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Gastroenterology > Esophagus DDX > Flashcards

Esophagus DDX Flashcards

1
Q

Pyrosis

A

Heartburn

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2
Q

Voluntary phase of swallow

A

Oral: tongue pushes the food bolus into the oropharynx

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3
Q

Involuntary phase of swallow, Pharyngeal phase:

A

1 food bolus stimulates receptors in pharynx
2 breathing is interrupted
3 elevation of the soft palate
4 glottis is pulled under the epiglottis
5 when the bolus reaches the esophagus the upper esophageal sphincter relaxes then closes behind the food bolus

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4
Q

Esophageal phase of swallow, Primary P

A

Primary peristalsis: vagal sense and motor until reaching the LES resulting in relaxation of the LES

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5
Q

Esophageal phase of swallow, Secondary P

A

Repetitive waves required to clear the esophagus of food

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6
Q

Saliva is acidic or alkaline?

A

Alkaline

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7
Q

GERD affects 20 percent of adults weekly and 10% daily

A

usually mild

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8
Q

Damage in GERD is usually in up to …% of pt’s

A

33%

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9
Q

Contents that could be included in GERD?

A

Most cases: Acidic gastric fluid

other: Bile or alkaline pancreatic secretions may contribute

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10
Q

Common timeframe that there is an issue with GERD

A

post-prandial, acidic reflux episodes after meals when acid is poorly mixed with food in the proximal stomach

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11
Q

GJD: 3 aspects:

A

Gastroesophageal Junction Dysfunction
1anti-reflux barrier depends on LES pressure
2intra-abdominal location of the sphincter(flap-valve)
3sphincter by the crural diaphragm

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12
Q

Most reflux occurs during the…

A

transient relaxation of the LES

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13
Q

An incompetent LES can happen when:

and how often

A

An increase in acid reflux.
Usually when supine or with increased intra-abdominal pressures.
Present in up to 50% of pt’s with severe erosive GERD

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14
Q

Hiatal Hernia 25,75,90.
caused by?
(GJD type)

A

25% of pt’s with non-erosive GERD.
75% of pt’s with severe erosive esophagitis.
90% of pt’s with Barrett esophagus.
-Caused by movement of the LES above the diaphragm
-associated with higher amounts of acid reflux and delayed esophageal acid clearance

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15
Q

Truncal obesity causes GJD how?

A

Increased intra-abdominal pressure.

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16
Q

Abnormal esophageal clearance occurs when…

A

acid is not cleared as it is normally by esophageal peristalsis and neutralized by salivary bicarbonate

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17
Q

50% of GERD pt’s have….

A

Hypotensive peristaltic contractions (leading to abnormal esophageal clearance)

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18
Q

Impaired salivation can occur from…

A

Sjogren syndrome, anticholinergic medications and oral radiation therapy

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19
Q

Signs and symptoms of GERD

A 
Heartburn
Regurgitation
Dysphagia(33%)
Extra-esophageal manifestations(rarer)
PE and labs are normal in uncomplicated cases
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20
Q

Style of heartburn in GERD

A

30-60 min after meals
reclining
relief with antacids or baking soda
severity not correlated with degree of tissue damage

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21
Q

Dysphagia in GERD

A

(33%)
erosive esophagitis
abnormal esophageal peristalsis
stricture

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22
Q

Extra-esophageal manifestations of GERD:

A 
asthma
chronic cough
chronic laryngitis
sore throat
non-cardiac chest pain
(In the absence of heartburn or regurgitation, atypical symptoms unlikely to be related to GERD)
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23
Q

Alarming features during GERD ddx

A

troublesome dysphagia,
odynophagia,
weight loss,
iron deficiency anemia

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24
Q

Endoscopy results of GERD

A
  • up to 33% with visible mucosal damage
  • may be healed win patients treated with prior empiric PPI
  • detect other gastroesophageal lesions
  • esophageal stricture
  • barrett esophagus
  • esophageal adenocarcinoma
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25
Q

DDX of GERD

A

Esophageal motility disorders

  • Peptic ulcer
  • Angina pectoris
  • Functional disorders
  • Pill-induced damage
  • Eosinophilic esophagitis
  • Infections like CMV, Herpes, Candida
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26
Q

Tx of mild GERD

A 
Lifestyle,
Eating smaller meals,
Elimination of acidic foods, 
Elimination of foods known to cause reflux(fatty foods, chocolate, peppermint, alcohol)
Smoking cessation
Weight loss as indicated
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27
Q

Patients with nocturnal symptoms should…

A
  • avoid eating 3 hours prior to laying down and elevate the head of the bed.
28
Q

PRN meds for GERD

A

Antacids -rapid 2 hour relief

OTC oral H2 receptor antagonists - delayed onset, longer relief 8hrs

29
Q

Tx for troublesome symptoms or with known complications:

A

Once daily PPI for 4-8 weeks
10-20 % do not achieve relief and require BID PPI dosing.
If still inadequate relief, evaluation with upper endoscopy is indicated.

30
Q

If initial 4-8 week therapy followed by BID PPI still does not bring relief then…

A

endoscope

31
Q

Long term therapy:

If good symptomatic relief is obtained with once daily PPI then…

A

D/C after 8-12 weeks

32
Q

80% will experience relapse of GERD…tx options include:

A

tx with continuous PPI (or BID H2 blocker if no erosive esophagitis is present)
tx intermittent 2-4 week course
tx on demand, pt dosed

33
Q

If twice daily dosing was required, and in pt’s with complications of GERD….

