Gastro- Quiz 1 Flashcards
Symptomatic esophageal web + iron deficiency anemia + dysphagia
(esp. in middle age woman, with koilonychia-spoon nails, and glossitis)
Plummer-Vinson Syndrome
Surgical Tx for Achalasia
Heller Myotomy +/- Nissen or Toupet
DDx of GERD
Esophagitis, PUD, Cancer, biliary colic (bad gallbladder)- “great imitator”, CAD, motility disorders
Complications of Achalasia
Pts are at a higher risk for bronchitis, pneumonia, lung abscess (due to aspiration), stasis esophagitis, esophageal squamous cell carcinoma (17x’s a normal person)
Mediastinitis is a serious complication of what disorder?
perforation from instrumentation
Tx for PUD
- PPI - 90% effective by 8 wks
- Sucralfate (carafate) - only first few days, helps heal ulcer, interupts absorption of other meds
Refractory (uncommon)-
- MC due to noncompliance
- Refer for surgery if ruled out NSAID use or H.pylori -Vagotomy +/- antrectomy (Billroth I or II)
An esophageal infection with a pathogen that is common in an immunocompromised host (organ transplants, chemo, HIV/AIDS w/CD4 count < 100) -> doesn’t occur in healthy people
Infectious Esophagitis
Tx of EoE
- PPI (either exclude GERD, or could help Sx of EoE- overlap thing)
- Elimination diet: milk, wheat, egg, soy, nuts, and seafood, followed by reintroduction
- swallowed glucocorticoids
- severe cases = systemic glucocorticoids
-Surgical dilation? -> higher risk of perforation due to stiffness of esophagus
4 types of hiatal hernias
1: sliding- GEJ and cardia extend through hiatus
2: paraesophageal- cardia & fungus extend through hiatus, GEJ stays fixed
3: combo of 1 & 2
4: other viscera extend through hiatus
Factors that exacerbate GERD:
- Abdominal obesity
- pregnancy
- gastric hypersecretory states
- delayed gastric emptying
- disruption of esophageal peristalsis
- gluttany
A break in the mucosal surface greater than 5 mm and a depth penetrating the submucosa
Ulcer
Sx of B ring
usually asymptomatic
present in 10-15% of population
Sx of esophageal disorders
heartburn dysphagia odynophagia chest pain regurgitation globus sensation water brash
Common symptoms of esophageal disease;
heartburn regurgitation chest pain dysphagia odynophagia globus sensation water brash
Tx for corrosive esophagitis
supportive, pain meds, IV fluids
Sx of Radiation esophagitis
dysphagia and odynophagia that can last weeks to months following therapy. Esophageal mucosa can look red, swollen and friable
Tx of GERD
Lifestyle changes & acid inhibitors for 8-12 wks
-avoid refluxogenic foods: Fatty foods ETOH Spearmint/peppermint Tomato-based foods Coffee/tea
Omeprazole 30 min prior to first meal of the day for 8-12 wks (No proven differences in efficacy between the subtypes of meds in this class -prazole)
+/- H2 blockers (-tidine)
Long term use of PPI only for Sx return after discontinuance, erosive disease, and/or Barrett’s esophagus
Nissen (for intractable GERD, reqiures pH probe & normal esophageal function)
Toupet (abnormal esophageal function)
Least common complication of PUD
Gastric Outlet Obstruction
Look for new onset early satiety, nausea, vomiting, increase in postprandial abdominal pain, and weight loss
2 causes:
- Ulcer-related inflammation and edema in the peripyloric region; resolves with ulcer healing
- A fixed, mechanical obstruction secondary to scar formation in the peripyloric area; requires endoscopic balloon dilatation or surgical intervention
Sx of Esophageal cancer
Progressive dysphagia, weight loss, heartburn, hoarseness
MC complication of PUD
Bleeding- 15%, >60 yo, and 20% have no warning
Tx of perforation
NG suction, IV Abx, prompt surgical drainage & repair.
conservative Tx- NPO, IV Abx
What is the work up with suspected Achalasia
Barium swallow
+/- manometry
Endoscopy if pseudoachalasia is suspected
Characteristics of Duodenal Ulcers (DU)
Discomfort is 90 min-3 hours after eating, is relieved by antacid or eating, and may be awakened at night by Sx*
MC with H.pylori infection
With penetration perforation, this type usually goes to the pancreas
MC in 30-55 yo
5x more common
How do you get rid of Achalasia?
No known prevention or reversibility.
Therapy: reduce pressure, improve movement
Rx
Surgery/ Dilation
B ring with a lumen < 13 mm
Schatzki’s ring
Dx of perforation
CT- to check for air in mediastinum
Contrast swallow w/ gastrografin followed by thin barium
How does esophageal chest pain differ from cardiac chest pain?
