Gastro- Quiz 1 Flashcards
1
Q
Symptomatic esophageal web + iron deficiency anemia + dysphagia
(esp. in middle age woman, with koilonychia-spoon nails, and glossitis)
A
Plummer-Vinson Syndrome
2
Q
Surgical Tx for Achalasia
A
Heller Myotomy +/- Nissen or Toupet
3
Q
DDx of GERD
A
Esophagitis, PUD, Cancer, biliary colic (bad gallbladder)- “great imitator”, CAD, motility disorders
4
Q
Complications of Achalasia
A
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)
5
Q
Mediastinitis is a serious complication of what disorder?
A
perforation from instrumentation
6
Q
Tx for PUD
A
- 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)
7
Q
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
A
Infectious Esophagitis
8
Q
Tx of EoE
A
- 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
9
Q
4 types of hiatal hernias
A
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
10
Q
Factors that exacerbate GERD:
A
- Abdominal obesity
- pregnancy
- gastric hypersecretory states
- delayed gastric emptying
- disruption of esophageal peristalsis
- gluttany
11
Q
A break in the mucosal surface greater than 5 mm and a depth penetrating the submucosa
A
Ulcer
12
Q
Sx of B ring
A
usually asymptomatic
present in 10-15% of population
13
Q
Sx of esophageal disorders
A
heartburn dysphagia odynophagia chest pain regurgitation globus sensation water brash
14
Q
Common symptoms of esophageal disease;
A
heartburn regurgitation chest pain dysphagia odynophagia globus sensation water brash
15
Q
Tx for corrosive esophagitis
A
supportive, pain meds, IV fluids
16
Q
Sx of Radiation esophagitis
A
dysphagia and odynophagia that can last weeks to months following therapy. Esophageal mucosa can look red, swollen and friable
17
Q
Tx of GERD
A
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)
18
Q
Least common complication of PUD
A
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
19
Q
Sx of Esophageal cancer
A
Progressive dysphagia, weight loss, heartburn, hoarseness
20
Q
MC complication of PUD
A
Bleeding- 15%, >60 yo, and 20% have no warning
21
Q
Tx of perforation
A
NG suction, IV Abx, prompt surgical drainage & repair.
conservative Tx- NPO, IV Abx
22
Q
What is the work up with suspected Achalasia
A
Barium swallow
+/- manometry
Endoscopy if pseudoachalasia is suspected
23
Q
Characteristics of Duodenal Ulcers (DU)
A
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
24
Q
How do you get rid of Achalasia?
A
No known prevention or reversibility.
Therapy: reduce pressure, improve movement
Rx
Surgery/ Dilation
25
B ring with a lumen < 13 mm
Schatzki's ring
26
Dx of perforation
CT- to check for air in mediastinum
Contrast swallow w/ gastrografin followed by thin barium
27
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
28
Work up/Dx of esophageal atresia
Inability to pass tube >10-15 cm
Flouroscopy
29
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
30
Ingestion of alkali or acid, typically accidental but can be suicide attempt
Corrosive esophagitis
31
Cause of hiatal hernias
wear and tear, obesity, pregnancy, or genetic predisposition
Risk increase with age
32
Hypertensive LES
Hypermotility
Minor abnormality of similar Sx to Achalasia, but this is diagnosis when not enough to Dx Achalasia
33
How do you Dx Schatzki's ring?
Barium swallow
34
"steakhouse syndrome" (solid food dysphagia)
Schatzki's ring
35
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)
36
Sx of perforation
pleuritic retrosternal chest pain
37
Full thickness rupture at the GEJ due to forceful vomiting or retching. Could also be from iatrogenic perforation during endoscopy
Boerhaave's Syndrome
38
Tx of Booerhaave's Syndrome
If small/stable - IV fluids, NPO, Abx, H2 blockers
If large/severe- surgery
39
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)
40
Sx: odynophagia, dysphagia, hematemesis, dypsnea
Corrosive esophagitis
41
Barrett's esophagus risk factors:
middle age white male with chronic GERD
42
Sx of Gastritis
often asymptomatic in chronic
Acute= anorexia, epigastric discomfort, n/v
43
Patient's with Barrett's Esophagus need regular screening for what?
Cytologic and endoscopic screenings for carcinoma. Can progress to adenocarcinoma
44
Thin, membranous narrowing at the squamocolumnar mucosal junction
B ring
45
MC meds associated with pill esophagitis
bisphosphanates, NSAIDs, ferrous sulfate, doxycycline, tetracycline, quinidine, phenytoin, potassium chloride,
46
Proximal and distal esophagus to not communicate and therefore cannot swallow or handle secretions in an infant
Esophageal Atresia
47
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
48
A herniation of mucosa and submucosa through esophageal muscle. Associated with achalasia or distal esophageal stricture.
Epiphrenic
| -False diverticula
49
MC tests for esophageal disorders
upper endoscopy and barium radiography
50
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
51
Factors that increase risk of developing DU or GU
NSAIDs, H. pylori, smoking, alcohol, stress, NG tubes, genetics, ischemia, medications, chemo, steroids, crack cocaine
52
3 types of Infectious Esophagitis
Candida albicans
Herpetic Esophagitis - HSV 1 or 2, varicella herpes zoster
Cytomegalovirus- w/ HIV/AIDS, organ transplant pt
53
Where does a perforation from instrumentation during endoscopy usually occur?
