Esophageal and Stomach CIS Flashcards
How do you treat GERD?
acid suppression and lifestyle modfication
- Decrease alcohol and caffeine
- small low fat meals
- assess psychosocial situation
- PPI usually first line compared to H2 blocker or other acid suppressing meds
- H. Pylori eradication if indicated
What are some red flags that need endoscopy or Abd imaging if we see them?
Weight loss persistent vomiting constant or severe pain dysphagia hematemesis melena anemia
When else would you do and endoscopy?
- failed response to 4-8 weeks of PPI
- or when frequent symptoms relapse after PPI discontinued
Esophageal stricture
- esophageal dysphagia
- structural problem
- solids… progressive to liquids don’t go down
What is the most common type of esophageal stricture?
peptic secondary to GERD
-can also occur because of eosinophilic esophagitis
How do you Dx an esophageal stricture?
Barium swallow/EGD
How do you Tx an esophageal stricture?
Dilation, PPI/H2 blocker
Esophageal ring (Schatzki)
Esophageal dysphagia
-structural problem
solids
intermittent symptoms
What is a typical instegator of esophageal rings?
meat
-that’s why it is AKA “steakhouse syndrome”
is esophageal ring acquired or congenital?
acquired!
How do you diagnose an esophageal ring
barium swallow/EGD
How do you treat an esophageal ring?
Dilation
Barret esophagus
-specialized columnar metaplasia that replaces normal squamous mucosa of the distal esophagus in some persons with GERD
What does Barret esophagus progress to?
esophageal adenocarcinoma
How do you diagnose Barrett esophagus?
EGD with Bx
what group is at greatest risk for Barrett esophagus?
obese white males older than 50
When should screening EGD for Barrett’s be considered?
in pts with a chronic 10 year history of GERD symptoms
How do you treat Barrett’s?
Surveillance endoscopy
endoscopic ablation
surgical resection
PPI (better than H2-receptor antagonists)
esophageal cancer
adenocarcinoma or SCC
Adenocarcinoma
- M>W
- Barrett’s
- distal 1/3 of esophagus
SCC
>45 -M>W -middle 1/3 smoking alcohol HPV Esophageal disorders like achalasia and plummer vinson syndrome -radiation 5-10 years prior
Scleroderma
- esophageal dysphagia
- dysphagia to mainly solids but some liquids
- motility disorder aka propulsion problem
- absent peristoalsis combine with severe weakness of the LES
What is the hallmark of Scleroderma?
microangiopathy and fibrosis of the skin and visceral organs
-Thickening and hardening of the skin
How will a patient with Scleroderma present?
-chronic heartburn and Raynaud phenomenon
What is Reynaud phenomenon?
that change in color of the fingertips
What are some characteristics about Scleroderma?
- ANA present in 90% speckled or centromere
- Topisomerase I antibodies
- Anticentromere antibodies
When is Topoisomerase I antibodies present in scleroderma?
- 30% in diffuse disease
- ABSENT in limited disease
When is there ANticentromere antibodies in Sclerdoerma?
in limited disease
-RARE in diffuse disease
Diffuse Scleroderma (dcSSC)
- includes proximal extremities and trunk
- early and progressive internal organ involvement
- worse prognosis
Limited Scleroderma (lcSSc)
-fingers, toes, face, distal extremities
-Raynaud’s commonly precedes other sxs
-CREST syndrome
-indolent course
GOOD PROGNOSIS
What is CREST syndrome
Calcinosis cutis raynauds esophageal dysmotility sclerodactylyl telangiectasia
Localized Scleroderma
- benign sckin conditions
- affect children
- discrete areas of discolored skin indruation
- NO raynauds
- NOT systemic
- histologicall indistinguishable from SSc
What do patches mean on localized scleroderma?
Morphea
What do coalesced patches mean on localized scleroderma?
generalized morphea
Zenker’s diverticulum
usually in upper esophagus
- structural abnormality
- False diverticula involving herniation of the mucosa and submucosa through the muscular layer of the esophagus
between what two muscles will a zenker’s diverticulum pop out at?
cricopharyngeus muscle and the inferior pharyngeal constrictor muscles
What are the symptoms of Zenker’s diverticulum?
dysphagia, regurg, choking, aspiration, voice changes, Halitosis, weight loss
What is the name of the area where a Zenker’s diverticulum will show up?
area of natural weakness proximal to the cricopharyngeus known as Killian’s triangle
How do we dx Zenkers?
