Disorders of the Esophagus and Stomach Flashcards
how many sphincters does the esophagus have?
2 - Upper and lower
what is the upper esophageal sphincter function?
striated muscle more voluntary
what is the LES function?
smooth muscle w/baseline tone so minimal reflux
what is the pathophysiology of peptic ulcer disease (PUD)?
excoriated segment of GI mucosa (stomach or beginning of duodenum)
imbalance b/w aggressive factors and defense mechanisms
what is there an imbalance of in PUD?
imbalance b/w aggressive factors and defense mechanisms
-H.pyloria, NSAIDs, ETOH, bile salts, etc.
sx’s of gastric ulcer vs duodenal ulcer
gastric ulcer: pain shortly after or during eating
duodenal ulcer: pain hours after eating, pain wakes pt @ night
what is the most common cause of PUD?
H. pylori
what is the second most common cause of PUD?
NSAIDs
sx’s of PUD
epigastric pain* - gnawing/burning esp after meals and worse at night
Hematemesis, coffee ground emesis, melena, hematochezia (sx’s when ulcer is bleeding)
PUD is the most common cause of what?
upper GI bleed
PUD risk factors
-alcohol, H. pylori, NSAIDs, hypersecretory state of gastrin
anything that can cause imbalance
PUD exam
ABD tenderness
-epigastric tenderness typically mild-moderate
GUAIAC +
Chronic duodenal ulcer
sudden onset of pain in PUD may indicate?
perforation
PUD work-up
- **H. Pylori testing
- Urea breath test
***Endoscopy - MODALITY OF CHOICE TO DX PEPTIC ULCER!!!
what is the dx modality of choice for PUD?
endoscopy
what is the treatment for PUD if H. pylori positive?
Triple therapy tx (2 abx and a PPI for 2 weeks)
-PPI + Calrithromycin + Amoxicillin
OR Quadruple therapy (PPI + Bismuth subsalicylate + Tetracycline + Metro)
what are dysmotility disorders?
dysfunction of coordinated peristalsis/motility pattern of the esophagus
examples of dysmotility disorders?
Achalasia, Diffuse esophageal spasm (DES), Nutcracker esophagus, HTN LES, Scleroderma esophagus
what is achalasia?
dysmotility disorder of the esophagus
Relative obstruction and proximal dilation of esophagus with food bolus stasis
what is lost in achalasia? what does the loss cause?
ganglion cells are lost from esophagus wall
loss causes LES to fail and completely relax (increased LES tone - stays contracted)
what is diffuse esophageal spasm (DES)?
dysmotility disorder of the esophagus
Functional imbalance between excitatory and inhibitory pathway
esophagus randomly contracts
what is HTN LES?
dysmotility disorder of the esophagus
Resting LES >45mmHg
-Pressure at LES is always high
what is scleroderma esophagus?
dysmotility disorder of the esophagus
Smooth muscle replaced by scar tissue -> lose peristalsis and LES tone
what is the most common presentation of dysmotility disorders?
Chest pain
- sudden onset and intermittent
- difficulty swallowing with chest pain
also have dysphagia (solid -> liquid)
what is the dx tool of choice for dysmotility disorders? others?
Barium Esophagram
can also do Manometry (measures pressure at the LES)
what is the tx of dysmotility disorders?
start with their diet (eat smaller meals, etc.)
nitrates and CCB
TCAs (Imipramine or Amitriptyline)
what tx can you do for dysmotility if meds don’t work?
Botox in LES
what is an esophageal stricture?
narrowing of lumen of the esophagus
what are the 2 main causes for esophageal strictures?
inflammation and cancer
what is the most common cause for distal esophageal stricture?
GERD
what are common causes of proximal/mid esophageal stricture?
malignancy, pill esophagitis, mediastinal radiation, caustic ingestion
what are the 2 most common sx’s of esophageal strictures?
dysphagia (difficulty swallowing) and food impaction (food gets stuck on stricture)
common epidemiology of pts with esophageal strictures?
GERD
what is the first line dx modality for esophageal strictures?
endoscopy
what is a good dx modality for esophageal strictures if stricture is very tight?
barium esophagram
what dx modality for esophageal strictures do you do if have malignant stricture?
CT - more for staging
what is the definitive tx of choice for esophageal strictures?
EGD - esophageal dilation
tx for esophageal strictures
meds - PPIs (b/c associated with GERD)
Diet
***EGD - esophageal dilation
what is a mallory-weiss tear?
Upper GI bleed due to longitudinal mucosal lacerations in GEJ or gastric cardia (distal esophagus) from persistent vomiting
what type of lacerations are in mallory-weiss tear?
longitudinal mucosal lacerations
most common hx of pt with mallory-weiss tear?
excessive ETOH binge
mallory-weiss tear sx’s
hematemesis -> Bright red blood
occurs after ETOH binge and vomiting
what is the dx modality of choice for mallory-weiss tears that is also therapeutic?
EGD
does mallory-weiss tear require treatment?
no!!!
if do outpatient tx for mallory-weiss tear, what is the tx?
PPI +/- sucralfate (mucosal suppressant)
antiemetic (don’t want them vomiting)
what is Boerhaave syndrome?
TRANSMURAL RUPTURE OF THE DISTAL ESOPHAGUS ALSO FROM VOMITING
risk factors for Boerhaave syndrome?
overeating and ETOH
most common sx of Boerhaave syndrome?
SEVERE chest pain that can radiate to back/shoulder
NO HEMATEMESIS
definitive dx for Boerhaave syndrome? can also do?
esophagram (see extravasation of gastrografin into pleural cavity)
CXR (see pleural effusion, mediastinal widening), CT
CT = imaging of choice
tx for Boerhaave syndrome?
