board review GI Flashcards
achlasia
Degeneration of myenteric plexus which results in loss of inhibitory neurons in LES - tonic contraction
screen: barium swallow
manometry is required to confirm dx and reveal esophageal aperistalsis and absence of relaxation at LES
EGD often performed
Tx depends on type:
-CCB/nitrate(more for spasm), botox (more for spasm), pneumatic dilation, POEM, heller myotomy
zenkers diverticulum
hypopharyngeal diverticulum
incoordination of UES leads to increased pressure
key hx: regurgitation, cough, halitosis
tx: surgical referral for endoscopic stapling
DES
DES >20% non-peristaltic
nutcracker esophagus (high amplitude peristalsis)
hypertensive LES (>40mmHg)
screen barium swallow
confirm with high resolution manometry
don’t forget to r/o cardiac causes
tx: start CCB (dilt best)/nitrates, TCAs eg, imipramine, botox, and sildenafil
mechanical obs int v consistent
int –> esophageal ring
constant –> malignancy
SCC of esophagus risk factors
alcohol/tobacco, lye ingestion, achalasia,, celiac, tylosis, H&N cancer
AC of esophagus risk factors
obesity, barretts, alcohol/tobacco, chronic reflux
staging of esop cancer
endoscopic US and CT scans
EUS is best for local staging (T&N)
CT or PET to evaluate for mets
breakthrough reflux in 62yo M with BID PPI use including nighttime awakenings
next step
EGD if >50 with persistent/breakthrough sx or new onset
if younger try conservative
alarm sx
dysphagia, odynophagia, bleeding, vomiting
anemia, weight loss
familg hx of esop or gastric cancer
most sensitive way to diagnose reflux
ambulatory esophageal impedance testing which measures resistance of electrical current and detects fluid and detects both acid and non-acid causes)
(can diagnose non-acid causes of reflux too as opposed to 24h pH probe)
v
ambulatory pH monitoring which is most sensitive for acid reflux and allows sx correlation. Can be done with catheter or telemetry (BRAVO) device.
GERD evaluations
best initial egd
best confimatory impedance/pH
barrett’s
found in 10-15% of patient’s undergoing EGD for GERD
<0.5% risk/yr of developing adenocarcinoma (HGD with 5-8% risk per year)
older, caucasion male at highest risk
goblet cells must be present on path to diagnose
note that surgery and anti-reflux meds can cause regression
current recommendations controversial
-screen selected patients?
surveillance patterns (1-5y)?
tx based upon extent and dysplasia
if indeterminate or low grade
-repeat biopsies sooner
-high grade
tx EMR, ablative therapy, esophagectomy, close surveillance
extraesophageal sx
typical gerd sx may be absent
testing may be inaccurate
GERD is common
empiric tx may be best method to determine
pulm: asthma, pna, bronchectasis, fibrosis
ent: chronic cough, laryngitis
may req high dose acid suppression including bid ppi
may require longer treatment course of up to 3 months
long-term risks of PPIs
associated with increased risk of hip fractures with OR 2.65
increased risk of PNA (OR 1.89) and C diff (OR 2.1)
(iron deficiency/malabsorption but really no good data that it causes iron deficiency?)
HIV not on ART with odynophagia
next step?
empiric trial of fluconazole before EGD (get EGD if they fail to respond)
pill esophagitis
doxycycline, bisphosphonates, nsaids, kcl, tetracyclines, iron, quinidine
