Gastric & Esophageal disorders Flashcards
MCC of PUD (2)
Helicobacter pylori infection
Chronic NSAID use
*uncommonly → Gastrinoma (Zollinger-Ellison syndrome)
Abdominal pain increases shortly after eating → weight loss
Gastric Ulcer
less common
Pain is relieved with food intake → weight gain
Pain increases 2–5 hours after eating.
Duodenal Ulcer
more common
Dyspepsia→ early satiety, gnawing, or burning epigastric pain
Pain relieved with ANTIACIDS
(+/-) anemia, hematemesis, or melena
(+) Fecal occult blood
Diagnosis?
Peptic Ulcer Disease
Stress ulcer causes: (3) major surgery SIRS kidney failure
Burns
TBI
polytrauma
Curling ulcers caused by
stress ulcer
severe burns
*decreased plasma volume → decreased gastric blood flow → hypoxic tissue injury of stomach surface epithelium → weakening of the normal mucosal barrier
Cushing ulcer caused by
stress ulcer
brain injury
*increased vagal stimulation → increased production of stomach acid via Ach release
Alarm features warranting an EGD in younger patients include: progressive \_\_\_, \_\_\_\_ rapid weight loss, persistent vomiting, suspected GI bleeding, FMH of upper GI malignancy
dysphagia
odynophagia
The most accurate test to confirm the diagnosis of PUD.
EGD
*with therapeutic measures: hemostasis via electrocautery for active bleeding
Indications for biopsy via EGD
Gastric ulcers present
To r/o malignancy
(Take from the edge and base of the ulcer)
Gastric ulcers increase the risk for what malignancy?
Carcinoma
First therapeutic approaches for PUD (3)
avoid NSAIDs, restrict alcohol, PPI
If patient presentation is suspicious for PUD what should be ruled out first?
H. Pylori
urea breath test
Posterior gastric ulcers are more likely to ___ and anterior ulcers are more likely to ___
bleed
perforate
Gastric outlet obstruction
MCC: ___ → scarring and fibrosis
Chronic PUD
Clinical features: Postprandial, nonbilious emesis, Succussion splash Early satiety→ Weight loss Dysphagia
hypokalemic hypochloremic metabolic alkalosis
Diagnosis?
Gastric outlet obstruction
Gastric cancer risk factors:
Diet rich in \_\_\_ \_\_\_ infection Nicotine use \_\_\_ virus Gastric ulcers Partial \_\_\_ (procedure) Chronic atrophic gastritis/ pernicious anemia
nitrates (smoked, cured)
H. pylori
Epstein-Barr
gastrectomy
a pathologically increased growth of bacteria in the small intestine
Small intestinal bacterial overgrowth (SIBO)
Suspect late dumping syndrome in a patient with previous ___ surgery and ___-glycemia.
gastric surgery
hypoglycemia
Dumping syndrome is rapid ___ as a result of:
defective gastric reservoir function
impaired pyloric emptying mechanisms
or anomalous post-op gastric motility
gastric emptying
late/early dumping syndrome
Late Dumping Syndrome Management
____
2nd-line treatment: ____
3rd-line treatment: surgery
Dietary modifications
Octreotide
__ is indicated for HER2-positive GASTRIC adenocarcinomas s/p late stage surgery
Trastuzumab
Gastric ___ (malignancy) are associated with H. pylori infection
MALToma
Gastric MALTomas therapy:
First-line:
H. pylori eradication tx
GERD is 2/2 imbalance between intragastric and ___ pressures
lower esophageal sphincter (LES)
Typical GERD symptoms w/o alarm features in patients < 60 years of age next step in management:
Start PPI w/ lifestyle modifications
Good response: often used to confirm GERD diagnosis
Alarm features warranting EGD as next best step: Dysphagia or Odynophagia [Lab finding] Unintentional weight loss \_\_\_\_\_ No symptomatic improvement after \_\_\_
Anemia
Aspiration pneumonia
PPI trial
Indications for ____ (surgery) in pts with GERD:
severe esophagitis
strictures
recurrent aspiration
Fundoplication (Nissen fundoplication)
Consider Roux-en-Y for obese patients
Complication of chronic GERD:
Barrett esophagus
Metaplasia of the esophageal mucosa
premalignant can become →
esophageal adenocarcinoma
*other cx:
