Esophagus,Stomach and Duodenum Flashcards
What is the definition of dysphagia?
Dysphagia literally means ‘difficulty swallowing.’
Dysphagia can occur at any age but is particularly common in elders.
What are the three phases of swallowing?
Oral, pharyngeal, and esophageal phases.
Precise motor control is necessary for successful food transfer.
What are the two types of dysphagia?
- Oropharyngeal dysphagia
- Esophageal dysphagia
Oropharyngeal dysphagia involves difficulty transferring a food bolus; esophageal dysphagia involves difficulty transporting material down the esophagus.
What is the most common cause of oropharyngeal dysphagia?
Neuromuscular disorders.
These account for approximately 80% of cases.
What symptoms are commonly associated with oropharyngeal dysphagia?
- Misdirection of the bolus
- Sticking
- Need for repeated swallowing attempts
Liquids at extreme temperatures cause dysphagia more commonly than solids.
What disorder is characterized by weakness of the cricopharyngeus muscle?
Stroke-related pharyngeal weakness.
This can result in failure to relax the muscle and contribute to dysphagia.
What is dysphagia lusoria?
Dysphagia caused by an anomalous right subclavian artery.
It is a vascular cause of dysphagia that may not be symptomatic until adulthood.
What are intrinsic mechanical lesions that can cause esophageal dysphagia?
- Strictures
- Webs
- Rings
- Tumors
- Esophagitis
- Postsurgical changes
- Esophageal foreign bodies
These lesions can obstruct the esophagus and lead to dysphagia.
What is Plummer-Vinson syndrome?
A condition characterized by anterior webs, dysphagia, iron deficiency anemia, cheilosis, spooning of the nails, glossitis, and thin friable mucosa.
Most patients are women between 30 and 50 years of age.
What is achalasia?
A disorder where the resting pressure of the lower esophageal sphincter is markedly increased, and peristalsis is absent.
The incidence of achalasia increases with age.
What are symptoms of esophageal spasm?
- Chest pain
- Dysphagia
Symptoms may be precipitated by swallowing very hot or cold liquids.
How can the history help differentiate oropharyngeal from esophageal dysphagia?
By focusing on the anatomic level involved, types of food leading to symptoms, and whether the symptoms are intermittent or progressive.
A careful history is effective in up to 85% of patients.
What diagnostic tests may be used for dysphagia?
- Nasopharyngoscopy
- Video esophagography
- Barium swallow
- Manometry
- Impedance monitoring
The choice of tests should be coordinated with consultants.
What is the first-line treatment for achalasia?
Peroral endoscopic myotomy (POEM).
This is recommended for patients able to tolerate surgical intervention.
What are some medical therapies for esophageal motility disorders?
- Anticholinergic drugs (e.g., hyoscyamine sulfate, dicyclomine)
- Calcium channel blockers
These therapies aim to decrease esophageal peristalsis and LES pressure.
What is the recommended disposition for patients at risk of aspiration?
Hospitalization for expedited work-up and management.
Otherwise, outpatient evaluation by a gastroenterologist is indicated.
Causes of Dysphagia
What are the four major groups of patients with esophageal foreign bodies?
- Pediatric patients
- Psychiatric patients or prisoners
- Patients with underlying esophageal disease
- Edentulous adults
What age group accounts for the peak incidence of pediatric foreign body ingestion?
18 to 48 months
What is the most common type of foreign body ingested by pediatric patients?
Coins
What are the common types of foreign body impactions in adults?
- Food
- Meat
- Bones
Which muscle is associated with the upper esophageal sphincter (UES)?
Cricopharyngeus muscle
Where are the four natural areas of narrowing in the esophagus located?
- Cricopharyngeus muscle
- Aortic arch
- Left mainstem bronchus
- LES at the diaphragmatic hiatus
What types of muscle make up the esophagus?
