Esophagus and Stomach - McGowan Flashcards
A uncontrolled diabetic, post viral, or post vagotomy pt who presents with nausea and vomiting, early satiety over months. possible cause of the N/V
gastroparesis
Older pt with history of extensive surgery who presents with nausea and bilious emesis and no BM. All else seems normal. Possible cause of her N/V
adhesion
Dysphagia with solids and liquids think what kind of obstruction?
Motility disorder. Mechanical obstruction has dysphagia worse with solids than liquids
for each of the following mechanical obstructions causing dysphagia, indicate the clues associated with it's distinction A. Schatzki ring B. Peptic stricture C. Esophageal cancer D. Eosinophilic esophagitis
A. intermittent dysphagia esp with solids; not progressive (“steakhouse syndrome” Dx: barium swallow/EGD. Tx: Dilation
B. Chronic heartburn; progressive dysphagia
C. Progressive dysphagia; over age 50
D. Young adults; small caliber lumen, proximal stricture, corrugated rings, or white papules
for each of the following motility disorder causing dysphagia, indicate the clues associated with it’s distinction
A. Achalasia
B. Scleroderma
C. Ineffective esophageal motility
A. Progressive dysphagia
B. Chronic heartburn; Raynaud phenomenon
C. Intermittent; not progressive; commonly associated with GERD
what is water brash
regurgitation of an excessive accumulation of saliva from the lower part of the esophagus often with some acid material from the stomach. Associated with GERD
Pts with persistent heartburn, dysphagia, odynophagia, or structural/mechanical abnormalities seen on barium esophagography, what is the study of of choice?
Upper endoscopy
what is the best imaging study for orophyngeal dyspphagia
Videoesophagraphy
What is the bariumm esophagography best used for?
pt with dysphagia and suspected to have a motility disorder
Best test for Acid reflux
Esophageal pH recording and impedance testing
Pt with worsening dysphagia, pain in chest with swallowing, weight loss, what is the best imaging study?
Esophagoduodenoscopy (EGD)
what are the signs and symptoms of GERD?
- heartburn 30-60mins after meals and upon reclining
- pain relieved from antacid
- regurgitation
What are the extraesophgeal manifestation of GERD?
- asthma
- chronic cough, laryngitis
- sore throat
- noncardiac chest pain (pyrosis: heart burn)
- sleep disturbances
Pt with GERD are usually first treated empirically with PPI, but if pt does not get relief with PPI, what special exams can be done to further evaluate?
- Upper endoscopy: look for tissue damage, strictures, metaplasia adenocarcinoma
- Barium esophagography (used prior to endoscopy to look for strictures)
- Esophageal pH or combined esophageal pH-impedance testing
Pt presents with gradual development of solid food dysphagia progressive over months to years, usually seen at the GE junction. Most likely _
Peptic stricture. Due to long time GERD. Diagnosed with barium swallow/EGD
How is peptic stricture treated?
dilation with graduated polyvinyl catheter over several session until diameter is 13-17mm; FU tx with PPI
In a patient with long term GERD, what changes are seen on biopsy of the lower esophagus
Orange, gastric type epithelium that extends upward from stomach into distal tubular esophagus in a tongue like or circumferential fashion. These are Squamous epithelium of esophagus replaced by metaplastic columnar epithelium with Goblet cells
what complications are associated with GERD?
- esophagitis
- strictures
- Barrett’s
- adenocarcinoma
How is GERD treated?
- First line: trial of acid suppression and lifestyle modification
- H.pylori eradication if indicated
what are the red flags that which require endoscopy or ABD imaging?
- wt loss
- Persistent vomiting
- Constant or severe pain
- Dysphagia
- Hematemesis
- Melena
- Anemia
A. Scleroderma is a cause of esophageal dysphagia mainly with 1 (solids or liquids).
B. Is it a mechanical or motility disorder?
C. What are the hallmark findings?
A. Solids
B. Motility
C. thickening and hardening of skin, microangiopathy and fibrosis of skin and visceral organs, may have chronic heartburn and Raynauds. Will be positive for one ore more of the following: ANA, Scl-70, Anticentromere
Zenker’s diverticulum is a false diverticulum that herniates posteriorly between what structures?
Cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. This is the area of natural weakness in the Killian’s triangle
what are the symptoms of zenker’s diverticulum?
- Dysphagia, regurg, choking, aspiration, voice changes, halitosis, wt loss
how is zenker’s diverticulum diagnosed and treated?
Dx: Barium swallow
Tx: surgery
What are the sicca symptoms of Sjogrens?
- Dry eyes, dry mouth –> oropharyngeal dyspphagia.
- vaginal dryness
- tracheo-bronchial dryness
- increased risk of oral infection
- dental caries
- parotid or other major salivary gland enlargement
what neoplasm does Sjogren have a strong association with?
- B cell non-hodgkin lymphoma
what bug is associated with chagas disease –> achalasia
Trypanosoma cruzi
For Achalasia:
A. motility or mechanical disorder?
B. acute or progressive?
C. Dyspagia with solids, liquids or both?
D. what are likely to see/not see in path?
E. How is achalasia diagnosed?
F. how is it treated?
A. Motility
B. Progressive
C. Both
D. loss of ganglion cells with myenteric plexus
E. Barium swallow xray and/or esophageal manometry (definitive)
F. Reduce LES pressure with nitrates and CCB therapy, pneumatic balloon dilatation, botox, or surgical myotomy
What triad of clinical findings are seen in achalasia with manometry?
