Dobbs - Esophagus Flashcards by Alice Richards

3 common complaints when esophagus is involved

heartburn

dysphagia

odynophagia

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ddx for esophagus

GERD

zollinger-ellison syndrome

cardiac

lots

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objective definition of GERD

endoscopy -> shows mucus injury

AND/OR

reflux monitoring -> abnormal acid

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which sphincter is impaired in GERD

lower esophageal

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incompetent lower esophageal sphincter leads to __

and compromised integrity of the __

impaired esophageal clearance

esophageal mucosa

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causes of LES pressure reduction

tomato

citrus

spicy foods

coffee

acidic foods

chocolate

etoh

caffeine

pregnancy

hiatal hernia

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what is a hiatal hernia

portion of the stomach is herniated thru diaphragm

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what is a nonreducible hiatal hernia

gastric rugal folds remain above diaphragm btw swallows

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T/F GERD is worse in pt’s w. nonreducible sphincter

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peristalsis is decreased at ___,

which can cause increased exposure to __

night

acidic refluxate

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name 3 conditions associated w. reduced peristalsis

scleroderma

achalasia

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3 typical sx of GERD

heartburn

acid taste/refluxate

dysphagia

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atypical presentation of GERD

cough

exacerbation of asthma

chronic laryngitis

sore throat

hoarseness

non cardiac cp

dental erosions

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pe and labs for GERD will usually be

normal

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2 special exams done for complicated/atypical cases of GERD

upper endoscopy (GI)

barium esophagography (barium swallow)

ambulatory esophageal pH monitoring

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typical sx w. uncomplicated GERD can be treated/monitored for __ weeks before further testing needs to be done

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which patients should receive an upper endoscopy (GI)

pt who doesn’t respond to pharm

pt who has sx suggesting complicated dz

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what are signs of complicated GERD

dysphagia

odynophagia

occult or overt bleeding

IDA

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gold standard test for documenting type/extent of tissue damage in GERD

UGI w bx

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ambulatory esophageal pH monitoring is mostly unnecessary, but may be used to

unresponsive to pharm

detect amt of reflux/association btw reflux episodes and atypical symptoms

pt w. normal UGI and refractory sx

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1st step in GERD dx

8 week-once before meal daily PPI trial

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if you trial a GERD pt on PPI and there is complete relief, dx is __;

next you should __;

if sx reoccur, you should order __ to confirm dx

likely

discontinue PPI

EGD

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in the previous pt, if the pt has a normal EGD, you should __;

if that is abnormal, dx is __;

if it is abnormal, you should __

reflux monitor off therapy

confirmed

consider other causes for symptoms

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diagnostic test for GERD

8 week PPI trial

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barium swallow studies are used to

evaluate dysphagia

endoscopy is used for (3)

alarm sx screening of high risk pt cp

esophageal bx is used to

exclude non GERD causes of sx

esophageal manometry is used for

pre operative evaluation for surgery

ambulatory reflux monitoring is used (3)

pre operatively for non-erosive dz refractory sx GERD dx in question

lifestyle interventions for GERD (5)

wt loss head of bed elevation avoidance of late evening meals tobacco/etoh cessation cessation of trigger foods

first step in GERD tx

lifestyle changes

is H.pylori testing recommended in GERD

no!

pharm for GERD

1. antacids 2. gaviscon (alginate antacid) 3. H2 receptor blockers 4. PPIs 5. Metoclopramide → Reglan

how are H2 receptor blockers used for GERD (2)

PRN w. breakthrough nocturnal sx on PPI low level symptoms

4 examples of H2 receptor blockers

pepcid (famotidine) zantac tagamet (cimetidine) axid → nizatidine

what med is used for empiric tx of GERD

PPIs

when should PPIs be used for tx of GERD

persistent sx after 6 weeks of H2 blocker tx

PPI tx should be d/c'ed after \_\_; if relapse, consider \_\_

2-3 mo intermittent tx for 2-4 weeks

when should PPI's be taken

before meals

long term PPIs can increase risk for (2)

