Atypical Chest pain and Odynophagia Flashcards
What are 3 NON-GI life threatening causes of atypical chest pain?
MI
PE
Aortic Dissection
What are 3 GI life threatening causes of atypical chest pain?
PUD
Iatrogenic Esophageal Perforation
Boerhaave Syndrome
What may cause Iatrogenic Esophageal Perforation?
Trauma due to tube placement/endoscopy
What may cause spontaneous Esophageal Perforation?
Forceful vomiting, alcohol use
What is Boerhaave’s Syndrome?
Transmural rupture at the gastroesophageal junction
Patient signs/symptoms with Iatrogenic Esophageal Perforation
Chest pain, dyspnea, patients in distress
- Subcutaneous emphysema/pneumomediastinum on CXR/Chest CT
- Hamman’s Sign
What is Hamman’s sign and what is it seen with?
- Seen with Iatrogenic Esophageal Perforation
= With Auscultation - crunching/rasping sound over the precordium, synchronous with muffled heart sounds during systole
– patient in left lateral decubitus position
Subcutaneous Emphysema/Pneumomediastinum on CXR/Chest CT with Hamman’s Sign may indicate?
Iatrogenic Esophageal Perforation
- Life threatening
- Hamman’s sign = With Auscultation - crunching/rasping sound over the precordium, synchronous with muffled heart sounds during systole
- patient in left lateral decubitus position
What may cause/make worse Peptic Ulcer Disease (PUD)?
Defensive factors overwhelmed by gastric acid, pepsin
- H. Pylori, NSAIDS
- Made worse by coffee, alcohol and stress
With PUD the ulcers extend through the?
Muscularis mucosa
Patient signs/symptoms with PUD?
Intervals of gnawing, hunger-like epigastric pain or Atypical chest pain
What test should be ordered with PUD?
EGD with biopsy - therapeutic and diagnostic
– X-ray/MRI/CT if suspecting obstruction or perforation
If a nasogastric lavage is (-) for blood, does that exclude an active DU bleed?
NO
2 tests to detect H. Pylori and confirm it is eradicated?
Fecal Antigen Test
Urea Breath Test
What test for H. Pylori can NOT confirm its eradication due to a (+) result years after infection?
IgA antibodies
What is the BEST, yet most invasive test for detecting H. Pylori?
EGD with Gastric Biopsy
When detecting H. Pylori, what tests should you do first?
NON-invasive first
– Fecal Antigen test, Urea breath test, IgA antibody test
Treatment for PUD?
Acid suppression with proton pump (-) and eradicate H. Pylori
What are a few alarming features of GERD?
Constant and severe pain
Dysphagia or Odynophagia
With GERD if there are signs of a GI bleed you need?
Further evaluation
What is Nutcracker Esophagus?
Swallowing contractions are too powerful
= Lower esophageal sphincter has an INCREASED baseline pressure
Swallowing contractions are too powerful, which causes the lower esophageal sphincter to have an increased baseline pressure
Nutcracker Esophagus
What are Diffuse Esophageal Spasms?
Uncoordinated esophageal contractions - spastic contractions of circular muscle
– imbalance between (+) and (-) post-ganglionic pathways
Uncoordinated esophageal contractions
Diffuse Esophageal Spasms
What are the symptoms for BOTH Nutcracker Esophagus and Diffuse Esophageal Spasms?
Atypical chest pain
Dysphagia
Intermittent symptoms
What are the symptoms for BOTH Nutcracker Esophagus and Diffuse Esophageal Spasms?
Atypical chest pain
Dysphagia
Intermittent symptoms
Tests and treatment for Nutcracker Esophagus and Diffuse Esophageal Spasms?
Tests - Manometry and Barium Swallow X-ray(for DES)
Treatment - Nitrates and calcium antagonists
A corkscrew esophagus/rosary bead esophagus on a barium swallow x-ray could indicate?
Diffuse Esophageal Spasms
Patient symptoms with Eosinophilic Esophagitis?