- Incomplete LES relaxation
- Increased LES tone/ elevated esophageal resting pressure
- Loss of peristalsis (aperistalsis)
For Esophageal web (plummer vinson):
A. Is dysphagia due to solids liquids or both
B. Motility or structural problem?
C. Are symptoms persistent or inermittant?
D. How is diagnosed?
E. How is it treated?
A. solids B. Structural C. intermittent D. Barium swallow/EGD E. dilatation
what is plummer-vinson syndrome?
Combo of:
- symptomatic proximal esophageal webs
- Iron-def anemia
- angular chelitis
- Glossitis
- Koilonychia (spoon nails)
- Commonly seen in middle-aged women
middle aged woman with fatigue, hx of scleroderma, anemia (iron def and B12 def). Endoscopy shows watermelon lesions. what is most likely?
Gastric antral vascular ectasia
In pts with esoinophilic esophagitis (EOE), what are you likely to see with EGD?
- Loss of vascular markings (edema), multiple circular esophageal rings creating a corrugated appearance (Feline esophagus) also been said to look like a trachea, longitudinally orientated furrows and punctuated exudate
18 yr male with dysphagia, hx of seasonal allergies and asthma, presents with esophageal food impaction. Eosinophilic esophagitis (EOE) is suspected. what are you likely to see on biopsy?
Squamous epithelium esosinophil-predominant inflammation. The diagnosis requires biopsy with histologic findings of > 15-20 eosinophils per high power field.
How is EOE treated?
PPI, elimination diets, swallow topical glucocorticoids, allergist referral
how do symptoms of EOE differ in adults vs kids?
Both have dysphagia and esosinophila. In addition:
Adults: pyrosis, poor response to meds, regurg
Kids: vomiting, difficulty feeding, failure to thrive,
what are some common drugs leading to drug-induced esophagitis?
- Doxycycline, quinidine, phenytoin
Infectious cause of esophagitis
- Candida: diffuse, linear, yellow-white plaques adherent to mucosa
- CMV (large, shallow, superficial ulcers
- Herpes (multiple small, deep ulcers)
Corkscrew esophagus, rosary bead esophagus are seen in what
diffuse esophageal spasm (DES) - uncoordinated esophageal contraction.
Corkscrew
DES: A. oropharyngeal or esophageal dysphaiga? B. Motility or mechanical disorder? C. Solids or liquids or both? D. Progressive or intermittent? E. What causes the corkscrew esophagus F. Is LES affected? G. HOw is it diagnosed? H. how is it treated?
A. esophageal
B. Motility
C. Solids and liquids
D. intermittent
E. spastic contraction of circular muscle of esophageal wall
F. LES is normal, disordered motility limited to esphageal body
G. Manometry, EGD
_ is a hypertensive peristaltic disorder where swallowing contraction are too powerful and produce greater amplitude and duration of peristalsis but normal coordinated contraction. LES relaxes normally but has elevated pressure
Nutcracker esophagus
Esophageal perforation that is commonly seen as spontaneous transmural rupture at the gastroesophageal junction and presents as pleuritic retrosternal pain
Boerhaave’s syndrome
Nontransmural tear at the GE junction and can be due to vomiting, retching, or vigorous coughing. How is this type of tear treated?
Described is a mallory-weiss tear. Tx: bleeding usually abates spontaneously. But if protracted, it may respond to local epinephrine or cauterization, endoscopic clipping or angiographic embolization.
what is pneumomediastinum and what esophageal disorder is it associated with?
It occurs when air leaks into the mediastinum and can be due to esophageal rupture, ie Boerhaave’s syndrome
How would a pt with Hiatal hernia present?
- Pt will have history of GERD and complain of reflux and chest pain
- CXR will be diagnostic
A pt with severe burn should be treated prophylactically with PPI to prevent what?
Curling ulcer of esophagus
Pt with long term H.pylori infection are risk of what neoplasm?
MALToma
What are the three biggest contributor to developing peptic ulcer disease?
- NSAID
- H pylori
- ETOH
How is peptic ulcer disease treated?
H2 blocker, PPI, and eradicate H pylori if they have it
Gastric ulcer disease: A. 75% is associated with _ B. typically occurs in which part of the stomach? C. What's the common symptom? D. Does it get relief or pain with meal?
A. H. pylori
B. lesser curvature of antrum of stomach
C. Burning epigastric pain
D. 30 min after eating
Duodenal ulcer
A. 95% is secondary to _
B. Presents as what kind of pain?
C. is pain relieved or aggravated with meal?
A. H pylori
B. Gnawing pain
C. relieved by food/eating, pain starts 1-3 hours after eating
What toxin of H pylori is associated with disease progression and gastric cancer?
CagA
What are the most sensitive and specific test for H pylori?
- Stool H pylori antigen immunoassay
- Carbon 13 or Carbon 14 urea breath test
What histological exam can be done to detect H pylori?
- EGD with biopsy and stain with H&E or Warthin-Starry
- Rapid CLO
Pt presents with pyrosis and epigastric pain, long history of GERD that isn’t responding to treatment. A tumor is suspected.
A. what kind of tumor?
B. 25% is associated with what autosomal dominant familial syndrome?
C. Is gastric mucosa atrophied or hypertrophied?
D. 2/3 are malignant and 1/3 presents as metastasis to what site commonly?
E. what is a common lab finding?
A. Zollinger- Ellison syndrome- non-beta islet cell-gastrin secreting tumor (Primary gastrinoma) B. MEN1 C. hypertrophied D. liver E. elevated fasting gastrin level
