Epigastric pain, GERD Flashcards
epigastric area?
part of abdominal surface just beneath the xiphoid process and in between the 2 set of ribs. Above the umbilicus
tenderness?
increased pain on palpation or pressure
Epigastric pain - epidemiology
common –> 25% of the population at the some point in their lives
tenderness is FAR LESS COMMON
pain - defintion
complant or senation that is stated by the patient
MCC of epigastric pain
Non ulcer dyspepsia
(but hospitalized patients with epigastric pain are far more likely to have ulcers, biliary diseas, pancreatic disease, cancer, gastritis with bleeding)
epigastric pain - precise diagnosis
only with endoscopy
Most likely diagnosis about epigastric pain - pain worse with food
gastric ulcer
Most likely diagnosis about epigastric pain - pain better with food
duodenal ulcer
Most likely diagnosis about epigastric pain - weigh loss
cancer, gastric ulcer
Most likely diagnosis about epigastric pain - tenderness
pancreatitis
Most likely diagnosis about epigastric pain - bad taste, hoarse, cough
GERD
Most likely diagnosis about epigastric pain - diabetes, bloating
gastroparesis
Most likely diagnosis about epigastric pain - NOTHING
non-ulcer dyspepsia
epigastric pain - diagnostic tests
endoscopy os the only way to truly understant the etiology of epigastric pain from ulcer disease
Radiologic + barium testing are modest in accuracy at best. You cannot biopsy with radiologic testing
esophagus vs stomach regarding barium
in the esophagus may be a good place to start with testing, but in the stomach barium is very poor
abdominal pain is divided by locations - locations?
- RUQ
- LUQ
- RLQ
- LLQ
- Midepigastrium
causes of RUQ abdominal pain
- cholecystitis
- biliary colic
- cholangitis
- Perforated duodenal ulcer
causes of LUQ abdominal pain
- spenic rupture
2. IBS - splenic flexure syndrome
Splenic flexure syndrome? (wiki)
- term to describe bloating, muscle spasms of the colon, and upper abdominal discomfort thought to be caused by trapped gas at the splenic flexure in the colon;
- may mimic heart attack pain
- Some physicians classify it as a type of IBS
causes of RLQ abdominal pain
- appendicitis
- ovarian torsion
- ectopic pregnancy
- Cecal diverticulitis
causes of LLQ abdominal pain
- sigmoid volvulus
- sigmoid diverticulitis
- ovarian torsion
- ectopic pregnancy
causes of midepigastrium abdominal pain
- pnacreatitis
- aortic dissection
- peptic ulcer disease
epigastric pain - treatment
- PPIs are always a good place to start
- H2 blockers (-tidine) are not as effective (work in 70%)
- Liguid antacids (same as H2)
epigastric pain - best initial treatment
PPIs are always a good place to start (no difference in efficacy between dif PPIs)
epigastric pain - misoprotsol
ALWAYS WRONG ANSWER
it is an artificial prostagladin analogue, was developed just before the invention of PPIs –> design to prevent NSAID-induced damage. When PPIs arrived, it became obsolete
GERD - definition
inappropriate relaxation of LES –> acid contents of the stomach coming up into the esophagus
GERD - worsened by
nicotine, alcohol, caffeine, chocolate, peppermint,
late-night meals, obesity
GERD is the answer when you see
epigastric burning pain radiating up into the chest
GERD symptoms
- epigastric burning pain radiating up into the chest
- sore throat
- bad taste in the mouth (metallic)
- hoarsness
- cough
GERD - physical findings
there is not unique physical findings (it is a symptom complex)
diagnosis of GERD is very clear by symptoms - next step
confirmatory testing is not necessary
give PPI
GERD - diagnostic tests
- most often based on history
- if it is not clear –> 24h ph monitoring
- endoscopy with some indications
GERD - indications for endoscopy
- signs of obstruction (dysphagia or odynophagia)
- weight loss
- anemia or heme (+) stools
- more than 5-10 years of symptoms to exclude Barrett
GERD - endoscopy - image?
- nothing when there is only pyrosis (heartburn)
- redness, erosions, ulcerations, strictures or Barrett
pyrosis?
anther term for heartburn
GERD - treatment (generally)
- all patients should change their lifestyle
2. depends on the severity (mild or intermittent, persistent or erosive, non responsive etc …)
GERD - all patients should change their lifestyle
all patients should
- loos weight if obese
- avoid alcohol, nicotine, caffeine, chocolate, peppermint
- avoid eating at night before sleep (3 hours of betime)
- elevate heat of bed 6-8 inches
GERD - treatment for mild or intermittent symptoms
liquid antacids or H2 blockers
GERD - treatment for persistent or erosive esophagitis
PPIs (no difference in efficacy between differnet PPIs
GERD - treatment of those not responsive to medical therapy (only names)
about 5% of GERD patients do not respond to medical therapy –> may require surgical or anatomic correction to tighten the lower esophageal sphincter such as
- Nissen fundoplication
- Endocinch
- local heat or radiation of LES
GERD - treatment - Nissen fundoplication
wrapping the stomach around the LES
GERD - treatment - Endocinch
using scope to place a suture around the LES to tighten it
GERD - treatment - local heat or radiation of LES
causes scarring
Barrett esophagus - definition, time, physical , labs
- long GERD leads to histologic chnges in lower esophagus with COLUMNAR metaplasia.
- usually needs at least 5 years of reflux
- no unique findings or lab tests
Barrett esophagus - diagnostic tests
only endoscopy can determine the presence of Barrett
–> biopsy is the only way to be certain of the presence of Barrett esophagus or dysplasia
Barrett esopagus - biopsy is indispensible because
it drives therapy
Barrett esopagus - complication
- columnar metaplasia with intestinal features has the greatest risk of transforming into esophageal cancer
- each year, about 0.5% of people with Barret esophagus progress to cancer
Barrett esopagus - stages
- Barrett alone (metaplasia)
- Low grade dysplasia
- High grade dysplasia
Barrett esophagus depends on …
the stages
Barrett esophagus - management on Barret alone
PPIs and rescope every 2-3 years
Barrett esophagus - management on low grade dysplasia
PPIs and rescope every 6-12 months
Barrett esophagus - management on high grade dysplasia
blation with aendoscopy: photodynamic therapy, radiofrequency ablation, endoscopic mucosal resection