A

maintain on long term PPI therapy with once or BID dosing for symptom control

34
Q

Esophageal pH testing in pt’s after…

A

3months with continued sx

35
Q

Tx of Extra-esophageal manifestations

A

Trial twice daily PPI for 2-3 months

36
Q

Tx for active erosive esophagitis found on endoscopy:

A

double PPI dose

37
Q

Refractory esophagitis causes

A

gastrinoma with gastric acid hypersecretion
Pill induced esophagitis
Proton pump inhibitor resistance
Medical non-compliance
Pt’s without visible esophagitis should undergo pH monitoring to determine cause

38
Q

New sx of fundoplication

A 
dysphagia
bloating
increased flatulence
dyspepsia
diarrhea
39
Q

Barrett esophagus

A

squamous epithelium replaced by metaplastic columnar epithelium containing goblet and columnar cells due to chronic reflux induced injury.

40
Q

Specialized intestinal metaplasia

A

increased risk of dysplasia

41
Q

Presentation rate of barrett’s with chronic reflux pt’s

A

10%

42
Q

Pts with Barrett esoph. will complain of a…

A

long hx of reflux symptoms

43
Q

Tx of Barrett’s esophagus:

A

long-term PPIs

44
Q

Barrett esoph. should be surveilled every ______ to look for low or high grade _______ or ___________

A

3-5 years

dysplasia or adenocarcinoma

45
Q

Peptic stricture pt’s complain of ________ over months to years

A

gradual development of solid food dysphagia

46
Q

Endoscopy in peptic stricture sus pt’s is mandatory bc we need to dif btw….

A

peptic stricture from esophageal carcinoma

47
Q

Long-term tx of peptic stricture?

A

PPI to decrease recurrence

48
Q

Common pt cases with infectious esophagitis

A

AIDS, Solid Organ Transplants, Leukemia, Lymphoma, Immunosuppressive drugs.

49
Q

Most common pathogens of In. Eso.

A

Candid albicans (uncontrolled diabetes , systemic corticosteroids , radiation therapy , abx)
Herpes simplex
Cytomegalovirus

50
Q

S/S of In. Eso.

A

Odynophagia

Dysphagia

51
Q

S/S of In. Eso.

A 
Odynophagia
Dysphagia
Substernal Chest pain
Occasionally asymptomatic
Oral thrush in 75% in C. Albicans, 25-50% with viral 
Oral Ulcers
52
Q

Tx of Infectious Esophagitis

A

Candida: Systemic empiric therapy of antifungals…non-responders within 3-5 days should undergo endoscopy with brushings, biopsy and culture.
CMV: in HIV pt’s HAART: highly active antiretroviral therapy is most effective
Herpetic esophagitis: Immunocompetent pt’s tx sx; Immunosuppressed pt’s tx with oral antivirals.

53
Q

Tx of Infectious Esophagitis

A

Candida: Systemic empiric therapy of antifungals…non-responders within 3-5 days should undergo endoscopy with brushings, biopsy and culture.
CMV: in HIV pt’s HAART: highly active antiretroviral therapy is most effective
Herpetic esophagitis: Immunocompetent pt’s tx sx; Immunosuppressed pt’s tx with oral antivirals.

54
Q

Pill-Induced Esophagitis meds:

A 
No Pills QARI VcA
NSAIDS
Potassium Chloride tabs
Quinidine
Alendronate 
Risendronate
Iron
Vitamin C
Abx: Doxy, Tetracycline, Clinda, Bactrim
55
Q

Most likely to be injured by pills

A

bed-bound or hospitalized pt’s

56
Q

S/S of pill-induced eso.

A

Severe retrosternal chest pain
Odynophagia
Dysphagia
Chronic injury may cause severe esophagitis(stricture, hemorrhage, perforation-taking pills with water and remaining upright for 30min after ingestion)

57
Q

Caustic esophageal injury

A

accidental (usually children) or deliberate (suicide) ingestion of liquid or crystalline alkali (drain cleaners) or acid

58
Q

s/s of Caustic esophageal injury

A 
Severe burning
Chest pain
Gagging
Hematemesis
Dyspnea
Dysphagia
Drooling
Aspiration(stridor, wheezing, pt's without major sx or oropharyngeal lesions have a very low likelihood of severe gastroesophageal injury)
59
Q

Tests with suspected caustic eso.

A

radiograph - pneumonitis, free air under the diaphragm

60
Q

Initial tx of caustic eso.

A

IV fluids, IV PPI to prevent gastric ulceration, Analgesics

61
Q

Endo within ___-___ hours often shows __ ____ ____ in caustic esophagitis

A

12-24 hrs

no mucosal injury

62
Q

Findings in pt’s with mild damage from caustic eso.

A 
Edema
Erythema
Exudates
Superficial ulcers
Recover quickly with low risk of developing strictures
63
Q

Findings in pt’s with severe injury from caustic eso.

A

Deep, circumferential, necrotic ulcers
High risk of acute complications like perforation with mediastinitis or peritonitis, bleeding, stricture, esophageal-tracheal fistulas

64
Q

Tx of severe injury from caustic eso.

A

Emergency surgery with possible esophagectomy

65
Q

Do not use _______ or _______ in severe caustic eso.

A

Corticosteroids or abx

Gastroenterology (2 decks)

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