Exam 1 Flashcards
how to tell leukoplakia from candidiasis
leukoplakia doesn’t debride easily
what to do about leukoplakia
biopsy if persistent
what percentage of leukoplakia/erythroplakia is malignant or premalignant
10%
most common site of oral cancer
lower lip
pain with oral cancer
painless until metastasis
risk factors for oral cancer
tobacco, actinic radiation, syphilis
signs of dysphagia
weight loss, avoiding certain foods
signs suggestive of oropharyngeal dysphagia
aspiration, nasal regurgitation, abnormal neuro exam
what to do if signs suggestive of oropharyngeal dysphagia with warning signs of malignancy
refer to ENT for laryngoscopic eval, FEES
what to do if signs suggestive of oropharyngeal dysphagia without warning signs of malignancy
refer for clinical swallow eval +/- modified barium swallow
voluntary phase of swallowing
oral phase
3 essential functions of oral cavity
production of speech, initiation of alimentation, host protection
what cells in salivary glands produce saliva and do they atrophy with aging
acinar cells, no
most common causes of xerostomia
iatrogenic, sjogrens, oral infections, gland obstructions, oral cancer
how many over 65 are adentulous
1/3
what medications can cause dry mouth
anticholinergics, antihistamines, antidepressants, diuretics, CCB
what factors contribute to teeth loss
xerostomia, lack of care, bone loss, caries, peridontal disease, poor diet
causes of angular chelitis
immune dysfunction, poor nutrition, mouth breathing, dry mouth
what malignancy does leukoplakia usually represent
SCC
is atrophic glossitis painful
no
causes of atrophic glossitis
deficiencies (B12, iron, vitamin E), medication reaction, autoimmune
classic presentation of oropharyngeal dysphagia
history of stroke or oral cavity problems, sensation of choking immediately after swallowing, with associated respiratory ssx
classic presentation of esophageal dysphagia
history of motility/neuromuscular disorder or mechanical esophageal problem with sensation of chest pain several seconds after swallowing and associated copious salivation
what does difficulty swallowing solid foods suggest
obstructive problem
what does difficulty swallowing liquids suggest
neurologic problem
sequelae of dysphagia
aspiration, pain, dehydration, malnutrition, increased cancer risk, need supervision/special diet/increased time to eat
warning sign of laryngeal cancer
persistent hoarse voice non-responsive to PPI or allergy medications
location of SCC of esophagus
mid esophagus
location of adenocarcinoma of esophagus
distal esophagus
what is Zenker’s diverticulum
extrusion of esophageal mucosa between weak muscle fibers in the posterior hypopharynx
Zenker’s diverticulum presentation
transient dysphagia with aspiration, gurgling, neck mass, regurgitation, esophageal obstruction
Zenker’s diverticulum diagnosis
barium examination
Zenker’s diverticulum complications
intubation during endoscopy/NGT, bleeding
Zenker’s diverticulum treatment
consider surgical closure if symptomatic
what to do if hx of PUD but cannot stop NSAID/ASA
consider misoprostol
duration of treatment for PPI in gastritis/PUD
minimum of 8 weeks
gold standard for diagnosis and confirmed tx of gastritis/PUD
upper endoscopy
most common causes of gastritis
H Pylori (70%), viral infections, irritants (NSAIDs, ASA)
what processes are increased in the normal aging of the stomach
contact time with irritants (NSAIDs), prevalence of H Pylori, pernicious anemia, cancers
what processes are decreased in the normal aging of the stomach
clearance of liquids, sensory neuron function, mucosal blood flow, acid/pepsin/fluid secretion, cytoprotective factors
infectious causes of esophagitis
candida, H pylori, chlamydia/gonorrhea
chemical causes of esophagitis
acid reflux, caustic material
diagnosis of esophagitis
EGD
barrett’s pathophys
abnormal columnar epithelium replaces stratified squamous epithelium in distal esophagus