- Striated muscle (upper third)
- Skeletal muscle (middle portion)
- Smooth muscle (distal third)
What is a Schatzki ring?
A fibrous, diaphragm-like stricture near the gastroesophageal junction
What symptoms do patients with esophageal obstruction typically experience?
- Dysphagia
- Odynophagia
- Neck or chest pain
What is a café coronary?
A proximal esophageal obstruction caused by food leading to sudden cyanosis and collapse
What symptoms should prompt consideration of unwitnessed foreign body ingestion in children?
- Fever
- Wheezing
- Stridor
- Rhonchi
- Poor feeding
What diagnostic tests are typically used to confirm esophageal foreign body ingestion?
- Anteroposterior (AP) and lateral radiographs
- Nasopharyngoscopy
- Laryngoscopy
- Upper GI endoscopy
What is the role of CT in the diagnosis of esophageal foreign bodies?
To identify and localize foreign bodies with higher sensitivity than radiography
What is the recommended treatment for complete esophageal obstruction?
Flexible endoscopy using procedural sedation
What objects require urgent intervention in cases of esophageal obstruction?
- Button batteries
- Magnets
- Large or sharp objects
- Coins lodged in the proximal esophagus
- Food boluses causing high-grade obstruction
What are the risks associated with foreign bodies remaining in the esophagus for more than 24 hours?
- Perforation
- Aorto-enteric fistula
- Tracheoesophageal fistula
- Abscess
What is the technique used to remove smooth foreign bodies like coins from the upper esophagus?
Foley catheter removal
What is bougienage?
A technique where an esophageal dilator is used to advance a coin into the stomach
What is the effect of glucagon in the management of esophageal foreign bodies?
No proven benefit and increased risk of adverse events
What should be done for a patient with a button battery lodged in the esophagus?
Endoscopy should be performed immediately
What is the conservative management approach for foreign bodies that have entered the stomach?
Outpatient management for most cases
What indicates the need for surgical removal of foreign bodies in the stomach?
Objects remaining in the stomach for more than 3 to 4 weeks or in the same intestinal location for more than 1 week
What should patients be discharged with after endoscopy for foreign body removal?
A proton pump inhibitor (PPI) and referral for further evaluation of structural abnormalities
What can cause esophageal perforation?
Esophageal perforation can result from:
* Rapid increase in intraesophageal pressure (e.g., forceful vomiting)
* Valsalva-like maneuvers (e.g., childbirth, coughing, heavy lifting)
* Iatrogenic causes (e.g., endoscopy, nasogastric tube placement)
* Foreign body ingestion
* Caustic substance ingestion
* Severe esophagitis
* Carcinoma
* Blunt or penetrating trauma
Where do most spontaneous esophageal ruptures occur?
More than 90% of spontaneous esophageal ruptures occur in the distal esophagus.
What are the common sites of iatrogenic injury during esophageal procedures?
Common sites of iatrogenic injury include:
* Pharyngoesophageal junction
* Esophagogastric junction
What is the Mackler triad?
The Mackler triad consists of:
* Subcutaneous emphysema
* Chest pain
* Vomiting
It is pathognomonic for spontaneous esophageal rupture, but the complete triad is seen in less than 50% of cases.
What symptoms may be present with an upper esophageal perforation?
Symptoms may include:
* Neck or chest pain
* Dysphagia
* Respiratory distress
* Fever
* Odynophagia
* Nausea
* Vomiting
* Hoarseness
* Aphonia
What are the physical findings in patients with esophageal perforation?
Physical findings may include:
* Epigastric or generalized abdominal tenderness
* Involuntary guarding and rigidity
* Mediastinal or cervical emphysema (noted by crepitus or Hamman sign)
What is a common misdiagnosis for esophageal perforation?
Common misdiagnoses include:
* Pulmonary embolism
* Acute myocardial infarction
* Aortic dissection
* Perforated ulcer
* Pneumothorax
* Lung abscess
* Pericarditis
* Pancreatitis
What is the first diagnostic study for suspected esophageal perforation?
