gonna gango upon CMV with GAN cyclone, right? But if you see HSV, think of the punched out ulcers, right? That's pretty high yield to keep in mind, right? Pretty high yield to keep in, keep in mind. And then what if they give you a question about a person, and this person has acne, right? So they're on, you know, the tell you that man, they've been on a long regimen of some kind of antibiotic for their acne, and then they're having like very painful dysphysia, right?

They have like ordino physia, when systems stuff like that, I want you to think of a peeling used as a vagina, they love to test peeling used as a vagina on the exams, and many times on the exams, they can just give you the condition of the person has, and then they will expect you to almost like divine, you know, that's a ridges of the term, but anyway, they almost expect you to like infer, let's use that, it's expected to like infer what they are going after, right? So you see, the person on acne treatment, the person on line disease treatment, and they have like painful dysphysia, think of the recyclings, right? The recyclings like doxysycline, mental cycling, those things can torture yourself with us. They can cause a peeling used as a vagina, right? Also think of this with NSAI Ds, right? So they can give you a person that has osteoarthritis, a person that has a gall to whatever, right? And then they, you know, they take in medication for their back pain or whatever, right? Think of a, think of a peeling used as a vagina, NSAI Ds can do that to you, or see a person that has like heavy menstrual bleeds, have like a malibral disease, right? And you're putting them on iris of oral alerus of limitation, that iron can torture the person's self-across and cause a peeling used as a vagina, right?

And then again, if you see a person that has like hypochylemia, you're giving them like oral potassium replenishment, potassium chloride pills can absolutely cause a peeling used as a vagina, so those are pretty real an example. But a big one, they love to test some examples as a person that has osteoporosis, right? They start taking pills for the osteoporosis and boom, being full this facial, being full this facial, think of your base force finnits. They love to test the stuff with base force finnits on the exact, remember, base force finnits, that's a very common side effect. That's why many times you're told to be like, you know, like be upright for like 30 minutes after you take a base force finnit, so you don't literally like, you know, like burn your, your sufferers, you don't literally burn your self-across. Okay. Now what if they give you a question about a person that has trouble swallowing, right? And then they give you a bunch of labs. And you notice that man, this person's MCV is like 60, you know, some low number, the MCV is like 60, and your human group is like nine. So they have like ironed it, micrositic anemia, which is going to be iron deficiency anemia. You see this, and you see a person that has dysphysia, pretty easy, as plum of incense syndrome, easy, easy, easy, easy, right? You're going to see this person is going to have iron deficiency anemia, right?

So they may not tell you they have iron deficiency anemia, but they'll give you the labs and support it. You see a micrositic anemia, right? It's going to be iron deficiency based, right? You're going to see this phasia. And then you're going to do an EGD, right? Because think about it, right? You see a person that has dysphysia, they have all these lab anomalies, like, oh, do you have cancer, right? No, go ahead and go and EGD, right? So if I go gastroplodernoscopy, right? Go ahead and do that. You're going to see all these as a phagel webs. We're going to see these as a phagel webs, right? And sometimes he may have glositis, but again, that glositis, I tell you, that's not a very common thing to put on exams, right? Many people memorize the glositis, very representation, but just for complete mistake, we're going to go ahead and throw that in, throw that in there. Remember from a vehicle, you're going to see a lot of people who are in the hospital, right? And since syndrome is going to jack up your wrist, obviously, the jail, swim or sell cancer, I'm going to say that again, Plum, Vincent syndrome is going to jack up your risk of a jail, swim or sell cancer. Again, you, you may notice that, um, why you seeing these pathologies and what kind of cancer increase risk of, you just be careful about it, right? Remember, there are two major is the material cancer is the abnormal person, that's like, gird, virus, I think this country. And then there is the screen or sale cancer.

Most of the things are going to raise your risk of a cell, scream or sell cancer. It's great and bar is that jack up your risk of a cell, you know, you can very high up to know these things for, for example, okay, now what if they give you a question about a person that like has some eating disorder, right? Like anorexia bulimia or person is like a big time alcoholic, right? Person is just going stone and then the, the puking puking puking and then they're like, oh man, you know, my chance hurts, right? They have this like, very low chest pain, very, very low chest pain. And the material that all that is part of blood like once or twice, like, one or two flex of blood, right? When you see stuff like that, that's pretty easy. That's a malarwized tear. That's a malarwized tear. And those people are going to be hemodynamically stable. That's very important to know because people will be like, divine, how can you differentiate a malarwized tear from bare health syndrome? Well, the difference is that people have bare health syndrome, you're going to know they're going to have fever, they're going to be hemodynamically unstable, they're going to have subcutaneous infosima, right? They're going to have wide-edmidious thina, they're going to have all those bad things I talked about earlier, but what they have malarwized, they're going to be in pain because it hurts. But, they're going to be completely stable, don't be completely stable, right?

