Casefiles 5: GERD, esophageal rupture/cancer, PUD, SBO Flashcards
get ? for GERD to measure the pattern and severity of acid reflux
get ? to confirm that the patient has LES dysfunction and that there is no esophageal dysmotility
ambulatory pH monitoring
esophageal manometry
A very commonly selected surgical option for GERD patients in the United States is ?
a complete (360°) fundoplication procedure (Nissen fundoplication) performed by the laparoscopic approach.
Hiatal hernia types
Type I hiatal hernia is a sliding hernia where the GE junction slides above the diaphragmatic opening.
Type II hiatal hernia is a rolling hernia where the GE junction remains in its normal location and the intra-abdominal contents such as stomach and colon herniate above the diaphragm and can produce obstructive symptoms.
Type III hernia is a combination of type I and II hernias
Barrett’s esophagus is reported to be associated with a 40-fold increase in the risk of ?
adenocarcinoma
endoscopy
Evaluates for erosive esophagitis or Barrett esophagus, or alternative pathology.
Biopsy for suspected dysplasia or malignancy.
barium esophagogram
Identifies the location of the GE junction in relation to the diaphragm.
Identifies a hiatal hernia or shortened esophagus.
Evaluates for gastric outlet obstruction (in which case fundoplication is contraindicated).
Can demonstrate spontaneous reflux.
pH monitoring for 24h
Correlates symptoms with episodes of reflux.
Quantitates reflux severity.
pharyngeal pH monitoring
Correlates respiratory symptoms with abnormal pharyngeal acid exposure.
manometry
Evaluates the competency of the lower esophageal sphincter.
Evaluates the adequacy of peristalsis prior to planned antireflux surgery. Partial fundoplication may be indicated if aperistalsis is noted.
Can diagnose motility disorders such as achalasia or diffuse esophageal spasm.
nuclear scintigraphy
May confirm reflux if pH monitoring cannot be performed.
Evaluates gastric emptying.
pneumomediastinum is often associated with ?
most commonly diagnosed by ?
tracking of air into the neck, therefore a physical finding that is sometimes present is soft tissue crepitus in the neck
CXR or CT
esophageal perforation score
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867773&gbosContainerID=92&gbosid=246078
Treatment options for esophageal perforation
NPO + antibiotics, NPO + antibiotics + drainage, NPO + antibiotics + endoscopic repair or endoscopic stent placement, NPO + antibiotics + surgical debridement, repair, and drainage
Perforations that are associated with underlying esophageal pathology (such as esophageal cancer and achalasia) generally carry a worse prognosis and are more likely to require ?
stent placement, resection, or repairs and myotomies
Indicative findings of esophageal perforation include ?
Chest radiograph demonstrating ? are common
subcutaneous crepitus over the neck and Hamman’s sign on chest auscultation
pneumomediastinum and/or left pleural effusion
what is the best diagnostic study to help confirm esophageal perforation?
Esophagram with water-soluble contrast
also helps us to determine if the leakage is large and whether it is contained.
can identify a perforation and provide information regarding its size and location
the current preferred imaging modality for assessment of the local extent of esophageal and GE-junction tumors (T stage) and for the assessment of regional lymph nodes (N stage)
endoscopic US (EUS)
EUS-guided fine-needle aspirations of the regional lymph nodes can be performed for cytologic diagnosis
Siewert classification of GE junction tumors: Type I
centered in the esophagus, at more than 1 cm above the GEJ
surgical treatment typically is an esophagectomy
Siewert classification of GE junction tumors: Type II
“at the GE junction”, within 1 cm above the GEJ and up to 2 cm distal to GEJ
surgical resection consists of esophagectomy with resection of the proximal stomach
Siewert classification of GE junction tumors: Type III
located in the cardia of the stomach, more than 2 cm distal to the GEJ
treatment consists of total gastrectomy
? continues to account for the majority of esophageal cancers encountered in developing countries, ? is the predominant cancer encountered in North America (about 70%)
squamous cell carcinoma
adenocarcinoma
sandwich therapy for esophageal adenocarcinoma
preoperative chemotherapy (epirubicin, cisplatin, 5-FU) followed by surgical resection and then postoperative chemotherapy
other esophageal cancer treatments
preoperative chemoradiation therapy (carboplatin + external beam radiation) followed by surgery
chemotherapy + trastuzumab (if HER2 overexpression)
surgical options for esophageal cancer
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867912&gbosContainerID=92&gbosid=246079
palliative measures for esophageal cancer
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867916&gbosContainerID=92&gbosid=246079
noninvasive tests for H. pylori
immunoglobulin G serology test (does not correlate necessarily with active infection)
urea breath test (is highly specific in detecting active infection)
invasive tests for H. pylori
rapid urease assay performed on biopsy specimens and histologic studies performed on biopsy samples
Common treatment regimens for H. pylori
OAC, OMC, and OAM (O, omeprazole or other PPI; A, amoxicillin; C, clarithromycin; and M, metronidazole) for a treatment duration of 1 to 2 weeks
treatment for patients with PUD who are H. pylori negative?
if the patients are taking NSAID?
