Clinical Approach to the GI Patient: Atypical Chest Pain and Odynophagia Flashcards
1
Q
When a patient presents with atypical chest pain, what 3 non-GI things should you rule out first?
A
MI, pulmonary embolism, aortic dissection
2
Q
when a patient presents with atypical chest pain, what 3 GI things should you rule out first?
A
Boerhaave Syndrome, Iatrogenic Esophageal Perforation, and Peptic Ulcer Disease (PUD)
3
Q
what are the 6 non-life threatening GI causes of atypical chest pain?
A
GERD, hiatal hernia, nutcracker esophagus, diffuse esophageal spasm, eosinophilic esophagitis, and esophageal impaction
4
Q
what are the 5 risk factors for MI?
A
smoking, age, hypertension, diabetes mellitus, hyperlipidemia
5
Q
What are the risk factors for atypical presentation of MI?
A
elderly, female sex, diabetes mellitus
6
Q
What are 2 examples of atypical presentation of MI?
A
dyspepsia and epigastric pain
7
Q
what are the risk factors for PE?
A
hypercoagulable state
8
Q
what 4 things could cause a hypercoagulable state?
A
recent travel, surgery, cancer, genetics
9
Q
what is the presentation of PE? (4)
A
sudden onset, pleuritic chest pain, shortness of breath, hypoxia
10
Q
what might the vital signs look like like in a patient with a PE?
A
can have hemodynamic collapse–> tachypnea and tachycardia
11
Q
what are the diagnostics used for PE? (4)
A
wells criteria, ECG (sinus tach vs S1Q3T3), CTA, lower extremity venous doppler ultrasound
12
Q
what are the risk factors for aortic dissection? (5)
A
atherosclerosis, male sex, smoking, age, hypertension
13
Q
what is the presentation like in a patient with aortic dissection (4)
A
sudden onset, “tearing or ripping” chest pain, can have some radiation to neck, Syncope
14
Q
what are some common symptoms of an aortic dissection? (3)
A
CVA symptoms (hemiparesis), AMS, and “impending doom”
15
Q
what might the vital signs look like in a patient with aortic dissection? (2)
A
high or low BP, asymmetrical pulses
16
Q
what are the diagnostics used for aortic dissection? (2)
A
CXR with widen mediastinum or CT with contrast (definitive)
17
Q
what is the etiology of PUD?
A
defensive factors (gastric mucus, bicarbonate, and prostaglandins) are overwhelmed by gastric acid, pepsin
18
Q
What could cause the defensive factors to be overwhelmed by gastric acid, pepsin? (3)
A
H. pylori, NSAIDs or Zollinger Ellison Syndrome
19
Q
what are the exacerbating factors to PUD? (3)
A
anxiety/stress, coffee, alcohol
20
Q
How far do ulcers extend?
A
ulcers extend through the muscularis mucosa
21
Q
What could be 2 symptoms of PUD?
A
epigastric pain, atypical chest pain
22
Q
How is the epigastric pain seen in PUD described? (4)
A
gnawing, dull, aching, or “hunger-like”
23
Q
What is the timing like in PUD?
A
symptomatic periods (several weeks) with intervals of pain free (months/years)
24
Q
What is a more significant sign/ symptom of PUD?
A
Signs of GI bleeding
25
What are the signs of GI bleeding? (4)
"coffee ground" emesis, hematemesis, melena, hematochezia
26
What might the physical exam look like in a patient with PUD?
PE often normal in uncomplicated peptic ulcer disease; mild localized epigastric tenderness to deep palpation; hyperactive bowel sounds
27
PUD can be life threatening when there are complications; what are these complications? (4)
bleeding (erosion into artery), obstruction (from edema), perforation (referred shoulder pain, pneumoperitoneum), gastric adenocarcinoma or MALT-lymphoma
28
What are the diagnostics used for PUD?
H&H (anemia?), BUN/creatinine (UGIB= increase in BUN), EGD with biopsy (diagnostic and therapeutic)--> exclude malignancy in gastric ulcer; barium x-ray; x-ray/CT/MRI if suspect complication (perforation/obstruction); nasogastric lavage can be considered
29
what are 4 ways to detect H. pylori? What is the best way? what is the first way?
