Disorders of Esophagus and Stomach Flashcards
Which esophageal spinchter is voluntary?
UES b/c it is striated muscle
LES is smooth muscle–>involuntary
Four regions of the stomach
cardia, fundus, body, antrum
PUD is an imbalance between what
aggressive factors and defense mechanisms (H pylori, NSAIDs, ETOH)
Signs of a gastric ulcer
pain shortly after or during eating
Signs of a duodenal ulcer
pain hours after eating
pain wakes patient up at night
Presentation of PUD
- epigastric pain (gnawing/burning)
- dyspepsia
- chest pain/heart burn
- hematemesis, coffee ground emesis, melena, hematochezia
- sx’s of anemia
Difference of an ulcer vs erosion
ulcers go into muscularis, erosions are more superficial
Whats the number 1 thing you should think of with PUD
H pylori
Risk factors for PUD
- alcohol
- H pylori
- NSAIDs
- caffeine
- smoking/tobacco
- physiological stress
- genetics
What would a sudden onset of pain suggest in PUD
perforation or peritonitis
Exam findings in PUD
- abd tenderness
- GUAIAC +
- gastric outlet obstruction w/ chronic duodenal ulcer
What is the work up for PUD
- H pylori testing (urea breath test)
- endoscopy
- fasting gastrin level
- CXR
- upper GI contrast study
Gold standard for PUD diagnosis
endoscopy
What will an endoscopy show if pt has PUD
discrete mucosal lesion w/ punched out smooth ulcer base
When would you do a CXR in patietns with PUD
if they look sick, looking for perforation or pneumomediastinum
Treatment for PUD in a stable patient
- endoscopy- epi injection, hemoclips, thermal coagulation
- PPI
if H pylori tx w/ tripple therapy
What is the triple therapy for H pylori
PPI and Clarithro and amox or flagyl
Treatment for PUD in an unstable patient
- ABCs
- IVF resucitation
- PPI infusion
- NGT
- GI consult
When would you consult surgery for a patient with PUD
of perforation present or failed EGD for hemostasis
What is a dysmotility disorder
dysfunction of coordianted peristalsis/motility pattern of the esophagus
Achalasia
obstruction and proximal dilation of esophagus w/ food bolus stasis due to loss of ganglion cells from esophagus wall causing LES to fail to completely relax
(failure to relax)
Diffuse esophageal spasm
functional imbalance between excitaroy and inhibitory pathyway–>disrupted peristalsis (entire esophagus contracts)
manometry w/ >20% simultaneous contractions
Nutcracker esophagus
distal esophagus mmhg @ peristalsis >220 at LES
high pressure
HTN LES
chronic high pressure at LES
Scleroderma esophagus
- smooth muscle atrophy and fibrosis
- smooth muscle is replaced by scar tissue and lose peristalsis and LES tone
Presentation of dysmotility syndromes
DEPENDS ON THE CAUSE
- dysphagia
- chest pain
Work up for dysmotility disorders
BARIUM ESOPHAGRAM
- manometry (measure the pressure)
- endoscopy
- CXR
Tx for dysmotility disorders
- start with dietary changes
- nitrates and CCB
- TCA (pain modifier)
- botox in LES
- endoscopy therapy (pneumatic dilation)
If all other methods fail how do you treat dysmotility disorder
surgery- Heller myotomy
-decreases the pressure at LES by cutting the muscle
What is an esophageal stricture
narrowing of lumen of the esophagus
Causes of distal strictures
- GERD
- adenocarcinoma
- collagen vascular disease
- extrinsic compression
- prolonged NGT
Causes of proximal/mid strictures
- caustic ingestions
- malignancy
- mediastinal radiation
- various types of esophagitis
- dermal disease (pemphigoid)
Sx of stricture
- dysphagia (most common)
- odynophagia
- heartburn
- food impaction
- chest pain
- chronic cough
What is the biggest contributer to strictures
GERD
Work up for strictures
- basic labs
- endoscopy (rule out malignancy)
- barium esophagram: shows size of structure
- CT: stage malignancy
- manometry: suspected dysmotility
Treatment of strictures. What is the treatment of choice
- PPI
- adjust diet
- esophageal dilation via EGD
- intralesional steroid injection if all else fails
dilation is treatment of choice
What is a mallory-weiss tear
upper GI bleed d/t longitudinal mucosal lacerations
What causes a mallory weiss tear
persistent wretching/vomiting
Where is the location of mallory weiss tears
distal esophagus
Risk factors for mallory weiss tears