Barium swallow
Tx of Zenkers
Surgery
Sjogren’s
Rheumatologic F>M Postmenopausal -sicca symptoms -keratoconjunctivitis sicca (foreign body sensation
What are the sicca symptoms?
Dry eyes, mouth… leads to oropharyngeal dysphagia
- vaginal dryness, tracheo-bronchial dryness
- increased incidence of oral infx (candida)
- dental caries
- Parotid or other major salivary gland enlargement
What has a strong assoction with Sjogren’s?
B cell non-hodgkin lymphoma
What were some of the parasites she talked about?
Trichinella spiralis Trypanosoma cruzi Trypanosoma Brucei Trypanosoma Gambiense Toxooplasma Gondii
Trichinella spiralis
Fever , myalgia, splinter hemorrhage,
-Wild game meat
Trypanosoma Cruzi
Chagas disease
-vector is kissing bug (Reduviid)
Trypanosoma brucei
African sleeping sickness
-Tsetse fly
Trypanosoma gambiense
Antigenic variation
-African sleeping sickness
Tsetse fly
Toxoplasma Gondii
Toxoplasmosis, Ring enhancing Lesions,
-Kitty cat
Achalasia
esophageal dysphagia
- motility disorder…. solids to liquids (progressive)
- propulsion problem: absent peristalsis and failure of deglutitive LES relaaxtion
What does primary Achalasia show?
loss of ganglion cells within the esophageal myenteric plexus
What is secondary cause of achalasia?
Chagas Disease
-chronic phase develops years after infection and results fromd estructino of autonomic ganglion cells throughout the body, includeing hte heart, gut, urinary tract, and respiratory tract
What will we see on barium esophagram for achalasia?
Bird-beak and sigmoid deformity of the esophagus
How do you dx achalasia?
barium swallow x-ray and/or esophageal manometry (definitive)
Tx of achalasia
LES pressure can be reduce by nitrates and CCB therapy, pneumatic balloon dilatation, Botox injection, or surgical myotomy
What does manometry look like in Achalasia?
- incomplete LES relaxation
- Increased LES tone/ Elevated esophageal resting pressure
- Loss of peristalsis (aperistalsis)
Esophageal Web (plummer Vinson)
- esophageal dysphagia
- solids
- structural problem
- INTERMITTENT symptoms
- When circumferential, similar to Schatzki rings
How to Dx esophageal web
Barium swallow/ EGD
Tx esophageal web
dilatation
Plummer Vinson syndrome
combo of
- symptomatic proximal esophageal webs
- IRON DEFICIENCY anemia
- angular chelitis
- glossitis
- koilonychia (spoon nails)
- middle aged woman
Eosinophilic Esophagitis (EOE)
-M>F with hx of allergies or atopic conditions
Dx of EOE
lost of vascular markings (edema)
- multiple circular esophageal rings creating a corrugated appearance
- “feline esophagus”… looks like trachea
- longitudinally oriented furrows, and punctate exudate
What does Bx look like on EOE
squamous epithelial eosinophil-predominant inflammatio
-diagnosis requires biopsy with histologic finding of >15-20 eosinophils per high -power field
When should we suspect EOE?
in a patient with dysphagia and esophageal food impactions
What are some complications of EOE?
Esophageal stricture, narrow-caliber esophagus, food impaction, and ESOPHAGEAL PERFORATION
Tx EOE
PPI, elimination diets, swallow topic glucorticoids, allergist referral
- empiric elimination of common food allergies
- esophageal dilation is very effective at relieving dysphagia in patients with fibrostenosis
What is a risk of esophageal dilation?
deep esophageal mural laceration or perforation
How does eosinophilic esophagitis present in adults?
- dysphagia
- pyrosis
- poor medication response
- regurgitation of undigested food
- eosinophilia
How does EOE present in children?
- Vomiting
- difficulty feeding
- dysphagia
- failure to thrive
- eosinophilia
What is the result of foreign bodies and food impaction?
complete obstruction
- cause an inability to handle secretions
- FOAMING AT THE MOUTH
- SEVERE CHEST PAIN
Esophagitis
dysphagia and frequently Odynaphagia
-mainly solids
What pill is with esophagitis?
Doxycycline, quinidine, pheytoin
-virtually any pill has the potential to cause
What are some causes of esophagitis?
infectious (candida/herpes/CMV)
eosinophilic
caustic
How does diffuse esophageal spasm present?
can’t eat solids or liquids… intermittent and nonprogressive
- CORCKSCREW ESOPHAGUS”
- results from spastic contraction of the circular muscle in the esophageal wall…. it’s a helical array of muscle so it looks like a corkscrew
- could also look like a ROSARY BEAD thing
What is normal in Diffuse esophageal spasm?