barrett’s sequelae
predisposes to adenocarcinoma
barrett’s ssx
usually painless
esophageal cancer presentation
progressive obstruction, dysphagia, weight loss, GI bleeds, persistent GERD
esophageal cancer risk factors
white males, obesity, tobacco, ETOH
esophageal cancer prognosis
generally poor (usually found in later stages)
NSAIDs typically cause ulcers in what location
gastric, may also be duodenal
is acute or chronic NSAID use more of a risk factor for gastritis
acute
pathophys of NSAID associated gastritis
COX-1 inhibition leads to decreased mucosal defense and inhibition of thromboxane A2 leading to reduced platelet function and risk of bleeding
gastritis common but atypical presentation
vague, low-intensity abdominal pain
GERD symptoms more common in elderly
vomiting, anorexia, belching, laryngitis, postprandial fullness, dysphagia, respiratory ssx
esophagitis correlation with degree of ssx
correlates poorly in elderly
GERD red flag symptoms
weight loss, anemia, nausea/vomiting, dysphagia, anorexia, early satiety, fecal occult blood
blood work for GERD
CBC, B12, folate, H pylori, chem
diagnosis of GERD
mostly clinical with empiric PPI treatment
gold standard for H Pylori diagnosis
urea breath test 30 minutes before and after urea liquid, rapid urease or culture on endoscopic biopsies
major problem with H pylori serologic testing
remains elevated for 2 months after infection
single most important risk factor for esophageal adenocarcinoma
Barrett’s esophagus (accounts for 50% of newly diagnosed cancer)
most important risk factor for esophageal squamous cell carcinoma
tobacco use
most common symptom of esophageal SCC
dysphagia
hallmark of gastric cancer
pernicious anemia followed by weight loss
prognosis of gastric cancer
poor - generally found at more advanced stage
gastric cancer is associated with what 2 conditions
partial gastrectomy, H pylori
causes of gastroparesis
DM, drugs, surgery, bulimia, PD (?), scleroderma, hypothyroid, smoking, cancer/cancer treatment
surgery associated with gastroparesis
anything damaging the vagus nerve
drugs associated with gastroparesis
narcotics, clonidine, calcium channel blockers, antidepressants, TCAs
most common population with gastroparesis
women, mean age 34
pathophys of gastroparesis
loss or dysfunction of interstitial cells of Cajal, which are the pacemakers of the antrum/pylorus
presentation of gastroparesis
labile glucose due to erratic gastric emptying, epigastric fullness, satiety, vomiting
gastroparesis treatment, nonpharmacological
small meals, increased fluids, low fat, thorough chewing, postprandial walking
gastroparesis treatment, pharmacologic
erythromycin (stimulates motilin receptors), metoclopramide (dopamine receptor agonist)
black box side effect of metoclopramide
tardive dyskinesia
gastroparesis treatment, surgical
endoscopic injection of botox, dilation of pylorus
what nerve mediates relaxation of LES
vagus
normal transit time through esophagus
8-10 sec
first-line test in patient with suspected esophageal dysphagia
barium esophagram
test to diagnose achalasia
manometry
most common cause of oropharyngeal dysphagia
neurological
management for oropharyngeal dysphagia of neurological origin
speech language pathologist referral
what is achalasia
incomplete LES relaxation combined with lack of peristalsis
achalasia treatment
botox, endoscopic pneumatic balloon dilation or myotomy
what is nutcracker esophagus
high amplitude peristaltic contractions in the distal esophagus
pathophys of protein-losing enteropathy
increased intestinal leakage of plasma proteins due to mucosal injury, increased lymphatic pressure, or genetics
diagnosis of protein-losing enteropathy
endoscopy with biopsy (suspect in pt with rheumatologic disease and low albumin)
when is weight loss concerning
at least 5%
sarcopenia
