esophageal disorders

Question 1

2 classic sx of GERD and 5 ‘Atypical’ sx

Answer 1

• classic: heartburn (pyrosis) & regurg.
• atypical: chest pain, globus sensation, nausea, LPR, dental erosions

Question 2

4 complications/progessive dz of GERD

Answer 2

• esophagitis
• scarring (rings, strictures)
• barretts esophagus
• esophageal cancer

esophagitis + strictures» B.E + dysplasia&raquo_space; adenocarcinoma

Question 3

3 surgical options to treat GERD

Answer 3

• fundoplication– dysphagia, bloat as complications
• LINX: strong of magnes; not for hiatal hernia
• Roux-en-y: surgery of choice for anti-reflux if BMI > 35

Question 4

who should be screen for BE?

Answer 4

chronic or frequent sx of GERD + at least 2 risk factors

Question 5

list 4 risk factors for barretts esophagus

Answer 5

over 50
central obesity
smoking hx
family hx of BE or esophageal adenocarcinoma

Question 6

4 ways to treat Barretts esophagus including dysplasia treatment

Answer 6

• acid suppression w/ PPI forever
• endoscopy surveillance Q 3-5 yrs
• pathologist if low grade dyplasia
• surgery or RFA if high grade dysplasia

Question 7

gold standard for diagnosing esophagitis

Answer 7

Endoscopy

Question 8

what do you do it patient has alarming sx

Answer 8

screen for barretts esophagitis & refer

Question 9

list 5 alarming sx of GERD

Answer 9

dysphagia or odynophagia
GI bleeding or anemia
weight loss
sx over 5 yrs
relapses or does not respond to PPI

Question 10

when do you do 24 hr pH monitoring

Answer 10

• to quanitfy reflux if unresponsive to empiric therapy and may have non-acid reflux

Question 11

first thing you can do if patient has classic sx of GERD without alarming sx

Answer 11

2 month PPI trial

Question 12

What is this condition & how is it evaluated?

• neurogenic + myogenic d/o
• difficulty initating swallowing
• coughing, choking, nasal regurgitation
• voice changes with or after meal

Answer 12

oropharyngeal dysphagia
evaluate w/ video swallow study

Question 13

what is this condition?

• food moving slowly or getting stuck in esophagus seconds after swallowing;
• affects solids & liquids = motility d/o
• solids only= mechanical obstruction
• progressive= cancer or stricture or achalasia

Answer 13

esophageal dysphagia

Question 14

• painful swallowing related to pill esophagitis, infectious diseases, radiation therapy

Answer 14

odynophagia

Question 15

what is achlasisa and what is the key term for what it looks like on imaging?

Answer 15

• uncurable, progressive LES impaired relaxation and abnormal esophageal peristalsis WITHOUT structural explanation
• looks like birds beak

Question 16

though uncurable, what are 4 ways to treat achalasia

Answer 16

• smart eating habits
• CCB/NTG (less effective)
• surgical myotomy or balloon dilation with controlled tear
• endoscopic botox injection into LES if not surgical candidate

Question 17

when evaluating dysphagia, how do you rule out mechanical lesions as the cause?

mechanical lesions- esophagitis, cncer, eosinophilic esophagitis

Answer 17

endoscopy
barium esophogram– indirect inspection for mechanical or functional cause of dysphagia

Question 18

a way to do motility testing for hyper or hypocontractile peristalsis

Answer 18

esophageal manometry

Question 19

what is the condition?

diffuse spasm
nutcracker esophagus
hypertensive LES

Answer 19

hypercontractile peristalsis

Question 20

what is the condition?

scleroderma
inefficient motility disorder

Answer 20

hypocontractile peristalsis

Question 21

what is eosinophilic esophagitis?

Answer 21

chronic allergic inflammation that can affect anyone but esp. in mid 30 white males with atopic dz

Question 22

how is eosinophilic esophagitis diagnosed (1) and treated (3)?