Fecal antigen test, urea breath test, IgA antibodies in serum, upper endoscopy with gastric biopsy; best= upper endoscopy with gastric biopsy; first: IgA antibodies
30
how can you confirm eradication of H. pylori? What is generally used?
fecal antigen test and urea breath test; urea breath test is generally used to confirm eradication
31
how do you treat/manage PUD?
acid suppression (proton pump inhibitor or H2 blocker); eradicate H. pylori; stop smoking (and alcohol); discontinue NSAIDs; endoscopic intervention (for active bleeding)
32
for gastric ulcers, what should you do for treatment/management?
exclude malignancy (follow endoscopically to healing: EGD with repeat biopsy of ulcer)
33
what type of disorder is reflux esophagitis?
a motility disorder: ineffective esophageal motility
34
what is occurring in reflux esophagitis?
the lower esophageal sphincter is allowing stomach acid to reflux
35
what are the risk factors for reflux esophagitis?
increased abdominal girth/obesity, pregnancy, hiatal hernia/scelroderma/Zollinger-ellison syndrome, fat-rich diet/caffeine/smoking/alcohol
36
what are the typical symptoms associated with reflux esophagitis?
pyrosis (heartburn), relationship to meals (30-60 minutes after eating), symptoms upon reclining, waterbrash, epigastric abdominal pain, esophageal dysphagia
37
what are the atypical symptoms/ extraesophageal manifestations of reflux esophagitis?
asthma, laryngitis, chronic cough, aspiration pneumonitis, chronic bronchitis, sleep apnea, dental caries, halitosis, hiccups, and hoarseness
38
what is the physical exam of someone with reflux esophagitis?
might be normal; epigastric pain? dental caries? hoarseness?
39
what are the alarming symptoms/features associated with reflux esophagitis?
unexplained weight loss, persistent vomiting (--> dehydration), constant and severe pain, dysphagia/odynophagia, palpable mass or adenopathy, hematemesis, melena, anemia
40
The alarming features of reflux esophagitis require further evaluation- what is this further evaluation?
endoscopy, directed radiographic abdominal imaging, surgical evaluation
41
how do you diagnose reflux esophagitis?
clinical: based on presentation, history, and PE; labs to consider: H&H and h.pylori testing
42
what can be done later to diagnose reflux esophagitis (aka not done initially)?
ambulatory 24-48 h esophageal pH recording and impedance testing; barium x-ray; EGD with biopsy
43
what if you have a 60 years or older patient presenting with reflux esophagitis symptoms that are not resolving with treatment?
a further workup is need--> EGD and imaging
44
what is the treatment/management of reflux esophagitis?
Empiric (if no alarm features present)- trial of acid suppression and lifestyle modification; surgical techniques; H.pylori eradication if indicated
45
what are the acid suppressions used for treatment/management of reflux esophagitis?
antacids, proton pump inhibitors> histamine receptor blockers
46
what lifestyle modifications can be made to treat reflux esophagitis?
decrease alcohol and caffeine, small low fat meals, bed at an incline, weight reduction, avoidance of smoking, chocolate, fatty food, citrus juices, and NSAIDs
47
what are the complications associated with reflux esophagitis?
barrett's esophagus--> esophageal adenocarcinoma; Laryngopharyngeal reflux (LPR)
48
what is a hiatal hernia?
herniation of the stomach into the mediastinum through the esophageal hiatus of the diaphragm
49
what is a sliding hiatal hernia?
result of increased intraabdominal pressure from abdominal obesity, pregnancy and hereditary propensity of affected individuals to have GERD
50
what are the symptoms/ presentation of a hiatal hernia?
atypical chest pain and Pyrosis (GERD)
51
what is the physical exam like in a patient with a hiatal hernia?
can have but not limited to: increased abdominal girth (obesity/pregnancy)
52
what are the diagnostics used for a hiatal hernia?
EGD- can see it; sometimes seen on chest x-ray; barium swallow x-ray
53
what is the treatment/management of a hiatal hernia?
asymptomatic: no treatment; symptoms: surgical repair
54
what is nutcracker esophagus?
hypertensive peristalsis--> swallowing contractions are too powerful (greater amplitude and duration)
55
what occurs during nutcracker esophagus?
the lower esophageal sphincter relaxes normally, but has elevated pressure at baseline
56
how does nutcracker esophagus present?
atypical chest pain, dysphagia to solids and liquids, intermittent, not progressive
57
what is nutcracker esophagus associated with?
increased frequency of depression, anxiety, and somatization
58
what are the diagnostics used for nutcracker esophagus?
manometry; EGD- used to exclude mechanical and inflammatory lesions
59
what is the treatment/management of nutcracker esophagus?