loss of muscle tissue as a natural part of the aging process
elements of metabolic syndrome
obesity, hyperglycemia/hyperinsulinemia, dyslipidemia, HTN
ssx of vitamin D deficiency
depression, hair loss, fatigue, muscle pain, recurrent infections, bone pain
causes of vitamin D deficiency in elderly
reduced sun exposure, less ability of skin to manufacture vitamin D, decreased consumption due to meds/diet
what is considered vitamin D sufficiency
> 20
what is considered vitamin D deficiency
<12
vitamin D deficiency treatment
50,000 IU of D2 or D3 weekly for 8 weeks or 6000 IU D2 or D3 daily to achieve level >30
vitamin D maintenance dose
1500-2000 IU daily
functions of vitamin B12
blood cell formation, neuro function, DNA synthesis
dietary sources of vitamin B12
fish, meat, poultry, eggs, milk, milk products
B12 deficiency ssx
megaloblastic anemia, fatigue, weakness, loss of bowel/bladder control, loss of appetite, weight loss
what meds are linked to B12 deficiency
acid suppressants, metformin, colchicine
cutoff for B12 deficiency
<200
B12 level for sufficiency
> 350
goal for B12 level
> 400
B12 deficiency treatment
1000 mcg sublingual daily and retest in 3 months
what to do if B12 deficiency doesn’t respond to SL treatment
switch to 1000 mcg IM monthly
types of osteoporosis
primary and secondary
types of primary osteoporosis
type 1 (menopausal) type 2 (involutional, age-related)
causes of secondary osteoporosis
endocrine abnormalities, multiple myeloma
complications of osteoporosis
kyphosis, compression fracture, low-velocity fractures
what are osteoclasts
macrophage-like cells for bone removal
what are osteoblasts
differentiate from mesenchymal cells to form bone
when does bone remodeling occur
it is lifelong
what are osteocytes
bone cells embedded in the matrix
what type of bone is more metabolically active
trabecular bone
what type of bone makes up the majority of skeletal mass
trabecular
factors affecting bone remodeling
genetics, hormones, calcium, vitamin D
what hormones affect bone remodeling
estrogen/androgens, PTH, calcitonin
risk factors for osteoporosis
hypogonadism, FMH (?), inactivity, nulliparity, hyperthyroidism, smoking, drugs, “caucasian or asian,” short stature, age/sex, gastric/small bowel surgery, hyperparathyroidism, ETOH
dietary sources of Ca
milk products, broccoli, spinach
dietary sources of B12
animal meat products, beans
dietary sources of vitamin D
salmon, tuna, eggs, milk, breakfast cereals, cod liver oil
blood tests prior to treating osteoporosis
serum Ca, PTH, TSH, Vit D, GFR, serum creatinine, B12
indications for DEXA scan
post-menopausal, suspicious radiographs, tx monitoring, risk due to meds, malabsorption syndromes, CKD, spontaneous fracture, FMH (?), kyphosis
side effects of bisphosphonates
reflux, osteonecrosis of the jaw, atypical fractures, inflammatory eye disease
bisphosphonates MOA
structural analogs of pyrophosphate that bind to resorptive surfaces and are taken up by osteoclasts and inhibit binding proteins needed for osteoclast function
protein energy malnutrition definition
insufficient protein or energy to meet metabolic needs
causes of protein energy malnutrition
poor diet, increased metabolic demands (trauma, infection, surgery), increased nutrient loss
most common macronutrient deficiency
protein
3 most common causes of malnutrition
depression, GI problems, cancer
labs to obtain with weight loss
albumin, prealbumin, transferrin, lymphocytes
what constitutes severe weight loss
15-20%
what constitutes alarming weight loss
5%
medication to enhance oral intake
mirtazapine
when is osteopenia treated the same way as osteoporosis
if there is a fracture
test to determine if B12 deficiency is due to pernicious anemia
Shillings test
protein-losing enteropathy presentation
low serum proteins, edema, ascites, pleural/pericardial effusions, malnutrition
largest insulin-sensitive tissue in body
skeletal muscle