11) GI (Part 1) Flashcards
Zenker’s diverticulum pathology
- Weakness in posterior pharyngeal wall at pharyngoesophageal junction due to loss of elasticity of UES
Zenker’s diverticulum symptoms
- Dysphagia
- Halitosis
- Choking
Zenker’s diverticulum diagnosis
- Barium esophagram
Zenker’s diverticulum Tx
- Cricopharyngeal myotomy with or without diverticulectomy
- Surgical excision of diverticula
Achalasia pathology
- Motor disorder
- Absence of ganglion cells of Auerbach’s plexus (Myenteric plexus)
Achalasia symptoms
- Gradual, progressive dysphagia for solids & liquids
- Regurgitation of undigested food
Achalasia diagnosis
- Barium Esophagram/barium swallow (“bird’s beak” distal esophagus)
- Esophageal manometry – incomplete LES relaxation with swallowing, absence of peristalsis, Increased intraesophageal pressures
Achalasia Tx
- Endoscopy guided botox injection
- Pneumatic dilation
- Surgical myotomy (modified Heller cardiomyotomy )
Diffuse esophageal spasm pathology
- Motor disorder
- High amplitude, repetitive, non-peristaltic esophageal contractions with intermittent normal peristaltic contractions
- Normal function of the LES
Diffuse esophageal spasm symptoms
- Often presents as chest pain
Diffuse esophageal spasm diagnosis
- Corkscrew/rosary bead esophagus on barium swallow
Diffuse esophageal spasm Tx
- Nitroglycerin SL
- CCBs
- Stress reduction
- Avoid very cold or hot fluids
Scleroderma pathology
- Motor disorder
- Patchy smooth muscle atrophy with fibrosis, with ensuing decreased esophageal contractility and absence of resting LES tone.
Scleroderma symptoms
- Dysphagia, odynophagia
- Chronic reflux due to incompetent LES
- Decreased motility
Scleroderma diagnosis
- Stricture of the distal esophagus on barium esophogram
Scleroderma Tx
- PPI’s
- Promotility agents
- Dilatation of stricture prn
Esophagitis
- Seen in immunosuppressed pts
- Odynophagia, dysphagia, and chest pain
Esophagitis diagnosis
- Endoscopy with biopsy
- Seen with candida, CMV, and HSV
Esophagitis from candida
- Yellow, white patches adhere to mucosa
- Tx with PO antifungal agents (fluconazole, itraconazole)
Esophagitis from CMV
- Large, linear ulcers (furrows)
- Tx with antiviral agents if immunosupressed (acyclovir, famciclovir, valacyclovir)
Esophagitis from HSV
- Multiple, shallow “volcanic shaped” ulcers
- Tx with antiviral agents (valacylovir, acyclovir)
Causes of pill-induced esophagitis
- NSAIDS
- KCl tabs
- Quinidine
- Po bisphosphanates (alendronate & risedronate)
- Iron
- Antibiotics (doxycycline, tetracycline, minocycline, clindamycin, trimethoprim-sulfamethoxazole)
Pill-induced esophagitis symptoms
- Dysphagia
Pill-induced esophagitis diagnosis
- Endoscopy
- Shallow or deep ulcers
Pill-induced esophagitis Tx
- Endoscopy to remove the offending medication
- PPIs to aid in healing
Pill-induced esophagitis prevention
- Swallow with plenty of water
- Bisphosphonates: take with 4 oz of water, remain upright for at least 30 min after ingestion
- NSAIDS: take after eating
Eosinophilic esophagitis pathology
- Strong association with food & seasonal allergies
- Asthma
- Atopic dermatitis
Eosinophilic esophagitis symptoms
- Similar to GERD
- Seasonal allergy sxs (rhinorrhea, sneezing, etc)
Eosinophilic esophagitis diagnosis
- EGD with biopsy (extensive eosinophilic infiltration with mast cells, basophils; basal cell hyperplasia)
Eosinophilic esophagitis Tx
- Diet: avoid food allergens (cow’s milk, wheat, peanut/tree nuts, eggs, soy, and seafood/shellfish*)
- Medical: PPI’s, swallowed (not inhaled) steroids for 8 wks (fluticasone or budesonide), PO steroids if no improvement
- Endoscopic dilation for persistent dysphagia despite Rx with dietary elimination and medical therapy
Mallory-Weiss Tear
- Non-penetrating (incomplete) mucosal tear at the GE junction
- Prior H/O vomiting, retching
- Most are self-limiting
