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Gen Med: GI > Esophageal Disorders > Flashcards

Esophageal Disorders Flashcards

1
Q

What is Dyspepsia?

A
  1. Impaired Digestion
  2. Discomfort in upper abdomen or chest described as gas, feeling of fullness, gnawing, or burning
  3. Described as Indigestion, heartburn, & Agida
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2
Q

What are the most common causes of dyspepsia?

A
  1. GERD

2. PUD

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3
Q

Name some less common causes of Dyspepsia?

A
  1. Gastritis
  2. Esophageal/Gastric Ca
  3. Celiac Dz
  4. Food allergy
  5. Gastroparesis
  6. Ischemic bowel Dz
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4
Q

What is Dysphagia?

A 
Difficulty swallowing (generally painless)
A. Pressure sensation or food gets stuck
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5
Q

With Dysphagia what do you want to determine?

A

Do Solids or Solids & Liquids get stuck?
A. Solids (Obstruction)
B. Solids & Liquids (mechanical abnormality)

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6
Q

Causes for Dysphagia

A
  1. Achalasia
  2. Esophageal CA
  3. Zenker’s diverticulum
  4. Schatzki’s ring
  5. Esophageal stenosis/stricture
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7
Q

What is Odynophagia?

A

Painful swallowing

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8
Q

Causes for Odynophagia

A
  1. Esophageal spasm
  2. Esophagitis
  3. Mallory-Weiss tear
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9
Q

What are the alarm symptoms of esophageal cancer

A 
Dysphagia with:
Age > 60 yr
Anemia
Heme (+) stools
Sx’s > 6 mo
Weight loss
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10
Q

Name for Diagnostic Modalities

A
  1. Esophagram (Barium Swallow)
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11
Q

What is GERD?

A

Recurrent reflux of gastric contents into distal esophagus due to mechanical or functional abnormality of Lower Esophageal Sphincter (LES )

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12
Q

Symptoms of GERD

A
  1. Pressure
  2. Heartburn (pyrosis)
  3. Dysphagia
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13
Q

Factors promoting GERD

A
  1. ↑ Gastric volume after meals
  2. ↑ Gastric pressure
    A. Truncal obesity
    B. PP recumbency
    C. Pregnancy
  3. Delayed gastric emptying
    A. Gastroparesis
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14
Q

Contributing Factors of GERD

A
  1. Medications
    A. Anticholinergics (dyspepsia/constipation), TCA’s (ileus)
    B. NSAID’s, ASA, Steroids, Bisphosphanates
  2. Foods
    A. Caffeine, chocolate, spicy foods, citrus, carbonated liquids
    Fats (Slow to digest)
    B. Peppermint, ETOH (Relax LES)
  3. Lifestyle behaviors
    A. Smoking, wt gain, eating late, overeating
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15
Q

Complications of GERD

A
  1. Reflux Esophagitis
    A. Visible mucosal damage
    B. Erosions or ulcers in distal esophagus at squamocolumnar junction (Z-line)
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16
Q

Causes of esophagitis

A
  1. Inflammation of esophagus
  2. Causes in non-immunocompromised pt
    A. Candidiasis (Tx with oral fluconazole (Diflucan))
    B. Pills
    Alendronate (Fosamax), risendronate (Actonel), doxycycline, NSAIDs, iron, Vit C, KCl, quinine
    Tx w/ Sucralfate (Carafate) susp., viscous lidocaine
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17
Q

Complications of esophagitis

A
  1. Esophageal Stricture

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18
Q

Risk factors for esophageal adenocarcinoma

A
  1. Large HH
  2. Duration of GERD
  3. Long segment of BE
  4. Abnormal mucosa
    A. Ulcerations
    B. Stricture
    C. Nodules
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19
Q

What is the gold standard for diagnosing Barrett’s Esophagitis?