IVF, abx
surgical consult w/Thoracotomy w/direct repair of rupture and drainage of pleural cavity
what is esophagitis?
general term for any inflammation, irritation, swelling of the esophagus
most common etiology of esophagitis?
reflux esophagitis (Gastric contents passively regurgitate into esophagus and irritate mucosa)
what do pts with infectious esophagitis commonly have?
bad odynophagia if fungal (candida)
medication induced esophagitis?
injury with abx, NSAIDS, DOXY, tetracyclines
common sx’s of esophagitis
dysphagia, bitter/sour taste in mouth, odynophagia
common risk factors for esophagitis?
GERD, meds that treat dysmotility (NSAIDS, pill esophagitis), obesity and pregnancy
dx modality of choice for esophagitis?
EGD
-diagnostic visually and with pathology bx/brushings
therapeutic if bleeding
esophagitis tx
stabilize
pain - narcotics, H2 blockade, liquid antacid therapy or sucralfate
PPI for 2-4 weeks (to decrease acid production)
education for esophagitis - what should these pts decrease?
meal size, weight, ETOH, NSAIDs, ASA, fatty food, citrus food, spicy food
education for esophagitis - what should these pts stop?
smoking
education for esophagitis - what should this pts start doing?
- Raise head of bed 6-8 inches on blocks
- Stay upright for @ least 3 hrs after meals
- Taking pills w/o LOTs of H2O, in upright position and w/ ‘mattress’ of food
what is gastritis?
inflammatory changes to gastric mucosa
what causes erosive gastritis?
Reactive gastritis d/t exposure and gravity usually @ greater curvature of stomach most often w/NSAIDs
what causes non-erosive gastritis?
H. pylori (chronic inflammation, chronic atrophic gastritis)
most common etiologies of gastritis
NSAIDs, ETOH (esp liquid - vodka, gin, whiskey), H. pylori
gastritis work-up
H. pylori urea breath test
EGD
what will you see on EGD for gastritis?
thick, edema, erosions, erythematous gastric folds
most common sx’s for gastritis?
epigastric pain, burning, gnawing
tx for gastritis?
if H. pylori + then treat w/triple therapy or quadruple therapy
D/C offending agents (NSAIDs, ETOH)
Antacid, sucralfate, H2 blocker, PPI
what is GERD?
Reflux of gastric contents (acid, bile, pancreatic secretions) into esophagus causing sx’s associated w/mucosal injury d/t impaired clearance of esophageal refluxate
what is the most common etiology of GERD?
LES transient relaxation most commonly d/t HIATAL HERNIA
GERD sx’s
very bad heartburn, dysphagia, regurgitation, hoarseness/dysphonia/laryngitis, night time cough
gold standard dx of GERD?
24hr esophageal pH monitoring (but not often done)
-quantifies mount of reflux w/sx’s
most GERD dx is what?
clinical
GERD dx with EGD?
not doing this with all pts with classic sx’s of GERD
-done if persistent sx’s or complications of GERD
GERD tx
lifestyle modifications
PPIs - best for GERD
what tx is the best for GERD?
PPIs
complication of GERD?
Barrett’s esophagus
-get metaplastic conversion of distal squamous epithelium to columnar epithelium from chronic acid exposure
esophageal carcinoma cells types seen in Eastern Europe/asia? where in esophagus and due to what?
small cell carcinoma
upper half of esophagus
d/t smoking & ETOH
esophageal carcinoma cells types seen in US? where in esophagus and due to what?
adenocarcinoma
lower half esophagus
d/t GERD/Barrett’s metaplasia
esophageal carcinoma risk factors
ETOH, GERD
most common sx’s of esophageal carcinoma?
dysphagia (progress from solids to liquids VERY QUICKLY)
weight loss >50%
Virschow node (means very advanced) - left sided supraclavicular node
2 most common sx’s of esophageal carcinoma?
dysphagia and weight loss >50%
what is the difference with dysphagia in esophageal cancer vs dysmotility disorders?
in esophageal cancer:
-dysphagia progress VERY QUICKLY from solids to liquids
in dysmotility:
-takes months to progress from solids to liquids
esophageal cancer dx
Endoscopy with bx = definitive
when is endoscopic U/S done for esophageal cancer?
once have diagnosis for staging
when is CT done for esophageal cancer?
when looking for mets
esophageal cancer medical treatment - is there an ideal tx? medical tx reserved for who?
no ideal tx is agreed upon
reserved for non-surgical candidates and palliative in nature
esophageal cancer medical tx meds
chemotherapy and XRT combined
-5-FU, cisplatin, paclitaxel, anthracyclines
esophageal ca surgical tx
esophagectomy
does the type of esophageal cancer surgery influence survival?
no!! staging at the time of surgery does
what needs to be stopped for pt to have lower risk of esophageal cancer?
GERD inflammation (can lead to Barrett’s)
once pt has high grade dysplasia in esophagus, what do you need to talk to them about?
getting an esophagectomy
gastric cancer decreased in U.S. due to what?
refrigeration of foods and screening for H. pylori
most common etiologies for gastric cancer?
H. pylori (strongest risk factor)
Pernicious anemia
Diet with high salt foods and no fridge
sx’s of gastric cancer?
insidious presentation
-indigestion, dysphagia, weight loss
if pt has gastric cancer that has spread to liver, what are some signs?
sister Mary Joseph node (periumbilical node), virschow node
gastric cancer work-up/definitive dx
EGD w/bx = definitive dx
gastric cancer standard of care tx
Neoadjuvant chemoradiotherapy preoperative
epirubicin/cisplatin/5-FU or docetaxel/cisplatin/5-FU
gastric cancer surgery options
total gastrectomy, esophagogastrectomy (tumor @ GEJ and cardia), subtotal gastrectomy (tumors of distal stomach)