nitrates (isosorbide dinitrate); calcium antagonists (nefedipine); treat concomitant mental health
60
what is diffuse esophageal spasm?
multiple spastic contractions of the circular muscle in the esophagus; functional imbalance between excitatory and inhibitory postganglionic pathways; disrupting the coordinated components of peristalsis
61
what is occurring in diffuse esophageal spasm?
uncoordinated esophageal contraction (long duration and recurrent)
62
what are the causes of diffuse esophageal spasm?
primary (idiopathic); secondary due to GERD, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia, or collagen vascular disease
63
how does diffuse esophageal spasm present?
atypical (retrosternal) chest pain, dysphagia to solids and liquids, intermittent, not progressive
64
what is diffuse esophageal spasm associated with?
increased frequency of depression, anxiety, and somatization
65
what are the diagnostics used for diffuse esophageal spasm?
manometry, EGD, barium swallow x-ray
66
what is the gold standard for diagnosing diffuse esophageal spasm?
manometry: shows uncoordinated peristalsis
67
what are the findings of a barium swallow x-ray in a patient with diffuse esophageal spasm?
"corkscrew esophagus" or "rosary bead esophagus"
68
what is the treatment/management for diffuse esophageal spasm?
medical treatment is first line: nitrates (isosorbide dinitrate) and calcium antagonists (nifedipine); then treat concomitant mental health
69
what is the etiology of eosinophilic esophagitis (EOE)?
etiology unknown: eosinophil chemokine?; GERD? PPI use? celiac disease? Crohn disease?
70
how does eosinophilic esophagitis present in adults?
vague retrosternal chest pain, dysphagia, pyrosis, regurgitation of undigested food
71
how does eosinophilic esophagitis present in children?
vague retrosternal chest pain, vomiting, difficulty feeding, dysphagia, failure to thrive (weight loss)
72
what is the PMHx like in patients with eosinophilic esophagitis?
allergies or atopic conditions (>50% of patients)--> thought to stimulate inflammation; long history of dysphagia to solid foods; history of food bolus impaction
73
what are the diagnostics used for eosinophilic esophagitis?
CBC with differential= eosinophilia; EGD
74
what does the EGD look like in a patient with eosinophilic esophagitis?
loss of vascular markings (edema), longitudinally oriented furrows, and punctate exudate; multiple circular esophageal rings creating a corrugated appearance--> "feline esophagus" also been said to look like a trachea "tracheal esophagus"
75
what does a biopsy of the esophagus look like in a patient with eosinophilic esophagitis?
squamous epithelial eosinophil-predominant inflammation
76
what is the treatment/management like for eosinophilic esophagitis?
PPI, swallow inhaled (topical) glucocorticoids (corticosteroids); allergist referral; empiric elimination of common food allergies; esophageal dilation is very effective at relieving dysphagia
77
when treating eosinophilic esophagitis with esophageal dilation, what do you have to be cautious of?
there is a risk of deep, esophageal mural laceration of perforation
78
what are the complications associated with eosinophilic esophagitis?
esophageal stricture, narrow-caliber esophagus, food impaction, and esophageal perforation
79
how can you prevent the complications that are associated with eosinophilic esophagitis?
by working on treating EOE early; careful dilation is needed to prevent iatrogenic esophageal perforation during EGD
80
what is the etiology of esophageal impaction?
schatski ring, peptic stricture, webs, esophagitis (eosinophilic!), achalasia, cancer, accidental
81
what is the typical presentation of someone with an esophageal impaction?
hypersalivation: inability to swallow liquids including their own saliva--> drooling/frothing/ foaming at the mouth; chest pain/ pressure (severe); dysphagia, odynophagia, sensation of choking, neck or throat pain, retching and emesis
82
what are the diagnostics used for esophageal impaction?
emergent EGD
83
what is the treatment/management for esophageal impaction?
pass spontaneously, endoscopically removed or pushed through lower esophageal sphincter, surgery
84
what are the complications associated with esophageal impaction?
perforation and ulceration
85
what is odynophagia?
pain on swallowing
86
what are three things you should consider if a patient presents with odynophagia and atypical chest pain?
pill induced esophagitis, infectious esophagitis, caustic esophagitis
87
what is the etiology of pill induced esophagitis?
medications--> direct, prolonged mucosal contact or mechanisms that disrupt mucosal integrity
88
what medications commonly cause pill induced esophagitis?
