Approach to GI Patient Atypical Chest pain & Odynophagia McGowan Flashcards
1
Q
What are the life threatening GI causes of chest pain?
A
- Boerhaave Syndrome
- Iatrogenic Esophageal Perforation
- Peptic Ulcer Disease (PUD)
2
Q
What are the life threatening non-GI causes of chest pain?
A
- Myocardial infarction
- Pulmonary Embolism
- Aortic Dissection
3
Q
What are the non life threatening GI causes of atypical chest pain?
A
- GERD
- Hiatal Hernia
- Esophageal Dysmotility
- Nutcracker Esophagus
- Diffuse Esophageal Spasm (DES)
- Eosinophilic Esophagitis
- Esophageal Impaction
4
Q
What are the iatrogenic and spontaneous causes of esophageal perforation?
A
Iatrogenic:
- Trauma such as nasogastric tube or endoscopy
Spontaneous:
- Forceful vomiting
- Hx of EtOH abuse
-
Boerhaave’s
- transmural rupture at gastroesophageal junction
5
Q
What does a HPI and PE look like for a patient with Esophageal perforation?
A
HPI:
- Patient is in distress
- Pleuritic/retrosternal chest pain
PE:
- Subcutaneous emphysema
- air in tissue usually in neck or precordial area
- Hamman’s Sign: auscultation: crunching rasping sound heard simultaneously with the heart beat. Particularly over precordium during systole and in left lateral decubitus position
- Dyspnea
6
Q
How do you diagnose and treat Esophageal perforation?
A
Diagnose:
- CXR or CT of chesst
- Looking for pneumomediastinum or subcutaneous emphysema
Tx:
- stabilize
- NPO
- Parenteral abx
- Surgery
- Endoscoping stenting
7
Q
What causes PUD?
A
- H. pylori
- NSAIDS
- Zollinger Ellison syndrome
exacerbated by stress/anxiety, coffee, alcohol
8
Q
What will the HPI and PE of a person with PUD look like?
A
HPI:
- gnawing, dull aching or “hunger like” epigastric pain
- atypical chest pain
- symptomatic periods with pain free intervals
- Coffee ground emesis, hematemesis, melena, or hematochezia
PE:
- Often normal in uncomplicated PUD
- Milkd, localized epigastric tenderness to deep palpation
- Hyperactive bowel sounds
9
Q
Complications of PUD?
A
- Bleeding due to erosion into left gastric artery or gastroduodenal artery
- Obstruction from edema
- Perforation presenting as referred shoulder pain, pneumoperitoneum
- Gastric adenocarcinoma or MALT lymphoma
10
Q
What tools are used to diagnose PUD? What are we excluding?
A
Diagnose:
- EGD with biopsy
- exclude malignancy in GU
- BUN/Creatine
- UGIB has increased BUN
- Hbg/Hct look for anemia
- Barium XR
- Nasogastric lavage considered
- if fluid is negative for blood it doesn’t exclude active bleeding from duodenal ulcer
11
Q
What are the alarm features of reflux esophagitis secondary to GERD? What further follow up is needed with these sx?
A
- constant &/or severe pain
- Dysphagia/odynophagia
- unexplained weight loss
- Persistent vomiting
- Palpable mass or adenopathy
- Hematemesis
- MElena
- Anemia
Need Endoscopy, radiographic Abd imaging and surgical eval
12
Q
What is the etiology of Reflux esophagitis secondary to GERD? What are the risk factors?
A
- Motility DO: ineffective esophageal motility
- Lower esophageal sphincter allowing stomach acid to reflux
Risks:
- increased abdomen girth/obesity
- Pregnancy
- Hiatal hernia
- Zollinger Ellison syndrome
- Scleroderma
- Fat rich diet/caffiene/alcohol/smoking
13
Q
Complications of GERD?
A
- Barrets esophagus
14
Q
Etiology of a hiatal hernia?
A
- Herniation of stomach into mediastinum through esophageal hiatus of diaphragm
- Can be sliding
- Result of increased intraabdominal pressure from abdominal obesity pregnancy and heredity
15
Q
Hiatal hernia presents with pain in what region?
A
Atypical cause of chest pain
16
Q
How do you diagnose and treat a hiatal hernia?
A
- Barium swallow XR
- surgical repair if having symptoms
17
Q
What is the cause of the esophageal dysmoltility disorder nutceracker esophagus?
A
- Hypertesive peristalsis
- swallowing contractions are too powerful- they are increased in ampitude and duration
- Lower esophageal sphinter relaxes normal, but has elevated pressure at the baseline
18
Q
What will a HPI and PE look like for a person with Nutcracker esophagus?
A
HPI and PE
- Atypical chests pain
- Dysphagia to solids and liquids
- Intermittent not progressive
- Assoc with increased frequency of depression, anxiety, and somatization
19
Q
How do you diagnose and treat nutcracker esophagus?
A
- EDG
- Nitrates such as isosorbide dinatrate
- Calcium antagonists such as nifedipine
20
Q
What is the etiology of the esophageal dysmotility disorder Diffuse Esophageal Spasm (DES)?
A
- Multiple spastic contractions of the esophagus’s circular muscles
- Functional imbalance between excitatory and inhibitory post ganglionic paths
- Disrupts peristalsis
- long duration and recurrent uncoordinated esophageal contractions
21
Q
What will HPI and PE look like for patient with DES?
A
same as nutcracker esophagus
HPI and PE
- Atypical chests pain
- Dysphagia to solids and liquids
- Intermittent not progressive
- Assoc with increased frequency of depression, anxiety, and somatization
22
Q
How do you diagnose and treat DES?
