Clinical Approach to GI Patients Week 1 Flashcards by Tom Porter

What is the difference between Latrogenic and Spontaneous Esophageal Perforation?

L: trauma, caused by endoscopy/nasogastric tube

S: forceful retching/vomiting, history of alcohol use

Boerhaave’s Syndrome: transmural rupture
- at gastroesophageal junction

Pneumomediastinum and SubQ emphysema

emphysema in neck/precordial area
Hamman Sign: crunching synchronous w/heartbeat
- systole, left lateral decubitus position

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Peptic Ulcer Disease

What does the pain feel like, how can it be diagnosed (3), and how is it treated?

gnawing, dull, aching, “hunger-like” atypical chest pain (epigastric) with “coffee ground” emesis

D: EGD w/biopsy (exclude malignancy), detection of H. pylori, Fecal Antigen Test, Urea Breath Test (eradicate)
- stop PPI x 14 days before fecal or breath tests

T: acid suppression (PPI), remove offending agent

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What is the difference between Nutcracker Esophagus and Diffuse Esophageal Spasm?

NE: hypertensive peristalsis (too powerful w/greater amplitude and duration)

elevated LES pressure at baseline
diagnose with mamometry

DES: multiple spastic contractions disrupting coordinated peristalsis

“corkscrew” or “rosary bead” esophagus
LES function is normal
diagnose with mamometry/barium swallow

atypical chest pain and dysphagia to solids/liquids

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What is “waterbrash” and what is it associated with? What are 3 atypical symptoms of this condition?

bad taste in mouth from refluxed acid (associated with GERD)

atypical symptoms: asthma, chronic cough, hoarseness

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What is a Hiatal Hernia and what is the difference between Sliding vs Paraesophageal?

stomach herniation into mediastinum through esophageal hiatus of diaphragm

Sliding: inc. intraabdominal pressure from obesity, pregnancy, etc (GERD)

Para: includes visceral structure other than cardia, commonly the colon –> “upside down stomach”
- gastric volvulus and stomach strangulation

barium x-ray and surgical repair if symptoms

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What is a common symptom associated with Foreign Body or Food impaction?

HYPERSALIVATION

inability to swallow liquids including own saliva (drooling, frothing, foaming of the mouth)

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How are Oropharyngeal and Esophageal dysphagia diagnosed?

O: video fluoroscopy of swallowing

E: mechanical (barium swallow/EGD w/biopsy) or motility (barium swallow/mamometry)

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What are two structural and one rheumatologic causes of Oropharyngeal Dysphagia?

S: Esophageal Web and Zenker Diverticulum

R: Sjogren’s Syndrome

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Esophageal Web

What is it and what condition is it associated with, how is it diagnosed, and how is it treated?

thin, mucosa membrane located at proximal or mid esophagus and is associated with Plummer-Vison Syndrome and Eosinophilic Esophagitis

D: Barium Swallow (EGD less sensitive)

T: dilation (bougie dilator) and PPI long term (if needing repeat dilation)

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What are 4 symptoms of Plummer-Vinson Syndrome, who is it commonly seen in, and what is it a complication of?

S: angular chelitis, glossitis, spoon nails (koilonychia), symptomatic proximal esophageal webs

Middle-aged females

C: iron-deficiency anemia (weakness and fatigue)

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Zenker Diverticulum

What is it and where does it commonly occur, what are 4 symptoms it causes, and how is it diagnosed? (2)

false diverticula with herniation of mucosa/submucosa through muscular layer of esophagus posteriorly (proximal to Killian’s Triangle = loss of UES elasticity)
can retain food, halitosis, regurgitation, nocturnal choking

D: video esophagography/Barium Swallow BEFORE EGD (risk of perforation) –> SURGERY

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Esophageal Stricture

What is it caused by, what problem actually gets better because of it, and how is it diagnosed?

structural problem caused by GERD, usually at gastroesophageal junction
starts as trouble swallowing solids but progresses to solids AND liquids; heartburn/reflux actually improves because the stricture acts as a barrier to it

D: endoscopy (mandatory in all cases) –> helps to differentiate from stricture caused by esophageal carcinoma

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Barrett Esophagus D and T

inc. risk: obese white males > 50 who smoke

D: EGD w/biopsy (orange, gastric type epi. that extends upward from stomach in a tongue-like fashion; GOBLET CELLS)

T: PPIs and Endoscopic Ablation
- DO NOT SURGICALLY RESECT (not recommended)

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Esophageal Squamous Cell Carcinoma vs Adenocarcinoma

Who does it affect, what is it caused by, and how is it diagnosed/treated?

