esophageal disorders, gastritis, GERD Flashcards
what are the dysmotility disorders
- achalasia
- diffuse esophageal spasm (DES)
- nutcracker esophagus
- hypertensive LES
- scleroderma esophagus
achalasia
- loss of ganglion cells -> LES unable to relax
- more common in elderly
- causes dysphagia and obstruction -> proximal dilation of esophagus
diffuse esophageal spasms (DES)
- multiple areas of esophagus spasm at same time
- imbalance between excitatory and inhibitory pathways
- manometry with > 20% simultaneous contractions
nutcracker esophagus
- LES exerts very high pressures during peristalsis
- > 220 mmHg
hypertensive LES
- LES always elevated resting tone
- > 45 mmHg
clinical presentation of dysmotility disorders
- depends on disorder
- progressive dysphagia
- regurg esp at night and in supine
- chest pain, sudden onset and intermittent- likely to get cardiac work up
work up for dysmotility disorders
- EKG/ troponins, and CXR to r/o cardiac issues
- barium esophagram
- endoscopy- r/p mechanical and inflammatory lesions
- manometry- last line
what does a birdbeak on esophagram suggest
- achalasia
what does a cork screw on esophagram suggest
- DES
treatment for dysmotility disorders
- dietary modifications
- nitrates and CCB
- TCAs
- botox in LES- achalasia and HTN LES
- endoscopic pneumatic dilation
- if fail dilation twice then consider surgery
esophageal strictures
- narrowing of lumen of the esophagus
- need to r/o malignancy- often assoc with GERD
what causes distal esophageal strictures
- GERD
what causes proximal or mid esophageal strictures
- inflammation
- esophagitis, malignancy etc.
schatzki ring
- benign stricture at distal part of esophagus
symptoms of esophageal strictures
- dysphagia- slow onset without weight loss
- odynophagia
- heart burn and chest pain
- food impactoin
- chronic cough, asthma- mainly d/t GERD
work up for esophageal strictures
- barium esophagram- det location, length, and diameter
- endoscopy*- biopsy to det if malignant
- CT for staging
- esophageal manometry if everything else is normal
treatment for esophageal strictures
- PPI
- life style modifications
- avoid meds that cause pill esophagitis
- EGD- esophageal dilation
- possible intralesional steroid injection if PPI or dilation fails
mallory weiss tears
- upper GI bleed d/t longitudinal mucosal lacerations
- at of GEJ or gastric cardia
- stomach prolapses into esophagus -> tears in distal esophagus
what is the most common cause of mallory weiss tears
- persistent retching/ vomiting
- usually due to alcohol abuse
clinical presentation of mallory weiss tears
- hematemsis- vomit a lot THEN vomit blood
- melena
- syncope/ assoc hemorrhagic hypovolemia
treatment for mallory weiss tears
- usually none- spontaneously heal
- antiemetic
- PPI +/- sucralfate
- can do EGD- most have stopped bleeding and low risk rebleed
boerhaave syndrome
- transmural rupture of esophagus
- “worse version of mallory weiss”
- high mortality rates
where does boerhaave syndrome usually occur
- distal 1/3 of esophagus
si/sx of boerhaave syndrome
- repetitive retching/ vomiting then sudden chest pain
- pain may radiate to back/ intrascap region
- no hematemesis
risk factors for boerhaave syndrome
- male
- alcohol/ alcohol withdrawal
- overeating
treatment of boerhaave syndrome
- requires surgical repair
- IVF, abx
- mediastinal/ pleural cavity drainage
esophagitis
- inflammation, irritation, or swelling of esophagus
different types of esophagitis
- reflux
- infectious
- medication induced
- radiation
- systemic disease
- eosinophilic
reflux esophagitis
- gastric contents regurg into esophagus and irritate mucosa
infectious esophagitis
- usually in immunocompromised pts
- can be fungal, viral, Tb
medications that commonly cause esophagitis
- doxycycline*
- NSAIDs*
- KCl
- bisphosphonates
- tetracyclines
- vit C
- chemotherapy
symptoms of esophagitis
- dysphagia**
- heart burn and ches tpain
- bitter/ sour tates
- nausea
- bloating/ satiety
- abdominal pain in epigastric area
- odynophagia
- cough, wheeze, hoarseness
risk factors for esophagitis
- GERD*
- NSAIDs, doxy, CCB, BB, nitrates
- tobacco/ smoking
