DSA 1: Clinical Approach to GI Patient Flashcards
What are non-GI causes of atypical chest pain?
What is an important consideration when deciding how to manage atypical chest pain?
MI, Aortic dissection, PE
Rule out all the life threatening possibilities first both GI and non-GI
What demographic usually presents with atypical chest pain due to MI?
Elderly, females, DM patients (may present as dyspepsia or epigastric pain that would make you thinik it’s a GI issue)
What is the typical presentation of aortic dissection?
What imaging finding is indicative of aortic dissection?
sudden tearing/ripping chest pain
CXR shows widened mediastinum (CT will give definitive dx)
What is the typical presentation of PE?
What diagnostic finding on ECG is indicative of PE?
What imaging modalities are used for suspected PE?
sudden pleuritic CP with SOB
S1Q3T3, on ECG
CT Angio, VQ scan and LE venous doppler US
What is a life-threatening GI cause for pleuritic/retrosternal chest pain?
Esophageal perforation
What are iatrogenic causes of esophageal perforation? What are spontaneous causes? What is spontaneous esophageal perforation referred to as when there is transmural rupture at gastroesophageal junction?
1) Trauma from NG tube or endoscopy 2) Forceful vomiting or history of alcohol use 3) Boerhaave’s syndrome
What does esophageal perforation present with and can be seen on CXR or CT chest with contrast?
1) Pneumomediastinum 2) SubQ emphysema
Where is subcutaneous emphysema typically detected?
Neck or precordial area
What is the crunching, rasping sound, synchronous with the heartbeat, heard over the precordium and particularly in the left lateral decubitus position, and in many occasions associated with muffling of heart sounds? What part of the heartbeat is it heard? What is it diagnostic of?
1) Hamman’s sign 2) Systole 3) Pneumomediastinum and SubQ emphysema
What are these images indicative of?
top: SubQ emphysema (puffy stuff represents air in tissues)
bottom: pneumomediastinum (air around the pericardium)
What bacteria causes peptic ulcer disease? Where are the most common locations for it?
1) H. pylori 2) Duodenal ulcer and Gastric ulcer
How does PUD present on history/PE? What is a sign of GI bleeding?
1) Gnawing, dull, aching epigastric pain along with atypical chest pain 2) Coffee ground emesis
What does EGD with biopsy exclude in PUD? What should be considered if fluid is negative for blood with a nasogastric lavage?
1) Malignancy in gastric ulcer 2) This doesn’t exclude active bleeding from a duodenal ulcer
In the detection of H. Pylori, why do we stop PPI 14 days before fecal and breath tests? Why are the fecal antigen test and urea breath test good diagnostic tests for H pylori?
1) Prevent false negative 2) They confirm eradication
What is the treatment plan for PUD?
1) Acid suppression (PPI or H2 blocker) 2) Eradicate H pylori 3) Stop smoking 4) Stop NSAID use
What can ulcers located along the posterior wall of the duodenum or stomach cause if they perforate?
Pancreatitis
What condition causes hypertensive peristalsis with greater amplitude and duration but normal coordinated contractions?
Nutcracker esophagus
What condition causes multiple spastic contractions of the circular muscle in the esophagus in a disrupted coordinated fashion?
Diffuse Esophageal Spasm
What does diffuse esophageal spasm look like on barium swallow x-ray?
Corkscrew esophagus, rosary bead esophagus
What effect does nutcracker esophagus have on the lower esophageal sphincter? What effect does diffuse esophageal spasm have on the LES?
1) Relaxes normally, but has elevated pressure at baseline 2) LES function is normal
What symptoms are seen with both nutcracker esophagus and diffuse esophageal spasm?
1) Dysphagia to solids and liquids 2) Atypical chest pain
How is nutcracker esophagus diagnosed? How is diffuse esophageal spasm diagnosed?
1) Manometry 2) Manometry and barium swallow
What is the etiology for gastroesophageal reflux disease (GERD)?