anticoags, excessive ETOH
Treatment for mallory weiss tears
typically nothing, self limiting
-supportive
Sx’s of esophagitis
- heartburn
- DYSPHAGIA
- odynophagia
- sour taste in mouth
- nausea
- bloating
- abd pain/ chest pain
- cough/wheeze/hoarseness
Number one cause of esophagitis
reflux
Tx of esophagitis
- pain
- PPI
- sucralfate
How would you treat infectious esophagitis? Candidia, HSV, CMV
-candida: fluconazole, clotrimazole, amphotercin B
HSV: acyclovir
CMV: gangiclocvir and fosacarnet
5 causes of esophagitis
- reflux
- infection
- radiation
- medication
- systemic disease
How do you treat eosinophillic esophagitis
- determine allergen
- leukotriene inhibitors
- steroids
What are some complications of esophagitis
- esophageal stricures
- malnutrition
- perforation and/or GI bleeding
- Barretts esophagus
Where does erosive gastritis typically occur
at greater curvature of stomach
What typically causes erosive gastritis
NSAIDs
Most common cause of non erosive gastritis
H pylori
What would an EGD show in a patient with gastritis
thick, edema, erosions, erythematous gastric folds
Sx’s of gastritis
- burning/gnawing epigastric pain
- N/V
- melena/hematemesis/ hematochezia/coffee ground emesis
Tx of gastritis
- triple therapy w/ H pylori infection
- D/C offending agents
- antacid
- sucralfate
- H2 blocker
- PPI
What can cause GERD
- impairment or failure of LES
- delayed gastric emptying
- decreased esophageal motility
What is the most common cause of GERD
hiatal hernia
Sx’s of GERD
- heartburn
- dysphagia
- regurgitation
- sour taste in mouth
- night time cough
- chest pain
- asthma/hoarseness
- aspiration pneumonia
Tx of GERD
- lifestyle modifications
- antacid
- H2 blocker
- PPI
- corrective surgery (last resort)
When would a patient get anti reflux surgery for GERD
- poorly controlled on PPI
- barretts esophagitis
- young age
- poor therapy compliance
- extra esophageal sx
- medical therapy too expensive
What is the corrective surgery for GERD
Nissen Fundoplication
Complications of GERD
- strictures
- Barrett esophagus
Where are small cell carcinomas of the esophagus found? What are the main causes?
upper half of the esophagus
caused by smoking and ETOH
Where are adenocarcinomas of the esophagus located? What causes it?
lower half of the esophagus
caused by GERD/Barrett esophagus
What is Barrett esophagus
chronic reflux and esophageal exposure causes metaplasic conversion of distal squamous epithelium to columnar epithelium
Presentation of esophageal CA
- dysphagia
- weight loss/cachexia
- regurgitate food
- epigastric pain
- chronic cough
- hoarseness/dysphonia
What would an endoscopy of early esophageal cancer show
superficial plaque, nodule, ulceration
What would an endoscopy show in advance esophageal cancer
stricture, ulcerated mass, circumferential mass, large ulceration
How is used to stage esophageal cancer
- endoscopic ultrasound (T and N staging)
- CT/PET scan/bone scan (M staging)
When would you do a bronchospy in a pt with esophageal CA
if CA found in middle upper 1/3 of esophagus or above the carina
What is the definitive tx for esophageal CA
esophagectomy
What is the therapy for non surgical candidates
- chemo/radiation
- laser therapy
- stents
What are the contraindications of an esophagectomy
- N2 or greater
- mets to solid organs
- invasion of local structures
- severe comorbidity
What are the complications of an esophagectomy
- anastamotic leaks
- stricture
What is correlated with gastric cancer
- what you are eating
- H pylori
What type of cancer is gastric cancer (typically)
adenocarcinoma
Risks for gastric cancer
- family hx
- h pylori
- smoming
- pernicious anemia
- previous gastric surgery
- obesity
- diet
Sx’s of gastric cancer
- insidious presentation of vague symptoms
- weightloss/anorexia
- gastric outlet obstruction
- small bowel obstruction
- palpable enlarged stomach
What are the signs of hematongenous spread of gastric cancer
- sister mary joseph node
- virchow node
- hepatomegaly
- pleural effusion
Tx of gastric cancer
pre op chemo + surgery
Why types of surgery do you do for gastric CA
- total gastrectomy
- esophagastrectomy
- subtotal gastrectomy
