Esophageal and Stomach Flashcards
What is the esophagus
muscular tube that connects pharynx to stomach
Twi sphincters of the esophagus and what they do
UES : Prevents aspiration; voluntary
LES: Prevents reflux of gastric content; less voluntary
Two sphincters of the stomach
Pyloric (dital; connects stomach to duodenum) and LES (gateway between esophagus and stomach
Fxn stomach
- Movement and release of chemicals all controlled via the autonomic nervous system
- Digest, Absorb, Store
Patho dysmotility disorder
DYSFUNCTION OF COORDINATED PERSITALSIS/MOTILITY PATTERN OF THE ESOPHAGUS
Causes dysmotility disorder
- Achalasia
- Diffuse Esophageal Spasm
- Nutcracker esophagus
- Hypertensive LES
- Scleroderma esophagus
What is achalasia
Failure of the LES to relax–> obstruction and proximal dilation of the esophagus
What is Diffuse Esophageal Spasm
uncontrolled movement of the esophagus
What is nutcracker esophagus
Increase in pressure in the distal esophagus
Hypertensive LES
relaxing LES has increase in pressure
Scleroderma esophagus
Smooth muscle atrophy–> replaced by fibrosis–> lack of function and tone of LES
Clinical dysmotility disorder
dysphagia - progressive solid to liquid - regurg at night and supine - long duration of sx Chest pain - sudden, squeezing in the retrosternal exacerbated by food and stress
DX dysmotility disorder
Barium Esophagram- birdbeak or corkscrew
Esophageal Manometry
Tx dysmotility disorder
Lifestyle - eat slow, not at bed time CCB/Nitrates Botulism injection into LES Pneumatic dilation Heller Myotomy
Patho Esophageal strictures
NARROWING OF THE LUMEN OF THE ESOPHAGUS
Causes Esophageal distal strictures
Peptic- GERD
Adenocarcinoma
Collagen vascular disease (scleroderma, lupus)
Causes Esophageal proximal/mid strictures
- caustic ingestion
- malignancy
- radiation
- esophagitis (infectious, pill)
- Eosinophilic esophagitis
What is Schatzki ring?
narrowing of the esophagus due to ring of tissue
Clinical Esophageal stricture
- Dysphagia*- slow onset, solid to liquid
- Odynophagia
- Heartburn
- Food impaction
- Chest pain
- Chronic cough, asthma
Clinical Schatzki ring
- Dysphagia*- intermittent, non-progressive, solids only
- Odynophagia
- Heartburn
- Food impaction
- Chest pain
- Chronic cough, asthma
Dx esophageal stricture
- Barium Esophagram
* Endoscopy- can see pathology in the lumen
Tx esophageal stricture
Lifestyle Modifications o Weight loss o Avoid exacerbate food and medications o Small meals & eat slowly and deliberately Rx o PPI o Intralesion steroid injection- If PPI and/or dilation fails; Only benign lesion EGD w/ Esophageal dilation*
Patho Zenker Diverticulum
PROTRUSION OF PHARYNGEAL MUCOSA. CAUSING A PHARYNGOESOPHAGEAL DIVERTICULUM
Due to loss of elasticity in UES
Clinical Zenker Diverticulum
halitosis, regurgitation of undigested food, gurgling in throat
Dx Zenker Diverticulum
barium esophagram
Tx Zenker Diverticulum
myotomy
Patho Mallory Weiss Tear
Upper GI bleed d/t longitudinal mucosal lacerations @GIJ or gastric cardia typically d/t persistent retching/vomiting (sudden rise in esophageal pressure
Classic ptn for Mallory Weiss Tear
pregnancy; alcoholic males
Clincal Mallory Weiss Tear
Hematemesis 85%
o Vomit/retch then hematemesis classic- blood streaked vomit
Melena
Hematochezia
Syncope/Assoc GI hemorrhagic hypovolemia
Guaic stool positive
Gold standard Mallory Weiss Tear
EGD
Tx Mallory Weiss Tear
Stable patient- healing in 24-48hrs without intervention • IVF PRN • Anti-emetics • Sulcrafate for 1-2wks • PPI for 1-2wks • D/c home Unstable Patient • H/H q6 o pRBC for hemodynamic support PRN o HCT <30 w/ CAD and symptoms • Correct coagulopathy (warfarin) o Vitamin K/FFP/PCC • EGD • Admit
Patho Boerhaave Syndrome
Transmural perforation of the esophagus
What is the most lethal perforation of the GI tract
Boerhaave Syndrome
Clinical Boerhaave Syndrome
- repeated episodes of retching and vomiting
- severe chest pain lower thorax and upper abdomen radiating to the back or left shoulder.