- mediastinal radiation
- obesity
- pregnancy
- scleroderma
esophagitis diagnosis
- history
- EGD- get biopsy, can be therapeutic if bleeding
treatment for esophagitis
- pain mangament*
- PPI X 2-4 weeks
- sucralfate
- if infectious or systemic then treat the cause
- eosinophilic- avoid food allergen, give leukotriene inhibitors and steroids
- d/c any offending agents
- lifestyle modifications
pain management for esophagitis
- narcotics*
- H2 blockers
- liquid antacids or magic mouthwash
what is in magic mouthwash
- viscous lidocaine
- liquid benadryl
- liquid maalox
complications of esophagitis
- esophageal strictures
- malnutrition
- perforation and/or GI bleed
- barretts esophagus -> cancer
gastritis
- inflammation of gastric mucosa
- can be entire stomach vs. one region
- can be erosive vs. non-erosive
erosive gastritis cause and location
- usually d/t NSAIDs
- occurs at greater curvature of stomach
common cause of non-erosive gastritis
- h pylori
what is the overall most common cause of gastritis
- h pylori
causes of gastritis
- drugs- NSAIDs*
- h pylori
- liquor
- bile reflux
- radiation therapy
- acute stress- shock
- trauma
- ischemia
- allergy/ eosinophilic
diagnosis of gastritis
- h pylori tests
- EGD- only “true” way to dx
- CT- not tool of choice but may see thick folds, inflamed nodules, etc.
symptoms of gastritis
- epigastric pain*, burning, gnawing
- N/V +/- eating
- melena, hematemesis, hematochezia, coffee ground emesis
treatment for gastritis
- if h pylori positive then triple therapy
- d/c offending agents
- antacids
- sucralfate/ carafate
- h2 blockers
- PPI
causes of GERD
- LES impaired- LES transient relaxation or hiatal hernias
- delayed gastric emptying
- decreased esophageal motility
hiatal hernia
- cardia of stomach moves up into esophagus
- contents get sucked into esophagus
how many pts with GERD develop esophagitis?
- half
sx of GERD
- heart burn*- retrosternal burning
- dysphagia*
- regurgitation*
- sour taste in mouth
- night time cough, asthma, wheeze
- chest pain
- hoarseness/ dysphonia/ laryngitis
- aspiration pna/ pneumonitis
diagnosis of GERD
- usually clinical
- EGD for chronic GERD assessment
- 24 hour esophageal pH monitoring- gold std, not used often
- esophageal manometry
treatment for GERD
- lifestyle modifications
- minimize gastric acid secretions
- antacids
- H2 blockers
- PPI
- corrective surgery (nissen fundoplication)- last line
complications of GERD
- strictures
- barret esophagus
why is barrett esophagus problematic?
- pts 30-40 X more likely to develop adenocarcinoma
barrett esophagus
- metaplastic conversion of squamous epithelium to columnar epithelium
esophageal small cell carcinoma
- upper half of esophagus
- common in eastern europe and asia
- due to smoking and alcohol
esophageal adenocarcinoma
- lower half of esophagus
- common in north america and western europe
- usually d/t GERD/ barrett esophagus
risk factors for esophageal cancer
- GERD/ barrett esophagus
- alcohol, tobacco
- obesity
- significant vitamin deficiency
- family hx
clinical presentation of esophageal cancer
- dysphagia- quick onset
- weight loss > 50%, cachectic
- regurgitate food
- epigastric pain, retrosternal pain, bone pain from METS
- chronic cough
- hoarseness/ dysphonia
- virschow node
diagnosis of esophageal cancer
- endoscopy* with bx
- endoscopic US for staging
- CT for METs
- bronchoscopy
- PET and bone scans
- laproscopic staging- common to have intraabdominal mets that arnt picked up on CT
C/I for surgery in esophageal cancer pts
- N2 or greater
- METs to solid organs
- invasion of local structures
- severe comorbidities
what is the most common type of gastric cancer
- adenocarcinoma
risk factors for gastric cacner
- h. pylori*
- genetics
- smoking
- pernicious anemia
- obesity, diet
- adenomatous polyps
- radiation exposure
sx of gastric cancer
- insidious onset vague gastric sx
- weight loss
- gastric outlet obstruction
- small bowel obstruction
- palpable enlarged stomach
- local spread, spread to liver
- hepatomegaly
diagnosis of gastric cancer
- labs, esp CEA
- EGD for definitive dx and biopsy
- CT for staging
- endoscopic US for tumor staging