Again, I've given you the people that you can present this at, eating disorder patients and alcoholics. Eating disorder patients and what alcoholics, right? So what's the pathophage? Well, the thing that happens is you basically have like a partial thickness, longitudinal tear in the distal sufferings, very high autonone. It's a partial thickness, longitudinal tear in the distal sufferings, right? You have like a mucus, or you know, like a minor soapy, it goes to tear. It is not transmural, like you have in bare health syndrome. Bare health syndrome is a transmural, just the whole thing ruptures, tears apart, right? Again, you're going to see this include at a big time, right? And again, you know, again, they can have like some low chest pain, but maybe they don't know, they can also throw in back pain. You want to be careful about these people. Because remember, the esophagus is retroperitoneal, right? So you wonder why they mediate memorize all those retroperitoneal organs in the first two years of med school? I wonder why? I truly sincerely wonder why? Well, that's why because, right? You can see the integrations you can make with the stuff on the exact right? So that's pretty high autonone. So you can give you a minor rice tear question as a back pain. And how will they try to confuse you on the exact, they try to confuse you on the exact and they'll put an answer choice that says a unique dissection, right?

Because again, that's a beautiful way to see people really know what they're doing, right? But you're going to notice that man, this person seems to have a unique dissection like pain, both a hemodynamically stable. Their chest actually looks completely normal. They don't have any wide and medium-stiny. They are not hypotensive. None of those things. They'll tell you that. You notice that their symptoms seem to have been precipitated by a vomited. They vomited first and then bombed the symptoms scheme right after that. Now, all right? If that's the case, that's going to be a minor rice tear. That's not going to be a erotic dissection. Right? That's not going to be erotic dissection. Okay, so you notice that people are not going to be hypertensive, right? Because hypertension is found almost exclusively very commonly put out of the hearing dissection, right? Because why hypertension happens to be the biggest risk factor for aortic dissection, right? Happens to be the biggest risk factor for aortic dissection. Biggest risk factor for aortic dissection. Okay, now what if you see a question about a person that has a dysphysia and a minor rice tear just turned into chill out, so what if care? That's all you need to do. Okay, now what if they give you a question about a patient and they tell you that this patient has dysphysia. But then they describe like anginal like chest pain, right? They have like chest pain, so the jaw or to the arm, right?

But the eGGS is stoncule normal, completely normal and they get better with nitrates. When you see something like this, that's going to be diffuses of a gel spasim. Okay? It's going to be diffuses of a gel spasim. But the thing is the fuses of a gel spasim, they live it or not. Our friends at the Indian is they also have a different name for it. Now sometimes on the exam, they can call it distal, it's of a gel spasim. Like, really man? Yeah, yeah, yeah. Some people think they can call it the fuses of a gel spasim, but sometimes they can also call it a distal, it's of a gel spasim. So just going to be mindful of mindful of that. Be mindful of that. Basically, right? These people and these things just what happens to these people? They just have these spontaneous, this almost like on provokes, it just kind of happens, you know, crazily. And they have these crazy, uncoordinated contractions of their softwares. Right? They have these crazy uncoordinated contractions of the softwares. Right? So they have like, I almost think of it like, and a softwares that has like generalize anxiety, just what is like, is kind of like spasim. And then they're getting getting a lot of control. One thing that's going to be helpful because some of you may be like, man, divine. But people have a calisia, you know, you just told me that they have like a sargeomotility problems in a calisia as well, right? Because some neurons are all messed up. Well, let me tell you something.