It is non-exertional, doesn’t improve with rest, meal-related, improved with antacids and can be accompanied by heartburn, dysphagia, and regurgitation.
If difficult to determine origin, do an EKG
Work up/Dx of esophageal atresia
Inability to pass tube >10-15 cm
Flouroscopy
Disorder characterized by healthy esophageal epithelium is replaced by metaplastic columnar and goblet cells (stomach cells) from prolonged exposure to gastric aced of GERD
Barrett’s Esophagus
Ingestion of alkali or acid, typically accidental but can be suicide attempt
Corrosive esophagitis
Cause of hiatal hernias
wear and tear, obesity, pregnancy, or genetic predisposition
Risk increase with age
Hypertensive LES
Hypermotility
Minor abnormality of similar Sx to Achalasia, but this is diagnosis when not enough to Dx Achalasia
How do you Dx Schatzki’s ring?
Barium swallow
“steakhouse syndrome” (solid food dysphagia)
Schatzki’s ring
What disorder is characterized by dysphagia, esophageal food impactions, atypical chest pain (due to spasms), heartburn non responsive to PPIs, and a Hx of atopy in adults?
And…chest and abdominal pain, N/V, and food aversion in children?
Eosinophilic esophagitis (EoE)
Sx of perforation
pleuritic retrosternal chest pain
Full thickness rupture at the GEJ due to forceful vomiting or retching. Could also be from iatrogenic perforation during endoscopy
Boerhaave’s Syndrome
Tx of Booerhaave’s Syndrome
If small/stable - IV fluids, NPO, Abx, H2 blockers
If large/severe- surgery
This rare disorder is characterized by hypermotility, and abnormal esophageal contractions in the presence of normal swallowing. It has an ill-defined pathology, but is sometimes seen post-op
Diffuse Esophageal Spasm (DES)
Sx: odynophagia, dysphagia, hematemesis, dypsnea
Corrosive esophagitis
Barrett’s esophagus risk factors:
middle age white male with chronic GERD
Sx of Gastritis
often asymptomatic in chronic
Acute= anorexia, epigastric discomfort, n/v
Patient’s with Barrett’s Esophagus need regular screening for what?
Cytologic and endoscopic screenings for carcinoma. Can progress to adenocarcinoma
Thin, membranous narrowing at the squamocolumnar mucosal junction
B ring
MC meds associated with pill esophagitis
bisphosphanates, NSAIDs, ferrous sulfate, doxycycline, tetracycline, quinidine, phenytoin, potassium chloride,
Proximal and distal esophagus to not communicate and therefore cannot swallow or handle secretions in an infant
Esophageal Atresia
Esophageal Foreign Bodies/Food Impaction
- complete obstruction of esophagus
- could be associated with stricture, carcinoma, rings, EoE, or carelessness
Sx: foaming at the mouth, chest pain
Tx: spontaneous resolution or w/ endoscope
(sometimes try glucagon
Should evaluate for possible causes
A herniation of mucosa and submucosa through esophageal muscle. Associated with achalasia or distal esophageal stricture.
Epiphrenic
-False diverticula
MC tests for esophageal disorders
upper endoscopy and barium radiography
This rare disorder is characterized by Hypomotility- basically a lazy esophagus that isn’t contracting due to a degeneration of ganglion cells in the esophageal myenteric plexus. The esophagus becomes dilated with a “sigmoid deformity” and the LES becomes hypertrophied. Thought to be an autoimmune disorder triggered by Herpes Simplex 1 + genetic susceptibility
Achalasia
Factors that increase risk of developing DU or GU
NSAIDs, H. pylori, smoking, alcohol, stress, NG tubes, genetics, ischemia, medications, chemo, steroids, crack cocaine
3 types of Infectious Esophagitis
Candida albicans
Herpetic Esophagitis - HSV 1 or 2, varicella herpes zoster
Cytomegalovirus- w/ HIV/AIDS, organ transplant pt
Where does a perforation from instrumentation during endoscopy usually occur?
Hypopharynx, GEJ, or at site of stricture
What disorder is secondary to eosinophilic infiltration, has an overlap with GERD, is immunologically induced by antigen sensitivity- often with dietary factors and food sensitivity?
Eosinophilic esophagitis (EoE)
Dx of Corrosive esophagitis
Early endoscopy to assess and grade the injury and look for possible complications
A thin, eccentric, smooth extension of normal esophageal tissue consisting of mucosa and submucosa typically in the proximal esophagus
Esophageal web
How to Dx Booerhaave’s Syndrome
Chest CT/CXR + contrast swallow w/ gastrografin
Normal Esophageal Motility has primary and secondary peristaltic contractions. As well as tertiary non peristaltic contractions. What is the difference?
Primary contraction waves begin high in the pharynx and progress down the entire esophagus once swallowing is initiated.