SCC: most common, African Americans > Caucasians

heavy smoking and alcohol use = synergistic
weight loss, cough, hoarseness, dysphagia
Dx: EGD w/biopsy
Tx: surgery (esophagectomy)

AC: Caucasians > African Americans, distal esophagus

GERD, Barrett metaplasia
Dx: EGD w/biopsy
Tx: endoscopic therapy (ablation)

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Esophageal Ring (Schatzki)

What is it and where it is located, what syndrome is associated with it, and how is it diagnosed/treated?

smooth, circumferential, thin mucosal structure of DISTAL esophagus; associated with hiatal hernia
“Steakhouse Syndrome” = poorly chewed food bolus is usually instigator (not progressive)

Dx: barium swallow
Tx: dilation (bougie dilator) and PPI use if heartburn

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What is Achalasia and what is the difference between Primary, Secondary, and Pseudoachalasia?

motility disorder that is progressive (solids and liquids) due to propulsion problem in distal 2/3 of esophagus and failure of LES relaxation

P: loss of ganglion cells in myenteric plexus
S: CHAGAS (Trypanosoma cruzi); endemic areas
- destruction of ganglion THROUGHOUT the body
PC: tumors invade gastroesophageal junction

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Achalasia

What are three common findings associated with it (R/B/S), what are three diagnostics that can be performed, and how can it be treated?

Findings: Romana Sign (unilateral swelling around eye - Chagas), “Bird Beak” distal esophagus, Sigmoid Esophagus (markedly dilated)

D: Peripheral smear for parasites, Barium Esophagram (“Birds Beak”), and Esophageal Mamometry (CONFIRMS DIAGNOSIS)

What is Pill-induced Esophagitis?

How is it diagnosed and how can it be treated?

medications (usually taken without water or while supine) lead to esophageal dysphagia, odynophagia, and severe retrosternal chest pain due to breakdown in esophagus
can use endoscopy to see shallow/deep lesions
remove offending agent or take with water and remain upright during ingestion

What are 5 common causes of Pill-induced esophagitis? (N/PC/AR/I/A)

NSAIDS, potassium chloride, alendronate/risedronate (osteoporosis), iron, antibiotics

Infectious Esophagitis

What is the difference in presentation and treatment of CMV, Candida, and Herpes Simplex associated esophagitis?

CMV: one to several large, shallow, superficial ulcerations (immune restoration with antiretroviral therapy)

Candida: diffuse, linear, yellow-white plaques adherent to mucosa (systemic treatment: fluconazole)

HSV: multiple small, deep ulcer and oral ulcers (immunosuppressed: oral acyclovir; immunocompetent: symptomatically)

What is “Feline Esophagus” or “Tracheal Esophagus” and what is it associated with?

multiple circular esophageal rings creating corrugated appearance (seen on EGD of pt. with Eosinophilic Esophagitis)
pts. with history of allergies or atopic conditions; MALES; history of food bolus impaction

What are common symptoms of Caustic Esophagitis and what are two diagnostic tests that should be performed?

What should NOT be administered to pts. with Caustic Esophagitis?

Sx: severe burning, chest pain, gagging, dysphagia, drooling IMMEDIATELY after ingestion of liquid/crystalline alkali or acid

Dxs: Laryngoscopy (need for tracheostomy) and EGD (12-24 hours to assess damage)

DO NOT give nasogastric lavage or oral antidotes –> do not want reexposure to caustic agents

What test should ALWAYS be performed in female patients presenting with nausea, vomiting, and abdominal pain?

PREGNANCY TEST

Gastroperesis

What are two common causes and how does the patient present, what diagnostic test can be used, and how is it treated? (2)

commonly caused by diabetes mellitus or post-viral infection; present with postprandial fullness (early satiety)

Dx: Gastric Scintigraphy (gastric emptying study)

low-fat solid meal (eggs)
60% retention after 2 hrs or 10% after 4 hrs = BAD

Tx: metoclopramide (tardive dyskinesia: involuntary/uncontrollable/unintentional lip-smacking or other twitching movements) and erythromycin

DO NOT use agents that reduce GI motility
keep blood glucose below 200 mg/dL

Acute Paralytic Ileus What is it, what is it commonly caused by, how is it diagnosed, and how can it be treated? (3)

- loss of peristalsis in intestine in ABSENCE of mechanical obstruction, commonly seen in hospital pts. due to surgery, electrolyte problems, and severe medical illness Dx: plain radiography or CT scan - gas/fluid in small or large bowel Tx: treat precipitating condition, nasgastric suction (SEVERE Ileus), or potential OMM **postoperative ileus reduced by analgesia, gum chewing, clear liquid diet**

Acute Small Bowel Obstruction (SBO) What is it, what are its symptoms, how is it diagnosed, and how can it be treated?

- caused by adhesions (Crohns/surgeries) and can present with feculent N/V, obstipation, and dec. bowel sounds (possible TINKLING bowel sounds) Dx: plain radiography or CT scan - dilated loops or air/fluid levels Tx: nasogastric tube for suction and supportive

Menetrier Disease What is it, what are its symptoms, and how can it be diagnosed? What is the pt. at increased risk for?

- idiopathic; giant thickened gastric folds involving body of the stomach with chronic protein loss (hypoproteinemia and anasarca) Sx: usually nausea, epigastric pain, WL, and diarrhea Dx: suspicion and EDG with biopsy Tx: cetuximab, gastric resection in severe cases **inc. risk of gastric adenocarcinoma**

What is the top three differentials for dyspepsia/heartburn/indigestion?