Chest and upright abdominal radiography is generally the first diagnostic study.
What radiographic abnormalities may indicate esophageal perforation?
Radiographic abnormalities may include:
* Pneumomediastinum
* Pleural effusion (right-sided or left-sided)
* Subcutaneous emphysema
* Mediastinal widening
* Pulmonary infiltrates
What is the recommended initial contrast agent for suspected esophageal perforation?
Water-soluble agents (e.g., Gastrografin) are recommended for initial contrast studies.
What are the common organisms found in the esophagus that may cause infections after perforation?
Common organisms include:
* Gram-positive bacteria
* Gram-negative bacteria
* Anaerobic organisms
* Fungal species
What is the recommended antibiotic regimen for esophageal perforation?
Recommended regimen includes:
* IV vancomycin 15 mg/kg q8h to q12h
* IV piperacillin-tazobactam 3.375 g q6h
* Consider adding empiric antifungal coverage (fluconazole 400 mg IV daily) if risk factors are present
What are the management options for clinically stable patients with iatrogenic perforations?
Management options include:
* Close monitoring
* NPO status
* Broad-spectrum antibiotics
* Parenteral nutrition
* Surgical consultation available
What factors are associated with worse outcomes in traumatic, noniatrogenic esophageal perforation?
Factors associated with worse outcomes include:
* Thoracic location of esophageal injury
* More extensive esophageal damage
What is the recommended disposition for patients with esophageal perforation?
Patients require close monitoring in a hospital setting, often in an intensive care unit, with early surgical consultation recommended.
What is the most common cause of esophagitis?
Gastroesophageal reflux disease (GERD).
List other important causes of esophagitis.
- Eosinophilic infiltration
- Infection
- Foreign body
- Toxic ingestion
- Radiation
What is gastroesophageal reflux disease (GERD)?
When reflux of gastric contents becomes symptomatic or causes histopathologic alterations.
What percentage of the population experiences symptomatic reflux in the form of heartburn?
10% to 20%.
What primary mechanism allows reflux of gastric contents into the esophagus?
Inappropriate relaxation of the lower esophageal sphincter (LES).
What factors can decrease LES pressure and lead to reflux?
- Medications (e.g., nitrates, calcium channel blockers)
- Fatty meals
- Chocolate
What are some conditions that can contribute to GERD?
- Esophageal motility abnormalities
- Increased intragastric pressure
- Acid hypersecretion
- Gastric outlet obstruction
- Delayed gastric emptying
What histological change can occur due to chronic GERD?
Replacement of normal stratified squamous epithelium with metaplastic columnar epithelium (Barrett metaplasia).
What is the prevalence of Barrett esophagus in patients with reflux undergoing endoscopy?
Approximately 10% to 15%.
What is eosinophilic esophagitis?
A condition characterized by eosinophilic infiltration within the esophageal mucosa.
What is the association of eosinophilic esophagitis with age?
Initially thought to be a disease of children, now diagnosed in adults with a prevalence rate approaching 3%.
What criteria are necessary for diagnosing eosinophilic esophagitis?
- Clinical symptoms of esophageal dysfunction
- More than 15 eosinophils in one high-power field on esophageal biopsy
- Lack of responsiveness to high-dose PPI therapy
Who is most at risk for infectious esophagitis?
Immunocompromised hosts.
What is the most common esophageal pathogen in infectious esophagitis?
Candida species (primarily Candida albicans).
What are the most common viral pathogens causing infectious esophagitis?
- Herpes simplex virus 1 (HSV-1)
- Cytomegalovirus (CMV)
What is pill esophagitis?
Inflammation and injury of the esophageal mucosa due to a pill or capsule remaining in contact with it for a prolonged period.
What are common predisposing factors for pill esophagitis?
