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GI-II, Exam 1 > 11-20 Diseases of the Esophagus and Stomach > Flashcards

11-20 Diseases of the Esophagus and Stomach Flashcards

1
Q

What are some types of dysphagia?

A

oropharyngeal dysphagia

esophageal dysphagia

odynophagia

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2
Q

What is oropharyngeal dysphagia?

A

difficulty swallowing due to problems transferring the food bolus to the upper esophagus

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3
Q

What goes into the oropharyngeal phase of swallowing?

A

Complex process:

elevation of the tongue,

closure of the nasopharynx,

relaxation of the upper esophageal sphincter,

closure of the airway, and

pharyngeal peristalsis

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4
Q

What are some causes of oropharyngeal dysphagia?

Try to get 8, but up to 13 possible

A

Often neurological:

  1. CVA,
  2. tumors,
  3. ALS,
  4. MS,
  5. pseudobulbar palsy,
  6. Guillain-Barre,
  7. Parkinson’s,
  8. muscular dystrophies

Can also include infectious causes; or muscular, rheumatological, metabolic, structural (Zenker’s diverticulum), or motility disorders

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5
Q

What is the clinical presentation of oropharyngeal dysphagia?

A

problems with the oral phase of swallowing cause drooling or spillage of food from the mouth,

inability to chew or initiate swallowing, or

dry mouth.

Pharyngeal dysphagia is characterized by an immediate sense of the bolus catching in the neck,

the need to swallow repeatedly to clear food from the pharynx, or

coughing or choking during meals

(Think drunk person attempting saltine challenge)

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6
Q

What is the general theme for causes of esophageal dysphagia?

A

mechanical obstructions of the esophagus or by motility disorders

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7
Q

What are some specific causes of esophageal dysphagia?

A

Mechanical:

  1. Schatzki ring
  2. Peptic stricture
  3. Esophageal cancer
  4. Eosinophilic Esophagitis

Motility disorders:

  1. Achalasia
  2. Diffuse esophageal spasm
  3. Scleroderma
  4. Ineffective esophageal motility
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8
Q

What is the general presentation for esophageal dysphagia?

A

mechanical obstruction:

dysphagia, primarily for solids

recurrent, predictable, will worsen as the lumen narrows

motility disorders/obstruction:

dysphagia for both solids and liquids

episodic, unpredictable, and can be progressive

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9
Q

What is odynophagia?

A

difficulty swallowing due to sharp substernal pain on swallowing that may limit oral intake.

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10
Q

What is odynophagia caused by?

A

(It usually reflects severe erosive disease)

most commonly associated with infectious esophagitis due to Candida, herpesviruses, or CMV

(especially in immunocompromised patients)

It may also be caused by corrosive injury due to caustic ingestions and by pill-induced ulcers.

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11
Q

What is the clinical presentation of odynophagia?

A

Immunocompromised patient with c/o severe substernal pain on swallowing

-or-

patient with Hx of pill injury

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12
Q

What is infectious esophagitis?

A

odynophagia, dysphagia and chest pain d/t infections in immunocompromised patients

Patients are often are/have HIV+/AIDS, transplant recipients, blood cancer, or on immunosuppressive meds

Common pathogens are HSV, CMV, Candida albicans

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13
Q

What is the clinical presentation of infectious esophagitis?

A

most common Sx: odynophagia and dysphagia, some have substernal chest pain

Oral thrush in ~75% with Candida infection

CMV infection at other sites (colon, retina) in CMV-mediated infection

Herpes labialis associated with HSV-mediated esophagitis

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14
Q

What is the best way to Dx infectious esophagitis?

A

Endoscopy with biopsy and brushings (for micro and histo studies)

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15
Q

What will the 3 major causes of infectious esophagitis look like under endoscopic examination?

A

Candida:

diffuse, linear, yellow-white plaques adherent to the mucosa

CMV:

one to several large, shallow, superficial ulcerations

HSV:

multiple small, deep ulcerations

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16
Q

Name 7 benign esophageal lesions.