A

Upper Endoscopy (EGD) w/ Bx of distal esophagus

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20
Q

Lifestyle modifications for GERD

A
  1. Small meals
  2. Eliminate acidic/caffeinated foods
  3. Eliminate factors that relax LES
  4. Weight reduction
  5. Avoid lying down w/in 3 hr of meals
  6. Elevate HOB 6-8”
  7. Smoking cessation
  8. Chew (non-mint) gum to ↑ saliva
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21
Q

What can someone take for mild intermittent GERD Sx’s

A
  1. Antacids

2. Histamine 2 Receptor Antagonists

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22
Q

What can someone take for persistent GERD Sx’s

A
  1. Proton Pump Inhibitors (PPI)
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23
Q

Long Term Therapy for GERD

A
  1. PPI Therapy
    A. If sx’s relieved, therapy may be d/c’d after 8-12 wk
    B. Pt w/complications of GERD, lifelong PPI qd-bid
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24
Q

If the patient is unresponsive to PPI’s what is indicated?

A
  1. Upper endoscopy

2. Want to r/o Reflux esophagitis, ZE syndrome, Barrett’s esophagus, stricture, PUD, eosinophilic esophagitis, tumor

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25
Q

When to get an upper endoscopy for Barrett’s Esophagus
A. For no dysplasia
B. Low grade dysplasia
C. High grade dysplasia

A

A. q 2-3 yr, after 2 yearly (-) results

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26
Q

Indications for Surgery

A
  1. Extra-esophageal manifestations of reflux
  2. Severe GERD & noncompliant w/ lifelong medical Tx
  3. Large HH & persistent regurgitation despite PPI’s
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27
Q

General Characteristics for infectious esophagitis

A 
Most common in immunocompromised
A. HIV/AIDS
B. Organ transplants
C. Leukemia
D. Lymphoma
E. Chronic steroid therapy
28
Q

Pathogens involved in infectious esophagitis

A 
1. Candida albicans
A. Immunocompromised 
B. Uncontrolled DM
C. Chronic steroid therapy
D. Undergoing radiation  treatments
E. Systemic Abx
2. Herpes simplex virus (HSV)
A. Immunocompromised
3. Cytomegalovirus (CMV)
A. Immunocompromised
29
Q

S&S of infectious esophagitis

A 
1. Odynophagia (most common)
 2. Dysphagia (this sx & above are most common in immunocompromised)
3. May also have: 
A. CP
B. Oral thrush (Candida) 
C. Oral ulcers (HSV)
30
Q

When is an endoscopy w/ Bx done for diagnostic certainty?

A
  1. Candida
    A. EGD not required if (+) oral thrush-Tx
    B. Diffuse linear yellow-white plaques adhering to mucosa
  2. CMV
    A. Large shallow superficial ulcerations
  3. HSV
    A. Multiple small deep ulcerations
31
Q

Treatment for candida esophagitis

A
  1. Fluconazole (Diflucan) 200 mg PO/IV x 1, then 100 mg PO/IV qd x 14-21 d (2 weeks after sx’s resolve)
  2. IV Amphotericin B for life threatening infection 0.3mg/kg/day
32
Q

Treatment for CMV esophagitis

A

Ganciclovir (Cytovene) 5mg/kg IV q 12 h x 3-6 wk

33
Q

Treatment for Herpes (HSV) esophagitis

A
  1. Acyclovir (Zovirax) 400 mg po 5 X daily x 7-10 d

2. Acyclovir 5mg/kg IV q8h x 7-14 d if odynophagia

34
Q

What is Mallory-Weiss Tear?

A
  1. Non-transmural mucosal tear at lower esophagus
  2. May arise from events that suddenly increase trans-abdominal pressure
    A. 2° to severe prolonged vomiting (50% cases)
35
Q

Primary RF for Mallory-Weiss Tear

A
  1. Chronic Alcoholism

2. Bulimia

36
Q

Signs & Sx’s of Mallory-Weiss Tear

A
  1. Painless hematemesis following severe vomiting
  2. +/- melena
  3. Abd pain from retching
37
Q

Diagnostic test for Mallory-Weiss Tear

A
  1. Upper Endoscopy (EGD)
    A. Only necessary if (-) Hx
    B. Linear tears (0.5 – 4 cm) usually located at GE junction
38
Q

