CLMD: Esophagus, Stomach, Pancreas Flashcards
Upper endoscopy (EGD) is the study of choice for what conditions?
Evaluating persistent heartburn
Dysphagia
Odynophagia
Structural abnormalities detected on barium esophagography
What makes EGD both diagnostic and therapeutic?
Direct visualization + ability to take biopsies + allows dilation of strictures
Video esophagography (rapid-sequence videofluoroscopy) is the study of choice to evaluate what condition?
Oropharyngeal dysphagia
What diagnostic study differentiates between mechanical lesions and motility disorders of the esophagus?
Barium esophagography
[barium study more sensitive for detecting subtle esophageal narrowing d/t rings, achalasia, and proximal esophageal lesions]
What diagnostic study should be done to establish the etiology of dysphagia in pts in whom a mechanical obstruction cannot be found, especially if a dx of achalasia is suspected based on previous endoscopy or barium study?
Esophageal manometry — assesses esophageal motility
2 types of esophageal pH recording and impedance testing
Catheter-based (trans-nasal)
Wireless (capsule attaches directly to esophageal mucosa)
What clues indicate mechanical obstruction vs. motility disorder as the cause of esophageal dysphagia?
Mechanical obstruction = solid foods worse than liquids
Motility = solid and liquid difficulty
Types of mechanical obstruction
Schatzki ring
Peptic stricture
Esophageal cancer
Eosinophilic esophagitis
Clinical clues associated with schatzki ring as the cause of esophageal dysphagia
Intermittent dysphagia, not progressive
[note that Schatzki ring is not progressive while peptic stricture is progressive]
Clinical clues associated with peptic stricture as the cause of esophageal dysphagia
Chronic heartburn + progressive dysphagia
[patient may exhibit improving heartburn but worsening dysphagia because the stricture creates a scar that blocks acid from causing irritation]
Clinical clues associated with esophageal cancer as the cause of esophageal dysphagia
Progressive dysphagia
Clinical clues associated with eosinophilic esophagitis as the cause of esophageal dysphagia
Young adults, small-caliber lumen, proximal stricture, corrugated rings, or white papules
Clinical clues associated with achalasia as the cause of esophageal dysphagia
Progressive dysphagia
Clinical clues associated with diffuse esophageal spasm as the cause of esophageal dysphagia
Intermittent, not progressive — may have chest pain
Clinical clues associated with scleroderma as the cause of esophageal dysphagia
Chronic heartburn + Raynaud phenomenon
Clinical clues associated with ineffective esophageal motility as the cause of esophageal dysphagia
Intermittent, not progressive, commonly associated with GERD
What conditions cause progressive dysphagia?
Mechanical: peptic stricture, esophageal cancer
Motility disorders: achalasia
Do esophageal webs cause progressive or non-progressive dysphagia?
Non-progressive
Alarm features of GERD
Weight loss Persistent vomiting Constant/severe pain Dysphagia/odynophagia Hematemesis Melena Anemia (iron deficiency)
[needs endoscopy or abdominal imaging]
Patients with typical symptoms of heartburn and regurgitation should be treated empirically with what?
Once daily PPI for 4-8 weeks
T/F: severity of GERD is correlated with degree of tissue damage
False: some pts with severe esophagitis are only mildly symptomatic
Extraesophageal reflux manifestations and recommended tx
Asthma, hoarseness (possible laryngopharyngeal reflux), cough, sleep disturbance
Trial of PPI BID x2-3 months
Esophageal impedance pH testing may be performed in pts whose esophageal sxs persist after 3 months of PPI BID
If a pt presents with hx of GERD, pyrosis, and chest discomfort and an air-fluid level is seen on CXR, what is the likely dx?
Hiatal hernia
____ is a motility d/o that causes dysphagia to mainly solids but some liquids, affects women>men between ages 30-50 (more severe in african americans), and exhibits the hallmark of thickening and hardening of skin
Scleroderma
Pt presents with dysphagia, regurgitation, choking, aspiration, voice changes, halitosis, and weight loss. What is the dx study of choice to confirm your dx?
Barium swallow (likely Zenker diverticulum) — tx is surgery
Which potential cause of oropharyngeal dysphagia has a strong association with B cell non-hodgkin lymphoma?