Secondary contraction of the circular esophageal muscle that begins without swallowing.
Usually in response to distention (something getting stuck)
Tertiary contraction occur simultaneously at different levels of the esophagus (or entire length). Isolated event can be normal, repetitive events are disease process. May be spontaneous or in relation to swallowing.
Perforation is the 2nd MC complication of PUD. What are the 2 types?
Free Perforation- contents spill into abdominal cavity
Penetration perforation- ulcer tunnels to other organ
DU MC to pancreas
GU MC to L hepatic lobe
Diagnosis of EoE is by symptoms plus endoscopy. What can be seen on endoscopy?
edema, multiple esophageal rings, longitudinal furrows, exudate/punctate
Also may see eosinophils on CBC
Diagnosing H.pylori Gastritis
No hard and fast guidelines to test for H.pylori, although most EGD’s will bx and test for it.
Non-invasive testing:
- Quant Serologic Elisa test (blood, 80% accuracy, only measures antigens)
- Fecal antigen or urea breath test (sensitivity and specificity over 95%,
Sx of DES
chest pain, dysphagia
Sx of persistent drooling & aspiration, with regurgitation of food in an infant
Esophageal Atresia
Work up for GERD
Manometry, ph testing
complications of Radiation esophagitis
submucosal fibrosis, degenerative tissue changes, and stricture can occur years later
Nutcracker (Jackhammer) Esophagus
Hypermotility, excessive esophageal contractions > 2 SD above normal
Sx: chest pain, dysphagia
Dx: manometry-> increased pressure during peristalsis
Tx: reduce esophageal pressure with CCBs, nitrates, botox, Sildenafil
The 2 types of work ups for PUD are:
1) Endoscopy
- most sensitive and specific
- have photo documentation
- good when suspicions are high
2) Textbook= barium swallow
- if ulcer identified, then endoscopy
- some small lesions will not show up on barium swallow
Hallmark Sx of GERD
Heartburn & regurgitation (can treat empirically based on these Sx)
Can also experience chronic cough at night, hoarseness, recurrent laryngitis, asthma exacerbations, dental erosions, aspiration
If also experiencing dysphagia or chest pain, must rule out other causes
Complications of GERD
at risk for esophagitis, stricture, Barrett’s, bleeding, adenocarcinoma (metaplasia -> dysplasia -> adenocarcinoma)
*Endoscopic screening q 3-5 years
3 parts of Mucosal Defense System:
- Mucous gel layer -composed of 95% water and 5% mucin (serves as barrier protection)
- Surface epithelial cells (mucus production, pH regulation, and produce protective heat shock proteins that prevent protein denaturation)
- Subepithelial elements that provide cell protection and regeneration (they produce a host of protective factors and can migrate to repair areas where the pre-epithelial layers have been breached)
plus significant microvasculature that helps with defense and healing
Risk factor for adenocarcinoma of the esophagus
Barrett’s esophagus
Lower esophageal cancer is more likely to be what type of cancer?
adenocarcinoma
DDx of EoE
GERD, drug hypersensitivity, connective tissue disorder, hyper-eosinophilic syndrome, infection
Disorders of the esophagus manifest by impaired _____ or _______.
function or pain
Causes of esophageal web
congenital or due to inflammation (ex. with EoE)
An inflammation of the stomach, most commonly by H.pylori, that is often an incidental finding
Gastritis
At risk for gastric carcinoma
Testing for esophageal disorders includes:
upper endoscopy (EGD) Barium radiography esophageal manometry endoscopic US Ambulatory Reflux testing
Age of onset for Achalasia
ages 25-60
Who should be tested to check for Gastritis?
pts with PUD, Hx of PUD, or gastric cancer
Tx of Radiation esophagitis
supportive/ pain control
Dilation for chronic strictures
3 dominant mechanisms of GERD:
- Frequent transient LES relaxation (90%)
- LES hypotension
- Anatomic distortion of GEJ
Tx of Barrett’s Esophagus
PPI, GERD related diet plan: avoid fatty foods, chocolate, peppermint, alcohol, coffee, tomatoes, acidic foods
Pernicious Anemia Gastritis
Severe lack of IF due to gastric atrophy
- may be a genetic link
- often a comorbid autoimmune disease
Sx: gastric output of HCl acid, pepsin, IF severely reduced
More common in men, 60 yo, although blacks and latinos are often younger
Normal life expectancy for women. Men slightly reduced due to higher incidence of gastric cancer
Upper esophageal cancer is more likely to be what type of cancer?
Squamous cell carcinoma
This disorder is characterized by symptoms that include solid & liquid dysphagia, regurgitation of food and secretions often seen as foaming at the mouth, chest pain from esophageal spasm, heartburn and weight loss (esp later in the disease).