LES function
-disordered motility restricted to the esophageal body
Dx DES
Manometry, EGD
Nutcracker esophagus
swallowing contractions are too powerful
-greater amplitude and duration but normal coordinated contraction
how is the LES in nutcracker esophagus?
relaxes normally
-but has an elevated pressure at baseline
If they can’t keep solid foods down more so than liquids, what’s the problem?
mechanical obstruction
If they can’t do solids or liquids, then what?
it’s a motility disorder
What problems could be going on if there’s issues with the oral phase of swallowing?
neuro muscular rheumatic metabolic infectious structural motility
esophageal perforation, what causes it?
trauma: instrumentation
What syndrome can lead to spontaneous rupture at the GE junction?
Boerhaave’s syndrome
How does Boerhaave’s syndrome present?
pleuritic retrosternal pain that can be associated with pneumomediastinum and subcutaneous emphysema
Dx of Boerhaave’s syndrome
CT of the chest… detecting MEDIASTINAL air
How is esophageal perforation confirmed?
by contrast swallow, usually Gastrografin followed by thin barium
Tx of Esophageal Perforation
NGT suction, NPO, Parenteral antibx and surgery
What does Mallory-Weiss Tear look like?
vomiting, retching, or vigorous coughing
What is Mallory Weiss Tear?
nontransmural tear at the GE junction
-common cause of upper GI bleeding
How is MWT dx
history, RGD
Tx MWT
Bleeding usually abates spontaneously
-protracted bleeding may respond to local epinephrine or cauterization therapy, endoscopic clipping, or angiographic emobolization
Esophageal Varices
Dilated submucosal veins
- asymptomatic or hemetemesis… emergency
- liver disease workup
How do diagnose Esophageal varices
EGD
How to Tx esophageal varices
banding, sclerotherapy, balloon tamponade, variceal ligation, B blocker to decrease portal HTN
How will a hiatal hernia present?
more acid reflux and chest discomfort
-radiograph will have their left diaphragm up higher
What causes peptic ulcer disease?
NSAID
-H. Pylori
_ETOH
Dx of PUD
Esophagoduodensocopy (EGD) +/- H. Pylori
- Can be colonized with H. pylori and not have an ulcer
- Can have an ulcer and be (-) for H. Pylori
Tx of PUD
H2 blocker and PPI
-eradicate H. Pylori
Gastric Ulcer disease
- Associated with H. Pylori 75% of the time
- lesser curvature of the antrum
- burning epigastric pain
- worsens 30 min after eating (postprandial)
What increases the risk for Gastric Ulcer disaes?
H. pylori and smoking
Duodenal Ulcer
-95% 2ndary to H. Pylori
-presents as gnawing pain
-1 to 3 hours after eating
-anterior wall of proximal duodenum
NSAIDs/steroids fall into the other 5% for risk factor
Helicobater pylori… what are they?
Curved gram negative rods that produce urease (microaerophilic spiral gram negative baccili with flagella
- poverty, overcrowding
- person to person fecal oral transmission most likely
What will H. Pylori cause?
Chronic Gastritis
- antrum
- increased gastrin
- increase in HCl production by parietal cells
- increased risk of duodenal ulcer
what tumor is H. pylori associated with?
MALToma
What toxin is associated with disease progression and gastric cancer?
CagA
How to test for H. Pylori
Stool antigen immunoassay
C 13 or 14 urea breath test
-these two are most sensitive and specific
Histologic exam for H. Pylori
EGD with biopsy
-H and E stain or warthin starry stain
Or rapid CLO (clofazimine test)
-could be inaccurate if patient recently treated with PPI
Serology for H. pylori
H. pylori antibodies, IgA
*ideally, patient should be off PPI and/or Abx for 7-14 days prior to testing
Zollinger Ellison syndrome
PUD that isn’t repsponding to tx, is severe, atypical, recurrent
- non-beta islet cell- gastrin secreting tumor: (primary gastrinoma)
- hypertrophic gastric mucosa
Where are the gastrin secreting tumors located in ZE syndrome?
- Pancreas 25%
- Proximal duodenum 45%
- Lympho nodes 5-15 %
What autosomal dominant familial syndrome is ZE associated with?
MEN1
Malignancy in ZE
2/3 are malignant
-1/3 have already metastasized to the liver at presentation
How to rule out MEN1
fasting Gastrin and other tests