1) Ineffective esophageal motility 2) Esophageal dysphagia 3) LES allowing stomach acid to reflux
What is the “water-brash” symptom seen with GERD? What are some atypical symptoms of GERD?
1) Bad taste in mouth from refluxed acid 2) Asthma, chronic cough, hoarseness
Would should be done if there are alarming features associated with GERD such as unexplained weight loss, hematemesis and melena?
Endoscopy and abdominal imaging
What complications can arise from GERD?
1) Laryngopharyngeal reflux 2) Barrett’s esophagus -> Adenocarcinoma
What is a hiatal hernia?
Herniation of the stomach, into the mediastinum through the esophageal hiatus of the diaphragm
What hernia is a result of increased intraabdominal pressure from abdominal obesity or pregnancy? Which one causes a herniation into the mediastinum that includes a visceral structure other than the gastric cardia, most commonly the colon? Which one is associated with GERD?
1) Sliding hiatal hernia 2) Paraesophageal hernia 3) Sliding hiatal hernia
What is this image indicative of?
Paraesophageal hernia (air bubble above diaphragm instead of below due to herniation of part of the stomach upwards)
What is a major symptom of foreign bodies and food impaction?
Hypersalivation
What should your differential look like if a patient presents with atypical chest pain that is GI related?
1) Esophageal perforation 2) PUD 3) Esophageal dysmotility: Nutcracker Esophagus or Diffuse Esophageal Spasm 4) GERD 5) Hiatal hernia 6) Food bolus
Which dysphagia is categorized as difficulty initiating swallowing? At what level does food stick?
1) Oropharyngeal dysphagia 2) Suprasternal notch
Esophageal web is a structural problem dealing with what area of the esophagus? How do the affected areas correlate with dysphagia?
1) Proximal -> Oropharyngeal dysphagia 2) Middle -> Esophageal dysphagia
What is an acquired form of esophageal web?
Eosinophilic esophagitis
What is the best diagnostic tool for esophageal webs? How is it treated?
1) Barium swallow 2) Dilation
What population does plummer-vinson syndrome mostly affect? What physical findings are found with these patients? What causes weakness and fatigue for these patients?
1) Middle-aged female 2) Angular cheilitis, glossitis, proximal esophageal web, and koilonychia 3) Iron deficiency anemia
What is the etiology of Zenker diverticulum? How is the Upper esophageal sphincter (UES) affected? It occurs in an area of natural weakness proximal to the cricopharyngeus known as?
1) False diverticula involving herniation between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles (at pharyngoesophageal junction) 2) Loss of elasticity 3) Killian’s triangle
As the zenker diverticulum enlarges what hallmark symptom is noted? How can it affect the lungs?
1) Halitosis 2) Pneumonia
How are zenker diverticulum diagnosed? Why would you want to use the above tools first before an EGD?
1) Video esophagography or Barium swallow 2) Due to risk of perforation
What should your differential look like if a patient presents with a structural oropharyngeal dysphagia?
1) Esophageal web 2) Plummer-Vinson syndrome 3) Zenker Diverticulum
What can the dry mouth symptoms of Sjogren syndrome lead to?
Oropharyngeal dysphagia
With esophageal dysphagia where does food stick?
Mid to lower sternal areas
What GI issues are present with Scleroderma?
1) Dysphagia 2) Barrett esophagus
What should your differential look like if a patient presents with esophageal dysphagia due to mechanical obstruction?
1) Esophageal web (plummer-vinson syndrome) 2) Hiatal hernia 3) GERD 4) Barrett Esophagus 5) Esophageal stricture
What structural problem most commonly at the GE junction causes esophageal dysphagia?
Esophageal stricture
What is the most common cause of esophageal stricture? What can also cause it?
1) Peptic esophageal stricture secondary to GERD 2) Eosinophilic esophagitis
As esophageal strictures progress what happens to reflux/heartburn and why? What happens to the esophageal dysphagia?
1) Reflux/heartburn improves because the stricture acts as a barrier to reflux 2) Gets worse
What diagnostic tool is mandatory in all cases of esophageal stricture? Why?