A
  1. Mallory-Weiss Syndrome (Mucosal Laceration of Gastroesophageal Junction)
  2. Eosinophilic Esophagitis
  3. Esophageal Webs & Rings
  4. Zenker Diverticulum
  5. Esophageal Varices
  6. Esophageal Diverticula
  7. Benign Esophageal Neoplasms
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17
Q

What are the ‘essentials’ for dx of Mallory-Weiss Syndrome?

A

Hematemesis; usually self-limited.

Prior history of vomiting, retching in 50%.

Endoscopy establishes diagnosis.

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18
Q

What is Mallory-Weiss Syndrome?

A

nonpenetrating mucosal tear at the gastroesophageal junction

from events that suddenly raise transabdominal pressure, such as lifting, retching, or vomiting

Alcoholism is a strong predisposing factor.

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19
Q

What is the clinical presentation for Mallory-Weiss Syndrome?

A

Patients usually present with hematemesis with or without melena.

A history of retching, vomiting, or straining is obtained in about 50% of cases.

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20
Q

How is Mallory-Weiss Syndrome dx’ed?

A

upper endoscopy

0.5- to 4-cm linear mucosal tear usually located either at the gastroesophageal junction

or, more commonly,

just below the junction in the gastric mucosa

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21
Q

What is eosinophilic esophagitis?

A

disorder in which food or environmental antigens are thought to stimulate an inflammatory response

A history of allergies or atopic conditions (asthma, eczema, hay fever) is present in over half of patients

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22
Q

What are the SSXs associated with eosinophilic esophagitis?

A

Most adults have a long history of dysphagia for solid-foods or an episode of food impaction. Heartburn may be present.

Children may have abdominal pain, vomiting, chest pain, or failure to thrive.

Endoscopy should be performed, with multiple biopsies (at least 2–4) from the proximal and distal esophagus should be obtained to demonstrate multiple eosinophils in the mucosa.

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23
Q

How is eosinophilic esophagitis treated?

A

Before making a diagnosis of eosinophilic esophagitis, all patients should be given an empiric trial of a PPI b.i.d. for 2 months followed by repeat endoscopy and mucosal biopsy to exclude GERD.

If no response, cut out all food allergens the patient is sensitive to and use topical (PO or inhaler) cortisone therapy if needed (budesonide PO or fluticasone 2 puffs p.c.)

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24
Q

What are some examples of things that cause mucosal webs or rings?

A

may be congenital but also occur with eosinophilic esophagitis, graft-versus-host disease, pemphigoid, epidermolysis bullosa, pemphigus vulgaris, and, rarely, in association with iron deficiency anemia (Plummer-Vinson syndrome).

Esophageal “Schatzki” rings are smooth, circumferential, thin (less than 4 mm in thickness) mucosal structures located in the distal esophagus at the squamocolumnar junction

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25
Q

What are Schatzki rings associated with?

A

associated in nearly all cases with a hiatal hernia, and reflux symptoms are common

acid gastroesophageal reflux may be contributory in many cases

(exact pathogenesis unclear)

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26
Q

At what sizes do esophageal webs and rings start to cause trouble?

A

Rings less than 13 mm in diameter

Solid food dysphagia most often occurs

dysphagia is intermittent and not progressive.

Large poorly chewed food boluses such as beefsteak are most likely to cause symptoms.

Obstructing boluses may pass by drinking extra liquids or after regurgitation

27
Q

How are esophageal webs and rings dx’ed?

A

best visualized using a barium esophagogram with full esophageal distention

(Endoscopy is less sensitive than barium esophagography)

28
Q

What is Zenker diverticulum?

A

protrusion of pharyngeal mucosa that develops at the pharyngoesophageal junction between the inferior pharyngeal constrictor and the cricopharyngeus

29
Q

What causes Zenker diverticulum?

A

loss of elasticity of the upper esophageal sphincter, resulting in restricted opening during swallowing

30
Q

What are the SSXs of Zenker diverticulum?

A

dysphagia and regurgitation tend to develop insidiously over years in older, predominantly male patients

Initial symptoms include vague oropharyngeal dysphagia with coughing or throat discomfort.

