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Esophagus Flashcards

1
Q

What is GERD?

A

reflux of stomach contents causing symptoms/complications

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2
Q

factors contributing to GERD

A 
impaired LES function
hiatal hernia
irritant effect of refluxate
abnormal esophageal clearance
delayed gastric emptying (gastroparesis)
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3
Q

typical clinical features of GERD

A

asymptomatic
sour taste
water brash
retrosternal burning

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4
Q

atypical clinical features of GERD

A 
asthma
chronic cough
laryngitis
sore throat
non-cardiac chest pain
halitosis
dental erosions
yellow tongue
chronic sinusitis
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5
Q

alarming clinical features of GERD

A 
troublesome dysphagia
odynophagia
weight loss
iron deficiency anemia
persistent disease despite treatment
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6
Q

the classification system of severity of erosive esophagitis

A

Los Angeles grade A B C D

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7
Q

DDx of GERD (clinical and endoscopic)

A 
clinical:
motility disorders
peptic ulcer
angina
functional dyspepsia

endoscopic:
pill induced
eosinophilic esophagitis
infections

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8
Q

medical treatment for mild/intermittent GERD:

A

lifestyle changes and meds on need (antacids / H2R blocker)

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9
Q

medical treatment for troublesome cases of GERD

A

PPI 1/day

if not controlled after 4 - 8 weeks, PPI 2/day

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10
Q

Long term S/Es of PPI

A 
gastroenteritis
pneumonia
iron and B12 deficiency
impaired calcium absorption -> hip fractures
fundic gland polyps

gastric acid is antibacterial, thats why PPIs cause gastroenteritis and pneumonia

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11
Q

_ months PPI for those with typical reflux symptoms

A

3

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12
Q

what do u do with the 5% of GERD patients who don’t respond to PPI 2/day or change of agent?

A

endoscopy, look for other diagnosis

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13
Q

u do endoscopy for a patient with suspected GERD unresponsive to treatment. what can be seen?

A

residual esophagitis (low dose or not compliant)

truly not responding:
gastrinoma
pill induced
resistance to PPI

could also be normal

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14
Q

GERD not responsive to meds –> endoscopy

endoscopy normal –> ?

A

pH - impedance test

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15
Q

Treatment of functional GERD (everything seems normal)

A

tricyclic antidepressants (cuz its probably cuz of stress)

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16
Q

surgery for GERD

A

fundoplication

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17
Q

fundoplication offers good relief and healing of esophagitis in __% of properly selected patients

A

85

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18
Q

complications of fundoplication

A

recurrence (10 - 30 %)

new symptoms - dysphagia, bloating, dyspepsia, diarrhea (>30 %)

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19
Q

indications for fundoplication in GERD

A
  • healthy patient w/ atypical symptoms
  • severe GERD but don’t wanna take PPIs for the rest of their life
  • large hiatal hernia
  • persistent reflux despite PPI
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20
Q

complications of GERD

A

Barret esophagus

Peptic stricture

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21
Q

how does barret esophagus look?

A

orange gastric type epithelial tongue like projections into the esophagus

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22
Q

what percentage of chronic GERD results in barret esophagus?

A

10%

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23
Q

OGD goes down until where?

A

second part of duodenum

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24
Q

Barium swallow is pretty much useless in GERD (cuz mucosal damage doesn’t show on the x-ray), except in which case?

