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GI 2 Exam 1 > DSA 1: Dysphagia, Odynophagia, Atypical Chest Pain > Flashcards

DSA 1: Dysphagia, Odynophagia, Atypical Chest Pain Flashcards

1
Q

What is atypical chest pain?

A

chest pain that is not angina

- not left substernal, worse with exertion, radiation to neck/left arm

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2
Q

What must you exclude with a c/c of chest pain?

A

cardiac (or life-threatening causes)
- MI, aortic dissection, pulmonary embolus/pneumothorax

NOTE: hx and physical can NOT distinguish GI from CV cause

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3
Q

What are the possible life-threatening GI ddx to consider?

A
  • Boerhaave Syndrome (torn esophagus leading to increased pressure/subQ emphysema)
  • lactogenic esophageal perforation
  • PUD
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4
Q

Life threatening non-GI:

  • chest pressure
  • distressed, diaphoretic
  • “impending doom”
  • murmur
  • ECG, troponins, CXR
A

MI

- tx: stabilize, MONA, PCI

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5
Q

Life threatening non-GI:

  • sudden onset
  • “tearing or ripping” chest pain
  • radiation to neck
  • syncope
  • hemiparesis, paresthesias
  • altered mental status
  • “impending doom”
  • asymmetrical pulses
  • CXR with widened mediastinum
A

Aortic dissection

- tx: surgery and BP management

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6
Q

Life threatening non-GI:

  • recent travel or surgery
  • suddent onset
  • pleuritic chest pain
  • shortness of breath
  • hypoxia
  • hemodynamic collapse
  • ECG showing sinus tachy or S1q3t3 (rare)
  • lower extremity venous duplex ultrasound
A

Pulmonary embolism

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7
Q
  • life threatening
  • pt in distress upon presentation
  • iatrogenic (caused by trauma or med procedure like NG tube/endoscopy)
  • spontaneous (forceful retching/vomiting, hx of alcohol use, Boerhaave’s)
  • pleuritic/retrosternal chest pain
  • pneumomediastinum or subQ emphysema
A

Esophageal perforation

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8
Q

What is the dx and tx of esophageal perforation?

A
  • dx: CXR with air in mediastinum/subQ emphysema or chest CT with contrast (Gastrografin** NOT barium)
  • tx: NPO, parenteral antibiotics, surgery, endoscope stenting
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9
Q
  • subQ emphysema (detected in neck/precordial area)
  • Hamman’s sign (crunching, rasping sound, synchronus with heartbeat)
  • dyspnea (must differentiate lung disease from GI)
A

pneumomediastinum (Boerhaave’s)

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10
Q
  • duodenal or gastric ulcer
  • PE shows signs of gastrointestinal bleeding (coffee ground emesis, hematemesis, melena, hematochezia)
  • EGD (esoph/gastro/duodeno endoscopy) with biopsy (exclude malignancy in GU**)
  • detection of H.pylori
A

Peptic Ulcer Disease (PUD)

NOTE: must stop PPI 14 days before fecal tests due to risk of false negative

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11
Q
  • hypertensive peristalsis
  • LES relaxes normally, but has elevated baseline pressure
  • dysphagia to solids and liquids
  • atypical chest pain
A

Nutcracker Esophagus

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12
Q

what is the dx and tx for nutcracker esophagus?

A
  • dx: manometry, video fluoroscopy

- tx: nitrates and calcium antagonists, also concomitant mental health

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13
Q
  • multiple spastic contractions of inner circular muscle in the esophagus, disrupting the coordinated components of peristalsis
  • “corkscrew” esophagus
  • “rosary bead” esophagus on barium x-ray
  • LES function is normal
  • dysphagia to solids and liquids, atypical chest pain
A

diffuse esophageal spasm

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14
Q

what is the dx and tx for diffuse esophageal spasm?

A
  • dx: manometry, EGD, barium swallow

- nitrates, calcium antagonists, also concomitant mental health

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15
Q
  • motility disorder (ineffective esophageal motility of LES)

- esophageal dysphagia when accompanied by weak peristalsis (intermittent, NOT progressive)

A

GERD

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16
Q

what is the dx and tx of GERD?

A
  • dx: clinically
  • tx: trial of acid suppression and lifestyle modification first line

NOTE: EGD if alarm features are found

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17
Q

what are the alarm features of GERD?