As the diverticulum enlarges and retains food, patients may note halitosis, spontaneous regurgitation of undigested food, nocturnal choking, gurgling in the throat, or a protrusion in the neck.

31
Q

How is Zenker diverticulum Dx’ed?

A

video esophagography

32
Q

What are the ‘essentials’ of Dx for esophageal varices?

A

Develop secondary to portal hypertension.

Found in 50% of patients with cirrhosis.

One-third of patients with varices develop upper gastrointestinal bleeding.

Diagnosis established by upper endoscopy.

33
Q

What are esophageal varices?

A

dilated submucosal veins that develop in patients with underlying portal hypertension

  • may result in serious upper gastrointestinal bleeding, most common cause of important gastrointestinal bleeding

Bleeding most commonly occurs in the distal 5 cm of the esophagus

34
Q

What are the risk factors that increase the risk of bleeding from esophageal varices?

A

(1) the size of the varices
(2) the presence at endoscopy of red wale markings (longitudinal dilated venules on the varix surface)
(3) the severity of liver disease (as assessed by Child scoring)
4) active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding

35
Q

What are the SSXs of bleeding from esophageal varices?

A

Hematemesis (bright red blood or “coffee grounds”).

Melena in most cases; hematochezia in massive upper gastrointestinal bleeds.

Volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss

Sometimes dyspepsia or dysphagia

36
Q

What is the treatment for bleeding esophageal varices?

A

acute resuscitation - normalize volume status, transfuse blood or packed RBCs, add platelets or FFP if INR > 1.8

Emergent endoscopy for every serious upper GI bleed

Meds - give AB therapy, vasopressors, vitamin K and lactulose (avoid encephalopathy)

Tx: - ligation, balloon tamponade, intrahepatic portosystemic shunt

37
Q

What are esophageal diverticula?

A

Diverticula may occur anywhere in the esophagus.

  • may arise secondary to motility disorders (diffuse esophageal spasm, achalasia)
  • or may develop above esophageal strictures.

Diverticula are seldom symptomatic

38
Q

What are some benign esophageal neoplasms?

A

Rare - often leiomyomas or leiomyosarcomas

Often asymptomatic, larger ones can cause dysphagia

Diagnosis important - need to make sure tumor isn’t malignant

39
Q

What are some major esophageal motility disorders?

A
  1. Achalasia
  2. Diffuse esophageal spasm
  3. Hypertensive peristalsis (nutcracker esophagus)
  4. Small cell lung cancers causing a paraneoplastic syndrome via secreting ANNA-1, an antineuronal nuclear Ab
  5. Tumor invasion into gastroesophageal junction
40
Q

What is achalasia?

A

idiopathic motility disorder characterized by loss of peristalsis in the distal two-thirds (smooth muscle) of the esophagus and impaired relaxation of the LES.

There appears to be denervation of the esophagus resulting primarily from loss of nitric oxide-producing inhibitory neurons in the myenteric plexus

41
Q

What are the SSXs of achalasia?

A

gradual onset of dysphagia for solid foods and liquids Symptoms at presentation may have persisted for months to years.

Substernal discomfort or fullness may be noted after eating

Regurgitation, sometimes post-prandial or nocturnal

42
Q

How is achalasia Dx’ed?

A

Ba esography/ Ba swallow

43
Q

How is achalasia treated?

A

pneumatic dilation

botox injections

surgery

44
Q

What is gastritis?

A

inflammation of the stomach, with 3 categories:

(1) erosive and hemorrhagic “gastritis” (gastropathy)
(2) nonerosive, nonspecific (histologic) gastritis
(3) specific types of gastritis, characterized by distinctive histologic and endoscopic features diagnostic of specific disorders.

45
Q

What are some causes and types of gastritis?

A

Nonerosive, Nonspecific Gastritis

  • often due to H. pylori infection, pernicious anemia, or eosinophilic gastritis

Specific Types of Gastritis

  • infections, eosinophilic gastritis, and Menetrier Disease/Hypertrophic Gastropathy
46
Q

What is gastropathy?

A

conditions in which there is epithelial or endothelial damage without inflammation

47
Q

What are the essentials of Dx for gastropathy?