Sjogrens
Characteristics of sjogrens
Rheumatologic condition affecting F>M in mid-50s, usually postmenopausal
Sicca sxs: dry eyes, dry mouth —> oropharyngeal dysphagia, vaginal dryness, tracheo-bronchial dryness, increased incidence of oral infections and dental caries
Parotic or other major salivary gland enlargement
What epithelial changes occur with Barrett esophagus?
Squamous epithelium of esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells (specialized intestinal metaplasia)
Risk factors for Barrett vs. peptic stricture
Risk factors for Barrett: chronic reflux, truncal obesity
Risk factors for peptic stricture: reduction in heartburn because stricture acts as barrier to reflux
If endoscopy shows presence of orange, gastric type epithelium that extends upward from stomach into distal 1/3 tubular esophagus in tongue-like or circumferential fashion, what might your dx be?
Barrett esophagus
Purpose of PPI therapy to tx barrett esophagus
PPIs do not cause regression of Barrett esophagus but may reduce risk of esophageal adenocarcinoma
2011 clinical guidelines recommend against endoscopic screening for Barrett esophagus in adults with GERD except in those with multiple risk factors for adenocarcinoma. What are the risk factors?
Chronic GERD Hiatal hernia Obesity White race Male gender Age 50+
Endoscopy every 3-5 years is recommended to look for low- or high-grade dysplasia or adenocarcinoma in these pts
SCC of the esophagus is the most common type of esophageal cancer in the world. What are the risk factors?
Males > females and AA > caucasians
Age 50+
Heavy smoking, alcohol use, achalasia, Plummer-Vinson syndrome, Tylosis, lye ingestion, hot beverages
[note that adenocarcinoma of the esophagus has higher incidence in caucasians than AA]
Truly refractory (unresponsive) reflux disease with esophagitis may be caused by what conditions?
ZE syndrome
Pill-induced esophagitis
Resitance to PPIs
Medical noncompliance
Most commonly implicated pills that cause pill-induced esophagitis
NSAIDs, potassium chloride pills, alendronate and risedronate, antibiotics
[others not highlighted in her slide: quinidine, zalcitabine, zidovudine, bisphosphonates, emepronium bromide, iron, vitamin C]
Dx and possible complications of pill-induced esophagitis
Endoscopy may reveal one to several discrete ulcers that may be shallow or deep
Complications: chronic injury may result in severe esophagitis with stricture, hemorrhage, or perforation
[note that healing occurs rapidly when offending agent is eliminated]
Most common pathogens implicated in infectious esophagitis
Candida albicans
HSV
CMV
Risk factors for infectious esophagitis
Immunosuppression (AIDS, solid organ transplants, leukemia, lymphoma)
Uncontrolled diabetes, tx with systemic corticosteroids, radiation therapy, systemic abx therapy
Dx of infectious esophagitis is done by endoscopy with brushings, biopsy, and culture. Which pathogen is characterized by one to several large, shallow, superficial ulcerations and may be compounded with infection at other sites such as the colon and retina?
CMV
Tx: in pts with HIV, immune restoration with antiretroviral therapy is most effective means of controlling CMV infection. Initial therapy is with ganiciclovir — although neutropenia is frequent dose-limiting SE
Dx of infectious esophagitis is done by endoscopy with brushings, biopsy, and culture. Which pathogen is characterized by multiple small, deep ulcerations as well as possible associated oral ulcers?
HSV
Tx: immunocompetent pts treated symptomatically but immunosuppressed pts require tx with acyclovir
Dx of infectious esophagitis is done by endoscopy with brushings, biopsy, and culture. What pathogen is implicated with diffuse, linear, yellow-white plaques adherent to esophageal mucosa?
Candidal esophagitis
Tx: systemic antifungal like fluconazole
Sxs of caustic esophageal injury
Almost immediate severe burning and varying degrees of CP, gagging, dysphagia, and drooling
Aspiration results in stridor and wheezing
Other symptoms may include dyspnea and hematemesis
Dx of caustic esophageal injury
Initial exam directed to circulatory status as well as assessment of airway patency and oropharyngeal mucosa including laryngoscopy
Chest and abdominal radiographs are obtained looking for pneumonitis or free perforation (both potential complications of caustic injury)
Why should endoscopic surveillance be considered 15-20 years after caustic ingestion esophageal injury?