A
  • unexplained weight loss
  • persistent vomiting
  • constant/severe pain
  • dysphagia/odynophagia
  • palpable mass or adenopathy
  • hematemesis
  • melena
  • anemia
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18
Q

herniation of the stomach, into the mediastinum through the esophageal hiatus of the diaphragm

A

hiatal hernia

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19
Q

result of increased intra-abdominal pressure from abdominal obesity, pregnancy or hereditary
- increased likelihood to have GERD

A

sliding hiatal hernia

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20
Q

herniation into the mediastinum includes a visceral structure other than the gastric cardia, most commonly the colon
- can lead to an upside down stomach, gastric volvulus, strangulation of the stomach

A

paraesophageal hernia

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21
Q

what is the dx and tx of hiatal hernia?

A
  • dx: barium Xray

- tx: asymptomatic => none, symptoms => surgical repair

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22
Q

what are the risk factors for foreign bodies/food impaction? (6)

A
  • Schatzki’s ring
  • peptic stricture
  • webs
  • eosinophilic esophagitis
  • achalasia
  • cancer
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23
Q
  • chest pain/pressure, dysphagia/odynophagia, choking sensation
  • inability to swallow liquids including own saliva
A

foreign body/food impaction

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24
Q

the sensation of a lump lodged in the throat, with swallowing unaffected

A

globus pharyngeus

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25
Q
  • difficulty initiating swallowing
  • food sticks at level of suprasternal notch
  • may have nasopharyngeal regurgitation or aspiration
  • can be with solids only, or liquids and solids
A

oropharyngeal dysphagia

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26
Q
  • mainly esophageal dysphagia, but if proximal -> oropharyngeal
  • can be asymtomatic, or intermittent symptoms that are NOT progressive
  • structural problem (thin diaphragm-like membranes of squamous mucosa
  • proximal or mid esophagus
A

esophageal web

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27
Q

what is the dx and tx of esophageal web?

A
  • dx: barium swallow (esophagogram is best view, EGD can be done but is less sensitive)
  • tx: dilation (bougie dilator) or small endoscopic electrosurgical incision, PPI longterm
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28
Q
  • middle aged women
  • combination of angular chelitis (painful inflammed corners of the mouth), glossitis, esophageal webs, koilonychia (spoon nails), iron deficiency anemia
A

Plummer-Vinson syndrome

29
Q
  • oropharyngeal dysphagia due to affected upper esophagus
  • vague symptoms at first -> coughing or throat discomfort
  • halitosis, spontaneous regurgitation, nocturnal choking, gurgling in the throat, protrusion in the neck
A

Zenker’s diverticulum

30
Q

what is the structural abnormality of Zenker’s diverticulum?

A

FALSE diverticula: herniation of the mucosa and submucosa through the muscular layer of the esophagus posteriorly between cricopharyngeus muscle and the inferior pharyngeal constrictor muscles

  • loss of elasticity of upper esophageal sphincter (UES)
  • occurs in area of natural weakness, proximal to cricopharyngeus (Kilian’s triangle)
31
Q

What is the dx and tx of Zenker’s diverticulum?

A
  • dx: video esophagography or barium swallow

- tx: surgery - upper myotomy or surgical diverticulectomy

32
Q

rheumatologic cause of dysphagia

  • dry eyes, dry mouth -> oropharyngeal dysphagia
  • vaginal dryness, tracheo-bronchial dryness
  • increased incidence of oral infection (candida*)
  • dental caries
  • parotid or other major salivary gland enlargement
  • keratoconjunctivitis sicca (foreign body sensation)
  • strong association with B cell non-Hodgkin lymphoma
A

Sjogren’s syndrome

33
Q

what is the dx and tx of Sjogrens?

A
  • dx: lip biopsy, serology

- tx: supportive

34
Q

what are the mechanical obstruction examples that cause esophageal dysphagia?

A
  • schatzi ring
  • peptic stricture
  • esophageal cancer
  • eosinophilic esophagitis
35
Q

what are the clues for the following mechanical obstructions?