PPI or H2 blocker
if taking NSAID, co-therapy with misoprostol (a prostaglandin analogue) is helpful to improve ulcer healing
PUD evaluation and treatment algorithm
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130868049&gbosContainerID=92&gbosid=246080
mechanism of Sucralfate
Complexes with pepsin and bile salts and binds to proteins in mucosa
mechanism of PPIS
Inhibits H+-K+-adenosine-triphosphatase pump
Ulcer disease is generally considered intractable if ?
the process persists for 3 months despite appropriate medical therapy
OR the ulcer recurs within 1 year after initial healing despite appropriate maintenance therapy
OR the ulcer disease is characterized as having cycles of prolonged activity with only brief periods of remission
magnitude of operations for PUD ranges from ?
highly selective vagotomy to truncal vagotomy with gastric drainage to vagotomy + antrectomy to subtotal gastrectomy to total gastrectomy
Surgical treatment of type I gastric ulcers can be accomplished with ?
distal gastrectomy to include the area of the ulcer and reconstruction with a gastroduodenostomy (Bilroth I) or a gastrojejunostomy (Bilroth II)
an alternative procedure is ulcer excision with vagotomy and pyloroplasty (for pts who cannot tolerate long sx)
Type V gastric ulcers are related to ?
NSAIDs or aspirin use, and these ulcers rarely need surgical therapy
The indications for surgery for PUD are ?
obstruction, hemorrhage, perforation, and intractable symptoms
Acid-reduction therapy such as PPI and surgery can be beneficial for patients with ulcers that are not related to hyperacidity (eg, type I gastric ulcer), and the reason is that ?
acid aggravates the healing of these ulcers.
Patients who develop recurrent ulcers following vagotomy and antrectomy suggest unusual causes of their ulcer diseases such as ?
excess gastrin production related to gastrinomas (Zollinger–Ellison syndrome)
next step after diagnosing SBO with XR/CT
ultimate therapy?
Place an NG tube to help decompress his stomach and relieve his vomiting, initiate fluid resuscitation, place a Foley to monitor UOP and determine his response to fluid resuscitation
Exploratory laparotomy/laparopscopy
common etiologies of SBO
postoperative intra-abdominal adhesions, incarcerated hernias, IBD: Crohn disease, and tumors/malignancies, gallstone ileus
abdominal XR with SBO may show
dilated small bowel and a paucity(lack) of air in the colon
persistent pain associated with SBO raises the concern for ?
bowel ischemia or severe bowel distension
as it is typically colicky pain
abdominal CT is useful in SBO, how so?
(first make sure intravascular volume depletion is corrected with fluid resuscitation to prevent risk of contrast-associated AKI)
provide valuable information regarding whether a tumor or Crohn disease may be the reason for the SBO
assess the perfusion status of the bowel wall, intestinal distension, and/or determine the severity and location of the obstruction
can help identify intestinal necrosis and high-risk features indicating high-grade obstruction, and intestinal volvulus
concerning clinical features for complicated SBO (bowel ischemia and/or strangulation)
pain out of proportion to clinical examination, fever, tachycardia, hypotension, peritonitis, leukocytosis, localized abdominal tenderness, reduced serum bicarbonate, and elevated serum lactate or amylase
no improvement of fever and tachycardia with initial fluid resuscitation and NG decompression
Ileus
Distension of the small intestine and/or colon due to non obstructive causes:
inflammatory/infectious processes, metabolic derangements, recent abdominal surgery/trauma, and meds
may be associated with acute pancreatitis, appendicitis abscess, or may be postop ileus.
The usual passage of the gallstone in gallstone ileum is through an opening between the gallbladder and ?
The obstructive point is most commonly in ?
what should raise suspicion for this diagnosis?
the adjacent duodenum (cholecysto-duodenal fistula)
the distal ileum where the luminal diameter is smaller
Air in the biliary tree or in the gallbladder in a patient with SBO (pneumobilia)
a diagnostic and therapeutic maneuver for SBO involving infusion of a water-soluble contrast material into the bowel (by NG tube)
Gastrografin Challenge
(datrizoatemeglumine/diatrizoate sodium)
causes fluid to shift into the bowel lumen, decreasing the edema within the intestinal wall and may promote resolution of the obstruction
most common causes of SBO in neonates, infants, and young children
hernias, malrotation, meconium ileus, Meckel diverticulum, intussusception, and intestinal atresia
if SBO inquire about
history of prior abdominal sx, prior GI or GU malignancies, IBD, prior SBO, and hernias
ddx SBO from ileus
patients with SBO will generally describe cramp-like pain, while patients with ileus generally will complain of constipation and distension without cramps
(intestinal peristalsis often remains intact in obstruction despite intestinal narrowing or blockage)
Laboratory studies for patients with suspected SBO
CBC with diff, serum electrolytes and amylase, U/A, ABG, lactate (indicator of already present bowel ischemia, but not impending)
CT scan is helpful to differentiate SBO from ileus, because it can identify ?
a point of caliber change in the small bowel (“transition point”)
CT feature suggestive of complicated SBO includes ?
intraperitoneal free fluid, decreased bowel wall perfusion, and presence of a swirl sign
