Esophageal disorders Flashcards
SAD CREaP
Solids and liquids: (motility)
- Scleroderma
- Achalasia (watch out for “pseudoachalasia”)
- Diffuse esophageal spasm – “corkscrew esophagus”
Solids only (mechanical)
- Carcinoma
- Ring(Schatski’s)*/webs**
- Eosinophilic esophagitis
- Peptic stricture
*distal esophagus - associated with HH and reflux symptoms
**mid or upper esophagus – congenital, epidermolysis bullosa, GVHD, pemphigus, pemphigoid,
Plummer-Vinson syndrome
transfer (oropharyngeal dysphagia)
problem with food getting from mouth to esophagus.
Causes: stroke, Parkinson’s, corticobulbar problems (ALS, MS)
Treatment:
Thickening agents:
Transmit dysphagia
Problem getting food through the esophagus to the stomach: SAD Creap
eosinophilic esophagitis TQ
Symptoms: GERD to food impaction
History: allergies/atopy-peripheral eosinophilia
Mucosa: normal to tapered strictures (could see rings)
Biopsy: eosinophilia > 20%/HPF
Treatment: swallowed fluticasone (steroids)
barium swallow showing “birds beak”
= achalasia = failure of lower esophageal sphincter to relax and aperistalsis of smooth mm. above it
Diagnosis of achalasia would be made with
- esophagography (Bird’s beak),
- endoscopy
- manometry
(absent peristalsis, elevated LES pressure, and intraesophageal pressure > gastric pressure).
see decreased numbers of neurons (ganglion cells) in m yenteric plexuses
barium swallow shows beading
think “esophageal spasm”
pseudoachalasia?
could be due to
- Chagas disease (Reduviid/kissing but) - Trypanasoma cruzi
- preferentially attacks the cardiac (causing dysrrhythmias/CHF) and smooth muscle (megaesophagus + megacolon) - cancer (ADCA in lower 1/3, SCC in upper 2/3)
- amyloidosis
- sarcoidosis]
- neurofibromatosis
what is ADCA of esophagus related to?
GERD, Barretts, obesity
located in lower 1/3
What is SCC of esophagus related to?
mostly men and blacks, mid to lower esophagus, and risk factors = ETOH, smoking, HPV, nitrates, lye, achalasia, hot liquids, tylosis, and PV syndrome.
antineuronal nuclear antibodies (ANNA-1)
produced by small cell carcinoma –> destroy the myenteric plexus, simulating achalasia.
(cancer that is a cause of “pseudoahcalasia”)
causes for dysphagia related to esophagitis?
- GERD with peptic stricture
- pills
- infections:
- herpes (CD4< 500)
- CMV = (CD 4 < 50; look for involvement of CNS, lung, colon and retina).
owl eyes?
indicates CMV, a cause of esophagitis seen in HIV+ patients w/ CD4s disease!
A’s of Addison’s disease? CMV is a cause of Addison’s disease…
Anorexia and weight loss Asthenia and weakness Arterial hypotension and fatigue Affect (flat) Abdominal pain with N, V and D Anxiety and personality change Aglycemia, anatremia Aching muscles Apigmentation (vitiligo) Axillary, areolar and anal pigmentation
which bug causes infectious chronic gastritis most often?
H. pylori!
noninfectious causes of chronic gastritis?
- autoimmune = pernicious anemia
* chemicals = NSAIDs, ASA, bile reflux
best test for H. pylori?
stool antigen
can also used urea breath test
what is nonerosive gastritis related to?
- AI gastritis = Pernicious anemia:
- associated with parietal cell antibodies (wipes out acid producing cells)
- achlorhydria (low gastric acid production)
- gastric gland atrophy
- intestional metaplasia (probably sets the stage for adenocarcinoma)
- hypergastrinemia (may stimulate gastric enterochromaffin cells to proliferate into carcinoid tumors).
* * carcinoid as well as ADCA! - H. pylori:
74% - mild diffuse pangastritis (acute or chronic)
15% - antral gastritis (duodenal ulcers)
1% - fundic and corpus gastritis (atrophic gastritis, gastric ulcers, metaplasia, adenocarcinoma, and MALT lymphoma)
how can H. pylori manifest?
74% - mild diffuse pangastritis (acute or chronic)
15% - antral gastritis (duodenal ulcers)
1% - fundic and corpus gastritis (atrophic gastritis, gastric ulcers, metaplasia, adenocarcinoma, and MALT lymphoma)
- antral gastritis –> stimulates gastrin output, this time the gastrin WILL interact w/ parietal cells and produces HCL –> causes duodenal ulcers
What are causes of erosive gastritis?
DASH
Erosive, hemorrhagic gastritis =
- Drugs (NSAID- especially COX-1)
- Alcohol
- Stress:
- Portal Hypertensive Gastropathy (DASH).
see “coffee ground” appearance in NG tube
What criteria are used to determine prophylaxis for stress gastritis?
set you up to bleed w/ erosive gastritis
Respiratory failure, especially on a respirator.
Platelets < 50,000 or PT > 1.5
Recent NSAID use and alcohol status
causes of stress/erosive gastritis?
**Mechanical ventilation (> 48 hrs) Trauma Burns Shock Sepsis Liver and kidney disease CNS injury Multiorgan failure **Coagulopathy (platelets < 50,000; INR > 1.5)
Prophylaxis should be used: enteral feeding, H2 blockers
Bleeding: tx w/ PPIs
Menetrier’s Disease?
“Hypoproteinemic hypertorphic gastropathy” = allows albumin to be secreted
see hypochlorhydria (low stomach acid) as well as xs mucus secretion
see EGFR is increased in this disease –> hypertrophy of folds of stomach
= a rare, acquired, premalignant disease of the stomach characterized by massive gastric folds, excessive mucous production with resultant protein loss, and little or no acid production
tx: cetuximab (EGFR monoclonal Ab)
(note: also think ZE syndrome if see large gastric folds…)
what test is used to determine if the protein loss is due to menetrier or liver disease?
24 hour feces for α-1-antitrypsin excretion (>13 ml/24 hr = abnormal), since it is not normally absorbed or secreted into the bowel.
In Menetrier disease you will see excretion of alpha1 AT in GI tract (this is not seen in liver problems of hypoalbunemia)
portal hypertensive gastropathy
(PHG = “snake skin” or “mosaic stomach” - usually in fundus and body) with or without varices.
usually involves the stomach diffusely w/ dilated and twisted blood vessels
- cause of bleeding and is an early form of portal HTN