A

Most commonly seen in alcoholic or critically ill patients, or patients taking NSAIDs.

Often asymptomatic; may cause epigastric pain, nausea, and vomiting.

May cause hematemesis; usually in significant bleeding

48
Q

What are the causes of gastropathy?

A

medications (especially NSAIDs),

alcohol,

stress due to severe medical or surgical illness,

and portal hypertension (“portal gastropathy)

49
Q

What are the SSXs of gastropathy?

A
  • usually asymptomatic
  • anorexia, epigastric pain, nausea, and vomiting

can present as upper gastrointestinal bleeding

hematemesis, “coffee grounds” emesis, or bloody aspirate, or as melena

50
Q

How is gastropathy Dx’ed?

A

Upper GI bleed = endoscopy

51
Q

What are some differentials to consider with gastropathy?

A

peptic ulcer disease, esophageal varices, Mallory-Weiss tear, and angiodysplasias.

52
Q

What is the treatment for gastropathy?

A

PPIs and H2 receptor antagonists

  • propranolol to lower portal system HTN if needed
53
Q

What are some benign tumors of the stomach?

A

Generally just gastric polyps

  • can be congenital (familial polyposis)
  • can be due to irritation (H. pylori)

Remove, potentially premalignant

54
Q

What are some malignant tumors of the stomach?

A

Gastrinoma

  • causes Zoll Ellison Syndrome
55
Q

What is Zollinger-Ellison syndrome?

A

caused by gastrin-secreting gut neuroendocrine tumors (gastrinomas), which result in hypergastrinemia and acid hypersecretion.

Less than 1% of peptic ulcer disease is caused by gastrinomas

56
Q

What are the common locations for gastrinomas?

A

pancreas (25%), duodenal wall (45%), or lymph nodes (5–15%), and in other locations or of unknown primary (20%).

Approximately 80% arise within the “gastrinoma triangle” bounded by the porta hepatis, the neck of the pancreas, and the third portion of the duodenum

57
Q

What are the SSXs associated with Zollinger-Ellison syndrome?

A
  • peptic ulcers

Gastroesophageal reflux symptoms

Diarrhea

Gastric acid hypersecretion can cause direct intestinal mucosal injury and pancreatic enzyme inactivation, resulting in diarrhea, steatorrhea, and weight loss; nasogastric aspiration of stomach acid stops the diarrhea

58
Q

How is Zollinger-Ellison syndrome dx’ed?

A

gastrin levels

stomach pH testing

somatostatin receptor scintigraphy (SRS) + endoesophageal US

(gastrinomas express somatostatin receptors that bind radiopaque octreotide, picked up on PET scan)

59
Q

What are some differential Dx for gastrinoma?

A

Other neuroendocrine gut tumors:

carcinoid, insulinoma, VIPoma, glucagonoma, and somatostatinoma. These tumors usually are differentiated by the gut peptides that they secrete

Atrophic gastritis with decreased acid secretion is detected by gastric secretory analysis. Other conditions associated with hypergastrinemia (eg, gastric outlet obstruction, vagotomy, chronic kidney disease) are associated with a negative secretinstimulation test

60
Q

What is the treatment for a gastrinoma?

A

Surgical resection and/or cryoablation usually fairly effective if done before liver invasion

Use PPIs for symptomatic relief

61
Q

What are some major causes of upper GI bleeding?

A

peptic ulcer disease

portal system HTN

Mallory Weiss tears

vascular anomalies - angiectasias and telangiectasias

gastric neoplasms

erosive gastritis

erosive esophagitis

62
Q

What does SAD CREaP stand for?

A

For Dysphagia: (MEMORIZE!!)

For solids and liquids (motility):

Scleroderma

Achalasia (watch out for “pseudoachalasia”)

Diffuse esophageal spasm – “corkscrew esophagus”

For solids only (Mechanical):

Carcinoma

Ring(Schatski’s)*/webs**

Eosinophilic esophagitis

and

Peptic stricture

63
Q

What is the exception to the SAD CREaP rule?

A

pseudo achalasia

64
Q
A

GI-II, Exam 1 (8 decks)

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