- Advanced age
- Decreased esophageal motility
- Extrinsic compression
What can be a consequence of sustained-release compounds in pill esophagitis?
More damaging than standard preparations.
What symptoms are commonly associated with esophagitis?
- Dysphagia
- Odynophagia
- Chest pain
- Esophageal bleeding
What is the most common clinical manifestation of GERD?
Heartburn.
What additional symptoms may occur with GERD?
- Regurgitation
- Water brash
- Dysphagia
- Odynophagia
What conditions or positions can precipitate reflux?
- Stooping
- Bending
- Leaning forward
- Valsalva-type maneuvers
- Supine position
What is a common symptom of eosinophilic esophagitis in adults?
Solid food dysphagia.
What are atypical presentations of pill esophagitis?
Burning type of pain, suggesting GERD.
What is the key point in differentiating cardiac chest pain from reflux?
Relief of chest pain from reflux by antacids.
What can endoscopy reveal in cases of infectious esophagitis?
Characteristic signs of infection, such as white plaques of Candida or herpetic vesicles.
Agents and conditions related to Gastroesophageal Reflux
List dietary changes to reduce GERD symptoms.
- Avoid caffeine
- Avoid alcohol
- Avoid chocolate
- Avoid fatty foods
- Avoid acidic foods like citrus products and spicy foods
What behavioral modifications are recommended for GERD?
- Weight loss
- Smoking cessation
- Elevation of the head of the bed
- Avoid recumbent position after eating
Which lifestyle recommendations have evidence-based support for GERD management?
- Weight loss
- Head of bed elevation
What types of medications are used in pharmacologic therapy for GERD?
- Antacids
- H2-receptor antagonists
- PPIs (Proton Pump Inhibitors)
- Agents that affect the LES or motility
- Mucosal protectants
What did a Cochrane systematic review conclude about PPIs in GERD treatment?
PPIs are more effective than H2 blockers in eliminating symptoms and healing mucosal damage.
What is sucralfate used for in GERD management?
Sucralfate is a mucosal protectant that binds to inflamed tissue to create a protective barrier.
What are the potential side effects of prolonged use of metoclopramide?
Significant irreversible extrapyramidal side effects such as tardive dyskinesia.
When should patients with GERD be referred to a gastroenterologist?
If they do not improve with empirical therapy or are at high risk for complications.
What surgical therapy may be considered for GERD patients intolerant of acid-suppressive medications?
Laparoscopic fundoplication.
What is the recommended treatment for eosinophilic esophagitis after food impaction is resolved?
Initiation of a daily PPI and referral to a gastroenterologist for urgent endoscopy.
What are potential consequences of untreated eosinophilic esophagitis?
Esophageal remodeling and stricture formation in up to 40% of adult patients.
List additional therapies considered for eosinophilic esophagitis.
- Topical corticosteroids
- Leukotriene receptor antagonists
- Mast cell stabilizers
- Azathioprine
- 6-mercaptopurine
- Biologic immunomodulators
What is the treatment for mild cases of oropharyngeal candidiasis?
Clotrimazole troches or nystatin.
How is moderate to severe esophageal candidiasis treated?
Oral fluconazole.
What is the typical treatment for herpes esophagitis in immunocompromised patients?
- Acyclovir
- Famciclovir
- Valacyclovir
What is the best treatment for pill esophagitis?
Prevention.
What instructions should be given to patients to prevent pill esophagitis?
- Drink at least 4 ounces of liquid with any pill
- Take medications in an upright position
- Remain upright for several minutes after medication ingestion
What additional treatments can provide symptomatic relief for infectious esophagitis?
- Antacids
- Topical anesthetics
- Sucralfate
Summary of Histamine Receptor Antagonist
Summary of PPI
What is gastritis?
A histologic diagnosis denoting inflammation of the gastric mucosa
Diagnosis made only by endoscopy and biopsy
What is the most common cause of gastritis?
Infection with Helicobacter pylori
How is H. pylori primarily spread?