A

strictures

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25
In barret's esophagus, the metaplasia can be into gastric cardiac/fundic epithelium or specialized intestinal epithelium. which one is premalignant?
specialized intestinal
26
symptoms of barret's esophagus
no symptoms
27
does GERD treatment (PPI & anti-reflux surgery) cure Barret's esophagus?
no, it just slows the progression
28
what cancer develops from barrett metaplasia?
adenocarcinoma
29
how often do u do surveillance in barret esophagus?
every 3 - 5 years
30
if on Barrett's esophagus surveillance u find LGD, what do u do?
repeat endoscopy to exclude HGD/Ca | if its only LGD, do yearly endoscopy
31
__% of high grade dysplasia have unrecognized carcinoma
13%
32
what do u do if u find high grade dysplasia on endoscopy for barrett esophagus?
repeat endoscopy to stage it & take biopsy resection EUS to exclude invasive Ca
33
surgical treatments for HGD
``` esophagectomy snare resection radiofrequency ablation (RFA) argon plasma coagulation (APC) photodynamic therapy (PDT) laser cryotherapy 3 monthly endoscopic surveillance with extensive biopsies until ca is detected (for ppl who can't have surgery) ```
34
complications of HGD surgical treatments
bleeding perforation stricture
35
what percentage of ppl with esophagitis develop peptic stricture?
5%
36
how does peptic stricture manifest?
progressive dysphagia for solid foods over months to years
37
progression of peptic stricture vs esophageal cancer
peptic stricture is slow (months to years), cancer is fast (month)
38
benefit of peptic stricture
its like a natural defense mechanism against GERD, it is a barrier against reflux and decreases heartburn
39
where in the esophagus are most peptic strictures found?
gastroesophageal junction (GEJ)
40
when a patient has peptic stricture, what is the mandatory test to do?
endoscopy with biopsy to exclude cancer
41
treatment for peptic stricture
dilatation with bougies/balloons long term PPI to prevent recurrence triamcinolone injection
42
most common treatment method for peptic strictures is
bougie/balloon dilation (90%)
43
what is the lumen diameter required to relieve dysphagia?
13 - 17 mm
44
Types of esophagitis other than GERD (reflux esophagitis)
infective pill induced caustic radiation
45
infective esophagitis is more common in
immunosuppressed people
46
most common pathogens causing infective esophagitis
CMV HSV Candida
47
most common symptoms of infective esophagitis
odynophagia and dysphagia sometimes substernal chest pain candida is sometimes asymptomatic
48
oral thrush is present in __% of candida esophagitis and __-__% of viral esophagitis
75 % 25 - 50 %
49
oral ulcers (herpes labialis) are usually associated with what type of esophagitis?
HSV esophagitis
50
Endoscopic findings in esophagitis candida CVM HSV
candida: diffuse yellow white plaques adherent to mucosa CVM: one to several large superficial ulcers HSV: multiple small deep ulcers
51
treatment of candida esophagitis
``` systemic treatment with fluconazole itraconazole suspension voriconazole IV caspofungin amphotericin B ``` for 2 - 3 weeks
52
treatment for CMV esophagitis
AIDS: HAART initially: IV ganciclovir or foscarnet for 3 - 6 weeks once controlled: oral vanganciclovir
53
S/Es of foscarnet
renal failure hypocalcemia hypomagnesemia
54
HSV esophagitis treatment
if immunocompetent: symptomatic treatment if immunesuppressed: oral or IV acyclovir for 2 - 3 weeks oral famiciclovir or valcyclovir if not responding: IV foscarnet for 21 days
55
Pill induced esophagitis is frequently cuz of what drugs?
``` NSAIDs KCl quinidine zalcitabine zidovudine alendronate risedronate emperonium ```
56
why are hospitalized patients at higher risk for pill esophagitis?
cuz they r sick they take a lot of pills and then lie down
57
clinical features of pill esophagitis
``` severe retrosternal chest pain odynophagia and dysphagia starts few hrs after taking drug may be sudden and persist for days old ppl: no pain but dysphagia ```
58
pill esophagitis endoscopic finding
1 or more discrete ulcers (deep/shallow)
59
chronic injury from pill esophagitis might cause
stricture hemorrhage perforation
60
does withdrawal from drug in pill esophagitis cure it?
yea healing is fast
61
when prescribing drugs for ppl with dysmotility, dysphagia, or strictures, what do u need to keep in mind?
avoid drugs that cause pill esophagitis
62
caustic injury to esophagus can be caused by ___ and ___ agents
Acidic and alkaline
63
ingestion of a caustic substance causes what symptoms and reactions?
``` severe burning chest pain gagging dysphagia drooling wheeze & stridor (if there was aspiration) ```
64
why does aspiration of caustic substance cause stridor?
laryngeal edema
65
what might u see on CXR and AXR after caustic injury?
pneumonitis and free perforation
66
treatment and management of caustic injury
initial: supportive treatment, IV fluids, analgesia 12 - 24 hrs later: endoscopy psychological assessment (they must have some mental problem if they drank acids and bases!) if mild: liquids for 1 - 2 days then back to normal diet if severe: emergency esophagectomy and colon/jejunal interposition nasogastric tube after 24 hrs oral feeding of liquids after 2-3 days no steroids or antibiotics
67
mild mucosal injury in caustic injury signs:
edema erythema exudate superficial ulcers
68
signs of severe caustic injury
deep/circumferential ulcers | black necrotic lesions
69
black necrotic lesions of severe caustic injury has a __% risk of acute complications
65%
70
complications of severe caustic injury (deep ulcers and necrotic lesions)
perforation + mediastinitis and peritonitis bleeding stricture esophago-tracheal fistula
71
in severe caustic injury, what percent develop strictures? and when?
70% weeks to months later
72
treatment of stricture after caustic injury
recurrent dilatation | intralesional triamcinolone between sessions
73
risk of Ca after caustic injury is _ - _ % after _ - _ years
2- 3 % after 15 - 20 years
74
years after someone had caustic injury, what do u need to do?
surveillance for cancer

Internal medicine (7 decks)

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