One of the things that can help you differentiate a calisia from the fuses or distal is of a gel spasim is the lawyers of a gel sphincter pressure. People have a calisia. They have high lawyers over a gel sphincter pressure. People that have diffuses or just spasim on monometry, you're going to notice that all they have normal s of a gel sphincter pressures. This is like Florida high use. I'm going to repeat it again. People that have a calisia, they have increased lower s of a gel sphincter pressures. People that have diffuses or just spasim DS, right? DS, DS, they're going to have normal lawyers or just fincter pressures. It's a subtle point with a very high up point to know for, for example, right? And again, the workup is very similar to a calisia. You're going to start with your bead, then you'll start off with your bar and swallow. What are you going to see on your bar and swallow? They're going to see a cox-screw-shaped and suffer those. Please make sure you're not going to buy an example of this stuff, right? You're going to see a cox-screw-shaped and suffer those. You're going to see a cox-screw-shaped and suffer those versus an ecalasia. Notice I'm doing a little of comparing contrast because this stuff is very, very high up to know, for example. They're going to have a cox-screw-shaped and suffer those. But in ecalasia, they're going to have a bird's beak, some. You're going to have a bird's beak, some again, make sure you look up an example of this stuff, right?

But after that, you're going to do the monometry, right? The monometry. You're going to do the monometry. You're going to see a lot of concord needed and solid your contractions. But you're going to notice that the lower solvajil's fincter pressure is what is normal. That's then that's going to tell you this is not ecalasia. This is the fuses of a gel or distal solvajil's passing. So, I think the word that we're going to manage is nitrates or calcium channel blockers. Okay? Give these people a nitrate or give them a dihydroperidine calcium channel blocker. A nitrate or a dihydroperidine calcium channel blocker like what? Like a looty peen or something like that. Now, what if they give you a question about a person that has a nasty gird and detailing the question that this person has pointed out in a pretension, what do you have someness of breath or they have like chronic bloating or whatever. Well, that's scleroderma, right? That's chryskeroderma. And just throwing this year for completeness seek. Remember when you have, you know, chryskeroderma, it kind of impact the esophagus, right? Remember the chrys, right? The c-sens for calciumoses are a sense for re-renotes phenomenon. The yeast for esophageodism, mortality, right? S is for sclerodactylian dentists for telogenjectages, right? So, people that have a scleroderma they can certainly have an involvement of the esophagus, right?

Because when you do all these fibrosis and all these craziness in the esophagus, the smoke muscle of the esophagus will atrophy, right? And if it atrophy, it becomes like wimpy. You almost have like a wimpy esophagus, right? You have a wimpy esophagus. So, basically, esophagus is not able to generate good enough pressures. So, it's going to be like open wide for acids to just flow right back through, right? You're going to have a lot of refluxes, but we're going to get in a lot of trouble, right? They can get strictures, they can get buried asophagus, they can get us, so which is not much of a question or more from that. I remember chryskeroderma is a sweet of the anti-centramere antibodies. The anti-centramere antibodies. So, remember, it's the defuse chryskeroderma that has that anti-SL70, you know, the anti-topolisomerysa antibodies. Pretty high up to know that stuff. And then the final thing I'm going to discuss here, what if they give you a question about an alcoholic, right? Presents to the emergency room, puking, puking, puking blood, right? Himodemic and unstable, super low blood pressure, that's easy, right? This person has an esophageal varicence, simple as that. It's an esophageal varicence, basically, right? You're going to see if this is a good outboard or hypertension, people that have cirrhosis. Usually it's going to be an alcoholic, right? They're going to be puking, puking, puking blood, they're going to have a lot of hematemesis.

And again, what's the pathophage? Well, you basically have increased portal pressures, so this is going to cause your sub-mucosovins in your esophagus, right? In the distal third, the distal third, distal third is very high, you know, distal third of the esophagus, they're going to pursue the conrupter, you're going to get in trouble. So, what in the world are you going to do for these people? Well, you're going to give them fluids, you're going to bring them into the hospital, step one, fluids, normal saline, step two, blood, patria, blood cells. Step three, you're going to do an EGD, you're going to do bandinoscural therapy. There's a bunch of other things you're going to do, give I Vocutotype to reduce portal pressures. And those people also deserve this BP-prophylaxis. A person that has a bleeding varicence, they deserve this BP-prophylaxis. And remember, poor people have a portal hypertension cirrhosis, right? They should be screened every year with an EGD-force of a geoviricence. That's actually kind of high-yield to know. That's actually kind of high-yield to know. This podcast kind of seems like one of those like, whatever podcast, but it's a super-high-yield podcast. It's probably like, easily like, I've made a lot of higher podcasts in my day, but it's probably like, top 25 on this website for sure. So, again, we've kind of talked about this on the geocancer, so I'm not going to be laborer the issue. Remember, again, it's a gelato, no carcinoma.