Achalasia
Sx of hiatal hernias
Most asymptomatic, but are likely to cause GERD
large ones cause: heartburn regurg. acid reflux dysphagia chest/ab pain SOB
MC congenital esophageal disorder
Esophageal Atresia and tracheoesophageal fistulas
Menetrier’s Disease (Hypertrophic gastropathy)
Large, tortuous mucosal folds in body and fungus. Often due to CMV in kids, but unknown in adults. Too much TGF-a?
Sx: epigastric pain, n/v, anorexia, peripheral edema, wt loss, GI bleeding
Dx: barium swallow, endoscopy w/ bx
Tx: anticholinergics, PG, prednisone, somatostatin analogues, H2 blockers, EGF inhibitory antibody- Cetuximab (last resort = gastrectomy)
DDx: ZES, malignancy, infx, gastritis
A herniation of mucosa and submucosa through esophageal muscle, with weakness at cricopharyngeus muscle that causes herniation or out-pouching
Zenker’s (or hypopharyngeal)
-False diverticula
Details to inquire about when assessing esophageal disorders include:
Weight gain or loss Gastrointestinal bleeding Dietary habits including the timing of meals Smoking Alcohol consumption History of vomiting History of eating disorders
This complicates Tx of thoracic cancers (breast and lung) with risk proportional to radiation dosing
Radiation esophagitis
Sx of PUD
epigastric pain that is burning, gnawing, dull, like a bad hunger pain (characteristic of both GU and DU)
May be asymptomatic until complications occur
Tx of esophageal web
Dilation
Complications from corrosive esophagitis
may lead to esophageal perforation, bleeding, stricture, and death.
Also associated with severe stricture formation and can require repeated dilation
Only true esophageal diverticula
Midesophageal- due to traction from adjacent inflammation (usually TB)
Tx of DES
Anxiolytics
+/- nitrates, CCB, vasodilators, botox
Surgery- long myotome or esophagectomy (rare- only in serious cases)
Characteristics of Gastric Ulcers (GU)
Discomfort with eating, nausea & wt loss
Usually NSAID use induced, because they block COX1 which decreases PG
With penetration perforation, this type usually goes to the L hepatic lobe
MC in 55-70 yo
Disorders of the esophagus are manifested by
impaired function or pain.
Triple therapy for Tx of Gastritis includes:
Omeprazole + clarithromycin + amoxicillin for 10 days
although there are 8 approved treatment combinations
eradication confirmation testing is done (fecal or breath)
When would you order an esophageal manometry?
To measure function of lower esophageal sphincter and muscles of esophagus.
Order for pts with dysphagia, odynophagia, intractable heartburn, non-cardiac chest pain
Tx of hiatal hernias
Antacids
PPIs
H2 blockers
lifestyle changes (food choices- avoid trigger foods, small meals, avoid laying down after eating, maintain healthy wt, stop smoking, elevate head of bed)
Surgery for persistent
Pts with Gastritis are at an elevated risk of developing…
Low grade B-cell lymphoma
Gastric MALT lymphoma
Tx of esophageal atresia
surgery
Good prognosis
SX of esophageal diverticula
usually asymptomatic until large enough to retain food, then coughing and regurgitation
Hallmark of Infectious Esophagitis
Odynophagia (no matter the infectious agent)
Can also have dysphagia, chest pain, hemorrhage
Tx for Infectious Esophagitis
Candida - fluconazole 14-21 days (if can’t swallow - IV echinocandin caspofungin 7-21 days)
Herpetic - Acyclovir PO or IV, if immunocompromised then increase days
CMV - ganciclovir 3-6 weeks, or foscarnet
May need maintenance therapy
DDx of Achalasia
DES, Chagas, pseudoachalasia
What is visualized on a barium swallow with Achalasia
Sigmoid esophagus, dilation, tapering, air/fluid levels
Tx for Schatzki’s ring
Dilation
In PUD, an ulcer appears in either of 2 areas:
stomach (GU) or duodenum (DU)
DDx of PUD
Functional dyspepsia, GERD, cancer, vascular disease, pancreatic disease, gallbladder disease, Crohn’s disease, post-op changes
Rx for Achalasia
nitrates, CCB, botox, phosphodiesterase inhibitors
Dilation of the submucosal esophageal glands. Associated with candida & proximal esophageal strictures. Pitting seen.
Intramural Esophageal Pseudodiverticula
-False diverticula
How do you diagnose DES?
Must rule out other causes of dysphagia
Manometry -> spastic esophageal activity in distal esophagus
“corkscrew” esophagus on Barium swallow (can also be seen in Achalasia)
Symptoms seen on Physical exam of PUD
- Epigastric tenderness (poor predictive value)
- Abdominal tenderness may fall right of midline 20% of the time
Watch for signs of bleeding or perforation:
Tachycardia
Orthostatic bp changes
Guarding, rigidity, rebound tenderness