Differential Dx for Mallory-Weiss Tear

A
  1. PUD
  2. Erosive gastritis
  3. AV malformations
  4. Esophageal varices/Portal HTN
  5. ZE syndrome
39
Q

Treatment for Mallory-Weiss Tear

A
  1. Fluid resuscitation
  2. Blood transfusions
  3. 80-90% of tear stop bleeding spontaneously w/in few days
40
Q

Treatment for Pt with continued bleeding in Mallory-Weiss Tear

A
  1. Endoscopic hemostatic therapy
    A. Local injection w/ epinephrine (1:10,000)
    B. Electrocautery
    C. Mechanical compression of artery - Endo-clip (hemoclip) or endoscopic band ligation
    D. Operative intervention
    (Pts who fail endoscopic therapy)
41
Q

What is a Schatzki’s Ring ?

A 
1. Circumferential ring of esophageal tissue in lower esophagus causing narrowing 
A. Squamocolumnar junction
B. Lower esophageal junction
2. Most asymptomatic
3. Dysphagia w/ solid foods
42
Q

Diagnostic studies for Schatzki’s Ring

A

Esophagram

43
Q

Treatment for Schatzki’s Ring

A

Endoscopic dilatation

44
Q

What is Eosinophilic Esophagitis ?

A
  1. Eosinophilic inflamm. of esophagus leading to clinical esophageal dysfunction
  2. Hallmark is marked tissue eosinophilia of esophagus on Bx obtained via EGD
  3. Esophageal dilatation to relieve dysphagia sx’s from strictures
  4. Pathogenesis is unknown
  5. Allergy testing
  6. PPI trial 8-12 wks
  7. Fluticasone MDI & swallowed
  8. Budesonide (steroid slurry) to coat esophagus
45
Q

What are Esophageal Varices ?

A 
1. Dilated esophageal veins 2° to portal HTN
A. Cirrhosis (50% of pts)
(Alcoholics, Chronic hepatitis)
B. Budd Chiari Syndrome
(Thrombosis of hepatic vein)
46
Q

1/3 of pts w/ varies develop?

A

Serious UGI bleed

47
Q

Signs & Sx’s of Esophageal Varices

A
  1. Acute & severe UGI hemorrhage
  2. +/- preceding vomiting
  3. Results in:
    A. Hypovolemia
    B. Shock
    C. Death
48
Q

Esophageal Varices: How do you assess hemodynamic status

A
  1. SBP < 100 mmHg, HR >100 bpm = severe GI bleed
  2. SBP > 100 mmHg, HR >100 bpm = moderate GI bleed
  3. Normal SBP & HR = minor GI bleed
49
Q

Hct take how long to show effect of active bleeding? (esophageal varices)

A

24-72 hrs

50
Q

Management of esophageal varices

A
  1. 2 large bore (≥ 18 g) IV lines
    A. Blood & fluid replacement dependent on hemodynamic status & labs
    (STAT CBC, PT/INR, BUN/Cr, LFT’s, Type & X-match)
  2. FFP, Plts, Vitamin K
    A. Correct coagulopathy
    (INR > 1.8 or platelets < 50,000)
  3. Antibiotic prophylaxis
    A. ↑ Risk for 2° peritonitis, pneumonia, UTI
    B. IV antibx (ceftriaxone/Rocephin or quinolone) - Covers gram (-) as well as resistant gram (+) organisms
  4. Nasogastric tube (NGT)
    A. Use for all suspected UGI bleeds
    B. (+) blood, coffee ground emesis, (+) guaiac = UGI bleed
51
Q

Initial management for esophageal varices?

A
  1. Balloon tube tamponade
    A. Mechanical tamponade w/ gastric & esophageal balloons
    - Provides temporary control of variceal bleeding
    - High complication rate (ulcerations, perforation, airway obstruction)
52
Q

Once initial bleeding controlled, Tx aimed at reducing high risk re-bleeding. How is this done?

A

Beta Blockers & variceal band ligation

53
Q

What is the TIPS Procedure?