Mallory-Weiss Tear symptoms
- Hematemesis
Mallory-Weiss Tear diagnosis
- EGD
Mallory-Weiss Tx
- Fluid resuscitation, blood transfusion prn
- Endoscopic hemostatic therapy in pts with continuous active bleeding
Esophageal Neoplasms
- Squamous cell carcinoma
- Adenocarcinoma (seen more often)
Squamous cell carcinoma most common causes
- Cigarette smoking
- Chronic ETOH use
Adenocarcinoma most commonly associated with
- Barrett’s Esophagus
Esophageal neoplasms symptoms
- Progressive dysphagia
- Weight loss
Esophageal neoplasms diagnosis
- EGD
- CT for staging
Esophageal neoplasms Tx
- Surgery +/- XRT, Chemotherapy
- Ablation
- Esophageal stent for palliation of sxs
Barrett’s esophagus pathology
- Replacement of the squamous epithelium of esophagus by columnar epithelium
- Often due to severe GERD
- Change in tissue has potential for esophageal adenocarcinoma
Barrett’s Esophagus diagnosis
- EGD with biopsy
Barrett’s Esophagus Tx
- Serial EGDs
- Long term PPI therapy
Esophageal stricture (Schatzki Ring)
- Mucosal projection that involves the most distal esophagus
- Thin, web-like constriction at/ near border of LES
Esophageal stricture (Schatzki Ring) pathology
- May be associated with chronic GERD
Esophageal stricture (Schatzki Ring) symptoms
- “steakhouse syndrome”
- May present with non-progressive dysphagia for solids
Esophageal stricture (Schatzki Ring) diagnosis
- EGD
- Barium esophogram
Esophageal stricture (Schatzki Ring) Tx
- Esophageal dilation
- Long term PPIs
Esophageal Stricture (Plummer-Vinson Syndrome) is associated with
- Iron-deficiency anemia, hypothyroidism
- More frequent in women
- Predominant in northern hemisphere/ Scandinavia descent
- Increased incidence of esophageal SCCA
Esophageal Stricture (Plummer-Vinson Syndrome) symptoms
- Glossitis &/or cheilitis
- Dysphagia
- Reflux
Esophageal Stricture (Plummer-Vinson Syndrome) diagnosis
- EGD
- Gastritis
- Upper esophageal web
Esophageal Stricture (Plummer-Vinson Syndrome) Tx
- Iron replacement
- Dilation of web
Esophageal varices
- Develop secondary to portal HTN
- Found in 50% of pts with cirrhosis
- 1/3 of patients develop UGIB
Esophageal varices diagnosis
- EGD
Acute variceal bleed Tx
1) STAT resuscitation, intravascular volume support & blood transfusions
2) Abx prophylaxis
3) Vasoactive drugs (somatostatin or its analogue octreotide)
4) Banding or sclerotherapy w/ EGD
With uncontrolled variceal bleeding
- Balloon tube tamponade or TIPS (transvenous intrahepatic portosystemic shunts)
Variceal bleed prevention
- Non-selective B-blockers (propranolol)
- Variceal band ligation
Gastroesophageal Reflux Disease (GERD)
- Persistent reflux of stomach contents into the esophagus secondary to LES dysfunction
Gastroesophageal Reflux Disease (GERD) symptoms
- Heartburn
- ENT complaints
- Chronic cough
- Dysphagia
- Possible regurgitation
ENT complaints associated with GERD
- ENT complaints
- Sour taste in mouth (water brash)
- Sore throat/ Laryngitis
- Hoarseness
GERD Tx
- Lifestyle modifications
- PPIs
- H2 Blockers
GERD long-term complicaitons
- Barrett Esophagus
- Esophageal Strictures
Peptic Ulcer Disease etiology
- H pylori
- NSAIDs
- Gastrinoma (<1%)
PUD diagnosis
- EGD
PUD Tx
- PPI therapy 6-8 wks
- Eradicate H Pylori
- Discontinue NSAIDs
Gastric ulcers
- MUST exclude malignancy via biopsy
- ALL pts with a Gastric Ulcer should have follow-up endoscopy in 6-12 wks to confirm healing
Complications with PUD
- GI bleeds
- Perforation
- Obstruction
H. Pylori first-line therapy
- 14 days triple therapy
- Clarithromycin 500 mg BID
- Amoxicillin 1 g twice daily (or metronidazole 500 mg BID)
- PPI one that BID
H. Pylori second-line therapy
- 10-14 days quadruple therapy
- PPI one tab BID
- Metronidazole 500 mg TID
- Tetracycline 500 mg QI
- Bismuth subcitrate 120 mg QID
3 major types of gallstones
- Cholesterol (most common in US)
- Pigment
- Mixed