Male > Female
= Vague retrosternal pain, dysphagia and regurgitation of food
2 common PMH items with Eosinophilic Esophagitis?
- Allergies or Atopic Conditions –> (+) inflammation
- History of food bolus impaction
2 common PMH items with Eosinophilic Esophagitis?
- Allergies or Atopic Conditions –> (+) inflammation
- History of food bolus impaction
What will the CBC and EGD show with Eosinophilic Esophagitis?
CBC - eosinophilia
EGD - multiple circular rings with corrugated appearance and edema
3 treatment options for Eosinophilic Esophagitis?
- Swallow inhaled (topical) glucocorticoids
- Refer to allergist
- Esophageal dilation to relieve dysphagia
With Eosinophilic Esophagitis, an Esophageal Dilation can be performed to relieve the dysphagia. What does that put the patient at risk for?
Esophageal perforation
What can cause Esophageal Impaction (food bolus/foreign body)?
Eosinophilic esophagitis
What are the symptoms of an Esophageal Impaction?
Hypersalivation, drooling, frothing and foaming at the mouth, chest pain
Symptoms and treatment for an Esophageal Impaction?
Hypersalivation, drooling, frothing and foaming at the mouth, chest pain
- Emergent EGD
3 types of Esophagitis that can present with Atypical chest pain AND Odynophagia?
Pill induced
Infectious
Caustic
Odynophagia
Painful swallowing
What pills may cause Pill-Induced Esophagitis?
NSAIDS, Antibiotics
Potassium Chloride
Bisphosphonates for Osteoporosis
What will make Pill-Induced Esophagitis more likely?
If the pills are swallowed without water or while supine
What will make Pill-Induced Esophagitis more likely?
If the pills are swallowed without water or while supine
Symptoms of Pill-Induced Esophagitis?
Retrosternal chest pain, odynophagia, dysphagia
- Hours after taking pill and may persist for several days
- Elderly usually have little pain
Treatment for Pill-Induced Esophagitis?
STOP medication and switch to a different form
= will heal rapidly
What are the 4 most common pathogens for Infectious Esophagitis?
Candida Albicans
Herpes Simplex
CMV
HIV
What are the 4 most common pathogens for Infectious Esophagitis?
Candida Albicans
Herpes Simplex
CMV
HIV
Risk factors for Infectious Esophagitis?
Immunosuppressed, uncontrolled diabetes, corticosteroids, antibiotics, radiation therapy
- normal hosts with Herpes Simplex
Symptoms of Infectious Esophagitis?
Atypical chest pain, odynophagia, dysphagia
What will the EGD show if Candida is causing the infectious esophagitis?
Yellow-white plaques adherent to mucosa
What will the EGD show if Herpes simplex is causing the infectious esophagitis?
Multiple DEEP ulcerations
What will the EGD show if CMV is causing the infectious esophagitis?
Large, SHALLOW, superficial ulcerations
What causes Caustic Esophagitis?
Ingestion of liquid/crystalline alkali or acid
Ingestion of liquid/crystalline alkali or acid may cause?
Caustic Esophagitis
Symptoms of Caustic Esophagitis?
Odynophagia, chest pain, severe burning with oral burns/lesions
What should you do for Caustic Esophagitis?
Stabilize the patient
- Laryngoscopy
- EGD within 12-24 hours
What should you NOT do for Caustic Esophagitis?
Nasogastric lavage and oral antidotes
= Risk re-exposure of esophagus to agent and cause more injuries
What should you NOT do for Caustic Esophagitis?
Nasogastric lavage and oral antidoes
= Risk re-exposure of esophagus to agent and cause more injuries
What are possible complications of Caustic Esophagitis?
Perforation, fistulas, esophageal strictures
What are 3 types of esophagitis that present with atypical chest pain and odynophagia (painful swallowing)?
Pill-induced
Infectious
Caustic
What are 3 life threatening causes of GI atypical chest pain?
PUD
Iatrogenic Esophageal Perforation
Boerhaave Syndrome