- Swallowing aggravates the pain
- Shortness of breath
- Mackler triad
- Neck pain, upper chest pain, epigastric pain
- rales (pleural effusion)
Dx Boerhaave Syndrome
Chest radiography- unilateral effusion
Esophagraphy- confirm dx
Tx Boerhaave Syndrome
IVF resuscitation
Broad Spectrum Antibiotics
Prompt Surgical Intervention (mainstay tx)- Left thoracotomy
Causes pre-hepatic esophageal varicies
- portal /splenic vein thrombosis
- portal vein stenosis
Causes intra-hepatic esophageal varicies
cirrhosis- alcohol or chronic hepatitis
Causes post-hepatic esophageal varicies
budd-chiari
extrinsic tumor compression
R. HF
IVC thrombosis
Clinical esophageal varicies
- Hematemesis
- melena
- hematochezia
- Pale, hypotensive, lightheaded, syncope, orthostatic, tachycardic
- Liver disease/Cirrhosis signs : jaundice, pruritus, ascites, encephalopathy/MS changes, muscle cramps, anorexia, spontaneous bleeding/easy bruising, abdominal pain, nausea/vomiting
Dx esophageal varicies
EGD- Every 2-3yrs to monitor enlargement
Capsule endoscopy
Ultrasound*- Screen for portal HTN
CT/MRI- When ultrasound inconclusive
Tx esophageal bleed
- 2 large bore IV access/Central access
- pRBC txn (target 25-30)
- Octreotide 50mcg/hr
- Desmopression 1-2 mg q 4 hours
- Endoscopy *- Varix ligation (banding)
- Band ligation*
Last resort
TIPS (transjugular intrahepatic portosystemic shunt)
Angiotherapy
Balloon tube tamponade
Patho esophagitis
INFLAMMATION, IRRITATION OR SWELLING OF THE ESOPHAGUS
Cause esophagitis
- Reflux Esophagitis (GERD)
- Infectious-HSV, Candida, CMV
- Allergic/Eosinophilic
- Pill-Esophagitis
- Radiation induced
- System Illness
Clinical esophagitis
- retrosternal pain
- heart burn
- odynophagia
- dysphagia
- water bursh
- globus densation
- food impaction
- laryngitis
- chronic cough
- hematemesis
- abdominal pain
- weight loss
MC site for pill induced esophagitis
aortic arch
Dx pill induced esophagitis
Clinical and EGD
Tx pill induced esophagitis
stop agent
take pill with 8oz water
stay upright for over 30 min after taking pill
eat in 30 min of pill
take antacids, sulcrafate, lidocaine, PPI
Cause pill induced esophagitis
aspirin NSAID tetracyclines doxycyclines clindamycin bisphosphonates **decrease pH to 3
Infectious esophagitis due to
Candida
HSV
CMV
Clinical Candida esophagitis
odynophagia
Immunocompromised ptn
Thrush
Dx Candida esophagitis
Clinical; EGD
Tx Candida esophagitis
Fluconazole
Isolated Eosinophilia Esophagitis has a history of
atopy, asthma, food or medicine allergies
Isolated Eosinophilia Esophagitis mainly occurs in
Men 20-30
Isolated Eosinophilia Esophagitis associated with
achalasia, GERD, crohns, connective tissue dx.