anemia & esophageal strictures
Management & Monitoring Barrett esophagus
EGD + Biopsy of the suspicious areas (salmon-colored mucosa)
If high-grade dysplasia: endoscopic treatment of mucosal irregularities
Dysphagia Regurgitation of undigested food Halitosis Aspiration Coughing after food intake Retrosternal pressure sensation and pain
Diagnosis
Zenker’s diverticulum
esophageal diverticulum
2 diagnostic test for Zenker’s diverticulum
1st: Barium swallow (best confirmatory test) with dynamic continuous fluoroscopy
2nd: EGD to r/o malignancy
Inadequate relaxation of the lower esophageal sphincter (LES) &
nonperistaltic contractions in the distal 2/3 of the esophagus
s/t degeneration of inhibitory neurons
Achalasia
Esophageal motility disorder
__ typically presents with progressive dysphagia to solids and liquids
Achalasia
while esophageal obstruction manifests with dysphagia to solids only
Achalasia diagnostic test
3
Manometry: (confirmatory test of choice) -Absent/ uncoordinated peristalsis in the lower 2/3 -Incomplete LES relaxation -High LES resting pressure
Esophageal barium swallow:
- Bird-beak sign: dilation of proximal esophagus w/ stenosis of the GE junction
- Delayed barium emptying
Upper endoscopy (r/o pseudoachalasia)
Chest x-ray
(Widened mediastinum)
Treatment of Achalasia:
- ## If a low surgical risk-
- If a high surgical risk
- Botox the LES
- nitrates or CCBs
- Pneumatic dilation via Endoscope-guided dilation of the LES
1a. LES myotomy (Heller myotomy)
Upper gastrointestinal bleeding caused by tears to the longitudinal mucous membrane at the gastroesophageal junction
Mallory-Weiss Syndrome
Longitudinal Lacerations
Epigastric or back pain
Hematemesis w/ HDS
Mallory-Weiss Syndrome
Precipitating factor:
Severe vomiting
Predisposing conditions \_\_\_\_ Bulimia nervosa \_\_\_\_ GERD
Alcohol use disorder
Hiatal hernia
Pt recently vomiting now has severe, retrosternal chest pain
mediastinal and/or subcutaneous emphysema
Diagnosis?
Esophageal Rupture (Boerhaave syndrome)
A spontaneous distal esophageal rupture as a result of a sudden increase in intra-esophageal pressure.
Usually 2/2 severe vomiting.
Treatment of patients with Mallory Weiss Tear
- Not actively bleeding
- Active bleeding
- PPI therapy alone
- Endoscopic injection of an Epi or fibrin sealant
2a. Endoscopic Electrocoagulation
2b. Endoscopic band ligation
2c. Angioembolization
Esophageal perforation causes (2)
Injury during upper endoscopy (sxs w/in 24hrs)
Boerhaave syndrome
Mackler triad:
- Vomiting
- Retrosternal pain radiating to the back
- Subcutaneous/mediastinal emphysema/crepitus
or
Hamman sign: crunching/crackling sound on chest auscultation
Diagnosis
Esophageal Rupture
esp. in Boerhaave syndrome
initial and confirmatory imaging for suspected esophageal perforation:
Initial: CXR
(Widened mediastinum, Pleural effusion,
Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema)
Confirmatory: Contrast Esophagography (Barium swallow)
Treatment approach to perforated esophagus
3
NPO
Broad-spectrum IV antibiotics
Surgery
Major complication of perforated esophagus
Mediastinitis:
Retrosternal and/or back pain
Subcutaneous emphysema
Esophageal Adenocarcinoma risk factors: Obesity \_\_\_\_\_\_ Age 50 ≤ \_\_\_\_\_\_
Smoking
GERD/Barrett esophagus
Esophageal Adenocarcinoma is located mostly in the __ of the esophagus
lower third
Esophageal Squamous cell carcinoma (SCC) risk factors: \_\_\_\_ \_\_\_\_ \_\_\_\_ Diet low in fruits and vegetables Nitrates (cured/smoked meat, bacon) Age 60 ≤ Plummer-Vinson syndrome Achalasia
Alcohol consumption
Smoking
HPV
Esophageal Squamous cell carcinoma located mostly in the ___ of the esophagus
upper two-thirds
Signs of advanced esophageal cancer: \_\_\_\_ Retrosternal chest or back pain Cervical adenopathy \_\_\_ and/or persistent cough
Dysphagia (from solids to liquids) +/- Odynophagia
Hoarseness