Cholelithiasis complications
- Cholecystitis
- Pancreatitis
- Cholangitis
Acute Cholecystitis symptoms
- Biliary colic - may radiate to the scapula
- Murphy’s sign
- Ultrasonic Murphy’s sign
- 4 F’s (female, fat, fertile, forty)
Acute cholecystitis diagnosis
- Abdominal ultrasound most sensitive
- Hepatobiliary imaging (hepato-iminodiacetic acid/HIDA scan)
Acute cholecystitis Tx
- Cholecystectomy
Choledocholithiasis may present as
- Incidental finding
- Biliary colic
- Obstructive jaundice
- Cholangitis
- Pancreatitis
Cholangitis usually presents as
- Fever
- RUQ pain
- Jaundice (Charcot’s triad)
Choledocholithiasis/Cholangitis diagnosis
- Abd ultrasound
- ERCP to visualize common bile duct stones
Choledocholithiasis/Cholangitis Tx
- Stabilize the pt prn (NPO, IV fluids, IV abx, hydration, analgesia)
- Stones should be removed surgically or via endoscope (ERCP)
Hepatitis A etiology
- Fecal –> oral route, contaminated food or drink sources, daycare outbreaks
- No long term effects; self-limiting course
Hep A serology
- Positive IgM anti-HAV during or shortly after jaundice
Hep A Tx and prevention
- Treat symptomatically
- Prevent w/ Hep A vaccine
Hepatitis B etiology
- Transmitted via blood, semen, or bodily fluids (needles, sex, perinatal transmission)
- Acute infections may fully recover or may progress to chronic Hep B
Sequalae of chronic Hep B infection
- Cirrhosis
- Hepatocellular carcinoma (HCC)
Hep B serology (HBsAg vs. Anti-HBs)
- HBsAg: (-) HBsAg = no Hep B, (+) HBsAg = positive Hep B
- Anti-HBs: (-) Anti-HBs = not immune, (+) Anti-HBs = immune
If the patient has Hepatitis B (Positive HBsAg) acute vs. chronic
- Acute Hep B: Positive Anti-HBc IgM, Positive Anti-HBc total
- Chronic Hep B: Negative Anti-HBc IgM, Positive Anti-HBc total
Hep B Tx
- Monitor viral load, antiviral Rx
- entecavir (Baraclude)
- tenofovir (Viread)
- lamivudine (Epivir)
- adefovir (Hepsera)
- telbivudine (Tyzeka)
- Pegelated interferon – older Rx
Hep B prevention
- Hepatitis B vaccine
Common side effects of interferon
- Influenza-like symptoms
- Psychiatric side effects (depression, irritability, insomnia)
Contraindications to interferon
- Major uncontrolled depressive illness
- Organ transplant
- Autoimmune hepatitis or other autoimmune condition
- Untreated thyroid disease
- Pregnant or unwilling to comply with adequate contraception
- Severe concurrent medical disease (severe HTN, HF, significant CAD, poorly controlled diabetes, COPD)
- Age < 2 yrs
Hepatitis C
- IV drug use accounts > 50% of reported cases
- Little evidence for frequent sexual or perinatal transmission
Hep C symptoms
- Often asymptomatic
- Frequently presents in the chronic phase with borderline consistently elevated LFTs
Hep C serology
- Positive Anti-HCV, HCV RNA
Rx options for chronic HCV
- Antivirals
- Ledipasvir-sofosbuvir
- Simeprevir plus sofosbuvir
- Ombitasvir-paritaprevir-ritonavir plus dasabuvir with ribavirin, or sofosbuvir/velpatasvir
- Pegylated interferon in combination with ribavirin SQ
Hepatitis D
- Requires the hepatitis B virus to survive and replicate (exists as coinfection with Hepatitis B)
- No specific Rx or vaccine available for Hepatitis D
- Vaccinate patients for Hepatitis B
Cirrhosis etiology
- Alcoholic liver disease most ocmmon
- Cryptogenic - NAFLD (risks: obesity, diabetes)
- Hep C
- Hep B
Miscellaneous cirrhosis etiologites
- Hemochromatosis
- Wilson’s Disease
- A1AT deficiency (Alpha1 antitrypsin deficiency)
- Autoimmune Hepatitis
- Primary Biliary Cirrhosis
- Primary Sclerosing Cholangitis
- Budd Chiari
Hemochromatosis (Bronze Diabetes) pathology
- Unrestricted absorption of iron due to inappropriately low production of the hormone Hepcidin
- Excessive amounts of iron are deposited in tissues, leading to eventual organ failure
Hemochromatosis (Bonze Diabetes) diagnosis
- Elevated serum iron
- Fasting elevated Transferrin Saturation >50% - test for iron overload