1. GERD 2. Gastritis 3. PUD and surgical stress ulcers

What is the difference between Type B Gastritis and Type A Gastritis?

Type B: H. Pylori (ANTRUM) --> inc. adenocarcinoma - can lead to B12 deficiency, B cell lymphoma - H. pylori eradication if PUD or MALToma Type A: Autoimmune (FUNDIC) --> inc. adenocarcinoma - loss of rugal folds with Abs to parietal cells/IF - can cause B12 deficiency or carcinoid tumors

Duodenal Ulcers vs Gastric Ulcers

D: anterior wall of proximal duodenum - gastric acid hypersecretion (90% due to H. pylori) - burning (gnawing) pain 60-180 min after meal - relieved by eating food G: lesser curvature of ANTRUM of stomach - gastric acid normal or low (75% due to H. pylori) - burning pain within 30 min of eating (food adverse) - perform endoscopy to rule out malignancy

What is a perforated viscus, how is it treated, and what can be seen on imaging that lead to diagnosis?

- any hollow organ that perforates (can happen in PUD) - NPO, IV antibiotics, preoperative labs, surgery consult and EMERGENCY SURGERY Dx: free air under diaphragm or in mediastinum (CT or plain X-Ray)

Stress Ulcers What is the difference between Curling's Ulcers and Cushing's Ulcers? Which stress ulcer is the most common?

Curling: peptic ulcer of duodenum in pts. with extensive BURNS Cushing: peptic ulcer occuring from severe head/brain injury or with other lesions of the CNS **most common stress ulcer is caused by severe medical or surgical illness**

What is the landmark that separates an Upper GI bleed from a Lower GI bleed?

Ligament of Treitz - can see with and EGD (endoscopy)

How should a pt. with an Acute UGIB be stabilized? How much should hemoglobin rise for each unit of transfused PRBC's?

- two large bore "18-gauge or larger" intravenous lines prior to further diagnostic testing - give intravenous fluids: 0.9% sodium chloride or Lactated Ringer - assess and manage their ABC's (airway, breathing, circulation) **hemoglobin should rise by 1 g/dL for each unit of transfused PRBC's**

What should each pt with an upper GI bleed undergo withing 24 hours of arriving to the emergency department? What are two pharmacologic therapies for Acute UGIB? (AIT/O)

- should undergo UPPER ENDOSCOPY - both diagnostic and therapeutic - ID bleeding, determine risk of rebleed, therapy Pharmacologic therapy: Acid Inhibitory Therapy (oral/IV PPIs) and Octreotide (dec. splanchnic blood flow and portal blood pressure)

What are the top 6 differentials for Upper Gastrointestinal Bleeds? (PS/EV/HG/MB/DL/GS)

1. PUD/stress ulcers 2. Esophageal varices 3. hemorrhagic gastritis/gastropathy (Zollinger-Ellison) 4. Mallory-Weiss Tear/Boerhaave Syndrome 5. Dieulafoy lesion 6. GAVE syndrome

What 4 things increase the risk of bleeding from esophageal varices? What are two things that can help prevent rebleeding?

1. size of varices (> 5 mm) 2. red wale markings 3. severity of liver disease 4. active alcohol abuse Prevention: nonselective beta-adrenergic blockers and long-term treatment with band ligation (dec. by 30%)

Zollinger Ellison Syndrome What is it and what genetics are it associated with, how does it present, how is it diagnosed (MF/SFG/SST), and how is it treated?

- primary gastrinoma found in the proximal duodenum, then pancreas (2/3 are malignant); associated with MEN1 (multiple endocrine neoplasia type 1 --> tumor often multifocal and unresectable) - presents as PUD that doesn't respond to tx and is severe, atypical, and recurrent Dx: large mucosal folds; Serum Fasting Gastrin (>1000 ng/L is confirmatory), Secreting Stimulation Test (+) Tx: PPIs

What are 4 levels that are drawn to exclude MEN1 in Zollinger Ellison? (P/P/L/G)

PTH, prolactin, LH-FSH, and GH

GAVE (Gastic Antral Vascular Ectasia) Syndrome What is it, how is it diagnosed, and what are treatment options?

- multiple superficial telangiectasias in gastric antrum (Watermelon Stomach) associated with diffuse scleroderma and cirrhosis Dx: EGD ("watermelon stripes") and can be confused with portal HTN gastropathy (more changes in fundus than antrum) Tx: transfusion (if needed) and endoluminal therapies

Dieulafoy Lesion

- obscure GI bleeding lesion that can be treacherous and life-threatening; large diameter vessel that protrude through mucosal defect in STOMACH - presents with MASSIVE, OBSCURE GI bleeding and can cause iron-deficiency anemia Dx: clinical suspicion and careful EGD Tx: transfusion (if needed), EGD therapy, angiographic interventions (if inaccessible), surgery (if all else fails)