Most times it's going to be the lower third of the esophagus. Usually we're going to get it from a gird, barretts, right? Although if you're obese, you can also get esophagellal macarcinoma. If you're a big-time smoker, you can certainly get esophagellal macarcinoma. And so, if a geosquimacel cancer is the upper to third, usually, then you can get this from like, ecaligia, smokin, hostic injections, alcohol. You drink a lot of hot liquids, all those things. They can certainly cause problems. Remember, in the US, right? In the US, esophagellal macarcinoma is the most common kind of esophagellal cancer. But worldwide, esophagellal cancer, the most common is esophagellal cancer. So, I think I'm going to go ahead and stop here today. Again, please, I would encourage you, petitions of this podcast. It's a lot of high-level stuff in here. Again, if you're interested in my review courses, I go for a bunch. If you like the way I teach, explain pathophage, make integrations, and use scenarios, then you will love my courses. My courses are not lectures. Most of them are scenarios. And then I have these helpful charts to really help people solve a fight certain things. But I have a testing class, taking care of them. I have a test-taking class, taking place in an hour from now. If you're interested, just shoot me an email. I can get you in. I have a bio-stats class tomorrow. That's for step one, to step three. It's a four hour class. I have a social sciences and ethics class on Monday.

And then on Tuesday, studying next Tuesday, I have a 20 hour step to step three class. Although we're going to take a few days off because of things given. But, yeah, it's a... So, that's more for step two, step three. But again, if you're interested in any of these classes, just shoot me an email. I have a step one class that's going to be taking place in January. Then I'll have a 100 hour step two, step three class, taking place next May. I can have make podcasts on these things. So, just check out those podcasts, get more information. Or, if you want, just shoot me an email. You can give us some more information. Divine intervention podcasts with an S at gmail.com. Divine intervention podcasts with an S at gmail.com. So, thank you for joining me today. Again, I offer one I want you to do for step one, two, step three. And I have these podcasts on major apps, Apple Google Spotify. And, you know, I also have another website called Divine Intervention Lifelesses.com. Basically, every week, I post like one or two podcasts, usually two podcasts. Publico perspective, I try to address a life lesson. Many people use the website and find it really helpful. And then I have that podcast actually on Apple Podcast. There's a Divine Intervention Life Lessons podcast. It's just an Apple Podcast though. Well, thank you for joining me today. I will see you in episode 490. God bless you all. Wonderful weekend done. Bye for now.

Elevated LES pressure and diminished peristalsis throughout the esophagus.

M-W tears are partial-thickness, longitudinal mucosal tears associated with vomiting; Boerhaave is a full-thickness, transmural rupture often presenting with systemic instability (fever, wide mediastinum).

Achalasia.

Chronic GERD/Barrett's esophagus, smoking, and obesity.

Plummer-Vinson Syndrome.

Episodic or transient decrease in the tone of the lower esophageal sphincter (LES).

Achalasia has high LES pressure; DES has normal LES pressures.

Non-keratinized stratified squamous epithelium is replaced by intestinal metaplasia, characterized by goblet cells.

Chronic inflammation (e.g., candidiasis) or caustic injury/chemical burns.

Iron deficiency anemia, glossitis, and dysphagia.

Calcium channel blockers (e.g., Nifedipine) or nitrates; they relax the LES muscle.

Adenocarcinoma (usually lower third, associated with GERD/Barrett's) and Squamous Cell Carcinoma (often upper third, associated with smoking/alcohol).

Achalasia has high LES pressure; DES has normal LES pressures.

Non-keratinized stratified squamous epithelium is replaced by intestinal metaplasia, characterized by goblet cells.

Chronic inflammation (e.g., candidiasis) or caustic injury/chemical burns.

Iron deficiency anemia, glossitis, and dysphagia.

Calcium channel blockers (e.g., Nifedipine) or nitrates; they relax the LES muscle.

Adenocarcinoma (usually lower third, associated with GERD/Barrett's) and Squamous Cell Carcinoma (often upper third, associated with smoking/alcohol).