- Elevated ferritin
- Confirmed with genetic testing for hemochromatosis
- Liver biopsy will also show excessive iron deposition
Hemochromatosis (Bonze Diabetes) Tx
- Avoid products containing iron (food, vitamins, etc)
Wilson’s Disease
- More common in young men
- Rare
- Autosomal recessive
Wilson’s Disease Pathology
- Low ceruloplasm (copper binding enzyme) in the serum
- Causes excessive copper accumulation in the liver and brain
Wilson’s Disease symptoms
- Neuro-psychiatric abnormalities
- Movement disorders
- Psychiatric disorders
- Kayser-Fleischer rings (pathognomonic)
Wilson’s Disease diagnosis
- Low serum ceruloplasmin
- Elevated urinary copper
Wilson’s Disease Tx
- Oral Penicillamine: enhances urinary excretion of copper
- Restriction of dietary copper (shellfish, organ foods, legumes)
- Liver complications & cirrhosis are possible
Autoimmune hepatitis
- Most common in middle-aged women with co-existing autoimmune conditions
Autoimmune hepatitis diagnosis
- Elevated transaminases
- Positive antinuclear antibody (ANA) and/or anti-smooth muscle antibody (ASMA)
- Hypergammaglobulinemia
Autoimmune hepatitis Tx
- Corticosteroids
Primary biliary cirrhosis (PBC)
- Autoimmune disease
- More common in women
PBC pathology
- Diffuse inflammation & fibrosis involving the entire biliary tree, resulting in chronic cholestasis –> portal HTN, cirrhosis
PBC symptoms
- Fatigue
- Pruritus
PBC diagnosis
- Cholestatic liver picture (elevated ALP and GGT)
- Positive Antimitochondrial antibody (AMA)
- MRCP
PBC Tx
- Ursodeoxycholic acid (Urso): improves pruritus, slows progression
- Liver transplant
Primary Sclerosing Cholangitis (PSC)
- More common in men
- 70% of patients have IBD (UC)
PSC pathology
- Progressive, diffuse inflammation and fibrosis of hepatic ducts leads to hardening and narrowing and liver damage
- Higher risk of developing cholangiocarcinoma
PSC symptoms
- Profound fatigue
- Pruritus
PSC diagnosis
- Cholestatic picture (elevated ALP and GGT)
- ERCP – Gold standard
PSC Tx
- Progression cannot be halted
- Liver transplant only known cure
Budd Chiari pathology
- Hepatic venous outflow obstruction due to hypercoagulable state, tumor, abscess, vascular anomaly, webs, strictures, etc.
Budd Chiari symptoms
- RUQ pain and tenderness
- Ascites
Budd Chiari diagnosis
- US/MRI show occlusion or absence of flow in the hepatic veins or IVC
Budd Chiari Tx
- Treat ascites and underlying disorder
Portal hypertension complications
- Ascites
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Varices
- Hepatic encephalopathy
- HCC/Hepatoma
- Coagulopathy
- Jaundice
Ascites (portal HTN comp.)
- Transudate (low protein & specific gravity)
- PE: + shifting dullness, + fluid wave
- Rx: sodium intake restriction, diuretics, therapeutic paracentesis if severely symptomatic
Spontaneous bacterial peritonitis (portal HTN comp.)
- Infection of ascites fluid w/o an identifiable source
- S&S: Fever, abd pain, change in mental status
- Dx: Ascites fluid - PMNs > 250
- Rx: cefotaxime (3rd gen cephalosporin)
- Prophylaxis: ciprofloxacin or Bactrim
Hepatorenal syndrome (portal HTN comp.)
- Renal failure due to severe renal vasoconstriction
- High mortality
Varices (portal HTN comp.)
- 30% mortality with each bleed
Hepatic encephalopathy (portal HTN comp.)
- Patho: toxins (ammonia) are not cleared by the liver
- S&S: waxing, waning alteration in mental status
Asterixis, confusion, personality changes –> somnolence –> coma - Rx: Lactulose
HCC/Hepatoma (portal HTN comp.)
- Dx: elevated AFP
Coagulopathy (portal HTN comp.)
- Liver does not synthesize clotting factors
- Dx: Vit K deficiency (II, VII, IX and X)
- Prolonged PT/INR (measures liver synthetic function)
Jaundice (portal HTN comp.)
- Hyperbilirubinemia
- Hemolysis
- Decreased ability for conjugation
- Impaired excretion
- Biliary obstruction