PNA osteoporosis

PPI's from least to most potent

Pantoprazole → Protonix Lansoprazole → Prevacid Omeprozole → Prilosec Dexlansoprazole → Dexilant Omeprazole and sodium bicarbonate → Zegerid

what are the 2 most potent PPI's

1. Omeprazole and sodium bicarbonate → Zegerid 2. Dexlansoprazole → Dexilant

least 2 potent PPI's

1. pantoprazole → Protonix 2. Lansoprazole → Prevacid

GERD tx in pregnancy (4)

1. lifestyle changes 2. antacids 3. alginate 4. sucralfate

when should you consider fundoplication for GERD

severe dz w.: ulceration, stricture barrett's espophagus dz at early age

is endoscopic tx recommended for GERD

what does the LINX device for GERD do

keeps LES closed to prevent reflux expands to allow normal swallowing

what 4 things should you consider in pt's unresponsive to tx

zollinger-ellison pill-induced esophagitis resistance to PPI's non-compliance

how to work-up pt's non responsive to tx (2)

ambulatory esophageal reflux monitoring upper endoscopy only if alarm sx

in barrett's esophagus, __ epithelium is replaced by \_\_ epithelium

squamous metaplastic columnar

test to confirm dx of barrett's esophagus

endoscopic bx

who should be screened for barrett's esophagus

3-5 years of chronic GERD sx plus other risk factors

risk factors for barrett's esophagus (besides GERD)

\>50 yo male hiatal hernia elevated visceral fat

barrett's progression (6)

squamous esophagus → chronic inflammation → barrett's metaplasia → low-grade dysplasia → high-grade dysplasia → adenocarcinoma

at what point in barrett's progression is ablation recommended

low-grade dysplasia

at what point in barrett's is esophagectomy recommended

adenocarcinoma

what do you think when you see gradual and progressive dysphagia w. solid foods over months to years

peptic stricture

t/f peptic stricture can lead to reduction in heartburn

test to order to exclude malignant cause in peptic stricture

endoscopy w. bx

tx for peptic stricture (2)

dilation (single or serial) long term PPI

what do you think when you see loss of peristalsis in distal ⅔ of esophagus

esophageal dysphagia/achalasia

sx of esophageal dysphagia/achalasia

gradual, progressive dysphagia substernal discomfort/postprandial fullness regurgitation of undigested food wt loss

pe for esophageal dysphagia/achalasia

normal

best initial study for esophageal dysphagia/achalasia

barium esophagagraphy/esophagram

tx for esophageal dysphagia/achalasia

pneumatic dilation surgical myotomy botulinum toxin injxn CCB/long acting nitrates

3 common complications of GERD

barrett's strictures (peptic or esophageal) schatzki's ring

mc cause of intermittent solid food dysphagia and food impaction

schatzki's ring

most sensitive test for schatzki's ring

barium swallow

tx for schatzki's ring

PPI's

what are rings

circumferential mucosa or muscle in the distal esophagus

what are webs

occupy only a part of the esophageal lumen

webs are always \_\_ and usually \_\_

mucosal proximal

sx of rings/webs (if symptomatic)

intermittent solid food dysphagia aspiration regurgitation

plummer-vinson syndrome triad

proximal esophageal webs IDA dysphagia

plummer vinson syndrome increases risk for

squamous cell carcinoma of esophagus and pharynx

most sensitive test for webs

barium radiography

tx for webs

mechanical disruption

75% of esophageal cancer pt's present w.

wt loss

rf for adenocarcinoma

obesity GERD/barrett's scleroderma

rf for squamous cell carcinoma

etoh/tobacco prior esophageal injury HPV achalasia

\_\_ is used to identify metastasis in esophageal ca, and __ is used to evaluate depth of invasion

CT US

sx of zenker's diverticulum

oropharyngeal dysphagia regurgitation halitosis cough aspiration pna

infectious esophagitis mc seen in

immunocompromised → HIV

mc pathogens in infectious esophagitis

candida albicans herpes simplex CMV

what do you think when you see, white exudates or papules, red furrows, currugated concentric rings

eosinophilic esophagitis

ddx for hematemesis

mallory-weiss syndrome esophageal varices PUD gastritis

what do you think when you see, sudden onset, mucosal tear from vomiting, etoh

mallory-weiss syndrome

what do you think when you see “bird's beak” on barium study

achalasia

what causes the bird's beak

tapering at LES narrowing at gastroesophageal junction dilated esophagus