Endoscopy with biopsy in order to rule out esophageal carcinoma
What condition is caused from specialized intestinal columnar metaplasia that may progress to esophageal adenocarcimoa?
Barrett Esophagus
What are risk factors for Barrett Esophagus?
1) GERD 2) Truncal obesity 3) White males older than 50 who smoke
What cells would be seen on biopsy for Barrett Esophagus?
Goblet and columnar cells
What is the general treatment for Barrett Esophagus? What should be performed for patients with high grade dysplasia or intramuscular adenocarcinoma? When should surgical resection take place?
1) PPI 2) Endoscopic ablation 3) Never
What is the most common type of Esophageal Cancer in the world? What is the greatest risk factor for it?
1) Squamous Cell Carcinoma 2) Heavy smoking combined with alcohol use
Where should the EGD with biopsy take place for squamous cell carcinoma? Where should it be done for adenocarcinoma?
1) Middle 1/3 of esophagus 2) Distal 1/3
Which esophageal cancer is more prevalent in african americans? Which is more prevalent in caucasians?
1) Squamous cell carcinoma 2) Adenocarcinoma
What distal esophageal structural problem causes esophageal dysphagia and it associated with hiatal hernia?
Schatzki ring
Are solids, liquids, or both cause problems with schatzki rings? This leads to?
1) Solids 2) Food bolus impaction
How are schatzki rings diagnosed? How is it treated?
1) Barium swallow 2) Dilation
What motility disorder causes esophageal dysphagia?
Achalasia
How is the LES affected with achalasia? What causes the denervation of the esophagus?
1) Fails to relax 2) Loss of NO producing inhibitory neurons (ganglion cells) in the myenteric plexus
When pathology shows loss of ganglion cells within the esophageal myenteric plexus, what should we be thinking of?
Primary (idiopathic) achalasia
What is the main secondary cause of achalasia?
Chagas disease from the bite of the reduviid bug that transmits Trypanosoma cruzi
What physical finding is common for achalasia?
Weight loss
What is romana sign? Which type of achalasia is it associated with?
1) Periorbital swelling 2) Secondary/Chagas
How is achalasia diagnosed on peripheral blood smear? How is it diagnosed on barium esophagram? How is it diagnosed on EGD? What does esophageal manometry do?
1) Presence of Trypanosoma cruzi 2) Bird beak distal esophagus 3) Loss of ganglion cells within the esophageal myenteric plexus 4) Confirms diagnosis
What condition causes esophageal dysphagia and frequent odynophagia and is affected mainly by solids?
Esophagitis
When is pill-induced esophagitis most likely to occur?
Pills are swallowed without water or while supine
How is pill-induced esophagitis diagnosed on endoscopy?
One to several discrete ulcers that may be shallow or deep
What are the most common pathogens that can cause infectious esophagitis?
Candida albicans, herpes simplex, and CMV
What does CMV show on endoscopy? What does Herpes simplex esophagitis show? What does candidal esophagitis show?
1) One to several large, shallow, superficial ulcerations 2) Multiple small, deep ulcerations 3) Diffuse, linear, yellow-white plaques adherent to the mucosa
What type of esophagitis is related to a history of allergies or atopic conditions along with a history of food bolus impaction?
Eosinophilic esophagitis
How is eosinophilic esophagitis diagnosed on EGD?
Multiple circular esophageal rings creating a corrugated appearance (“Feline Esophagus” or “Tracheal esophagus”
While esophageal dilation is very effective at relieving eosinophilic esophagitis, it poses a risk for?
Esophageal mural laceration/perforation
Ingestion of liquid or crystalline alkali (drain cleaners, etc.) or acid that leads to severe burning and what type of esophagitis?
Caustic esophagitis
What long term complication should we be watching for even years after the caustic ingestion?
Esophageal squamous carcinoma
What may be dangerous and should not be administered to treat caustic esophageal injury?
Nasogastric lavage and oral antidotes