Risk of esophageal SCC is 2-3% after caustic ingestion
T/F: nasogastric lavage and oral antidotes may be dangerous and should NOT be administered following caustic esophageal injury
True
Risk factors for eosinophilic esophagitis
GERD, PPI-responsive eosinophilia, celiac dz, Crohn dz, and pemphigus
Food or environmental Ags thought to stimulate inflammatory response
Children and young-middle-aged adults
Predominantly men and those with hx of allergies or atopic conditions (asthma, eczema, hay fever)
Dx of eosinophilic esophagitis
Barium swallow studies show small-caliber esophagus with multiple concentric rings
Endoscopy with esophageal biopsy is required to establish dx to demonstrate multiple eosinophils in mucosa [endoscopy also shows white exudates or papules, red furrows, corrugated concentric rings, and strictures]
Treatment for eosinophilic esophagitis
Topical corticosteroids effective in 70% — budesonide or fluticasone
Dilation of strictures can be done, but beware of high risk of perforation in these pts
Dx of esophageal webs
Best visualized with barium esophogram (more sensitive test for this than endoscopy)
Esophageal rings (Schatzki rings) are associated in nearly all cases with a ____ _____ and are bes visualized using ____ ____
Hiatal hernia; barium esophagogram
Combination of sxs seen with plummer vinson syndrome
Esophageal webs Iron-deficiency anemia Angular cheilitis Glossitis Koilonychia (spoon nails)
What factors increase the risk of bleeding from esophageal varices?
- Size > 5 mm
- Presence of red wale markings
- Severity of liver disease
- Active alcohol abuse
Tx for bleeding esophageal varices
Initial management in ICU: fluid resuscitation, FFP or platelets for possible coagulopathy, IV vitamin K
Antibiotic prophylaxis with fluoroquinolones or IV-3rd gen cephalosporins for possible infection
Somatostatin and octreotide to reduce portal pressures
Lactulose bc encephalopathy may complicate an episode of GIB in pts with severe liver dz
What is used to prevent re-bleed from esophageal varices?
Nonselective beta-adrenergic blockers (propranalol, nadolol)
Long term tx with band ligation reduces incidence of rebleeding in about 30%
[other invasive treatments include balloon tube tamponade, transvenous intrahepatic portosystemic shunts (TIPS), liver transplant]
Etiology of achalasia
Denervation of esophagus resulting primarily from loss of NO-producing inhibitory neurons (ganglion cells) in myenteric plexus
Secondary achalasia caused by Chagas disease — especially in endemic regions of Mexico, Central, and South America [trypanosoma cruzi infection]
Diagnostic tests used in series to dx achalasia
Barium esophagram (shows “birds beak” distal esophagus)
Then EGD to exclude distal stricture or submucosal infiltrating carcinoma
Esophageal manometry confirms dx
If achalasia is not treated, the esophagus may become markedly dilated, known as _____ esophagus
Sigmoid
[tx includes once-daily PPI and may include botulinum toxin injection, pneumatic dilation, or surgery]
Define and describe Nutcracker esophagus in terms of LES tone, symptoms, dysphagia pattern, and diagnostics
Nutcracker esophagus = hypertensive peristalsis; swallowing contractions are too powerful
LES relaxes normally but has elevated pressure at baseline
Sxs = dysphagia to solids and liquids, atypical CP
Dysphagia is intermittent and non-progressive
Dx by manometry and/or video fluoroscopy
Define and describe Diffuse Esophageal Spasm in terms of LES tone, symptoms, dysphagia pattern, and diagnostics
DES = Uncoordinated esophageal contraction (“corkscrew esophagus” or “rosary bead esophagus” on barium xray)
LES function is normal
Sxs = dysphagia to solids and liquids, atypical CP
Dysphagia is intermittent and nonprogressive
Dx by manometry, EGD, and/or barium swallow
Signs suggestive of pneumomediastinum
Subcutaneous emphysema (typically detected in neck or precordial area)
Hamman’s sign = crunching sound synchronous with heartbeat, heard over precordium mainly during systole
Dyspnea
What factors reduce incidence of stress ulcers or bleeding from those ulcers in ICU pts?