A

Transjugular intrahepatic portosystemic shunts (TIPS)
1. “Creation of low-resistance channel between hepatic vein & intrahepatic portion of portal vein using angiographic techniques”
A. Placement of wire stent from hepatic vein thru liver to portal vein –> decompresses portal venous system & controls acute varices bleeding

54
Q

What is Esophageal Dysmotility ?

A

Caused by neurologic factors, intrinsic or external blockage or malfunction of esophageal peristalsis

Includes:
Neurogenic dysphagia
Zenker’s diverticulum
Achalasia
Esophageal stenosis
Esophageal spasm
55
Q

What is Neurogenic Dysphagia ?

A
  1. Dysphagia of liquids & solids

A. Caused by injury/disease to brainstem or CN IX, X, XI & XII

56
Q

What is Zenker’s Diverticulum ?

A
  1. Posterior outpouching of esophagus thru pharyngeal constrictor muscles
    A. Impaired relaxation and spasm o cricopharyngeal muscle
    B. “Esophageal herniation”
  2. Pouch collects food → regurg & extreme halitosis
  3. Dysphagia (high)
  4. Globus
  5. Older pt
57
Q

Diagnostic studies for Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?

A

Esophagram

58
Q

Treatment of Esophageal Dysmotility, Neurogenic Dysphagia, & Zenker’s Diverticulum?

A
  1. Surgical Cricopharyngotomy
    A. Cut stronger muscle to equalize pressure, allowing hernia to retract
  2. Botox injection to cricopharyngeal muscle
    A. Relaxes
59
Q

What is Achalasia?

A
  1. Loss of peristalsis in distal 2/3 of esophagus & impaired relaxation of LES
  2. Causes gradual dysphagia w/ episodic regurg & chest pain
    A. Solids & liquids
    B. No alarm sx’s
  3. M=F
60
Q

Pathophysiology of Achalasia?

A
  1. Idiopathic
  2. Electroconduction abnormality
  3. Loss of inhibitory neurons w/in the wall of esophagus
    Aperistalsis
  4. LES sphincter muscle unable to relax
61
Q

Diagnostic Studies for Achalasia

A 
1. Esophagram (affirms suspicion)
A. 1st step in Dx
B. Dilated esophagus 
C. Loss of esophageal peristalsis
D. Poor esophageal emptying of barium
E. Narrow esophago-gastric junction w/ “bird-beak” appearance
- Caused by persistently contracted LES
  1. EGD 1st line if achalasia w/alarm sx’s
  2. Manometry (confirms diagnosis)
    Final and most accurate test
62
Q

Achalasia Treatment

A
  1. Pneumatic dilatation-1st line
  2. Botox injection into LES
    A. Blocks acetylcholine & relaxes LES
  3. Heller Myotomy
    A. Last resort due to risk of GERD
    B. Used if refractive to above Tx’s
63
Q

Esophageal Stenosis/Stricture characteristics

A
  1. Dysphagia for solid foods
  2. Slow progression indicates more benign process
  3. Rapid process suggests malignancy
64
Q

What is an Esophageal Spasm ?

A
  1. Neural conduction disorder causing intermittent substernal pain
  2. May not related to swallowing
    A. Triggered by cold drink
65
Q

Sx’s of Esophageal Spasm

A
  1. Substernal crushing CP, often radiates to back, possible dysphagia/regurg
    A. EKG & Cardiac enzymes to R/O CAD
66
Q

Diagnostic Studies for esophageal spasm

A
  1. Manometry-confirms Dx

2. +/- Esophagram

67
Q

Treatment for esophageal spasm

A
  1. CCB & Nitrates
  2. Symptomatic
    A. Eat slowly & take smaller bites of food
    B. Warm liquids may facilitate swallowing
    C. Trial PPI’s since GERD may cause dysphagia
  3. Neurogenic dysphagia
    A. Treat underlying Dz
  4. Esophageal spasm
    A. CCB – nifedipine 10 mg po 30-45 mins ac
    B. Oral nitrates –SL NTG prn or isosorbide 10-20 mg qid
  5. Benign strictures
    A. Esophageal dilation x 1-3 sessions
    B. Laproscopic myotomy
  6. Malignant strictures
    A. Surgical resection

Gen Med: GI (9 decks)

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