  • schatzi ring
  • peptic stricture
  • esophageal cancer
  • eosinophilic esophagitis
A
  • schatzi ring: intermittent dysphagia
  • peptic stricture: chronic heartburn, progressive dysphagia
  • esophageal cancer: progressive dysphagia, age over 50
  • eosinophilic esophagitis: young adults, small caliber lumen, proximal stricture, corrugated rings, or white papules
36
Q

what are the motility disorder examples that cause esophageal dysphagia?

A
  • achalasia
  • diffuse esophageal spasm
  • scleroderma
  • ineffective esophageal motility
37
Q

what are the clues for the following mechanical obstructions?

  • achalasia
  • scleroderma
  • ineffective esophageal motility
A
  • achalasia: progressive dysphagia (NO assoc heartburn)
  • diffuse esophageal spasm: intermittent, +/- chest pain
  • scleroderma: chronic heartburn, Raynaud’s, progressive
  • ineffective esophageal motility: intermittent (NOT progressive), commonly associated with GERD
38
Q
  • topoisomerase 1 antibodies (Scl-70)
  • diffuse involvement including proximal extremities and trunk
  • early progressive internal organ involvement
  • worse prognosis
A

Diffuse scleroderma (dcSSc)

39
Q
  • anti-centromere antibodies
  • fingers, toes, face, distal extremities
  • Raynaud’s commonly precedes other symptoms
  • CREST syndrome: calcinosis cutis, Raynauds, esophageal dysmotility, sclerodactyly (tightening of skin on fingers/toes), telangiectasia (tiny red blood vessels on skin)
  • indolent course (little/no pain)
  • good prognosis
A

Limited scleroderma (lcSSc)

40
Q
  • esophageal dysphagia (mainly solids), propulsion problem
  • 30-60 y/o
  • W>M, (increase severity in Af Am)
  • progressive dysphagia
  • atrophy of the esophageal smooth muscle
  • fibrosis of the skin and visceral organs -> A-peristaltic esophagus
  • may present with chronic heartburn (incompetent LES -> reflux esophagitis or stricture)
A

scleroderma

41
Q

what is the dx and tx of scleroderma?

A
  • dx: serology

- tx: controls symptoms and slows progression to improve quality of life and prolong survival

42
Q

what is the most common cause of GERD?

A

reflux esophagitis

43
Q

what are the 4 examples of what can cause esophagitis?

A
  • gastrinoma with gastric acid hypersecretion (ZES)
  • pill-induced esophagitis
  • resistance to proton pump inhibitors
  • medical noncompliance
44
Q
  • esophageal dysphagia
  • structural problem
  • most common is peptic secondary to GERD, can also occur because of eosinophilic esophagitis
  • as it progresses, reflux/heartburn lessens/improves
A

esophageal stricture

- heartburn improves as stricture narrows lumen, blocking more acid from flowing up

45
Q

what is the dx and tx of esophageal stricture?

A
  • dx: barium swallow, EGD with biopsy mandatory in all cases to rule out carcinoma
  • tx: dilation at time of EGD, long term therapy with a proton pump inhibitor, refractory strictures may benefit from endoscopic injection of steroids
46
Q

specialized intestinal (metaplastic) columnar metaplasia that replaces the normal squamous mucosa of distal esophagus

  • complications of GERD and truncal obesity
  • obese white males older than 50 who smoke most at risk
A

Barrett esophagus

NOTE: proximal displacement of the squamocolumnar junction progresses to esophageal adenocarcinoma

47
Q

what is the dx and tx of Barrett esophagus

A
  • dx: surveillance endoscopy (monitoring for adenocarcinoma)

- tx: PPI, endoscopic ablation better than surgery

48
Q

what are the risk factors for adenocarcinoma?

A
  • white male >50
  • chronic GERD
  • hiatal hernia
  • obesity
49
Q

most common type of esophageal cancer in the world

  • males > females
  • Af Am > caucasians
  • risk factors: heavy smoking, alcohol use, esophageal disorders (achalasia, HPV, Plummer-Vinson syndrome, Tylosis)
  • progressive dysphagia, weight loss, anorexia, bleeding, hoarseness, cough
A

squamous cell carcinoma

50
Q

what is the dx and tx of squamous cell carcinoma of esophagus?