Person to person by an oral-oral route
What percentage of patients with duodenal ulcers are infected with H. pylori?
Up to 95%
What percentage of patients with gastric ulcers are infected with H. pylori?
Up to 70%
What is suppurative gastritis?
A rare and often fatal disease from an acute bacterial infection of the stomach wall
What is the second most common cause of peptic ulcer disease (PUD)?
Use of aspirin and other NSAIDs
What complications can arise from chronic NSAID use?
Ulcer disease, perforation, or bleeding
What do prostaglandins promote in the gastric mucosa?
Mucosal integrity by maintaining blood flow and promoting mucus and bicarbonate formation
What is Zollinger-Ellison syndrome?
An acid hypersecretion syndrome caused by gastrin-secreting tumors
What are common symptoms of acute gastritis and PUD?
Epigastric abdominal pain, nausea, and vomiting
What is the classic presenting symptom of PUD?
Epigastric pain described as burning or gnawing
What is a key indicator of ulcer disease based on pain timing?
Symptoms that awaken a patient from sleep between midnight and 3 am
What percentage of patients with PUD experience pain relief with antacids?
More than 90%
What are the most serious complications of PUD?
- Hemorrhage
- Perforation
- Penetration
- Gastric outlet obstruction
What is the typical presentation of a perforated duodenal ulcer?
Pain first in the epigastrium that becomes generalized, often with vomiting
What should be considered in differential diagnoses for epigastric pain?
- Pancreatitis
- Biliary tract disease
- Small bowel obstruction
- Mesenteric ischemia
What characterizes the discomfort associated with gastritis?
Often mild to moderate, described as a hot burning pain or bloating
Fill in the blank: The gastric mucosal barrier prevents the back-diffusion of _______ from the gastric lumen.
Hydrogen ions
What are some potential causes of gastritis?
- Radiation
- Autoimmune reactions
- Crohn disease
- Sarcoidosis
What is the significance of gastric acid output timing in ulcer pain?
Highest at approximately 2 am, leading to pain that may wake a patient
What are the ulcerogenic potential drugs mentioned?
- 5-fluorouracil
- Mycophenolate mofetil
- Bisphosphonates
Risk of GI complications from NSAIDs
Substances that damage gastric mucosal barrier
What is the primary method for confirming the diagnosis of gastritis?
Upper endoscopy
This procedure is not typically performed in the ED unless necessary to treat complications of PUD.
What ancillary tests might be ordered to assess complications of gastritis?
Abdominal and chest radiographs
These should be ordered if obstruction, perforation, or penetration is suggested.
What imaging technique may visualize deep ulcers and signs of peptic gastroduodenitis?
Multiplanar CT interpretation
This can facilitate expedited endoscopic evaluation.
What tests can be used to detect H. pylori?
- Urea breath test
- Serum antibody testing
- Stool antigen testing
- Direct mucosal biopsy during endoscopy
These methods are not practical in the ED.
What is the initial management approach for NSAID-related ulcers?
Discontinuation of the offending agent combined with initiation of PPI therapy.
What are the recommended regimens for treating H. pylori infection?
Combination of antibiotics with acid-suppressing agents
Examples include Prevpac and Helidac.
How do antacids relieve symptoms in patients with PUD?
They bind bile acids or inhibit pepsin.
What side effect is associated with magnesium-containing antacids?
Diarrhea in up to 25% of patients.
What condition can excessive consumption of calcium-containing antacids lead to?
Milk-alkali syndrome
This includes hypercalcemia, alkalosis, and renal insufficiency.
What is the primary action of H2 blockers?
Inhibit gastric acid production by blocking H2 receptors on parietal cells.
What are common side effects of H2 blockers?
- Somnolence
- Dizziness
- Confusion
- Transient increases in liver enzyme levels
Cimetidine may cause gynecomastia.
What is the mechanism of action for proton pump inhibitors (PPIs)?