The use of enteral nutrition reduces risk of stress-related bleeding
Use of H2 blocker or PPI reduce incidence
Most common clinical manifestation of erosive gastritis
Upper GI bleeding, which presents as hematemesis, “coffee-ground” emesis, or bloody aspirate in pt receiving NG suction
May also see melena
Characteristics of Type A Gastritis (Fundic-type)
Body predominant and less common form
Generally asymptomatic and more common in elderly
Autoimmune mechanism may be associated with achlorhydria, pernicious anemia, and increased risk of gastric cancer [Abs to parietal cells present in 90%]
May see carcinoid tumors, decreased IF secretion, vit B12 malabsorption, and loss of rugal folds
Characteristics of Type B gastritis (Antral type)
Antral-predominant disease caused by H.pylori
Associated with dyspepsia, atrophic gastritis, gastric atrophy, gastric lymphoid follicles, and gastric B cell lymphomas may occur
Eradication of H.pylori not routinely recommended unless PUD or gastric MALT lymphoma is present
Idiopathic entity characterized by giant thickened gastric folds involving predominantly the body of the stomach resulting in chronic protein loss — pts may present with severe hypoproteinemia and anasarca
Menetrier disease
When H.pylori infection is located in the gastric antrum, there is ____ gastric acid secretion. When it is located in the gastric body, there is ____ gastric acid secretion
Increased;decreased
Risk factors for PUD not associated with H.pylori
NSAID use, corticosteroid use, smoking, hypercalcemia, mastocytosis, blood group O, alcohol
Detection of H.pylori infection
Tell pt to stop PPI 14 days prior to fecal and breath tests
Fecal Ag test sensitive, specific, and inexpensive for detection (can also do EGD with biopsy stained with warthin-starry silver stain)
Urea breath test typically used to confirm eradication
Possible lab findings with symptomatic H.pylori infection
Anemia - may occur with acute or chronic blood loss (hematocrit may also fall)
Leukocytosis - suggests ulcer penetration or perforation
Increased serum amylase + severe pain suggests ulcer penetration into pancreas
BUN may rise as result of absorption of blood nitrogen from small intestine and prerenal azotemia
Dietary and other risk factors for gastric adenocarcinoma
Dietary factors: smoked fish and meats, pickled vegetables, nitrosamines, benzpyrene, reduced intake of fruits and veggies
Others: H.pylori, smoking, blood type A, menetrier disease, more common in Japan
Histological and PE findings associated with gastric adenocarcinomas
Histology: Signet-ring cells and linitis plastica
PE: Virchow sentinel node and Krukenberg tumor
ZE syndrome is associated 25% of the time with what other syndrome?
MEN 1
[gastrinoma, hyperparathyroidism, hypercalcemia, pituitary neoplasm]
Dx of ZE syndrome
Suggestive = large mucosal folds on endoscopy or upper GI radiograph
Confirmatory = serum gastrin >1000 ng/L; secretin stimulation test +
What labs must be drawn in all pts with ZE syndrome to exclude MEN 1?
Serum PTH
Prolactin
LH-FSH
GH
Gastric scintigraphy imaging following a low-fat solid meal is used to dx what condition?
Gastroparesis
____ and _____ are each of benefit in tx of gastroparesis
Metoclopramide; erythromycin
[note that metoclopramide use x3+months —> slightly increased risk of tardive dyskinesia]
Diagnosis of pancreatitis is established by 2 out of what 3 criteria?
- Typical abdominal pain in epigastrium that may radiate to back
- Threefold or greater elevation in serum lipase and/or amylase (lipase more accurate than amylase)
- Confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging
Most common causes of pancreatitis in US
Cholelithiasis
Alcohol
[other common causes: hypertriglyceridemia, ERCP after biliary manometry, drugs, trauma, or post op]
Possible PE findings in pt with pancreatitis
Low-grade fever, tachycardia, hypotension
Erythematous skin nodules d/t subcutaneous fat necrosis
Basilar rales, pleural effusion, edema (3rd spacing — possible anasarca)
Abdominal tenderness and rigidity
Cullen’s sign
Grey Turner sign
Besides lipase/amylase, other labs found in acute pancreatitis
Proteinuria Granular casts in urine Glycosuria Leukocytosis Hyperglycemia Hyperbilirubinemia Increased alkaline phosphatase Abnormal coag studies Increased BUN Elevated creatinine Elevated ALT (suggest biliary etiology) Hypocalcemia (possible tetany) Elevated Hct (panc.necrosis) Increased CRP (severe) Hypoalbuminemia and increased LDH (increased mortality rate)
Imaging findings with acute pancreatitis
Xray may show sentinel loop (segment of air-filled small intestine in LUQ), colon cut-off sign, calcified gallstones, focal linear atelectasis of lower lobe of lungs with/without pleural effusion
US may identify gallstones, pseudocysts, mass lesions, or edema/enlargement of pancreas
CT can confirm clinical impression of acute pancreatitis and its complications
Rapid bolus IV contrast enhanced CT, MRI, endoscopic US
Perfusion CT (PCT) may show fluid collection in pancreas, which correlates with increased mortality rate
Pancreatitis is a possible complication of what imaging procedure?