A
  • dx: EGD with biopsy

- tx: surgery (esophagectomy)

51
Q
  • caucasians > Af Am
  • Males > females
  • distal 1/3 of esophagus
  • Barrett metaplasia -> dysplaisa -> ?
A

adenocarcinoma of esophagus

52
Q

what is the dx and tx of adenocarcinoma of the esophagus

A
  • dx: EGD with biopsy
  • tx: endoscopic ablation therapy

NOTE: esophagectomy used to be practiced, but has high morbidity and mortality rates

53
Q
  • esophageal dysphagia (usually distal, intermittent)
  • structural problem (smooth, circumferential, thin mucosal structures)
  • steakhouse syndrome: food bolus may pass on own with extra liquid, if impacted -> extracted endoscopically
A

esophageal ring (Schatzki’s ring)

RINGS ARE THICKER THAN WEBS

54
Q

what is the dx and tx of Schatzki’s ring?

A
  • dx: barium swallow (best view)

- tx: dilation or small endoscopic electrosurgical incision, PPI longterm

55
Q
  • esophageal dysphagia
  • motility disorder -> PROGRESSIVE dysphagia (solids and liquids)
  • propulsion problem loss of peristalsis (distal 2/3), failure of LES relaxation
  • denervation of esophagus resulting from loss of nitric oxide-producing inhibitory neurons in the myenteric plexus
  • weight loss is common
A

Achalasia

56
Q

what is considered primary achalasia?

A

loss of ganglion cells within esophageal myenteric plexus

57
Q

what is considered secondary achalasia?

A

Chagas:

  • esophageal dysfunction that is indistinguishable from primary idiopathic achalasia
  • *should be considered in patients from endemic regions (Mexico, Central, South America)

Other:
- lymphoma, carcinoma, chronic idiopathic intestinal pseudoobstruction

58
Q

what is the dx and tx of achalasia?

A
  • dx: barium esophagram -> “birds beak!”, esophageal manometry confirms dx
  • Secondary: peripheral blood smear shows parasite
  • tx: nitrates and CCB therapy, PPI, surgery
59
Q

what are the manometry findings in achalasia?

A
  1. incomplete LES relaxation (high pressure)
  2. decreased esophageal resting pressure, (lumen dilates) -> BIRDS BEAK/funnel shape
  3. loss of peristalsis
60
Q
  • what are the types of esophagitis?
A
  • pill
  • infectious (candida/herpes/CMV)
  • eosinophilic
  • caustic
61
Q
  • severe retrosternal chest pain, odynophagia, dysphagia
  • often begins several hours after taking a pill
  • some pt have relatively little pain (especially the elderly), presenting with dysphagia
A

pill-induced esophagitis

62
Q

what is the dx and tx of pill-induced esophagitis

A
  • dx: endoscopy may reveal one to several discrete ulcers (may be shallow or deep)
  • tx: eliminate offending agent (healing occurs rapidly)
  • if pill needs to be taken, take with 4oz of water and remain upright for 30 mins after ingestion
63
Q

what are the risk factors of infectious esophagitis?

A
  • immunosuppressed pt
  • uncontrolled diabetes
  • systemic corticosteroid use
  • radiation therapy
  • systemic antibiotic therapy
64
Q
  • long history of dysphagia
  • history of food bolus impaction
  • history of allergies or atopic conditions (>50% of patients), thought to stimulate inflammation
  • complication: esophageal perforation
A

eosinophilic esophagitis (EOE)

65
Q

what is the dx and tx of EOE?

A
  • dx: EGD shows multiple circular esophageal rings creating a corrugated appearance
  • “feline” or “tracheal” esophagus
  • dx requires biopsy with >15-20 eosinophils per HPF
66
Q

what is the dx and tx of a caustic esophageal injury?

A
  • dx: initial exam should be directed to circulatory status, assessment of airway patency, and oral mucosa, including laryngoscopy
  • chest and abdominal radiographs to look for pneumonic or free perforation
  • tx: supportive IV fluids, PPI and analgesics, psychiatric referral
67
Q

what is contraindicated in caustic esophageal injury?

A

nasogastric lavage and oral antidotes are considered dangerous

68
Q

what are the complications of caustic esophageal injury?

A
  • risk of esophageal squamous carcinoma is 2-3%, warranting endoscopic surveillance 15-20 years after caustic ingestion
  • pneumonitis
  • perforation
  • esophageal strictures develop in 70% of patients with serious esophageal injury weeks to months after initial injury

GI 2 Exam 1 (22 decks)

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