Irreversibly bind to proton pumps to block secretion of hydrogen ions.
How long do the antisecretory effects of PPIs last?
Up to 72 hours.
What is the recommended administration timing for PPIs?
Before the first meal of the day.
What potential risk is associated with PPIs when used with clopidogrel?
Inhibition of the effects of thienopyridines used to treat cardiovascular disease.
What protective effects do prostaglandins exert on the gastric mucosa?
- Inhibit acid secretion
- Decrease cyclic adenosine monophosphate
- Increase mucus and bicarbonate secretion
- Stimulate mucosal blood flow
What is the primary use of Misoprostol?
Prevention of NSAID-induced gastric ulcers in high-risk patients.
What is the mechanism of action of sucralfate?
Binds to epithelial cells and ulcerated surfaces to provide a protective layer.
What are the effects of bismuth compounds on ulcers?
- Decrease pepsin activity
- Increase mucus secretion
- Form a barrier to acid damage
- Increase prostaglandin synthesis
- Help heal ulcers through bactericidal action
What are the indications for referral to a gastroenterologist?
- Age 55+ with new-onset dyspepsia
- Dysphagia
- Progressive unintentional weight loss
- Persistent vomiting
- Iron deficiency anemia
- Epigastric mass
Suggested treatment regimens for H.pylori
What is gastric volvulus?
A rare cause of severe abdominal pain occurring when the stomach rotates on itself more than 180 degrees, creating a closed loop obstruction.
How is gastric volvulus classified?
According to cause (primary vs. secondary), anatomy (axis of rotation), or onset (acute vs. chronic).
What points fix the stomach in the abdomen?
- Esophagocardiac junction
- Pylorus
Where does the stomach lie when a person is supine?
Entirely above the umbilicus.
What is a primary (subdiaphragmatic) volvulus?
Accounts for approximately one-third of cases, occurring when stabilizing ligaments are too lax or congenitally abnormal.
What is a secondary (supradiaphragmatic) volvulus?
Occurs in patients with diaphragmatic defects or other conditions that increase the likelihood of volvulus.
What are the common causes of secondary gastric volvulus?
- Paraesophageal hiatal hernia
- Elevated diaphragm
- Gastric ulcer or carcinoma
- Diaphragmatic paralysis
- Extrinsic pressure from other organs
- Abdominal adhesions
What is organoaxial volvulus?
The most common form of gastric volvulus, occurring when the stomach twists on its long axis.
What is mesenteroaxial volvulus?
Occurs when the stomach folds on its short axis from its lesser to greater curvature.
What age group is most commonly affected by gastric volvulus?
Persons aged 40 to 50 years, with approximately 20% of cases in infants younger than 1 year.
What is Borchardt triad?
The combination of severe epigastric pain and distention, vomiting followed by violent nonproductive retching, and inability to pass a nasogastric tube.
What are common symptoms of a chronic gastric volvulus?
- Mild intermittent upper abdominal pain
- Early satiety
- Dyspnea
- Bloating
- Eructation
- Upper abdominal distension
What complications can arise from an untreated acute gastric volvulus?
- Gastric ischemia
- Perforation
- Death
- Ulceration
- Hemorrhage
- Pancreatic necrosis
- Omental avulsion
What is the reported mortality rate from acute gastric volvulus?
As high as 50%.
What initial diagnostic test is often used for gastric volvulus?
A plain abdominal radiograph.
What might a classical x-ray show in cases of gastric volvulus?
A large, gas-filled loop of bowel in the abdomen or chest with an air-fluid level, often with a lack of air in the distal bowel.
What is the primary goal of treatment for acute gastric volvulus?
Reduction of the volvulus.
What should be attempted immediately for acute gastric volvulus management?
Immediate passage of a nasogastric tube.
What is the ultimate treatment for gastric volvulus?
Surgical emergency to reduce the volvulus and prevent recurrence.