Dx Isolated Eosinophilia Esophagitis
Esophageal PH
EGD
PPI trial
Tx Isolated Eosinophilia Esophagitis
Elimination and elemental diets
PPI
Topical Glucocorticoid- Fluticasone 440-880mcg BID
Esophageal dilatation to tx strictures
Def GERD
CONDITION THAT DEVELOPS WHEN REFLUX OF STOMACH CONTENTS CAUSE TROUBLESOME SYMPTOMS OR COMPLICATIONS OF THE ESOPHAGUS
Patho GERD
Transient lower esophageal sphincter relaxation; hypotensive lower esophageal sphincter; anatomic disruption of the GE junction
RF GERD
- Obesity
- Pregnancy
- +/- Foods (coffee, alcohol, chocolate, fatty meals)
- +/- Tobacco/nicotine
- Zollinger-Ellison Syndrome
Clinical GERD
- retrosternal pain
- heart burn
- odynophagia
- dysphagia
WATER BRUSH - globus densation
- food impaction
LARYNGITIS - chronic cough
- hematemesis
- abdominal pain
- weight loss
MC complication of GERD
esophagitis
Barrets esophagus
DX GERD
Clinical; EGD
GERD classification
Grade I – erythema
Grade II – Linear non-confluent
erosions
Grade III – Circular confluent erosions
Grade IV – Stricture or Barrett Esophagus
Symptom
Mild symptoms or Intermittent <2 episodes/week
Severe or Frequent > 2 episodes/wk and severe
Tx GERD
Lifestyle modifications o Lose weight o Avoid exacerbating foods o Avoid large meals o Eat 3 hours before lying down o Elevate head of the bed Meds o Antacids- symptomatic o H2RA- mild o PPI- severe Surgery- Nissen Fundoplication
GERD endoscopy screening
Patients > 50 yo age
Patients with chronic GERD symptoms >5 years
- identify Barret’s esophagus, to prevent transition to adenocarcinoma
GERD Surgery indications
- Desire to discontinue medical treatment
- Medication non-compliance
- Presence large hiatal hernia
- Esophagitis refractory to treatment
- Persistent symptoms
Patho gastritis
INFLAMMATION OF THE LINING OF THE STOMACH ASSOCIATED WITH MUCOSAL INJURY
Erosive v. non-erosive
Erosive- bleeding, ulceration
Non-erosive= inflammation
Cause gastritis
Infection - H.Pylori Medications – NSAID #1 Alcohol Smoking Autoimmune: Crohn’s Radiation therapy Allergic/Eosinophilia
Complication gastritis
PUD
MALT lymphoma
Pernicious anemia
Clinical gastritis
- Epigastric pain
- Burning sensation
- Gnawing Sensation
- Nausea +/- vomiting
- +/- Hematemesis (BR or coffee ground)
Dx gastritis
Clinical Diagnosis
H. Pylori Testing- Breath, Stool, Serum
UGI series- Thick folds, inflammatory nodules, erosion
EGD
Tx gastritis
- H. Pylori – Triple therapy (PPI +Amoxicillin + Clarithromycin)
- D/c offending agent
- Antacids (Alka-Seltzer, Maalox, Mylanta, Rolaids)
- H2RA: cimetidine (Tagamet), famotidine (Pepcid), e.g
- PPI: omeprazole (Prilosec), lansoprazole (Prevacid), pantaprazole (Protonix
Patho PUD
DEFECT IN GASTRIC OR DUODENAL MUCOSA THROUGH THE MUSCULARIS MUSCOSA INTO DEEPER LAYERS OF THE WALL
RF PUD
H. Pylori-Produce urease NSAIDs Age Hypersecretory states (rare) Genetic Factors Acute physiologic stress- burns, cushing dz
Complication PUD
GI bleed, perforation, obstuction
Clinical PUD
- Asymptomatic
- Epigastric pain
o Gastric – while eating
o Duodenal – hours after eating or middle of the night - Early satiety
- Nausea +/- vomiting
- Belching, bloating, distention
- Chest pain/heartburn
- GI bleed– hematemesis, melena
- Guaic + stools
- Perforation – sudden onset of pain +/- peritoneal signs
Dx PUD
H. Pylori Testing Options
o EGD Biopsy w/ Rapid urease testing
o Urea breath test- best in patient with active GI bleed
Endoscopy +/- biopsy- Gold standard
Tx PUD
- Consider PPI – Non H.Pylori and Non-NSAID ulcer
- Advise discontinue of tobacco, minimize alcohol, avoid spicy foods
Consider long term PPI PUD
o Recurrent PUD
o Refractory PUD
o Continued NSAID or ASA therapy
o >50 yo age
Tx active bleed PUD
- IVF, Blood transfusion
- High dose IV PPI (Protonix)bolus and drip
- Endoscopic Intervention
o Epinephrine injection
o Hemoclips
o Thermal coagulation - Surgery
