Gastric & Esophageal disorders Flashcards by Stephanie Escobar

MCC of PUD (2)

Helicobacter pylori infection
Chronic NSAID use

*uncommonly → Gastrinoma (Zollinger-Ellison syndrome)

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Abdominal pain increases shortly after eating → weight loss

Gastric Ulcer

less common

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Pain is relieved with food intake → weight gain

Pain increases 2–5 hours after eating.

Duodenal Ulcer

more common

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Dyspepsia→ early satiety, gnawing, or burning epigastric pain

Pain relieved with ANTIACIDS

(+/-) anemia, hematemesis, or melena

(+) Fecal occult blood

Diagnosis?

Peptic Ulcer Disease

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Stress ulcer causes: 
(3)
major surgery
SIRS
kidney failure

Burns
TBI
polytrauma

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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

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Cushing ulcer caused by

stress ulcer

brain injury

*increased vagal stimulation → increased production of stomach acid via Ach release

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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

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The most accurate test to confirm the diagnosis of PUD.

EGD

*with therapeutic measures: hemostasis via electrocautery for active bleeding

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Indications for biopsy via EGD

Gastric ulcers present
To r/o malignancy

(Take from the edge and base of the ulcer)

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Gastric ulcers increase the risk for what malignancy?

Carcinoma

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First therapeutic approaches for PUD (3)

avoid NSAIDs, restrict alcohol, PPI

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If patient presentation is suspicious for PUD what should be ruled out first?

H. Pylori

urea breath test

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Posterior gastric ulcers are more likely to ___ and anterior ulcers are more likely to ___

bleed

perforate

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Gastric outlet obstruction

MCC: ___ → scarring and fibrosis

Chronic PUD

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Clinical features:
Postprandial, nonbilious emesis,
Succussion splash
Early satiety→ Weight loss
Dysphagia

hypokalemic hypochloremic metabolic alkalosis

Diagnosis?

Gastric outlet obstruction

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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

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a pathologically increased growth of bacteria in the small intestine

Small intestinal bacterial overgrowth (SIBO)

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Suspect late dumping syndrome in a patient with previous ___ surgery and ___-glycemia.

gastric surgery

hypoglycemia

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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

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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: 1. If a low surgical risk - - 2. If a high surgical risk - Botox the LES - nitrates or CCBs

1. 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 1. Not actively bleeding 2. Active bleeding

1. PPI therapy alone 2. 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: 1. Vomiting 2. Retrosternal pain radiating to the back 3. 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