Diagnostic Approaches And Management Of Common Upper GI Conditions - Part 2 Flashcards
How can GI bleeding present?
Melena
Hematemesis
Coffee ground emesis
Hematochezia
Peptic ulcer disease (PUD) vs. Erosion
Ulcer - break in the mucosa which extends through the muscularis mucosa
Erosion - break through the mucosa which does not penetrate the muscularis mucosa
Causes of upper GI ulceration
Infections - H. Pylori
Medications - NSAIDs
Vascular - ischemia, stress ulceration
Zollinger-Ellison syndrome
Inflammatory - radiation, Chron’s
Neoplastic - Adenocarcinoma
Zollinger-Ellison syndrome
- define
- epidemoiology
- presentation
Secretion of gastrin by duodenal or pancreatic neuroendocrine tumours (gastriomas)
- 20 to 50 year olds, higher incidence in men
- 20-30% occur in association with multiple endocrine neoplasia (MEN1)
Chronic diarrhea - failure of resabsorption of the increased gastric acid, inactivation of pancreatic enzymes, damage to intestinal epithelium and inhibition of the absorption of sodium and water
Abdominal pain, PUD
H pylori
Spiral shaped, micro-aerophilic, gram-negative bacterium
- 2-7 unipolar sheathed flagella that enhance mobility through viscous solutions-urease positive
- prevalence of 90-95% in DU, 80-85% in GU
- most common chronic bacterial infection worldwide (30% in Canada)
- strains with VacA and CagA gene most likely to cause PUD
- less than 1/4 of patients with H. Pylori dyspepsia symptoms response to eradication therapy
What can H. Pylori cause?
Gastric ulcer - infection more evenly speared throughout
Duodenal ulcer - antral predonimant H. Pylori
Indications to test and treat HP infection
1) active PUD
2) confirmed Hx of PUD (not previously treated for HP)
3) gastric MALT lymphoma
4) following endoscopic resection of early gastric cancer
5) uninvestigated dyspepsia (in high prevalence population)
H pylori diagnosis
Urea breath test (UBT)
Stool antigen assay
Histologically
Serology for HP?
Should we use?
How does it work?
Is an ELISA test to detect IgG abs against H. Pylori
Should not be used in low prevalence populations as low accuracy would result in inappropriate treatment in a large number of patients
- low PPV in low prevalence propulsion, but high NPV
- does not reliable distinguish between active and past infection
Most important factors in pathogenesis of PUD
HP infection
ASA/NSAIDs
Idiopathic
Risk factors for serious GI event with NSAID use
- advanced age
- Hx of PUD or ulcer complication
- major illness (heart disease)
- concomitant anticoagulants
- use of steroids
- Hx of PUD
- high dose of NSAIDs
- presence of H. Pylori
- smoking and alcohol
Complications of PUD?
Penetration/perforation
Bleeding
Obstruction
Management of PUD
Correct the cause
Lifestyle modifications
PPI
Endoscopic measures
- injection, coagulation, clipping, hemp spray, biopsies
PPIs for PUD
Generally considered safe
Can cause physiologic hypergastrinemia
- reduce stomach acid and therefore bioavailability of drugs reliant on intragastric acidity to maximize absorption (ketoconazole)
- anti-platelet action of clopidogrel maybe modestly reduced by PPIs
Hemospray
Family of hemostatic powders
Consists of small mineral granules that achieve homeostasis
TC-325 binds to actively bleeding sites
Granules absorb all the water from blood or secretions and then swell or adhere to the bleeding - acts as a bandage
Embolization for PPD
In case of ulcer bleeding refractory to medical/endoscopic therapy —> embolization
Surgical management of PUD
Ulcer-based management - ligation of bleeding vessels or placement and fixation of omentum within the ulcer bed to cover defect and promote healing (Graham patch)
Vagotomy - transects/removes a portion of vagus nerve/branches to decrease gastric acid secretion
Gastric draining - pyloroplastly, gastrojejunostomy
Gastrectomy and reconstruction
- partial gastrectomy removes portion of the stomach containing the ulcer, the gastrin producing and a number of parietal cells
- reconstruction: Billroth I, II and Roux-en-y
Causes of oropharyngeal dysphagia
CNS disease - CVA (brainstem, pseudobulbar palsy)
PNS disease - head and neck neoplasms, past radical neck surgery
Muscle disease - muscular atrophy, polymyositis and dermatomyositis, myasthenia Travis
Local disorders - Zenker’s diverticulum
Idiopathic conditions - idiopathic oropharyngeal incoordination
Zenker’s diverticulum (ZD)
What is it?
How does it present?
Diagnosis
A sac-like outpouching of mucosa and Submucosa through Killian’s triangle (area of muscular weakness b/w transverse fibres of cricopharyngeus muscle and oblique fibres of lower inferior constrictor muscle
Progressive oropharyngeal dysphagia, regurgitation of undirected food
Diagnosis done by barium swallow and an upper endoscopy under direct vision should be preformed to exclude cancer
Dysphagia 2-esophageal
Esophageal:
Mechanical:
- progressive - adenocarcinoma
- chronic - esophageal web, Schatzki’s ring
Motility
- hypomotility - scleroderma
- hypermotility - diffuse esophageal spasms
- both - achalasia
Esophageal rings and webs
Rings - concentric (2-5mm) diaphragm of tissue protruding into esophageal lumen, typically in distal, usually mucosal (e.g. Schatzki ring)
Webs - thin (<2mm) eccentric membrane that protrudes into the esophageal lumen, covered with squamous epithelium, anteriorly in the cervical esophagus, causing focal narrowing in postcricoid area
Esophageal webs
thin (<2mm) eccentric membrane that protrudes into the esophageal lumen, covered with squamous epithelium, anteriorly in the cervical esophagus, causing focal narrowing in postcricoid area
Esophageal rings
concentric (2-5mm) diaphragm of tissue protruding into esophageal lumen, typically in distal, usually mucosal (e.g. Schatzki ring)
Types of dysphagia
Oropharyngeal - can’t swallow, coughing, hoarseness
- structural and neuromuscular
- test with Barium swallow evaluation
Esophageal - food gets stuck below eternal notch
- if solids more affected than liquids - structural and do EGD
- if both solids and liquids affected - neuromuscular motility and do monometry (can be primary (achalasia) or secondary)
Investigations for dysphagia
Blood work
Radiology - X-rays, Barrie swallow, videofluoroscopy with modified barium swallow, CT, MRI
Esophagogastroduodenoscopy (EGD)
Endoscopic ultrasound (EUS)
Monometry
Diffuse esophageal spasm (DES)
- shows normal peristalsis
- interspersed with frequent high pressure non-propagated or “tertiary” waves and multi peaked waves
- chest pain and dysphagia
- barium X-ray shows corkscrew pattern
Etiology - unknown, maybe changes in intrinsic and extrinsic esophageal nerves
Tx - nitrates, CCB, injection of botulinum toxin in LES or distal esophagus
Achalasia on Manometry
Loss of peristalsis (no red waves)
EUS for cancer
At this time, it is only useful in distinguishing T1 and T2 cancers
Squamous Cell Carcinoma of the esophagus
Risk factors include smoking and alcohol consumption
Majority are located in mid-esophagus
Early lesions usually subtle and easily missed on endoscopy