Answer 22

• endoscopy w/ Biopsy (over 15 is positive)
• PPI, topical steroids or diet therapy; dilation if those fail

Question 23

inhibits histamine stimulation from parietal cells; can be used both sporadically or regularly

what is the class? what are the side effects?

Answer 23

• H2 antagonists–famotidine(pepcid), ranitidine (zantac), cimetidinie (tagamet)
• ADRs include bowel habits and drug intrxns with warfarin,phenytoin and propranolol

Question 24

MOA: irreversible inhibits H-K ATPase of parietal cell; works best taken 30mins before meals regularly

what is the class? what are the side effects?

Answer 24

• PPI– ometrazole (prilosec), lansoprazole, pantoprazole
• ADR: low profile; achlorhydria

achlorhydria– calcium malabsorption & hypoMg» infection

Question 25

taken right AFTER eating for temporary relief of episodic GERD (NOT for healing esophageal damage)

Answer 25

gastric antacids– aluminum & Mg salts; calcium carbonates

Question 26

enhances gastric emptying but no clear benefit shown; used as adjunctive therapy in GERD but also used for N/V in gut stasis

what is the medication & side effects?

Answer 26

prokinetic drug– metoclopramide (reglan)
EPS, restlessness, depression or sedation

Question 27

definitive tx for GERD

Answer 27

nissen fundoplication

Question 28

medications that cause pill-induced esophagitis (5)

Answer 28

• NSAIDs
• bisphosphonates
• KCl, iron sulfate
• alendronate
• doxycyline

Question 29

prostaglandin E1 analogue that increases mucosal protection and inhibits acid secretion
used only in prevention of NSAID-induced ulcers

what is this and the side effects?

Answer 29

misoprostol
diarrhea, cramping; abortificant

Question 30

forms viscous ulcer coating that promotes healing to protect stomach mucosa
used prophylactically for ulcers and taken on empty stomach 4x/daily

what is the medication & side effects?

Answer 30

sucralfate
metallic taste, constipation, nausea

Question 31

when should metoclopramide be avoided?

Answer 31

GI obstruction

Question 32

esophageal squamous epithelium replaced with precancerous metaplastic columnar cells from cardia of the stomach

Answer 32

barrets esophagus

Question 33

how often to do EGD for B.E metaplasia vs low grade vs high grade dysplasia

Answer 33

• metaplasia: PPI and rescope q 3-5 yrs
• low grade: PPI and rescope q 6-12 months
• high grade: ablation, photodynamic therapy, etc.

Question 34

endoscopic findings of linear yellow-white plaques

what is it and whats the first line tx?

Answer 34

Candida
tx: PO fluconazole

Question 35

endoscopic findings of large superficial shallow or punched out ulcers in immunocompromised state

what is it and whats the first line tx?

Answer 35

CMV
tx: Ganciclovir

Question 36

endoscopic findings of small, deep, well circumscribed ulcers w/ punched out or volcano like appearance in immunocompromised states

what is it and whats the first line tx?

Answer 36

HSV
tx: acyclovir

Question 37

FOR PUD

ectopic neuroendocrine gastrin secretig tumor causing severe hypersecretion– severe atypical PUD + chronic diarrhea

what is this? what are the 3 most common sx?

Answer 37

gastrinoma (zollinger-ellison syndrome)
most common sx: abdominal ain, chronic diarrhea, heart burn

Question 38

FOR PUD

fasting gastrin vs secretin test for gastrinoma

Answer 38

• fasting gastrin: best initial test; over 1,000 (10x upper limit) + low gastric pH (< 2) = diagnostic
• secretin test: increased fasting serum gastrin releas (over 200) after secretin admn = gastrinomas

ph > 3 excludes it. secretin test is used w/ intermediate gastrin levels

normally, secretin inhibits gastrin release

Question 38

PUD

after diagnosis of ZES is made, then what?

Answer 38

localize tumor via somatostatin receptor scintigraphy

Question 39

TX OF ZES

Answer 39

OMEPRAZOLE