Hypopharynx, GEJ, or at site of stricture
54
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)
55
Dx of Corrosive esophagitis
Early endoscopy to assess and grade the injury and look for possible complications
56
A thin, eccentric, smooth extension of normal esophageal tissue consisting of mucosa and submucosa typically in the proximal esophagus
Esophageal web
57
How to Dx Booerhaave's Syndrome
Chest CT/CXR + contrast swallow w/ gastrografin
58
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.
59
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
60
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
61
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%,
62
Sx of DES
chest pain, dysphagia
63
Sx of persistent drooling & aspiration, with regurgitation of food in an infant
Esophageal Atresia
64
Work up for GERD
Manometry, ph testing
65
complications of Radiation esophagitis
submucosal fibrosis, degenerative tissue changes, and stricture can occur years later
66
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
67
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
68
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
69
Complications of GERD
at risk for esophagitis, stricture, Barrett's, bleeding, adenocarcinoma (metaplasia -> dysplasia -> adenocarcinoma)
*Endoscopic screening q 3-5 years
70
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
71
Risk factor for adenocarcinoma of the esophagus
Barrett's esophagus
72
Lower esophageal cancer is more likely to be what type of cancer?
adenocarcinoma
73
DDx of EoE
GERD, drug hypersensitivity, connective tissue disorder, hyper-eosinophilic syndrome, infection
74
Disorders of the esophagus manifest by impaired _____ or _______.
function or pain
75
Causes of esophageal web
congenital or due to inflammation (ex. with EoE)
76
An inflammation of the stomach, most commonly by H.pylori, that is often an incidental finding
Gastritis
At risk for gastric carcinoma
77
Testing for esophageal disorders includes:
```
upper endoscopy (EGD)
Barium radiography
esophageal manometry
endoscopic US
Ambulatory Reflux testing
```
78
Age of onset for Achalasia
ages 25-60
79
Who should be tested to check for Gastritis?
pts with PUD, Hx of PUD, or gastric cancer
80
Tx of Radiation esophagitis
supportive/ pain control
Dilation for chronic strictures
81
3 dominant mechanisms of GERD:
- Frequent transient LES relaxation (90%)
- LES hypotension
- Anatomic distortion of GEJ
82
Tx of Barrett's Esophagus
PPI, GERD related diet plan: avoid fatty foods, chocolate, peppermint, alcohol, coffee, tomatoes, acidic foods
83
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
84
Upper esophageal cancer is more likely to be what type of cancer?
Squamous cell carcinoma
85
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
86
Sx of hiatal hernias
Most asymptomatic, but are likely to cause GERD
```
large ones cause:
heartburn
regurg.
acid reflux
dysphagia
chest/ab pain
SOB
```
87
MC congenital esophageal disorder
Esophageal Atresia and tracheoesophageal fistulas
88
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
89
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
90
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
```
91
This complicates Tx of thoracic cancers (breast and lung) with risk proportional to radiation dosing
Radiation esophagitis
92
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
93
Tx of esophageal web
Dilation
94
Complications from corrosive esophagitis
may lead to esophageal perforation, bleeding, stricture, and death.
Also associated with severe stricture formation and can require repeated dilation
95
Only true esophageal diverticula
Midesophageal- due to traction from adjacent inflammation (usually TB)
96
Tx of DES
Anxiolytics
+/- nitrates, CCB, vasodilators, botox
Surgery- long myotome or esophagectomy (rare- only in serious cases)
97
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
98
Disorders of the esophagus are manifested by
impaired function or pain.
99
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)
100
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
101
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
102
Pts with Gastritis are at an elevated risk of developing...
Low grade B-cell lymphoma
Gastric MALT lymphoma
103
Tx of esophageal atresia
surgery
| Good prognosis
104
SX of esophageal diverticula
usually asymptomatic until large enough to retain food, then coughing and regurgitation
105
Hallmark of Infectious Esophagitis
Odynophagia (no matter the infectious agent)
Can also have dysphagia, chest pain, hemorrhage
106
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
107
DDx of Achalasia
DES, Chagas, pseudoachalasia
108
What is visualized on a barium swallow with Achalasia
Sigmoid esophagus, dilation, tapering, air/fluid levels
109
Tx for Schatzki's ring
Dilation
110
In PUD, an ulcer appears in either of 2 areas:
stomach (GU) or duodenum (DU)
111
DDx of PUD
Functional dyspepsia, GERD, cancer, vascular disease, pancreatic disease, gallbladder disease, Crohn's disease, post-op changes
112
Rx for Achalasia
nitrates, CCB, botox, phosphodiesterase inhibitors
113
Dilation of the submucosal esophageal glands. Associated with candida & proximal esophageal strictures. Pitting seen.
Intramural Esophageal Pseudodiverticula
| -False diverticula
114
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)
115
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