A
- Manometry- goldstandard uncoordinated peristalsis
- EGD used to exclude mechanical and inflammatory lesions
-
Barium swallow XR
- Corckscrew esophagus or rosary bead esophagus
23
Q
How to treat DES?
A
- Nitrates such as isosorbide dinatrate
- Calcium antagonists such as nifedipine
24
Q
Eosinophilic esophagitis (EOE) etiology and who does it affect more?
A
- Males>females
- Unknown etiology
25
Complicatiosn of EOE?
* **Food impaction**
* **Esophageal perforation**
* Narrow caliber esophagus
* Esophageal stricture
26
Treatment of EOE?
* PPI
* **Swallow inhaled glucocorticoids**
* Allergist referral
* Empiric elimination of common food allergens
* _Esophageal dilation is effect at relieving dysphagia_
* __risk of deep esophageal mural laceration or perforation
27
In adults with EOE, what will a HPI and PMH look like ?
* Dysphagia
* Pyrosis
* Regurgitation of undigested food
PMH:
* Allergies or atopic conditions in \>50% patients
* Hx of food bolus impaction
28
In kids with EOE, what will a HPI and PMH look like ?
* Vomit
* Difficulty feeding
* Dysphagia
* Failure to thrive
PMH:
*same as adults*
* Allergies or atopic conditions
* Hx of food bolus impaction
29
What is the diagnostic feature of EOE on EGD and CBC?
* **multiple circular esophgeal rings creating a corrugated appearance**
* "feline esophagus"
* looks like trachea
* CBC shows eosinophillia
30
What can cause esophageal impaction?
* **Eosinophilic Esophagiti****s**
* Achalasia
* Cancer
* Peptic stricture
* Schatzki ring
* Accidental swallowing foreign body
31
what does HPI for esophageal impaction look like?
* **_Hypersalivation: inablity to swallow liquids including own saliva_**
* **Severe chest pain**
* Dysphagia
* Odynophagia
* Sensation of choking
* Neck/throat pain
* retching and emesis
32
How do you diagnose and treat an impacted esophagus?
* Diagnose with an emergent EGD
* Tx endoscopically by removing the bolus/object, or push it though lower esophgeal sphincter
* Surgery
* Possibility it passes spontaneously
33
Complications of an impacted esophagus?
* Perforation
* Ulceration
34
What are the three types of esophagitis that can cause Odynophagia and atypical chest pain?
1. Pill Induced Esophagitis
2. Infectious Esophagitis
3. Caustic Esophagitis
35
Etiology of pill induced esophagitis?
* Most common medications:
* **NSAIDS**
* **potassium chloride**
* **Abx**
* **Bisphosphonates for osteoperosis**
* Iron
* Most likely to occur if pills are swallowed without water or while supine
36
HPI of patient with pill induced esophagitis?
* **Severe retrosternal chest pain**
* **Odynophagia**
* **Dysphagia**
* may occur several hours after taking a pill
* May occur suddently and last days
* *elderly patients may have little pain and present with dysphagia*
37
Complications of pill induced esophagitis?
* Severe esophagitis with stricture
* Hemorrhage
* Perforation
38
Etiology of infectious esophagitis?
* **Candidia albicans**
* **HSV**
* **CMV**
* **HIV**
39
HPI of infectious esophagitis?
* **Odynophagia**
* Fever (?)
* Dysphagia
* Substernal chest pain
* sometimes asx
40
How do you diagnose CMV, HSV, and Candida infectious esophagitis?
CMV:
* EGD: shows one to several _large shallow superficial ulcerations_
* biopsy has inclusion bodies
HSV:
* EGD: shows multiple _small deep ulceration_
* oral ulcers may be present as well
Candida:
* EGD: diffuse linear yellow-white plaques **adherent to mucosa**
41
How do you treat infectious esophagitis due to CMV?
Gancyclovir
42
How do you treat infectious esophagitis due to HSV
Oral or IV acyclovir
43
How do you treat infectious esophagitis due to candida?
Systemic therapy such as fluconazole
44
how do you prevent and manage pill induced esophagitis?
* Manage by stopping the medication or switching to liquid/parenteral form
* Healing will occur quickly when offending agent is eliminated
* Consider adding a PPI
Prevent by taking pills with a 4-8 oz galss of water and stay sitting upright for 30 minutes
45
what is the etiology of caustic esophagitis?
* Ingestine of liquid or crysalline alkali such as drain cleaners or acid
* **usually accidental in children**
* **Deliberate with intentions of suicide**
46
HPI with caustic esophagitis?
* **odynophagia**
* **Severe burning**
* **Varying degrees of chest pain**
* oral burns and drooling
* hematemesis
* Oropharyngeal lesions
47
How do you diagnose caustic esophagitis?
* _Laryngoscopy_
* _Chest and abdominal radiographs to look for pneumonitis or free air_
* assess circulatory status
48
What do you do to treat patient with caustic esophagitis?
* **Stabilize them**
* Hospitalized in ICU
* Monitor for signs of deterioration in which emergency surgery is called for
* EGD is performed within 12-24 hrs to assess injury extent
* Laryngoscopy for patiets in respiratory distress to asses for a _Tracheostomy_
49
What should **NOT** be done for a patient with caustic esophagitis?
* Nasogastric lavage
* Oralantidotes
* Oral corticosteriords
* Oral abx
## Footnote
**basically anything oral shouldn't be done**
50
Complications of Caustic esophagitis?
* **Perforation**
* Bleeding
* Esophageal tracheal fistulas
* Long term:
* Esophageal strictures