NSAIDs, potassium chloride, bisphosphonates for osteoporosis, iron, antibiotics
89
when is pill induced esophagitis most likely to occur?
if pills are swallowed without water or while supine (hospitalized or bed bound patients are at increased risk)
90
how does pill induced esophagitis present?
severe, retrosternal chest pain, odynophagia, and dysphagia
91
what is the timing like of pill induced esophagitis?
several hours after taking a pill (may take longer); may occur suddenly and persist for days
92
how might the elderly and some other patients present with pill induced esophagitis?
they may have relatively little pain, but they are presenting with dysphagia
93
what are the diagnostics used for pill induced esophagitis?
history (ask medication history) and endoscopy- may reveal one to several discrete ulcers that may be shallow or deep
94
if you suspect a patient has pill induced esophagitis and you perform an EGD on them, what might it show?
may reveal one to several discrete ulcers that may be shallow or deep
95
what is the treatment/management for pill induced esophagitis?
stop medication; switch to different form (parenteral if possible or liquid form); healing occurs rapidly when the offending agent is eliminated; can consider adding PPIs
96
how can you prevent pill induced esophagitis?
take pills with 4-8 oz of water and remain upright for 30 minutes after ingestion; known offending agents should not be given to patients with: esophageal dysmotility, dysphagia, or strictures
97
what are the complications associated with pill induced esophagitis?
severe esophagitis with stricture, hemorrhage, perforation
98
what are the most common pathogens that cause infectious esophagitis?
candida albicans, herpes simplex (HSV), CMV, and HIV
99
what are the risk factors for getting candida infections?
uncontrolled diabetes, treated with corticosteroids, radiation therapy, systemic antibiotic therapy
100
what might the presentation be in someone with infectious esophagitis?
sometimes asymptomatic; fever, odynophagia, dysphagia, substernal chest pain
101
what are the diagnostics used for infectious esophagitis caused by CMV?
EGD; biopsy; check for HIV
102
what does an EGD show on a patient with infectious esophagitis caused by CMV?
one to several large, shallow, superficial ulcerations; biopsy with inclusion bodies
103
what does EGD show on a patient with infectious esophagitis caused by herpes simplex virus?
multiple small deep ulcerations; oral ulcers (herpes labialis) could be present
104
what does EGD show on a patient with infectious esophagitis caused by candidal infection?
diffuse, linear, yellow-white plaques adherent to the mucosa
105
what is the treatment for infectious esophagitis caused by CMV?
gancyclovir
106
what is the treatment for infectious esophagitis caused by herpes simplex virus?
oral or IV acyclovir
107
what is the treatment for infectious esophagitis caused by candida?
system therapy (example: fluconazole)
108
what is the etiology of caustic esophagitis?
ingestion of liquid or crystalline alkali (drain cleaners) or acid
109
what are the risk factors for caustic esophagitis?
accidental (usually children) or deliberate (suicidal)
110
what are the major symptoms associated with caustic esophagitis?
dyspnea, dysphagia, odynophagia, oral burns (drooling), hematemesis, oropharyngeal lesions, severe burning and varying degrees of chest pain, gagging
111
what does aspiration of liquid or crystalline alkali (drain cleaners) or acid cause?
stridor and wheezing
112
what are the diagnostics used for caustic esophagitis?
initial examination: circulatory status- assessment of airway patency and the oropharyngeal mucosa, including laryngoscopy; chest and abdominal radiographs are obtained looking for pneumonitis or free air--> perforation
113
what should you do for treatment of caustic esophagitis?
stabilize the patient, hospitalized in ICU, supportive care--> endotracheal tube, NPO, IV fluids, IV PPI, analgesics, antibiotics, NG tube; monitor for signs of deterioration--> emergent surgery; laryngoscopy in patients with respiratory distress to assess the need for tracheostomy; EGD is usually performed within the first 12-24 hours to assess the extent of injury
114
what should you not do for treatment of caustic esophagitis?
nasogastric lavage and oral antidotes--> might re-expose the esophagus to the corrosive agent and produce additional injuries; oral corticosteroids and/or antibiotics are not recommended
115
what are the complications associated with caustic esophagitis? short term
perforation--> pneumonitis, mediastinitis, peritonitis, bleeding, esophageal-tracheal fistulas
116
what are the long term complications associated with caustic esophagitis?
esophageal strictures (serious cases): weeks to months after the initial injury- requiring recurrent dilations