ERCP
[however, ERCP can be used to evaluate pancreatitis in certain pts]
Post ERCP prophylaxis includes NSAIDs, indomethacin rectally, and aggressive IV hydration with lactated ringers
Most important tx for acute pancreatitis
Safe but aggressive IV fluid rescuscitation
Other measures include nothing PO and parenteral analgesics for pain
Risk factors for high levels of fluid sequestration in acute pancreatitis (3rd spacing/edema)
Younger age, alcohol etiology, higher hematocrit value, higher serum glucose, and SIRS in first 48 hrs of hospital admission
In pts with pancreatitis, infusions of FFP or serum albumin may be necessary if coagulopathy or hypoalbuminemia is present. However, with these colloid solutions, there is increased risk of ______
ARDS
Complications of acute pancreatitis
Necrotizing pancreatitis Multisystem organ failure IV volume depletion Ileus Fluid collections Necrotic pancreatic pseudocysts ARDS (3-7 days after) Pancreatic abscess
Others include hemorrhage, colonic necrosis, portosplenomesenteric venous thrombosis, chronic pancreatitis, permanent DM and exocrine pancreas insufficiency
Ranson Criteria for assessing severity of pancreatitis (number of criteria correlates with increasing mortality rate)
GA-LAW for characteristics at admission: Glucose > 200 Age > 55 LDH > 350 AST > 250 WBC > 16,000
C & Hobbs for characteristics 48 hours after admission: Calcium <8 Hct drop >10% Oxygen (PaO2) <60 mmHg Base deficit >4 BUN increase > 5 Sequestration of fluid > 6L
Most frequent cause of clinically apparent chronic pancreatitis
Alcoholism
The pathogenesis of chronic pancreatitis may be explained by what hypothesis?
The SAPE hypothesis: by which the first (sentinel) acute pancreatitis event initiates an inflammatory process that results in injury and later fibrosis
Autoimmune pancreatitis is associated with ______, often with autoantibodies and other autoimmune diseases. It is responsive to tx with _____
Hypergammaglobulinemia (IgG4); corticosteroids
Genes associated with chronic pancreatitis and pancreatic exocrine insufficiency
PRSS1 — AD inheritance CFTR CASR CTRC SPINK1
Useful tests in evaluation of pts with suspected pancreatic steatorrhea (malabsorption/insufficiency)
Fecal elastase-1 and small-bowel biopsy
Fecal elastase will be low in pts with pancreatic insufficiency
Plain film imaging also may show pancreatic calcifications
Complications of chronic pancreatitis
Chronic abdominal pain, gastroparesis, malabsorption/maldigestion, impaired glucose tolerance (Brittle DM)
Nondiabetic retinopathy d/t vitamin A and/or zinc deficiency
GI bleeding, icterus, effusions, subcutaneous fat necrosis, metabolic bone dz
Opioid/narcotic addiction common
Pancreatic pseudocyst or abscess, bile duct stricture, steatorrhea, malnutrition, osteoporosis, peptic ulcer, increased risk of pancreatic cancer
Signs of pancreatic adenocarcinoma
Painless jaundice, N/V, fatigue, weight loss, steatorrhea, new onset diabetes
Trousseau sign of malignancy (migratory thrombophlebitis)
Courvoisier sign
Risk factors for pancreatic cancer
Smoking, obesity, male, african american, >65 y/o, DM, chronic pancreatitis, liver cirrhosis, family hx
3 P’s with MEN 1 syndrome
Parathyroid (hypercalcemia, increased intact PTH)
Pancreas (gastrinoma/ZE, insulinoma w/ hypoglycemia)
Pituitary (possible acromegaly, Cushing dz)
